Diagnosis and Treatment of Adult Flatfoot. Posterior Tibial Tendon Dysfunction. ADULT Acquired Flatfoot.

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Source: Clinical Practice Guideline Adult Flatfoot Panel. Diagnosis and treatment of adult flatfoot. J Foot Ankle Surg 2005 Mar-Apr;44(2):78-113. Diagnosis and Treatment of Adult Flatfoot Posterior Tibial Tendon Dysfunction ADULT Acquired Flatfoot Significant History *Middle Aged Female. *Unilateral Acquired Deformity. *No History of Trauma. Significant Findings and Classification Stage 1 *Medial Rearfoot Pain. *Localized swelling to course of TP. *No positional change in arch. X-Ray *No radiographic angular changes. *No degenerative changes. MRI *Tenosynovitis. Ultrasound *Fluid around tendon. Stage 2A - Early *Medial Rearfoot Pain. *Tendon swelling, warmth, tenderness. *+/- able to perform single heel raise. *Rearfoot valgus; too many toes. X-Ray *Peritalar subluxation. *Increased Talar 1st MT angle. MRI *Tenosynovitis. *Attenuation of tendon. *Tendinosis. Ultrasound *Tenosynovitis. *Attenuation of tendon. *Tendinosis. Stage 2B - Late *Same as 2A - Early. *Positional change in arch; rearfoot valgus. *Lateral pain; sinus tarsi, subfibular tenderness. X-Ray *Peritalar subluxation. *Increased Talar 1st MT angle. *Progressive angular changes on radiographs. MRI *Same as 2A - Early. *TP Rupture. *Early DJD (subchondral edema). Ultrasound *Same as 2A - Early. *Tendon Rupture. Stage 3 *Lateral symptoms predominant. *Fixed non-reducible deformity. *No heel inversion on double heel raise. *Unable to perform single heel raise. X-Ray *Same as 2B - Late. *Degenerative changes in rear foot complex. MRI* *Same as 2B - Late *DJD. Ultrasound* *Same as 2B - Late Stage 4 *Same as Stage 3. *Ankle valgus. X-Ray *Same as Stage 3. *+/- Ankle Valgus. MRI* *Same as Stage 3. Ultrasound* *Same as 2B - Late DIAGNOSIS * These diagnostic tests are not essential to establish the diagnosis Initial Treatment Options *Patient Education. *Orthotic Management. *Immobilization. *Antiinflammatory Medications. *Physical Therapy. *Shoe modifications. Surgical Management may be an Initial Treatment Option in more advanced Stages due to inherent disability. Continue NonSurgical Options SATISFACTORY Clinical Response UNSATISFACTORY Consider Surgical Options (BELOW) Stage 1 Surgical Options *Synovectomy Stage 2A - Early Surgical Options *Synovectomy. *Tendon Transfer. *Osteotomies. *Arthroereisis. *Adjunctive Procedures: -TAL. -Gastroc recession. Stage 2B - Late Surgical Options *Same as Stage 2A. *Isolated Rearfoot Fusions. *Medial Column Fusion. Stage 3 Surgical Options *Same as Stage 2B. *Triple Arthrodesis. Stage 4 Surgical Options *Same as Stage 3. *Pantalar Arthrodesis. *Deltoid Repair. *Total Ankle Replacement. *Supramalleolar Osteotomy. PATHWAY 3 All copyrights are reserved by the American College of Foot and Ankle Surgeons.