Topic of the Month: The Adult Acquired Flatfoot (AAF)

"…All of a sudden, my arch collapsed…"

This is a frequent complaint we hear from many of our patients. It is unlikely that this happened overnight, but rather, a more gradual process that finally became noticeable to the patient. The following information is to give you insight about the cause of this phenomenon and what can be done to help you.

Symptomatic adult acquired flatfoot (AAF) is one of the most common problems we see here at Main Street Foot & Ankle Care. Usually the patient has a preexisting flatfoot and "faulty biomechanics" that overloads the posterior tibial tendon and surrounding ligaments on the medial side of the foot and ankle. Insufficiency of the structures is what causes the "collapsed arch" over a period of time.

Symptoms usually occur gradually over time and are frequently seen on one side. There is usually associated pain, swelling, and weakness on the medial side of the foot. There is a strong correlation with obesity, high blood pressure, and diabetes. We often see this problem in patients that have had a knee replacement years earlier.

"…So, what is the cause?"

• Heredity
• Abnormal walking
• Ruptured tendon
• Tight Achilles tendon
• Preexisting flatfoot
• Trauma
• Other conditions such as cerebral palsy, spina bifida, and muscular dystrophy

"…What can be done for this problem?"

There are various treatment options for AAF, depending on the severity or stage of the deformity. Many times we will see a patient in the acute stage, demonstrating pain, swelling, deformity, and disability. This requires immediate intervention with protection, rest, ice, elevation, and oral anti-inflammatory medication. Often we dispense a device called a CAM walker in the office. This is a walking boot that allows protective ambulation while resting the foot. In the more severe cases, casting is required with several weeks of staying off of the foot. It is important to alleviate the acute symptoms before a thorough diagnostic work-up can be performed.

Inserts and Bracing
This is the most conservative form of treatment for AAF and will only be successful in the very early stages. The goal is to realign the foot while supporting the arch and medial soft tissue structures. Physical therapy and a stretching program may also be used in combination. It is a known fact that a tight Achilles tendon directly leads to a flat foot and arch collapse. Early strengthening, stretching and shoe inserts may prevent this condition from progressing.

Podiatric Ankle Foot Orthoses (AFO's) have also become common practice in conservative management for AAF. This is a type of bracing that supports the foot and ankle and can comfortably be worn with sneakers. In our practice, we often prescribe an insert called a UCBL orthotic, which can be made at a local pedorthic office. It is a rigid insert that has an extended medial arch support when compared to a standard orthotic. This also can be comfortably worn in sneakers.

Surgical Intervention
In the later stages of AAF, some patients may require surgery. This is performed after a thorough clinical and radiographic examination, and after the patient has failed 3 months of conservative care and bracing.

Sinus Tarsi Implant --- This simple, surgical procedure requires a small implant inserted between two of the rearfoot bones. This prevents the foot from collapsing by stabilizing the calcaneus (heel bone) under the talus, thus placing less stress on the medial soft tissue structures. This procedure will only be successful in the earlier stages when the foot remains flexible and can adapt to such an implant.

Other surgeries --- Other surgical options include tendon repairs, tendon transfers, calcaneal osteotomies and medial column fusions. It has been found that isolated tendon transfers do not have good long-term success; therefore, a medial displacement calcaneal osteotomy is now performed in conjunction. In the most advanced stages of AAF, rearfoot fusions may be necessary. This is a more extensive procedure, and would require 8-12 weeks of remaining off the foot with a long rehabilitation.

If you are experiencing pain, loss of your arch, and progressive weakness of the foot and ankle, it is necessary to come to the office for a full evaluation. A thorough clinical and radiographic exam would help determine the extent of the deformity and a treatment plan can be recommended to you. Unfortunately, we often see a patient for the first time in the more progressive stages. There are many things to take into consideration when recommending what treatment is the best for you. Older individuals often opt for more simpler, bracing techniques and physical therapy for strengthening and balancing to help with everyday walking. Younger, more active patients may require more aggressive care.

Whatever the case, we are happy to help you back on your feet at Main Street Foot and Ankle Care. Doctors Majeski and Paukovitz are determined to get you better!