(AAF) is the term used to describe the progressive deformity of the foot and
ankle that, in its later stages, results in collapsed and badly deformed feet. Although the condition has been described and written about since the 1980s, AAF is not a widely used acronym within the
O&P community-even though orthotists and pedorthists easily recognize the signs of the condition because they treat them on an almost daily basis. AAF is caused by a loss of the dynamic and
static support structures of the medial longitudinal arch, resulting in an incrementally worsening planovalgus deformity associated with posterior tibial (PT) tendinitis. Over the past 30 years,
researchers have attempted to understand and explain the gradual yet significant deterioration that can occur in foot structure, which ultimately leads to painful and debilitating conditions-a
progression that is currently classified into four stages. What begins as a predisposition to flatfoot can progress to a collapsed arch, and then to the more severe posterior tibial tendon
dysfunction (PTTD). Left untreated, the PT tendon can rupture, and the patient may then require a rigid AFO or an arthrodesis fixation surgery to stabilize the foot in order to remain capable of
walking pain free.
As discussed above, many health conditions can create a painful flatfoot. Damage to the posterior tibial tendon is the most common cause of AAFD. The posterior tibial tendon is one of the most
important tendons of the leg. It starts at a muscle in the calf, travels down the inside of the lower leg and attaches to the bones on the inside of the foot. The main function of this tendon is to
hold up the arch and support your foot when you walk. If the tendon becomes inflamed or torn, the arch will slowly collapse. Women and people over 40 are more likely to develop problems with the
posterior tibial tendon. Other risk factors include obesity, diabetes, and hypertension. Having flat feet since childhood increases the risk of developing a tear in the posterior tibial tendon. In
addition, people who are involved in high impact sports, such as basketball, tennis, or soccer, may have tears of the tendon from repetitive use. Inflammatory arthritis, such as rheumatoid arthritis,
can cause a painful flatfoot. This type of arthritis attacks not only the cartilage in the joints, but also the ligaments that support the foot. Inflammatory arthritis not only causes pain, but also
causes the foot to change shape and become flat. The arthritis can affect the back of the foot or the middle of foot, both of which can result in a fallen arch.
The types of symptoms that may indicate Adult-Acquired Flat Foot Deformity include foot pain that worsens over time, loss of the arch, abnormal shoe wear (excessive wearing on the inner side of shoe
from walking on the inner side of the foot) and an awkward appearance of the foot and ankle (when viewed from behind, heel and toes appear to go out to the side). It is important that we help
individuals recognize the early symptoms of this condition, as there are many treatment options, depending upon the severity, the age of the patient, and the desired activity levels.
Diagnostic testing is often used to diagnose the condition and help determine the stage of the disease. The most common test done in the office setting are weightbearing X-rays of the foot and ankle.
These assess joint alignment and osteoarthritis. If tendon tearing or rupture is suspected, the gold standard test would be MRI. The MRI is used to check the tendon, surrounding ligament structures
and the midfoot and hindfoot joints. An MRI is essential if surgery is being considered.
Non surgical Treatment
Orthotic or anklebrace, Over-the-counter or custom shoe inserts to position the foot and relieve pain are the most common non-surgical treatment option. Custom orthotics are often suggested if the
shape change of the foot is more severe. An ankle brace (either over-the-counter or custom made) is another option that will help to ease tendon tension and pain. Boot immobilization. A walking boot
supports the tendon and allows it to heal. Activity modifications. Depending on what we find, we may recommend limiting high-impact activities, such as running, jumping or court sports, or switching
out high-impact activities for low-impact options for a period of time. Ice and anti-inflammatory medications. These may be given as needed to decrease your symptoms.
If conservative treatments don?t work, your doctor may recommend surgery. Several procedures can be used to treat posterior tibial tendon dysfunction; often more than one procedure is performed at
the same time. Your doctor will recommend a specific course of treatment based on your individual case. Surgical options include. Tenosynovectomy. In this procedure, the surgeon will clean away
(debride) and remove (excise) any inflamed tissue surrounding the tendon. Osteotomy. This procedure changes the alignment of the heel bone (calcaneus). The surgeon may sometimes have to remove a
portion of the bone. Tendon transfer: This procedure uses some fibers from another tendon (the flexor digitorum longus, which helps bend the toes) to repair the damaged posterior tibial tendon.
Lateral column lengthening, In this procedure, the surgeon places a small wedge-shaped piece of bone into the outside of the calcaneus. This helps realign the bones and recreates the arch.
Arthrodesis. This procedure welds (fuses) one or more bones together, eliminating movement in the joint. This stabilizes the hindfoot and prevents the condition from progressing further.