Acquired Adult Flatfoot

(Posterior Tibial Tendon

Dysfunction)
CU Orthopedic Surgery - Foot & Ankle

Summary
Chronic posterior tibial tendon insufficiency can result in acquired adult flatfoot deformity, also
referred to as pes planus, a fallen arch, an abnormally pronated foot, or simply flatfoot
deformity. This is a chronic foot condition where the soft-tissues (including the posterior tibial
tendon, deltoid and spring ligaments) on the inside aspect of the foot and ankle are subject to
repetitive load during walking and standing. Over time, these structures may become painful,
swollen, or incompetent. When these supporting structures fail, the result is a change in the
alignment of the foot. This condition is typically associated with a progressive flatfoot
deformity, leading to increased strain on the supporting structures on the inside of the ankle,
and loading through the outer aspect of the ankle and foot. Both the inside and outside of the
ankle can become painful, resulting in significant disability. This condition can often be treated
without surgery by strengthening the involved muscles and tendons, or with bracing. When
non-operative treatment fails, surgery can improve alignment and pain through soft tissue
transfers, realignment of bones or fusions. Alignment and function can be restored, however,
the time to maximal improvement is typically six months to a year. It is also important to realize
that not all flatfoot deformities result from problems with the posterior tibial tendon. A flat foot
can be a normal variant and does not necessarily need treatment if it is non-painful and does
not limit function. In other words, some people have “normal appearing arches,” some people
have “high arches,” and other people have “pronated, or flat appearing arches.”

Clinical Presentation
Patients with acquired adult flatfoot deformity typically provide a history of longstanding pain at
the inside of the foot and ankle, resulting in progressive, painful flatfeet (Figure 1). Symptoms of
pain may have developed gradually as a result of overuse, or they may be traced to one injury.
Typically, the pain localizes to the inside (medial) aspect of the ankle, under the medial
malleolus (see circle in Fig. 1). However, some patients will also experience pain over the
outside (lateral) aspect of the hind-foot, because of the resultant deformity and pressure or
impingement on the lateral structures of the foot and ankle. This usually occurs later in the
course of the condition. Patients may walk with a limp or, in advanced cases, be disabled due
to pain.
Physical Examination
Looking at the patient when they stand will usually demonstrate a atfoot deformity or a
pronated foot (marked attening of the medial longitudinal arch). The front part of the foot
(forefoot) is often splayed out to the side, leading to the presence of a “too many toes” sign
(Figure 2). This sign is present when the toes can be seen from directly behind the patient.

Posterior tibial tendon dysfunction may a ect the patient’s walking, as the patient’s
dysfunctional posterior tibial tendon can no longer stabilize the arch of the foot when weight is
placed on it. There is often tenderness to touch and swelling over the inside of the ankle just
below the bony prominence (the medial malleolus). There may also be pain in the outside
aspect of the ankle with palpation. This pain originates from impingement or compression of
two tendons between the outside ankle bone ( bula) and the heel bone, (calcaneus) when the
patient is standing.

A single-leg heel rise test is used to determine whether the posterior tibial tendon is intact or
whether it has become dysfunctional. If the patient can stand on one foot and raise the heel o
of the ground 3-5 times, then this suggests that the posterior tibial tendon is intact (Figure 3
[left]). If they are unable to do this, the posterior tibial tendon is likely dysfunctional (Figure 3
[right]).
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 Imaging Studies
X-Rays of the foot taken while weight bearing allows the physician to assess the extent of the
atfoot deformity (Figures 4a and 4b).

MRI is usually not indicated for patients with acquired adult atfoot deformity, as the diagnosis
and the classi cation can be established on physical examination. However, if there are other
clinical signs that suggest either a problem within the ankle, the subtalar joint, (intra-articular
pathology) or another source of pain, then an MRI may be indicated.

Classi cation
Acquired adult atfoot deformity has been classi ed into four categories.
• First Stage: The rst stage represents in ammation and symptoms originating from an
irritated posterior tibial tendon, which is still functional.
• Second Stage: Stage two is characterized by a change in the alignment of the foot, noted on
observation while standing (see above photos). The deformity is supple, meaning the foot is
freely movable and a “normal” position can be restored by the examiner. Stage two is also
associated with the inability to perform a single-leg heel rise.
• Third Stage: The third stage represents a atfoot deformity that becomes sti because of
arthritis. Prolonged deformity causes irritation to the involved joints, resulting in arthritis and the
inability to correct the foot to a normal position.
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 • Fourth Stage: The fourth phase is a atfoot deformity where deformity, sti ness and/or
arthritis extends to involvement of the ankle joint. This occurs when the deltoid ligament, the
major supporting structure on the inside of the ankle, fails to provide support. The ankle
becomes unstable and will demonstrate a tilted appearance on X-ray. Failure of the deltoid
ligament results from an inward displacement of the weight bearing forces. When prolonged,
this change can lead to ankle arthritis.

The vast majority of patients with acquired adult atfoot deformity have reached stage 2 by the
time they seek treatment from a physician.

Treatment: Non-Operative Treatment

Nonoperative treatment of stage 1 and 2 acquired adult atfoot deformity can be successful.
General components of the treatment include:
• The use of comfort shoes.
• The use of an over-the-counter (store-bought) or custom made orthotic insoles to support the
arch
• Activity modi cation to avoid exacerbating activities and strengthening to build support.
• Weight loss if indicated.

Speci c components of treatment that over time can lead to marked improvement in
symptoms include:
• A high repetition, low resistance strengthening program
• Appropriate bracing or a medial longitudinal arch support.

If the posterior tibial tendon is intact, a series of exercises aimed at strengthening the
elongated and dysfunctional tendon can be successful. In stage 1 or 2 deformities, this may be
combined with an ankle brace and an o -the-shelf or custom made orthotic insert which may
help to support the arch.
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 Treatment: Operative Treatment
Operative treatment may be indicated for those patients that have stage 2 or higher
dysfunction and have failed nonoperative management.The principles of operative treatment of
stage 2 deformities include:
• Transferring another tendon to help serve the role of the dysfunctional posterior tibial tendon
(usually the exor digitorum or exor hallucis longus is transferred)
• Restoring the shape and alignment of the foot. This moves the weight bearing axis back to
the center of the ankle.

Changing the shape of the foot can be achieved by one or more of the following procedures:
• Cutting the heel bone and shifting it to the inside (Medializing calcaneal osteotomy)
• Lateral column lengthening restores the arch and overall alignment of the foot.
• Medial column stabilization, which sti ens the ray of the big toe to better support the arch.
• Lengthening of the Achilles tendon or Gastrocnemius. This will allow the ankle to move
adequately once the alignment of the foot is corrected.

Stage 3 acquired adult atfoot deformity may be treated operatively with a hindfoot fusion
(arthrodesis). This is done with either a double or triple arthrodesis – fusion of two or three of
the joints in hindfoot through which the deformity occurs. This is typically performed in such a
way that the underlying foot deformity is corrected rst.

Potential Surgical Complications

• Wound-healing problems
• Infection
• Failure to heal bone (non-union) that has been cut or joints that have be fused
• Deep Vein Thrombosis (DVT), (blood clot forms in the leg)
• Pulmonary embolism, (blood clot travels to the lungs)
• Neurological injury
• Vascular Injury
• Continued pain and deformity
• Recurrence of deformity and pain

Recovery from Surgery

The recovery from surgery is dependent upon the particular combination of procedures that are
performed. However, if cutting and repositioning bones or fusing joints is required, (as it usually
is) a typical recovery would be:
• Healing Phase: 6 weeks of non-weightbearing is usually required
• Rehabilitation Phase: a period of gradual rehabilitation following the Healing Phase.

The information contained in this handout is copyrighted by FootEducation LLC. It may be

reproduced in small quantities for non commercial educational purposes. This information is for
general education purposes only. It should not be used without guidance from a licensed
healthcare provider. Handout Courtesy of www.FootEducation.com
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