History

The clinical presentation of adult-acquired flatfoot deformity (AAFD) can be extremely variable, as can the progression and severity of the condition. Typically, the presentation directly correlates with the stage of the disease (see Staging). Common presenting symptoms include the following:

Visible pes planus (flatfoot) deformity (see the image below)
Inability or pain upon attempts to perform a single-leg heel rise
Pain along the course of the posterior tibial tendon (PTT)
Difficulty in walking

Photographs from patient with adult-acquired flatfoot deformity (AAFD) show typical features of condition, demonstrated by abducted forefoot and valgus hindfoot.

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The usual initial complaint of a patient with PTT dysfunction consists of pain and swelling in the medial ankle and midfoot during weightbearing. Over time, the patient may notice loss of the arch and the tendency to walk on the inner border of the foot. Loss of pushoff strength during gait occurs, and a limp may develop. As the patient's heel displaces into valgus and the forefoot abducts, pressure between the calcaneus and fibula may develop, causing painful impingement between the lateral ankle and calcaneus. Abnormal wear of the medial heel and inner border of footwear may also be noted.

Physical Examination

The patient is first examined while standing so as to facilitate comparison of the symptomatic foot with the asymptomatic foot. The arch heights of the two feet are assessed and compared. In later stages of PTT dysfunction, the arch is lowered and the forefoot abducted. Viewing the patient's foot from behind allows the examiner to evaluate forefoot abduction and heel valgus. The toes visible lateral to the heel are counted. Normally, one or two toes are visible lateral to the heel. In cases of significant forefoot abduction, three or more toes are visible. This "too-many-toes" sign is a test to confirm forefoot abduction (see the image below).

Pes planus (flatfoot). Too-many-toes sign. Three lateral toes are visible on symptomatic left foot, compared with only two toes on right foot (black arrow). Medial midfoot is prominent and swollen (yellow arrow).

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The angle that the heel forms with the longitudinal axis of the lower leg (the posterior tibiocalcaneal angle) also should be measured. This angle is increased in cases of significant heel valgus. The patient should then be asked to stand on one foot and rise up on the toes; he or she will usually need to hold on to the examining table or wall for balance during this maneuver. Normally, the heel inverts as the posterior tibial muscle contracts and as the gastrocnemius-soleus complex fires. In cases of PTT dysfunction, the heel does not invert, and the patient finds this single-limb heel-rise maneuver painful, difficult, or impossible (see the image below).

Pes planus (flatfoot). Single-limb heel-rise test. Patient with posterior tibial tendon (PTT) dysfunction is unable to rise up on toes because of inability to invert hindfoot.

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The patient then is examined seated on the examining table, and the course of the PTT is palpated for tenderness. Swelling along the PTT sheath may be noted, and fluid may be palpated within the sheath. Posterior tibial strength is tested by holding the forefoot in a position of plantarflexion and eversion and asking the patient to invert the foot. During this maneuver, the PTT should be palpated to assess its continuity. The sinus tarsi and distal fibular area also should be palpated for tenderness because in later stages of PTT dysfunction, these areas of impingement may also be painful.

The knee is extended, the foot is held in a subtalar neutral position, and passive ankle dorsiflexion is measured. Usually, 10-20° of dorsiflexion is possible, but in cases of long-standing pes planus, dorsiflexion past neutral is often limited because of the development of a plantarflexion contracture. During the final stages of PTT dysfunction, the subtalar joint may be fixed in eversion, and inversion to neutral may be impossible.

Finally, forefoot flexibility is assessed by pronating and supinating the forefoot while holding the heel in neutral position. Although the subtalar joint may be flexible, the transverse tarsal joint may have become fixed in varus, preventing plantigrade positioning of the forefoot (see the image below). This finding has important implications for surgical treatment.

Pes planus (flatfoot). Fixed forefoot varus is characterized by elevation of medial side of forefoot, even after heel is placed in neutral position.

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Workup

Deland JT. Adult-acquired flatfoot deformity. J Am Acad Orthop Surg. 2008 Jul. 16 (7):399-406. [QxMD MEDLINE Link].
Vittore D, Patella V, Petrera M, Caizzi G, Ranieri M, Putignano P, et al. Extensor deficiency: first cause of childhood flexible flat foot. Orthopedics. 2009 Jan. 32 (1):28. [QxMD MEDLINE Link].
Arai K, Ringleb SI, Zhao KD, Berglund LJ, Kitaoka HB, Kaufman KR. The effect of flatfoot deformity and tendon loading on the work of friction measured in the posterior tibial tendon. Clin Biomech (Bristol, Avon). 2007 Jun. 22 (5):592-8. [QxMD MEDLINE Link].
Deland JT, de Asla RJ, Sung IH, Ernberg LA, Potter HG. Posterior tibial tendon insufficiency: which ligaments are involved?. Foot Ankle Int. 2005 Jun. 26 (6):427-35. [QxMD MEDLINE Link].
Campbell KJ, Michalski MP, Wilson KJ, Goldsmith MT, Wijdicks CA, LaPrade RF, et al. The ligament anatomy of the deltoid complex of the ankle: a qualitative and quantitative anatomical study. J Bone Joint Surg Am. 2014 Apr 16. 96 (8):e62. [QxMD MEDLINE Link].
Kulowski J. Tendovaginitis (tenosynovitis): general discussion and report of one case involving the posterior tibial tendon. Missouri State Med Assoc. 1936. 33:135-7.
Pomeroy GC, Pike RH, Beals TC, Manoli A 2nd. Acquired flatfoot in adults due to dysfunction of the posterior tibial tendon. J Bone Joint Surg Am. 1999 Aug. 81(8):1173-82. [QxMD MEDLINE Link]. [Full Text].
Key JA. Partial rupture of the tendon of the posterior tibial muscle. J Bone Joint Surg Am. 1953 Oct. 35-A(4):1006-8. [QxMD MEDLINE Link]. [Full Text].
Fowler AW. Tibialis posterior syndrome. J Bone Joint Surg Br. 1955. 37:520-6.
Williams R. Chronic non-specific tendovaginitis of tibialis posterior. J Bone Joint Surg Br. 1963 Aug. 45:542-5. [QxMD MEDLINE Link]. [Full Text].
Kettelkamp DB, Alexander HH. Spontaneous rupture of the posterior tibial tendon. J Bone Joint Surg Am. 1969 Jun. 51 (4):759-64. [QxMD MEDLINE Link].
Mann RA. Acquired flatfoot in adults. Clin Orthop Relat Res. 1983 Dec. 46-51. [QxMD MEDLINE Link].
Jahss MH. Spontaneous rupture of the tibialis posterior tendon: clinical findings, tenographic studies, and a new technique of repair. Foot Ankle. 1982 Nov-Dec. 3 (3):158-66. [QxMD MEDLINE Link].
Goldner JL, Keats PK, Bassett FH 3rd, Clippinger FW. Progressive talipes equinovalgus due to trauma or degeneration of the posterior tibial tendon and medial plantar ligaments. Orthop Clin North Am. 1974 Jan. 5(1):39-51. [QxMD MEDLINE Link].
Johnson KA. Tibialis posterior tendon rupture. Clin Orthop Relat Res. 1983 Jul-Aug. 177:140-7. [QxMD MEDLINE Link].
Johnson KA, Strom DE. Tibialis posterior tendon dysfunction. Clin Orthop Relat Res. 1989 Feb. 239:196-206. [QxMD MEDLINE Link].
Myerson MS. Adult acquired flatfoot deformity: treatment of dysfunction of the posterior tibial tendon. Instr Course Lect. 1997. 46:393-405. [QxMD MEDLINE Link].
Bolgla LA, Malone TR. Plantar fasciitis and the windlass mechanism: a biomechanical link to clinical practice. J Athl Train. 2004 Jan. 39 (1):77-82. [QxMD MEDLINE Link]. [Full Text].
Kitaoka HB, Luo ZP, An KN. Effect of the posterior tibial tendon on the arch of the foot during simulated weightbearing: biomechanical analysis. Foot Ankle Int. 1997 Jan. 18 (1):43-6. [QxMD MEDLINE Link].
Anderson RB, Davis WH. Management of adult flatfoot deformity. Myerson MS, ed. Foot and Ankle Disorders. Philadelphia: WB Saunders; 2000. 1017-39.
Patil V, Ebraheim NA, Frogameni A, Liu J. Morphometric dimensions of the calcaneonavicular (spring) ligament. Foot Ankle Int. 2007 Aug. 28(8):927-32. [QxMD MEDLINE Link].
Kitaoka HB, Ahn TK, Luo ZP, An KN. Stability of the arch of the foot. Foot Ankle Int. 1997 Oct. 18(10):644-8. [QxMD MEDLINE Link].
Queen RM, Mall NA, Nunley JA, Chuckpaiwong B. Differences in plantar loading between flat and normal feet during different athletic tasks. Gait Posture. 2009 Jun. 29 (4):582-6. [QxMD MEDLINE Link].
Mann RA. Flatfoot in adults. Coughlin & Mann Surgery of the Foot and Ankle. St Louis: Mosby-Year Book; 1999. 733-67.
DiGiovanni CW, Langer P. The role of isolated gastrocnemius and combined achilles contractures in the flatfoot. Foot Ankle Clin. 2007 Jun. 12(2):363-79, viii. [QxMD MEDLINE Link].
Hansen ST, ed. Functional Reconstruction of the Foot and Ankle. Philadelphia: Lippincott Williams & Wilkins; 2000.
Pinney SJ, Lin SS. Current concept review: acquired adult flatfoot deformity. Foot Ankle Int. 2006 Jan. 27(1):66-75. [QxMD MEDLINE Link].
Kosashvili Y, Fridman T, Backstein D, Safir O, Bar Ziv Y. The correlation between pes planus and anterior knee or intermittent low back pain. Foot Ankle Int. 2008 Sep. 29(9):910-3. [QxMD MEDLINE Link].
Pisani G. About the pathogenesis of the so-called adult acquired pes planus. Foot Ankle Surg. 2010 Mar. 16(1):1-2. [QxMD MEDLINE Link].
Giza E, Cush G, Schon LC. The flexible flatfoot in the adult. Foot Ankle Clin. 2007 Jun. 12(2):251-71, vi. [QxMD MEDLINE Link].
Dyal CM, Feder J, Deland JT, Thompson FM. Pes planus in patients with posterior tibial tendon insufficiency: asymptomatic versus symptomatic foot. Foot Ankle Int. 1997 Feb. 18 (2):85-8. [QxMD MEDLINE Link].
Uchiyama E, Kitaoka HB, Fujii T, Luo ZP, Momose T, Berglund LJ, et al. Gliding resistance of the posterior tibial tendon. Foot Ankle Int. 2006 Sep. 27 (9):723-7. [QxMD MEDLINE Link].
Evans AM. The flat-footed child -- to treat or not to treat: what is the clinician to do?. J Am Podiatr Med Assoc. 2008 Sep-Oct. 98(5):386-93. [QxMD MEDLINE Link].
Levy JC, Mizel MS, Wilson LS, Fox W, McHale K, Taylor DC, et al. Incidence of foot and ankle injuries in West Point cadets with pes planus compared to the general cadet population. Foot Ankle Int. 2006 Dec. 27 (12):1060-4. [QxMD MEDLINE Link].
Michelson J, Easley M, Wigley FM, Hellmann D. Posterior tibial tendon dysfunction in rheumatoid arthritis. Foot Ankle Int. 1995 Mar. 16 (3):156-61. [QxMD MEDLINE Link].
Petersen W, Hohmann G. Collagenous fibril texture of the gliding zone of the human tibialis posterior tendon. Foot Ankle Int. 2001 Feb. 22(2):126-32. [QxMD MEDLINE Link].
Myerson M, Solomon G, Shereff M. Posterior tibial tendon dysfunction: its association with seronegative inflammatory disease. Foot Ankle. 1989 Apr. 9 (5):219-25. [QxMD MEDLINE Link].
Pecheva M, Devany A, Nourallah B, Cutts S, Pasapula C. Long-term follow-up of patients undergoing tibialis posterior transfer: Is acquired pes planus a complication?. Foot (Edinb). 2018 Mar. 34:83-89. [QxMD MEDLINE Link].
Mann RA, Thompson FM. Rupture of the posterior tibial tendon causing flat foot. Surgical treatment. J Bone Joint Surg Am. 1985 Apr. 67(4):556-61. [QxMD MEDLINE Link]. [Full Text].
Funk DA, Cass JR, Johnson KA. Acquired adult flat foot secondary to posterior tibial-tendon pathology. J Bone Joint Surg Am. 1986 Jan. 68(1):95-102. [QxMD MEDLINE Link]. [Full Text].
Posterior tibial tendon insufficiency. Myerson M, ed. Current Therapy in Foot and Ankle Surgery. St Louis: Mosby-Year Book; 1993. 123-35.
Holmes GB Jr, Mann RA. Possible epidemiological factors associated with rupture of the posterior tibial tendon. Foot Ankle. 1992 Feb. 13 (2):70-9. [QxMD MEDLINE Link].
Kou JX, Balasubramaniam M, Kippe M, Fortin PT. Functional results of posterior tibial tendon reconstruction, calcaneal osteotomy, and gastrocnemius recession. Foot Ankle Int. 2012 Jul. 33(7):602-11. [QxMD MEDLINE Link].
Ruffilli A, Traina F, Giannini S, Buda R, Perna F, Faldini C. Surgical treatment of stage II posterior tibialis tendon dysfunction: ten-year clinical and radiographic results. Eur J Orthop Surg Traumatol. 2018 Jan. 28 (1):139-145. [QxMD MEDLINE Link].
Conti MS, Jones MT, Savenkov O, Deland JT, Ellis SJ. Outcomes of Reconstruction of the Stage II Adult-Acquired Flatfoot Deformity in Older Patients. Foot Ankle Int. 2018 Sep. 39 (9):1019-1027. [QxMD MEDLINE Link].
Usuelli FG, Di Silvestri CA, D'Ambrosi R, Maccario C, Tan EW. Return to sport activities after medial displacement calcaneal osteotomy and flexor digitorum longus transfer. Knee Surg Sports Traumatol Arthrosc. 2018 Mar. 26 (3):892-896. [QxMD MEDLINE Link].
Finnern M Jr, Ryan P, Anderson C. Occupational Outcomes of Reconstructive Surgery for Adult Acquired Flatfoot Deformity. Mil Med. 2017 Nov. 182 (11):e2066-e2068. [QxMD MEDLINE Link].
Kong A, Van Der Vliet A. Imaging of tibialis posterior dysfunction. Br J Radiol. 2008 Oct. 81(970):826-36. [QxMD MEDLINE Link].
Younger AS, Sawatzky B, Dryden P. Radiographic assessment of adult flatfoot. Foot Ankle Int. 2005 Oct. 26(10):820-5. [QxMD MEDLINE Link].
Arangio GA, Wasser T, Rogman A. Radiographic comparison of standing medial cuneiform arch height in adults with and without acquired flatfoot deformity. Foot Ankle Int. 2006 Aug. 27(8):636-8. [QxMD MEDLINE Link].
Ellis SJ, Yu JC, Williams BR, Lee C, Chiu YL, Deland JT. New radiographic parameters assessing forefoot abduction in the adult acquired flatfoot deformity. Foot Ankle Int. 2009 Dec. 30(12):1168-76. [QxMD MEDLINE Link].
Arangio GA, Wasser T, Rogman A. The use of standing lateral tibial-calcaneal angle as a quantitative measurement of Achilles tendon contracture in adult acquired flatfoot. Foot Ankle Int. 2006 Sep. 27(9):685-8. [QxMD MEDLINE Link].
González Trujano A, Fuentes Nucamendi MA. [Radiological evaluation of the flexibles pes planus treated with conic endorthesis]. Acta Ortop Mex. 2008 May-Jun. 22(3):169-74. [QxMD MEDLINE Link].
Ellis SJ, Deyer T, Williams BR, Yu JC, Lehto S, Maderazo A, et al. Assessment of lateral hindfoot pain in acquired flatfoot deformity using weightbearing multiplanar imaging. Foot Ankle Int. 2010 May. 31 (5):361-71. [QxMD MEDLINE Link].
Conti S, Michelson J, Jahss M. Clinical significance of magnetic resonance imaging in preoperative planning for reconstruction of posterior tibial tendon ruptures. Foot Ankle. 1992 May. 13 (4):208-14. [QxMD MEDLINE Link].
Malicky ES, Crary JL, Houghton MJ, Agel J, Hansen ST Jr, Sangeorzan BJ. Talocalcaneal and subfibular impingement in symptomatic flatfoot in adults. J Bone Joint Surg Am. 2002 Nov. 84-A (11):2005-9. [QxMD MEDLINE Link].
Haleem AM, Pavlov H, Bogner E, Sofka C, Deland JT, Ellis SJ. Comparison of deformity with respect to the talus in patients with posterior tibial tendon dysfunction and controls using multiplanar weight-bearing imaging or conventional radiography. J Bone Joint Surg Am. 2014 Apr 16. 96(8):e63. [QxMD MEDLINE Link].
de Cesar Netto C, Schon LC, Thawait GK, da Fonseca LF, Chinanuvathana A, Zbijewski WB, et al. Flexible Adult Acquired Flatfoot Deformity: Comparison Between Weight-Bearing and Non-Weight-Bearing Measurements Using Cone-Beam Computed Tomography. J Bone Joint Surg Am. 2017 Sep 20. 99 (18):e98. [QxMD MEDLINE Link].
Kunas GC, Probasco W, Haleem AM, Burket JC, Williamson ERC, Ellis SJ. Evaluation of peritalar subluxation in adult acquired flatfoot deformity using computed tomography and weightbearing multiplanar imaging. Foot Ankle Surg. 2018 Dec. 24 (6):495-500. [QxMD MEDLINE Link].
Vora AM, Tien TR, Parks BG, Schon LC. Correction of moderate and severe acquired flexible flatfoot with medializing calcaneal osteotomy and flexor digitorum longus transfer. J Bone Joint Surg Am. 2006 Aug. 88(8):1726-34. [QxMD MEDLINE Link].
Beals TC, Pomeroy GC, Manoli A 2nd. Posterior tendon insufficiency: diagnosis and treatment. J Am Acad Orthop Surg. 1999 Mar-Apr. 7(2):112-8. [QxMD MEDLINE Link].
Francisco R, Chiodo CP, Wilson MG. Management of the rigid adult acquired flatfoot deformity. Foot Ankle Clin. 2007 Jun. 12(2):317-27, vii. [QxMD MEDLINE Link].
Logue JD. Advances in orthotics and bracing. Foot Ankle Clin. 2007 Jun. 12(2):215-32, v. [QxMD MEDLINE Link].
Rome K, Ashford RL, Evans A. Non-surgical interventions for paediatric pes planus. Cochrane Database Syst Rev. 2010 Jul 7. CD006311. [QxMD MEDLINE Link].
Marzano R. Functional bracing of the adult acquired flatfoot. Clin Podiatr Med Surg. 2007 Oct. 24 (4):645-56, vii. [QxMD MEDLINE Link].
Nielsen MD, Dodson EE, Shadrick DL, Catanzariti AR, Mendicino RW, Malay DS. Nonoperative care for the treatment of adult-acquired flatfoot deformity. J Foot Ankle Surg. 2011 May-Jun. 50 (3):311-4. [QxMD MEDLINE Link].
Manafi Rasi A, Kazemian G, Emami Moghadam M, Tavakoli Larestani R, Fallahi A, Nemati A, et al. Deep vein thrombosis following below knee immobilization: the need for chemoprophylaxis. Trauma Mon. 2013 Winter. 17 (4):367-9. [QxMD MEDLINE Link]. [Full Text].
Okamura K, Kanai S, Fukuda K, Tanaka S, Ono T, Oki S. The effect of additional activation of the plantar intrinsic foot muscles on foot kinematics in flat-footed subjects. Foot (Edinb). 2018 Nov 6. 38:19-23. [QxMD MEDLINE Link].
Arnold JB, May T, Bishop C. Predictors of the Biomechanical Effects of Customized Foot Orthoses in Adults With Flat-Arched Feet. Clin J Sport Med. 2018 Jul. 28 (4):398-400. [QxMD MEDLINE Link].
Yurt Y, Şener G, Yakut Y. The effect of different foot orthoses on pain and health related quality of life in painful flexible flat foot: a randomized controlled trial. Eur J Phys Rehabil Med. 2019 Feb. 55 (1):95-102. [QxMD MEDLINE Link].
Imhauser CW, Abidi NA, Frankel DZ, Gavin K, Siegler S. Biomechanical evaluation of the efficacy of external stabilizers in the conservative treatment of acquired flatfoot deformity. Foot Ankle Int. 2002 Aug. 23 (8):727-37. [QxMD MEDLINE Link].
Chao W, Wapner KL, Lee TH, Adams J, Hecht PJ. Nonoperative management of posterior tibial tendon dysfunction. Foot Ankle Int. 1996 Dec. 17 (12):736-41. [QxMD MEDLINE Link].
Walters JL, Mendicino SS. Flexible adult flatfoot: soft tissue procedures. Clin Podiatr Med Surg. 2014 Jul. 31 (3):349-55. [QxMD MEDLINE Link].
Walters JL, Mendicino SS. The flexible adult flatfoot: anatomy and pathomechanics. Clin Podiatr Med Surg. 2014 Jul. 31 (3):329-36. [QxMD MEDLINE Link].
Teasdall RD, Johnson KA. Surgical treatment of stage I posterior tibial tendon dysfunction. Foot Ankle Int. 1994 Dec. 15 (12):646-8. [QxMD MEDLINE Link].
McCormack AP, Varner KE, Marymont JV. Surgical treatment for posterior tibial tendonitis in young competitive athletes. Foot Ankle Int. 2003 Jul. 24(7):535-8. [QxMD MEDLINE Link].
Alvarez RG, Marini A, Schmitt C, Saltzman CL. Stage I and II posterior tibial tendon dysfunction treated by a structured nonoperative management protocol: an orthosis and exercise program. Foot Ankle Int. 2006 Jan. 27(1):2-8. [QxMD MEDLINE Link].
Benthien RA, Parks BG, Guyton GP, Schon LC. Lateral column calcaneal lengthening, flexor digitorum longus transfer, and opening wedge medial cuneiform osteotomy for flexible flatfoot: a biomechanical study. Foot Ankle Int. 2007 Jan. 28(1):70-7. [QxMD MEDLINE Link].
Myerson MS, Badekas A, Schon LC. Treatment of stage II posterior tibial tendon deficiency with flexor digitorum longus tendon transfer and calcaneal osteotomy. Foot Ankle Int. 2004 Jul. 25(7):445-50. [QxMD MEDLINE Link].
Niki H, Hirano T, Okada H, Beppu M. Outcome of medial displacement calcaneal osteotomy for correction of adult-acquired flatfoot. Foot Ankle Int. 2012 Nov. 33(11):940-6. [QxMD MEDLINE Link].
Chan JY, Williams BR, Nair P, Young E, Sofka C, Deland JT. The contribution of medializing calcaneal osteotomy on hindfoot alignment in the reconstruction of the stage II adult acquired flatfoot deformity. Foot Ankle Int. 2013 Feb. 34(2):159-66. [QxMD MEDLINE Link].
Rosenfeld PF, Dick J, Saxby TS. The response of the flexor digitorum longus and posterior tibial muscles to tendon transfer and calcaneal osteotomy for stage II posterior tibial tendon dysfunction. Foot Ankle Int. 2005 Sep. 26(9):671-4. [QxMD MEDLINE Link].
Dolan CM, Henning JA, Anderson JG, Bohay DR, Kornmesser MJ, Endres TJ. Randomized prospective study comparing tri-cortical iliac crest autograft to allograft in the lateral column lengthening component for operative correction of adult acquired flatfoot deformity. Foot Ankle Int. 2007 Jan. 28 (1):8-12. [QxMD MEDLINE Link].
Dumontier TA, Falicov A, Mosca V, Sangeorzan B. Calcaneal lengthening: investigation of deformity correction in a cadaver flatfoot model. Foot Ankle Int. 2005 Feb. 26(2):166-70. [QxMD MEDLINE Link].
Iossi M, Johnson JE, McCormick JJ, Klein SE. Short-term radiographic analysis of operative correction of adult acquired flatfoot deformity. Foot Ankle Int. 2013 Jun. 34(6):781-91. [QxMD MEDLINE Link].
Moore SH, Carstensen SE, Burrus MT, Cooper T, Park JS, Perumal V. Porous Titanium Wedges in Lateral Column Lengthening for Adult-Acquired Flatfoot Deformity. Foot Ankle Spec. 2018 Aug. 11 (4):347-356. [QxMD MEDLINE Link].
Cohen BE, Ogden F. Medial column procedures in the acquired flatfoot deformity. Foot Ankle Clin. 2007 Jun. 12(2):287-99, vi. [QxMD MEDLINE Link].
Choi JY, Cha SM, Yeom JW, Suh JS. Effect of the additional first ray osteotomy on hindfoot alignment after calcaneal osteotomy for the correction of mild-to-moderate adult type pes plano-valgus. J Orthop Surg (Hong Kong). 2017 Jan 1. 25 (1):2309499016684747. [QxMD MEDLINE Link].
Hirose CB, Johnson JE. Plantarflexion opening wedge medial cuneiform osteotomy for correction of fixed forefoot varus associated with flatfoot deformity. Foot Ankle Int. 2004 Aug. 25(8):568-74. [QxMD MEDLINE Link].
Logel KJ, Parks BG, Schon LC. Calcaneocuboid distraction arthrodesis and first metatarsocuneiform arthrodesis for correction of acquired flatfoot deformity in a cadaver model. Foot Ankle Int. 2007 Apr. 28(4):435-40. [QxMD MEDLINE Link].
Knupp M, Hintermann B. The Cobb procedure for treatment of acquired flatfoot deformity associated with stage II insufficiency of the posterior tibial tendon. Foot Ankle Int. 2007 Apr. 28(4):416-21. [QxMD MEDLINE Link].
Saxena A, Nguyen A. Preliminary radiographic findings and sizing implications on patients undergoing bioabsorbable subtalar arthroereisis. J Foot Ankle Surg. 2007 May-Jun. 46(3):175-80. [QxMD MEDLINE Link].
Schon LC. Subtalar arthroereisis: a new exploration of an old concept. Foot Ankle Clin. 2007 Jun. 12(2):329-39, vii. [QxMD MEDLINE Link].
Soomekh DJ, Baravarian B. Pediatric and adult flatfoot reconstruction: subtalar arthroereisis versus realignment osteotomy surgical options. Clin Podiatr Med Surg. 2006 Oct. 23(4):695-708, v. [QxMD MEDLINE Link].
Wukich DK, Rhim B, Lowery NJ, Dial D. Biotenodesis screw for fixation of FDL transfer in the treatment of adult acquired flatfoot deformity. Foot Ankle Int. 2008 Jul. 29(7):730-4. [QxMD MEDLINE Link].
Needleman RL. A surgical approach for flexible flatfeet in adults including a subtalar arthroereisis with the MBA sinus tarsi implant. Foot Ankle Int. 2006 Jan. 27(1):9-18. [QxMD MEDLINE Link].
Bernasconi A, Sadile F, Welck M, Mehdi N, Laborde J, Lintz F. Role of Tendoscopy in Treating Stage II Posterior Tibial Tendon Dysfunction. Foot Ankle Int. 2018 Apr. 39 (4):433-442. [QxMD MEDLINE Link].
Hix J, Kim C, Mendicino RW, Saltrick K, Catanzariti AR. Calcaneal osteotomies for the treatment of adult-acquired flatfoot. Clin Podiatr Med Surg. 2007 Oct. 24 (4):699-719, viii-ix. [QxMD MEDLINE Link].
Gleich A. Beitrag zur operativen Plattfussbehandlung. Arch Klin Chir. 1893. 46:358-62.
Koutsogiannis E. Treatment of mobile flat foot by displacement osteotomy of the calcaneus. J Bone Joint Surg Br. 1971 Feb. 53 (1):96-100. [QxMD MEDLINE Link]. [Full Text].
Sammarco GJ, Hockenbury RT. Treatment of stage II posterior tibial tendon dysfunction with flexor hallucis longus transfer and medial displacement calcaneal osteotomy. Foot Ankle Int. 2001 Apr. 22 (4):305-12. [QxMD MEDLINE Link].
Haeseker GA, Mureau MA, Faber FW. Lateral column lengthening for acquired adult flatfoot deformity caused by posterior tibial tendon dysfunction stage II: a retrospective comparison of calcaneus osteotomy with calcaneocuboid distraction arthrodesis. J Foot Ankle Surg. 2010 Jul-Aug. 49 (4):380-4. [QxMD MEDLINE Link].
Manoli A. Remodeling of the Calcaneocuboid Joint in the Acquired Flatfoot. J Surg Orthop Adv. Fall 2018. 27 (3):237-245. [QxMD MEDLINE Link].
Saunders SM, Ellis SJ, Demetracopoulos CA, Marinescu A, Burkett J, Deland JT. Comparative Outcomes Between Step-Cut Lengthening Calcaneal Osteotomy vs Traditional Evans Osteotomy for Stage IIB Adult-Acquired Flatfoot Deformity. Foot Ankle Int. 2018 Jan. 39 (1):18-27. [QxMD MEDLINE Link].
Scott RT, Berlet GC. Calcaneal Z osteotomy for extra-articular correction of hindfoot valgus. J Foot Ankle Surg. 2013 May-Jun. 52 (3):406-8. [QxMD MEDLINE Link].
Ettinger S, Mattinger T, Stukenborg-Colsman C, Yao D, Claassen L, Daniilidis K, et al. Outcomes of Evans Versus Hintermann Calcaneal Lengthening Osteotomy for Flexible Flatfoot. Foot Ankle Int. 2019 Jun. 40 (6):661-671. [QxMD MEDLINE Link].
Jordan TH, Rush SM, Hamilton GA, Ford LA. Radiographic outcomes of adult acquired flatfoot corrected by medial column arthrodesis with or without a medializing calcaneal osteotomy. J Foot Ankle Surg. 2011 Mar-Apr. 50 (2):176-81. [QxMD MEDLINE Link].
Thomas RL, Wells BC, Garrison RL, Prada SA. Preliminary results comparing two methods of lateral column lengthening. Foot Ankle Int. 2001 Feb. 22 (2):107-19. [QxMD MEDLINE Link].
Ebaugh MP, Larson DR, Reb CW, Berlet GC. Outcomes of the Extended Z-Cut Osteotomy for Correction of Adult Acquired Flatfoot Deformity. Foot Ankle Int. 2019 Aug. 40 (8):914-922. [QxMD MEDLINE Link].
Wang CS, Tzeng YH, Lin CC, Chang MC, Chiang CC. Comparison of screw fixation versus non-fixation in dorsal opening wedge medial cuneiform osteotomy of adult acquired flatfoot. Foot Ankle Surg. 2020 Feb. 26 (2):193-197. [QxMD MEDLINE Link].
Kunas GC, Do HT, Aiyer A, Deland JT, Ellis SJ. Contribution of Medial Cuneiform Osteotomy to Correction of Longitudinal Arch Collapse in Stage IIb Adult-Acquired Flatfoot Deformity. Foot Ankle Int. 2018 Aug. 39 (8):885-893. [QxMD MEDLINE Link].
Conti MS, Garfinkel JH, Kunas GC, Deland JT, Ellis SJ. Postoperative Medial Cuneiform Position Correlation With Patient-Reported Outcomes Following Cotton Osteotomy for Reconstruction of the Stage II Adult-Acquired Flatfoot Deformity. Foot Ankle Int. 2019 May. 40 (5):491-498. [QxMD MEDLINE Link].
Blackwood S, Gossett L. Hallux Valgus/Medial Column Instability and Their Relationship with Posterior Tibial Tendon Dysfunction. Foot Ankle Clin. 2018 Jun. 23 (2):297-313. [QxMD MEDLINE Link].
Hardy MA, Logan DB. Principles of arthrodesis and advances in fixation for the adult acquired flatfoot. Clin Podiatr Med Surg. 2007 Oct. 24 (4):789-813, x. [QxMD MEDLINE Link].
Kitaoka HB, Luo ZP, An KN. Subtalar arthrodesis versus flexor digitorum longus tendon transfer for severe flatfoot deformity: an in vitro biomechanical analysis. Foot Ankle Int. 1997 Nov. 18 (11):710-5. [QxMD MEDLINE Link].
Stephens HM, Walling AK, Solmen JD, Tankson CJ. Subtalar repositional arthrodesis for adult acquired flatfoot. Clin Orthop Relat Res. 1999 Aug. 69-73. [QxMD MEDLINE Link].
Johnson JE, Cohen BE, DiGiovanni BF, Lamdan R. Subtalar arthrodesis with flexor digitorum longus transfer and spring ligament repair for treatment of posterior tibial tendon insufficiency. Foot Ankle Int. 2000 Sep. 21 (9):722-9. [QxMD MEDLINE Link].
Chi TD, Toolan BC, Sangeorzan BJ, Hansen ST Jr. The lateral column lengthening and medial column stabilization procedures. Clin Orthop Relat Res. 1999 Aug. 81-90. [QxMD MEDLINE Link].
Maskill MP, Loveland JD, Mendicino RW, Saltrick K, Catanzariti AR. Triple arthrodesis for the adult-acquired flatfoot deformity. Clin Podiatr Med Surg. 2007 Oct. 24 (4):765-78, x. [QxMD MEDLINE Link].
Saltzman CL, el-Khoury GY. The hindfoot alignment view. Foot Ankle Int. 1995 Sep. 16(9):572-6. [QxMD MEDLINE Link].
van der Krans A, Louwerens JW, Anderson P. Adult acquired flexible flatfoot, treated by calcaneocuboid distraction arthrodesis, posterior tibial tendon augmentation, and percutaneous Achilles tendon lengthening: a prospective outcome study of 20 patients. Acta Orthop. 2006 Feb. 77(1):156-63. [QxMD MEDLINE Link]. [Full Text].
Miniaci-Coxhead SL, Weisenthal B, Ketz JP, Flemister AS. Incidence and Radiographic Predictors of Valgus Tibiotalar Tilt After Hindfoot Fusion. Foot Ankle Int. 2017 May. 38 (5):519-525. [QxMD MEDLINE Link].
Kelly IP, Easley ME. Treatment of stage 3 adult acquired flatfoot. Foot Ankle Clin. 2001 Mar. 6(1):153-66. [QxMD MEDLINE Link].
Steiner CS, Gilgen A, Zwicky L, Schweizer C, Ruiz R, Hintermann B. Combined Subtalar and Naviculocuneiform Fusion for Treating Adult Acquired Flatfoot Deformity With Medial Arch Collapse at the Level of the Naviculocuneiform Joint. Foot Ankle Int. 2019 Jan. 40 (1):42-47. [QxMD MEDLINE Link].
Johnson JE, Yu JR. Arthrodesis techniques in the management of stage II and III acquired adult flatfoot deformity. Instr Course Lect. 2006. 55:531-42. [QxMD MEDLINE Link].
Bluman EM, Myerson MS. Stage IV posterior tibial tendon rupture. Foot Ankle Clin. 2007 Jun. 12(2):341-62, viii. [QxMD MEDLINE Link].
Mandracchia VJ, Mandi DM, Nickles WA, Barp EA, Sanders SM. Pantalar arthrodesis. Clin Podiatr Med Surg. 2004 Jul. 21 (3):461-70. [QxMD MEDLINE Link].
Michelson J, Conti S, Jahss M. Survivorship analysis of tendon transfer surgery for posterior tibial tendon rupture [abstract]. Orthop Trans Relat Res. 1992. 16:30.
Neufeld SK, Myerson MS. Complications of surgical treatments for adult flatfoot deformities. Foot Ankle Clin. 2001 Mar. 6(1):179-91. [QxMD MEDLINE Link].
Kiewiet NJ, Benirschke SK, Brage ME. Triple arthrodesis: tips and tricks to navigate trouble. Foot Ankle Clin. 2014 Sep. 19 (3):483-97. [QxMD MEDLINE Link].
Lee MS, Maker JM. Revision of failed flatfoot surgery. Clin Podiatr Med Surg. 2009 Jan. 26 (1):47-58. [QxMD MEDLINE Link].

Media Gallery

Photographs from patient with adult-acquired flatfoot deformity (AAFD) show typical features of condition, demonstrated by abducted forefoot and valgus hindfoot.
Intraoperative images from patient with pes planus (flatfoot). (A) Flexor digitorum longus (FDL) transfer to navicular bone. (B) Torn spring ligament.
Pes planus (flatfoot). Axial magnetic resonance image demonstrating medial calcaneal shift.
Arizona Brace. Image courtesy of Don Pierson, CO of Arizona AFO, Inc.
Radiographs of foot in patient with pes planus (flatfoot). (A) Preoperative radiograph of stage 3 posterior tibial tendon (PTT) dysfunction. (B) Radiograph obtained 3 months after triple arthrodesis with bony union.
Anteroposterior and lateral radiographs of lower extremity in patient with pes planus (flatfoot). Images demonstrate stage 4 posterior tibial tendon (PTT) dysfunction with valgus tilt at ankle.
Pes planus (flatfoot). Too-many-toes sign. Three lateral toes are visible on symptomatic left foot, compared with only two toes on right foot (black arrow). Medial midfoot is prominent and swollen (yellow arrow).
Pes planus (flatfoot). Single-limb heel-rise test. Patient with posterior tibial tendon (PTT) dysfunction is unable to rise up on toes because of inability to invert hindfoot.
Pes planus (flatfoot). Fixed forefoot varus is characterized by elevation of medial side of forefoot, even after heel is placed in neutral position.
Pes planus (flatfoot). Standing lateral radiograph of foot of patient with posterior tibial tendon (PTT) dysfunction. A = lateral first talometatarsal angle (normal value, 0°). B = calcaneal pitch (normal value, 20-25°). C = Distance from medial cuneiform to floor (normal value varies with foot size). As deformity increases secondary to PTT dysfunction, talus plantarflexes and medial border of foot is lowered. Therefore, lateral first talometatarsal angle decreases, calcaneal pitch decreases, and medial cuneiform is depressed closer to floor.
Pes planus (flatfoot). Standing anteroposterior radiograph of patient with posterior tibial tendon dysfunction shows talonavicular coverage angle; navicular axis is formed by perpendicular line connecting medial and lateral aspects of navicular proximal articular surface. Talonavicular coverage angle is formed by talar and navicular axes. As forefoot abduction increases, talonavicular coverage angle increases.
Pes planus (flatfoot). Flexor hallucis longus (FHL) tendon is identified under sustentaculum tali and is pulled proximally. FHL and flexor digitorum longus (FDL) tendons then are sutured to each other with 2-0 nonabsorbable suture prior to division of FHL tendon.
Pes planus (flatfoot). Flexor hallucis longus (FHL) tendon is rerouted anterior to posterior tibial tendon (PTT) and sutured to navicular tuberosity with suture anchor. Multiple No. 2 nonabsorbable sutures also are used to suture FHL tendon to PTT stump and navicular tuberosity periosteum.
Pes planus (flatfoot). Incision for calcaneal osteotomy is made posterior to peroneal tendon sheath and sural nerve. Incision is made at 45° angle to plantar aspect of foot.
Pes planus (flatfoot). Calcaneal osteotomy is distracted with laminar spreader to spread medial soft tissues. This permits easy medial displacement of calcaneal tuberosity.
Pes planus (flatfoot). Lateral radiograph of fixated calcaneal osteotomy. After tuberosity is displaced medially 1 cm, two screws are inserted perpendicular to osteotomy site under fluoroscopic control.
Pes planus (flatfoot). Intraoperative axial view of fixated calcaneus documents satisfactory medial translation of tuberosity and satisfactory screw position.
Pes planus (flatfoot). Preoperative anteroposterior view of foot prior to lateral-column lengthening (LCL). Note forefoot abduction and increased talonavicular coverage angle.
Pes planus (flatfoot). Distraction arthrodesis of calcaneocuboid joint with tricortical iliac crest graft results in lengthening of lateral column. Osteotomy is fixated with laterally placed cervical plate. Note correction of forefoot abduction and correction of talonavicular coverage angle.
Pes planus (flatfoot). Outline of extended Z-cut osteotomy.
Pes planus (flatfoot). Axial model of extended Z-cut osteotomy demonstrating medialization of calcaneal tuberosity and lengthening of lateral column simultaneously through rotation of horizontal osteotomy arm.
Pes planus (flatfoot). Preoperative lateral radiograph of stage 2B adult-acquired flatfoot deformity (AAFD) prior to reconstruction with extended Z-cut osteotomy.
Pes planus (flatfoot). Preoperative anteroposterior radiograph of stage 2B adult-acquired flatfoot deformity (AAFD) prior to reconstruction with extended Z-cut osteotomy.
Pes planus (flatfoot). Postoperative lateral radiograph of stage 2B adult-acquired flatfoot deformity (AAFD) after reconstruction with extended Z-cut osteotomy displaying restored radiographic parameters and osteotomy union.
Pes planus (flatfoot). Postoperative anteroposterior radiograph of stage 2B adult-acquired flatfoot deformity (AAFD) after reconstruction with extended Z-cut osteotomy displaying restored radiographic parameters.

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Author

Gregory C Berlet, MD, FRCSC, FAOAO Partner, Orthopedic Foot and Ankle Center

Gregory C Berlet, MD, FRCSC, FAOAO is a member of the following medical societies: American Medical Association, American Orthopaedic Foot and Ankle Society, Canadian Medical Association, Canadian Orthopaedic Association, College of Physicians and Surgeons of Ontario, Ontario Medical Association, Royal College of Physicians and Surgeons of Canada

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Wright Medical Technology; DJO Global; Stryker; Tissue Tech; ZimmerBiomet<br/>Serve(d) as a speaker or a member of a speakers bureau for: Wright Medical Technology; Artelon, <br/> Received royalty from Wright Medical; ZimmerBiomet; Stryker; .

Coauthor(s)

M Pierce Ebaugh, DO, MS Resident Physician, Department of Orthopedic Surgery, Doctor's Hospital, Grant Medical Center, OhioHealth, Ohio University College of Osteopathic Medicine

M Pierce Ebaugh, DO, MS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Foot and Ankle Society, American Osteopathic Academy of Orthopedics, American Osteopathic Association, AO Foundation, Florida Osteopathic Medical Association, Orthopaedic Trauma Association, Sigma Sigma Phi Osteopathic Honor Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Vinod K Panchbhavi, MD, FACS, FAOA, FABOS, FAAOS Professor of Orthopedic Surgery, Chief, Division of Foot and Ankle Surgery, Director, Foot and Ankle Fellowship Program, Department of Orthopedic Surgery, University of Texas Medical Branch School of Medicine

Vinod K Panchbhavi, MD, FACS, FAOA, FABOS, FAAOS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Orthopaedic Trauma Association, Texas Orthopaedic Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Styker.

Additional Contributors

R Todd Hockenbury, MD Orthopedic Surgeon, KentuckyOne Health Orthopedic Associates

R Todd Hockenbury, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Foot and Ankle Society, Kentucky Medical Association

Disclosure: Nothing to disclose.

James K DeOrio, MD Professor of Orthopedics, Director, Duke Foot and Ankle Fellowship, Duke University Medical Center, Duke University School of Medicine; Associate Professor, Mayo Clinic College of Medicine; Clinical Assistant Professor, F Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences

James K DeOrio, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Foot and Ankle Society, Association of Graduates, United States Air Force Academy, Doctors Mayo Society, Mayo Clinic Alumni Association, Society of Air Force Clinical Surgeons, Society of Military Orthopaedic Surgeons

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Exactech; Treace Medical; Additive; Mirus; Crossroads Orthopedics<br/>Serve(d) as a speaker or a member of a speakers bureau for: Exactech; Treace Medical; Additive; Mirus; WoultersKluwer; Crossroads Orthopedics<br/>Received income in an amount equal to or greater than $250 from: Exactech; Treace Medical; Additive; Mirus; WoultersKluwer; Crossroads Orthopedics.

Abdi Raissi, MD Staff Physician, Desert Orthopaedic Center

Disclosure: Nothing to disclose.

Matthew Buchanan, MD Attending Surgeon, Orthopedic Foot and Ankle Surgery, Orthopaedic Foot and Ankle Center of Washington, DC

Matthew Buchanan, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Foot and Ankle Society

Disclosure: Nothing to disclose.

Acknowledgements

Thomas H Lee, MD, is gratefully acknowledged for the contributions made to this topic.