Acquired Adult Flatfoot Deformity

Acquired adult flatfoot deformity (AAFD) is a progressive flattening of the arch of the foot that occurs as the posterior tibial tendon becomes insufficient. It has many other names, such as posterior tibial tendon dysfunction, posterior tibial tendon insufficiency, and dorsolateral peritalar subluxation. This problem may progress from early stages with pain along the posterior tibial tendon to advanced deformity and arthritis throughout the hindfoot and ankle.

Symptoms and Clinical Presentation

​Patients often experience pain and/or deformity at the ankle or hindfoot. When the posterior tibial tendon does not work properly, a number of changes can occur to the foot and ankle. In the earlier stages, symptoms often include pain and tenderness along the posterior tibial tendon behind the inside of the ankle. As the tendon progressively fails, deformity of the foot and ankle may occur. This deformity can include progressive flattening of the arch, shifting of the heel so that it no longer is aligned underneath the rest of the leg, rotation and deformity of the forefoot, tightening of the heel cord, development of arthritis, and deformity of the ankle joint. At certain stages of this disorder, pain may shift from the inside to the outside aspect of the ankle as the heel shifts outward and structures are pinched laterally.

Cause (including risk factors)

​Posterior tibial tendon dysfunction is the most common cause of acquired adult flatfoot deformity. There is often no specific event that starts the problem, such as a sudden tendon injury. More commonly, the tendon becomes injured from cumulative wear and tear. Posterior tibial tendon dysfunction occurs more commonly in patients who already have a flatfoot for other reasons. As the arch flattens, more stress is placed on the posterior tibial tendon and also on the ligaments on the inside of the foot and ankle. The result is a progressive disorder.
 

Anatomy

​The posterior tibialis muscle originates on the bones of the leg (tibia and fibula). This muscle then passes behind the medial (inside) aspect of the ankle and attaches to the medial midfoot as the posterior tibial tendon. The posterior tibial tendon serves to invert (roll inward) the foot and maintain the arch of the foot. This tendon plays a central role in maintaining the normal alignment of the foot and also in enabling normal gait (walking).

In addition to tendons running across the ankle and foot joints, a number of ligaments span and stabilize these joints. The ligaments at the medial ankle can become stretched and contribute to the progressive flattening of the arch.

Several muscles and tendons around the ankle and foot act to counter-balance the action of the posterior tibial tendon. Under normal circumstances, the result is a balanced ankle and foot with normal motion. When the posterior tibial tendon fails, the other muscles and tendons become relatively over-powering. These muscles then contribute to the progressive deformity seen with this disorder.

Diagnosis

​The diagnosis of posterior tibial tendon dysfunction and AAFD is usually made from a combination of symptoms, physical exam, and X-ray imaging. The location of pain, shape of the foot, flexibility of the hindfoot joints, and gait all may help your physician make the diagnosis and also assess how advanced the problem is.

_{*Source:  American Orthopaedic Foot & Ankle Society® http://www.aofas.org}