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

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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.