Treatment
Medical Therapy
Management of the posterior tibial tendon (PTT) – deficient foot continues to be controversial. Treatment options take many forms, ranging from conservative management with the use of medication and orthotics to various surgical procedures.38,39
Surgical Therapy
Operative treatment may involve soft-tissue procedures alone, soft-tissue procedures with the addition of an osteotomy, or arthrodesis. Although the classification discussed above (see Staging) is not foolproof, it can be very useful in the discussion of management of adult-acquired flatfoot deformity (AAFD). Regardless of the stage, operative management should only be considered after conservative management is unsuccessful. The surgical procedure chosen should address all the fixed and dynamic deformities for the individual patient.Stage 1
By definition, patients with stage 1 pes planus do not demonstrate clinical deformity and are the group with the highest likelihood of responding to conservative management. If the patient is evaluated in an acute state, he or she can be treated with a short-term trial of immobilization. Casting can be supplemented with a trial of nonsteroidal anti-inflammatory drugs (NSAIDs). Often, the casting trial must be for as long as one month before a significant clinical effect is noted. Once the acute symptoms have diminished, the patient can be given a trial of physical therapy, which would consist of stretching and strengthening, and modalities such as iontophoresis. If the patient's condition does not improve with conservative management or if the patient's symptoms are sufficiently chronic in nature, then consideration can be given to surgical intervention. The exact nature of this intervention, again, is controversial.
Traditionally, stage 1 disease has been addressed with debridement and tenosynovectomy of the diseased PTT. A retrospective review of young athletes with stage 1 disease who were treated with surgical debridement revealed an "excellent likelihood to return to the previous level of athletic activity."40 Debridement should be reserved for patients who show no clinical deformity or weakness.
Stage 2
Many patients with stage I and II AAFD can be effectively treated nonoperatively with orthoses (either a short, articulated ankle-foot orthosis [AFO] or foot orthosis) and structured exercises.41 Alvarez et al studied patients with stage 1 and 2 AAFD (without complete tendon rupture). At the conclusion of the treatment protocol, most patients had "minimal or no pain, could walk on tiptoes, were not limited by walking distance, and could perform a painless SSHR [single-sided heel rise]."
If appropriate conservative treatment fails for patients with stage II disease, surgical management may be considered. The exact surgical procedure chosen for stage II varies widely, and numerous bone and soft-tissue reconstructive surgeries have been described to treat the various presentations of stage II pathology.Intraoperative images in a patient with pes planus. (A) Flexor digitorum longus transfer to the navicular bone. (B) Torn spring ligament.
Surgical management of stage II disease typically involves both a soft-tissue (FDL transfer) and a bony (medializing calcaneal osteotomy) reconstruction (see Image 2).42,43 This procedure has yielded excellent results with minimal complications and a high satisfaction rate.44 The osteotomy (and subsequent medial shift) of the calcaneal tuberosity shifts the moment arm of the gastrocsoleus complex medial to the subtalar axis. (See Image 3 for an axial MRI that demonstrates a calcaneal shift.) This then generates an inversion force that protects the medial soft-tissue reconstruction. The transferred FDL muscle hypertrophies significantly as it compensates for the diseased PTT.45
Axial magnetic resonance image that demonstrates a medial calcaneal shift.
More advanced stage II disease may be associated with medial column instability, severe forefoot abduction, or severe forefoot varus. In this clinical scenario, additional reconstructive techniques include both lateral and medial column bony procedures. The lateral column bony procedures include lateral column lengthening (LCL) through the anterior process of the calcaneus (joint sparing) and calcaneocuboid distraction arthrodesis (non–joint sparing). Lengthening of the lateral column through the anterior process of the calcaneus can be successfully performed with either autografts or allografts.46 Both techniques provide powerful corrective forces through medial and plantar translation of the navicular on the talar head, effectively restoring the longitudinal arch and correcting the forefoot abduction.47
Medial column bony procedures are indicated when residual forefoot varus exists after lengthening of a lateral column.48 Residual forefoot varus prevents the creation of a plantigrade foot and results in symptomatic lateral column overload. To reduce this overload, which is associated with LCL, clinical and biomechanical research has supported the use of medial procedures to redistribute load to the medial column.49,50 Such medial column bony procedures include plantarflexion opening wedge medial cuneiform osteotomies (joint sparing) and plantarflexion arthrodesis of the first tarsometatarsal articulation (non–joint sparing). Alternatively, medial soft-tissue reconstructive techniques have also proven useful for correcting associated forefoot supination deformities. The Cobb procedure involves use of a partial anterior tibial tendon graft that is rerouted through the first cuneiform to the proximal stump of the PTT.51,52
An additional procedure that is designed to correct the pes planovalgus deformity is subtalar arthroereisis.53,54,55 This procedure involves the placement of a plug or screw-type implant in an effort to correct the rotational malalignment of the subtalar joint.56 The long-term outcome of subtalar arthroereisis has been questioned; a significant number of patients develop persistent sinus tarsi pain that requires implant removal.57 The limited research on this procedure in adult patients means that there is insufficient evidence to make a recommendation for or against this procedure.29
Stage 3
In stage 3 disease, conservative management is limited to NSAID treatment and orthotic management with an Arizona Brace (Arizona AFO, Inc, Mesa, Ariz) (see Image 4). These orthotics must be accommodative rather than corrective because of the fixed deformity. Shoe modifications (larger size, rocker sole) are often required. The chances of success in relieving pain despite these measures are relatively low.
The Arizona Brace. Image courtesy of Don Pierson, CO of Arizona AFO, Inc.
Because fixed deformity is often associated with symptomatic arthrosis, an arthrodesis is often required for proper correction of stage 3 disease. The goals of surgery are to relieve pain and to restore proper alignment of the foot. Isolated arthrodesis of the subtalar joint is indicated in patients with subtalar arthrosis or fixed hindfoot alignment with flexible forefoot deformity. Isolated talonavicular arthrodesis is indicated for management of an unstable talonavicular joint in the presence of a flexible subtalar joint in patients older than 50 years.27
On the other hand, a double arthrodesis (fusion of the calcaneocuboid joint and the talonavicular joint without addressing the subtalar joint) is indicated in younger patients. A triple arthrodesis is indicated for cases of a rigid subtalar joint and fixed forefoot varus deformity. Long-term follow-up studies have shown that triple arthrodesis is associated with increased wear in the ankle joint and a higher rate of degenerative ankle arthrosis.58,59
Radiographs of the foot in a patient with pes planus. (A) Preoperative radiograph of a grade 3 posterior tibial tendon dysfunction. (B) Three months after triple arthrodesis with bony union.
To the authors' knowledge, no comparative studies to date have demonstrated a lower rate of adjacent joint arthrosis with the above limited fusions relative to triple arthrodesis. For this reason, triple arthrodesis continues to be the criterion standard for treatment of stage 3 AFDD.60 (See Image 5, which consists of a preoperative radiograph of a stage 3 AFDD and another radiograph 3 months after triple arthrodesis with bony union.)
Stage 4
Stage 4 disease is rare and often requires a pantalar arthrodesis or tibiotalocalcaneal arthrodesis.61 Conservative management is similar to that for stage 3 disease and often utilizes accommodative braces that immobilize the ankle as well as the foot.
Anteroposterior and lateral radiographs of the lower extremity in a patient with pes planus. These images demonstrate grade 4 posterior tibial tendon dysfunction with valgus tilt at the ankle.
Tibiotalocalcaneal arthrodesis involves fusion of the ankle joint and the subtalar joint. Pantalar arthrodesis involves fusion of the ankle and the subtalar, talonavicular, calcaneocuboid, and tibiotalar joints. These surgeries are technically demanding in nature and are considered salvage procedures. (See Image 6 for AP and lateral radiographs of a stage 4 PTT dysfunction with valgus tilt at the ankle.)62
Complications
Although some complications that are associated with adult-acquired flatfoot deformity (AAFD) treatment may be related to poor surgical planning and improper choice of procedure, others may be inherently related to the procedure itself. For example, a flatfoot deformity that is secondary to an arthritic Lisfranc joint may be wrongly diagnosed as a posterior tibial tendon (PTT) – deficient foot and therefore be treated as such. Other complications may be related to inadequate surgical intervention. For example, in a study by Michelson et al, tenodesis of the flexor digitorum longus (FDL) to the diseased PTT proved to have a 50% failure rate after 2 years.63 Similar long-term failure rates were noted for FDL transfers to the navicular that were performed for stage 2 PTT dysfunctions.64
Bony procedures such as a calcaneal osteotomy and various arthrodeses can also be associated with significant complications. Although nonunion of the calcaneal osteotomy is exceedingly rare, placement of the transosteotomy screw can be associated with postoperative morbidity. Penetration of the subtalar joint or a prominent screw head may cause postoperative symptoms. Risks associated with a triple arthrodesis include nonunion—in some cases in excess of 20%—and also malposition, both in hindfoot alignment and in forefoot rotation.64 Longer term complications involve arthrosis of adjacent joints.
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Further Reading
Clinical guidelines:
Diagnosis and treatment of adult flatfoot. American College of Foot and Ankle Surgeons - Medical Specialty Society. 2005 Mar/Apr. 36 pages. NGC:004194
Diagnosis and treatment of pediatric flatfoot. American College of Foot and Ankle Surgeons - Medical Specialty Society. 2004 Nov/Dec. 33 pages. NGC:004086
Clinical studies:
The Development of Flat Foot After Ankle Fractures
Exercise and Shoe Orthoses in Treatment of Posterior Tibial Tendon Dysfunction
Keywords
pes planus, acquired flatfoot, adult-acquired flatfoot deformity, AAFD, progressive flatfoot deformity, posterior tibial tendon dysfunction, PTTD, posterior tibial tendon insufficiency, PTTI, fallen arches, posterior tibial tendon, PTT, talipes planus, flat foot, flatfoot, splayfoot, pes planovalgus, spring ligament complex, spring-ligament complex, too many toes sign, too-many-toes sign, plantar fasciitis, cri-du-chat, plantar heel pain
