ADULT ACQUIRED FLATFOOT

DEFORMITY
• Adult acquired flatfoot deformity (AAFD) is a painful condition
resulting from the collapse of the longitudinal(lengthwise) arch of the
foot. As the name suggests, this condition is not present at birth or
during childhood. It occurs after the skeleton is fully matured.
• In the past it was referred to a posterior tibial tendon dysfunction (or
insufficiency). But the name was changed because the condition
really describes a wide range of flatfoot deformities. AAFD is most
often seen in women between the ages of 40 and 60.
ANATOMY
• The skeleton of the foot begins with the talus, or ankle bone, that
forms part of the ankle joint. The two bones of the lower leg, the
large tibia and the smaller fibula, come together at the ankle joint to
form a very stable structure.
• The two bones that make up the back part of the foot (sometimes referred
to as the hindfoot) are the talus and the calcaneus, or heel bone. The talus
is connected to the calcaneus at the subtalar joint. The ankle joint allows
the foot to bend up and down. The subtalar joint allows the foot to rock
from side to side.

• Just down the foot from the ankle is a set of five bones called tarsal bones
that work together as a group. These bones are unique in the way they fit
together. There are multiple joints between the tarsal bones. When the
foot is twisted in one direction by the muscles of the foot and leg, these
bones lock together and form a very rigid structure. When they are
twisted in the opposite direction, they become unlocked and allow the
foot to conform to whatever surface the foot is contacting.

• The tarsal bones are connected to the five long bones of the foot called
the metatarsals. The two groups of bones are fairly rigidly connected,
without much movement at the joints.
• The large Achilles' tendon is the most important tendon for walking, running,
and jumping. It attaches the calf muscles to the heel bone to allow us to rise up
on our toes. The posterior tibial tendon attaches one of the smaller muscles of
the calf to the underside of the foot. This tendon helps support the arch and
allows us to turn the foot inward. Failure of the posterior tibial tendon is a
major problem in many cases of adult-acquired flatfoot deformity (AAFD).

• The toes have tendons attached that bend the toes down (on the bottom of the
toes) and straighten the toes (on the top of the toes). The anterior tibial
tendon (tibialis anterior) allows us to raise the foot. Two tendons run behind
the outer bump of the ankle (called the lateral malleolus) and help turn the
foot outward.

• Many small ligaments hold the bones of the foot together. Most of these
ligaments form part of the joint capsulearound each of the joints of the foot. A
joint capsule is a watertight sac that forms around all joints. It is made up of the
ligaments around the joint and the soft tissues between the ligaments that fill in
the gaps and form the sac.
The spring ligament complex is often involved in adult-acquired flatfoot. This group of ligaments supports
thetalonavicular joint. The spring ligament complex works with the posterior tibial tendon and the plantar
fascia to support and stabilize the longitudinal arch of the foot. Failure of the ligaments that support this arch
can contribute to flatfoot deformity. Injury, laxity (looseness), or other dysfunction of the ligament and tendon
structures can result in deformity of the foot and/or ankle resulting in AAFD.
CAUSES
• There are multiple factors contributing to the development of this problem. Damage to the
nerves, ligaments, and/or tendons of the foot can cause subluxation (partial dislocation) of the
subtalar or talonavicular joints. Bone fracture is a possible cause. The resulting joint deformity
from any of these problems can lead to adult-acquired flatfoot deformity.

• Dysfunction of the posterior tibial tendon has always been linked with adult-acquired flatfoot
deformity (AAFD). The loss of active and passive pull of the tendon alters the normal
biomechanics of the foot and ankle. The reasons for this can be many and varied as well.
Diabetes, high blood pressure, and prolonged use of steroids are some of the more common
causes of adult-acquired flatfoot deformity (AAFD) brought on by impairment of the posterior
tibialis tendon. Overstretching or rupture of the tendon results in tendon and muscle imbalance
in the foot leading to adult-acquired flatfoot deformity (AAFD).
• Rheumatoid arthritis is one of the more common causes. About half of all adults with this type of
arthritis will develop adult flatfoot deformity over time. In such cases, the condition is gradual
and progressive.

• Obesity has been linked with this condition. Loss of blood supply for any reason in the area of the
posterior tibialis tendon is another factor. Other possible causes include bone fracture or
dislocation, a torn or stretched tendon, or a neurologic condition causing weakness.
• At first you may notice pain and swelling along the medial (big toe) side of
the foot. This is where the posterior tibialis tendon travels from the back of
the leg under the medial ankle bone to the foot. As the condition gets
worse, tendon failure occurs and the pain gets worse. Some patients
experience pain along the lateral (outside) edge of the foot, too.
• You may find that your feet hurt at the end of the day or after long periods
of standing. Some people with this condition have trouble rising up on
their toes. They may be unable to participate fully in sports or other
recreational activities
• The history and physical examination are probably the most important
tools the physician uses to diagnose this problem. The wear pattern on
your shoes can offer some helpful clues. Muscle testing helps identify any
areas of weakness or muscle impairment. This should be done in both the
weight bearing and nonweight bearing positions.

• A very effective test is the single heel raise. You will be asked to stand on
one foot and rise up on your toes. You should be able to lift your heel off
the ground easily while keeping the calcaneus (heel bone) in the middle
with slight inversion (turned inward).

• X-rays are often used to study the position, shape, and alignment of the
bones in the feet and ankles. Magnetic resonance (MR) imaging is the
imaging modality of choice for evaluating the posterior tibial tendon and
spring ligament complex.