the adult acquired flatfootrichiebrace.com.au/pdf/adult acquired flatfoot.pdf · summary of the...

The Adult Acquired Flatfoot

PATHOMECHANICSPATHOMECHANICS

CLINICAL EVALUATIONCLINICAL EVALUATION

TREATMENT GUIDELINESTREATMENT GUIDELINES

Douglas H. Richie Jr. D.P.M.

Associate Clinical Professor, Dept. Of Applied Biomechanics,

California School of Podiatric Medicine

Fellow, American Academy of Podiatric Sports Medicine

E-MAIL: [email protected]

OBJECTIVES

Review current understanding of the pathomechanics of AAF

Present an updated classification of AAF

Review studies of conservative care of AAF

Propose protocol for ankle foot orthotic (AFO) therapy for AAF

Loss of the dynamic and static supportive structures of the arch hindfoot and ankle

Loss of the dynamic and static supportive structures of the arch hindfoot and ankle

PathomechamicsPathomechamicsAdult Acquired FlatfootAdult Acquired Flatfoot

Dynamic supporting structures of the archDynamic supporting structures of the arch

PLANTAR APONEUROSISPLANTAR APONEUROSIS

POSTERIOR TIBIAL TENDONPOSTERIOR TIBIAL TENDON

PLANTAR INTRINSIC MUSCULATUREPLANTAR INTRINSIC MUSCULATURE

Static supportive structures of the archStatic supportive structures of the arch

SPRING LIGAMENT COMPLEXSPRING LIGAMENT COMPLEX

SUPERFICIAL DELTOID LIGAMENTSUPERFICIAL DELTOID LIGAMENT

LONG AND SHORT PLANTAR LIGAMENTSLONG AND SHORT PLANTAR LIGAMENTS

PLANTAR APONEUROSISPLANTAR APONEUROSIS

Adult Acquired FlatfootAdult Acquired Flatfoot Bracing the Adult Acquired FlatfootBracing the Adult Acquired Flatfoot

RECENT INSIGHTSRECENT INSIGHTS

Not solely due to TPD

Isolated loss of the PT tendon without ligementous disruption will not lead to

a progressive flatfoot deformity.

Isolated loss of the PT tendon without ligementous disruption will not lead to

a progressive flatfoot deformity.

Adult Acquired FlatfootAdult Acquired FlatfootThe adult acquired flatfoot deformity cannot be reproduced experimentally by releasing the tibialis posterior tendon alone.

Deland, J.T., Arnoczky, S.P., Thompson, F.M. Adult acquired flatfoot

deformity at the talonavicular joint: Reconstruction of the spring ligament in

an in vitro model. Foot and Ankle 13: 327, 1992

Deland, Deland, J.TJ.T., ., ArnoczkyArnoczky, , S.PS.P., Thompson, ., Thompson, F.MF.M. Adult acquired flatfoot . Adult acquired flatfoot

deformity at the deformity at the talonaviculartalonavicular joint: Reconstruction of the spring ligament in joint: Reconstruction of the spring ligament in

an in vitro model. Foot and Ankle 13: 327, 1992an in vitro model. Foot and Ankle 13: 327, 1992

Ligament Attenuation in FlatfootLigament Attenuation in Flatfoot

Spring Ligament Complex

Plantar Aponeurosis

Deltoid

Talo-Calcaneal

Long & Short Plantar

Medial Calcaneo-Cuboid

Deland, 1992Deland, 1992

Chu IN, Myerson MS, Nyska M, Parks BG: Experimental Flatfoot

Model: The Contribution of Dynamic Loading. Foot Ankle Int.

22:220, 2001.

Chu IN, Myerson MS, Chu IN, Myerson MS, NyskaNyska M, M, Parks BG: Experimental Flatfoot Parks BG: Experimental Flatfoot

Model: The Contribution of Model: The Contribution of Dynamic Loading. Foot Ankle Int. Dynamic Loading. Foot Ankle Int.

22:220, 2001.22:220, 2001.

Chu IN, Myerson MS, Nyska M, Parks BG: Experimental Flatfoot

Model: The Contribution of Dynamic Loading. Foot Ankle Int. 22:220, 2001.

Chu IN, Myerson MS, Chu IN, Myerson MS, NyskaNyska M, Parks BG: Experimental Flatfoot M, Parks BG: Experimental Flatfoot

Model: The Contribution of Dynamic Loading. Foot Ankle Int. Model: The Contribution of Dynamic Loading. Foot Ankle Int. 22:220, 2001.22:220, 2001.

“In conclusion, we have shown that, to create flattening of the plantar arch, there is a need to cut the medial structures, including the spring and plantar ligaments and possibly the plantar fascia.”

“In conclusion, we have shown that, to create flattening of the plantar arch, there is a need to cut the medial structures, including the spring and plantar ligaments and possibly the plantar fascia.”

� Eight Lower Leg Specimens

� All tendons vs all minus PTT

� Create AAF: cutting spring lig.

� Restore PTT to AAF model

Niki: H.N., Ching R.P., Kiser P., Sangeorzan B.J. “The Effect of Posterior TibialTendon Dysfunction on Hindfoot Kinematics.” Foot and Ankle 22:292-300, 2001

NikiNiki: : H.NH.N., ., ChingChing R.PR.P., Kiser P., ., Kiser P., SangeorzanSangeorzan B.JB.J. . ““The Effect of Posterior The Effect of Posterior TibialTibialTendon Dysfunction on Tendon Dysfunction on HindfootHindfoot Kinematics.Kinematics.”” Foot and Ankle 22:292Foot and Ankle 22:292--300, 2001300, 2001

Tendon vs LigamentTendon vs Ligament

� Intact osteo-ligamentous structures can maintain alignment after initial loss of PTT

� With creation of a flatfoot (cut lig.) restoring PTT function could not significantly improve alignment

� PTT had greatest influence on hindfoot kinematics during heel rise

� “Bracing should provide support during heel rise.”

� Intact osteo-ligamentous structures can maintain alignment after initial loss of PTT

� With creation of a flatfoot (cut lig.) restoring PTT function could not significantly improve alignment

� PTT had greatest influence on hindfoot kinematics during heel rise

� “Bracing should provide support during heel rise.”

Niki: H.N., Ching R.P., Kiser P., Sangeorzan B.J. “The Effect of Posterior

Tibial Tendon Dysfunction on Hindfoot Kinematics.” Foot and Ankle

22:292-300, 2001

NikiNiki: : H.NH.N., ., ChingChing R.PR.P., Kiser P., ., Kiser P., SangeorzanSangeorzan B.JB.J. . ““The Effect of Posterior The Effect of Posterior

TibialTibial Tendon Dysfunction on Tendon Dysfunction on HindfootHindfoot Kinematics.Kinematics.”” Foot and Ankle Foot and Ankle

22:29222:292--300, 2001300, 2001

“In this study, strain in the deltoid ligament was shown to increase significantly during the heel rise portion of the joint cycle after a properly positioned triple arthrodesis was performed. This finding is supported by the fact that the posterior tibial tendon has been shown to be most active during early heel rise.”

“In this study, strain in the deltoid ligament was shown to increase significantly during the heel rise portion of the joint cycle after a properly positioned triple arthrodesis was performed. This finding is supported by the fact that the posterior tibial tendon has been shown to be most active during early heel rise.”

Song SJ, Lee S, O’Malley MJ et al: Deltoid ligament strain after correction of acquired flatfoot deformity by triple arthrodesis. Foot Ankle Int 21: 573-577 2000

Song SJ, Lee S, O’Malley MJ et al: Deltoid ligament strain after correction of acquired flatfoot deformity by triple arthrodesis. Foot Ankle Int 21: 573-577 2000

Loading ResponseLoading Response

(0(0--20%)20%)

MidstanceMidstance

(20(20--60%)60%)

Terminal StanceTerminal Stance

(60(60--100%100%

Perry, 1992

eccentric concentric

What part of gait cycle is PT and ligament function most critical?

What part of gait cycle is PT and ligament function most critical?

Pathomechanics of the Adult Acquired Flatfoot:

Summary of the Literature

1. Pre-existing flatfoot

2. Increased gliding resistance of the Posterior Tibial Tendon

3. Everted Hindfoot unlocks midtarsal joint during mid-stance, terminalstance and heel rise

4. Increased strain on supportive ligaments and tibialis posterior

5. Attenuation and rupture of posterior tibial tendon

6. Sequential rupture of spring ligament, superficial deltoid,and interosseous talo-calcaneal ligaments.

Pre-existing Flatfoot as a Cause of PTTD

Dyal, CM; Feder, J; Deland, JT; Thompson, FM: Pes planus in

patients with posterior tibial tendon insufficiency: Asymptomatic

versus symptomatic foot. Foot Ankle Int. 18:85 – 88, 1997.

Jahss, MH: Spontaneous rupture of the tibialis posterior tendon:

Clinical findings, roentgenographic studies, and a new technique of

repair. Foot Ankle 3:158 – 166, 1982.

Mann, RA; Thompson, FF: Rupture of the posterior tibial tendon

causing flat foot: Surgical treatment. J. Bone Joint Surg. 67-A:556 –

561, 1985.

Causative FactorsCausative Factors

Holmes & Mann, 1992Holmes & Mann, 1992

67 pts. - 76% women, 57 years

Obesity in 33% (p= .005)HTN in 34% (p= .025)

52% had either DM, HTN or obesity

Tendon of Tibialis PosteriorTendon of Tibialis Posterior

1. Zone of hypovascularity

from tip of malleolus:

14 mm prox 10 mm distal

2. Abrupt change of direction

3. 1st Pulley: Malleolar groove

2nd Pulley: Navicular

Frey, JBJS 72A: 884, 1990Frey, JBJS 72A: 884, 1990

TP TendonTP Tendon

• No mesotendon distally

• blood supply : PT & DP art.

• Hypovascular zone begins40mm prox. to navicular, extends14mm prox.

VascularityVascularity

Marcelo Pires Prado, Antonio Egydio de Carvalho Jr, Consuelo Junqueira Rodrigues, T´ulio Diniz Fernandes, Alberto Abussamra Morreira Mendes, Osny Salomao. Vascular Density of the Posterior Tibial Tendon: A Cadaver Study. Foot & Ankle International/Vol. 27, No. 8/August 2006

ABSTRACTBackground: Degenerative pathology of the posterior tibial tendon, a common cause of foot and ankle dysfunction, frequently affects women over 40 years of age. Its etiology is still controversial. The literature reports decreased vascularizationcoinciding with the most common site of the lesion, near the medial malleolus. Methods: Forty pairs of PTT obtained from human cadavers were transversally cut into six levels, from the musculotendon transition to its insertion point. In each segment, a histologic cut was made and stained with Masson’s trichrome allowing viewing of the vascular structure of the tendon under a light microscope. By using an integrating eyepiece on the microscope, vascular density was calculated. This verified any variation of the vascular concentration in the normal tendon, a possible cause of its degeneration. Results: When the results were compared by side, sex, and age, no statistically significant difference was observed. When the levels were compared, no area of decreased vascularization was seen in the midportion of the tendons, the most common site of degeneration of the posterior tibial tendon. Conclusion: These results indicate that an area of decreased vascularity is not a factor in degeneration of the posterior tibial tendon at the medial malleolus.

Eiichi Uchiyama, Harold B. Kitaoka, Tadashi Fujii, Zong-Ping Luo, Toshimitsu Momose, et al. Gliding Resistance of the Posterior Tibial Tendon. Foot & Ankle International/Vol. 27, No. 9/September 2006.

Methods:An experimental system was developed that allowed direct measurement of gliding resistance at

the tendon-sheath interface. Seven normal fresh-frozen cadaver foot specimens were studied,

and gliding resistance between the posterior tibial tendon and sheath was measured. The effects

of ankle and hindfoot position and the effect of flatfoot deformity on gliding resistance were

analyzed. Gliding resistance was measured for 4.9 N applied load to the tendon. Results: Mean

gliding resistance for the neutral position was 77 ± 13.1 (×10−2 N). Compared to neutral

position, dorsiflexion increased gliding resistance and averaged 130 ± 38.9 (×10−2 N), and

plantarflexion decreased gliding resistance and averaged 35 ± 12.6 (×10−2 N). Flatfoot

deformity increased gliding resistance compared to normal feet, averaging 104 ± 17.0 (×10−2N)

for neutral, 205 ± 55.0 (×10−2 N) for dorsiflexion, and 58 ± 21.3 (×10−2N) for plantarflexion.

Conclusions: The findings indicate that patients with a preexisting flatfoot deformity may be

predisposed to develop posterior tibial tendon dysfunction because of increased gliding

resistance and trauma to the tendon surface.

Eiichi Uchiyama, Harold B. Kitaoka, Tadashi Fujii, Zong-Ping Luo, Toshimitsu Momose, et al. Gliding Resistance of the Posterior Tibial Tendon. Foot & Ankle International/Vol. 27, No. 9/September 2006.

“The increased gliding resistance measured for the flatfoot

suggested that for patients with PTTD who begin to develop

a flatfoot deformity, there is additional resistance about the

tendon that accelerates tendon degeneration and

dysfunction. These findings also suggested that a patient

with longstanding flexible flatfoot may be predisposed to

PTTD.”

Eiichi Uchiyama, Harold B. Kitaoka, Tadashi Fujii, Zong-Ping Luo, Toshimitsu Momose,

et al. Gliding Resistance of the Posterior Tibial Tendon. Foot & Ankle International/Vol. 27, No. 9/September 2006.

“It is likely that the increased gliding resistance is related to the

anatomical course of the posterior tibial tendon as it turns sharply

around the medial malleolus towards its medial and plantar foot

insertion. From an anatomical and mechanical point of view the

posterior tibial tendon closely approximates the bony surface of the

medial malleolus rather than that of a tendon sheath. The tendon curves

more acutely than the adjacent tendons in the medial aspect of the ankle,

the flexor digitorum longus and flexor hallucis longus. The posterior

tibial tendon is, therefore, under considerable tension in the area

posterior and distal to the medial malleolus, especially during the

dorsiflexed position and with flatfoot deformity.”

Pathophysiology of Adult Acquired Flatfoot:

Gliding Resistance of the Posterior Tibial

Tendon and Pre-Existing Flatfoot Deformity

Tadashi Fujii, MD; Eiichi Uchiyama, MD; Harold B. Kitaoka, MD; Zong-Ping Luo, PhD; Kristin D. Zhao,

MA; Kai-Nan An, PhD . The Influence of Flatfoot Deformity on the Gliding Resistance of Tendons

About the Ankle. Foot & Ankle International/Vol. 30, No. 11/November 2009

Materials and Methods: The gliding abilities of the posterior tibial,

flexor digitorum longus, and flexor hallucis longus tendons at the ankle

hindfoot level were compared, in terms of gliding resistance, with use of

a system that was developed in this laboratory. Six cadaveric specimens

were used and tested in a dorsiflexed position, then in simulated flatfoot

in a dorsiflexed position.

Results:

The gliding resistance was found to be significantly greater

in the simulated flatfoot in dorsiflexion compared to the

dorsiflexed position with an intact arch for the PT, FDL,

and FHL tendons. The gliding resistance was significantly

higher in the PT tendon than FDL or FHL tendons in the

flatfoot/dorsiflexion condition.

There was no significant difference between the FDL and

FHL tendons in resistance in either condition.

Conclusion: We concluded that the gliding ability of the PT tendon was

inferior to that of the FDL and FHL tendons in a simulated flatfoot model.

Clinical Relevance: The findings of the present study are

consistent with the clinical observations that tendinitis and

rupture of the PT tendon commonly occurs at the malleolar

level, whereas FDL and FHL ruptures do not. A pre-existing

flexible flatfoot deformity may be associated with PT tendon

dysfunction in the adult due to poor gliding ability of the PT

tendon.

Tibialis Posterior TendonTibialis Posterior TendonInsertionsInsertions

Anterior - Navicular tuberosityN-C joint capsule1st cuneiform

Middle - 2nd cuneiform3rd cuneiformcuboid, PL tendon2nd, 3rd, 4th, 5th mets

Posterior- Sustentaculum Tali

“the present study, however, reveals that the tibialis posterior muscle in man has a multi pennate origin from the fibula, and that the fibular sided fibers of the muscle are very numerous but very short. On this account, the fibular-sided fibers of the muscle are more powerful than the tibial”

Morimoto, I. Notes on architecture of tibialis posterior muscle in

man. Acta Anat Nippon 58:74-80, 1983

Morimoto, I. Notes on architecture of tibialis posterior muscle in

man. Acta Anat Nippon 58:74-80, 1983

“Between these two unequal levers (unequal in bulk, length and strength) lies the talus. When the foot is dorsiflexed at the ankle, the talus becomes firmly lodged in the tibiofibular socket and serves as part of the proximal lever or the leg”

“Between these two unequal levers (unequal in bulk, length and strength) lies the talus. When the foot is dorsiflexed at the ankle, the talus becomes firmly lodged in the tibiofibular socket and serves as part of the proximal lever or the leg”

Kelikian, 1985Kelikian, 1985

Two Lever TheoryTwo Lever Theory

Internal rotation of tibia =Internal rotation of tibia =

Internal rotation of talusInternal rotation of talus

Transverse PlaneTransverse PlaneAdolph S. Flemister, Christopher G. Neville, Jeff Houck. The Relationship BetweenAnkle, Hindfoot, and Forefoot Position and Posterior Tibial Muscle Excursion. Foot & Ankle International/Vol. 28, No. 4/April 2007.

“Unique to this study, the change in PT muscle

excursion associated with forefoot positions

suggested a large moment arm of the forefoot around

an abduction and adduction joint axis. The range of

movement in forefoot abduction and adduction was

approximately 20 degrees.”

Silver RL, Garza J: The myth of muscle balance JBJS

673:432, 1985


673:432, 1985

POWER AND EXCURSIONPOWER AND EXCURSION

5 cadaver specimens

Lower leg muscle dissection

Length and weight measurement

Fig. 4. Graph depicts fibre length (excursion) vs. percentage strength. Muscles in the same region of the graph have similar

strength and excursion characteristics.



Kinematic Studies of PTTD Subjects

NessME; Long J; Marks R; Harris GF: Foot and Ankle Kinematics in Subjects with Posterior

Tibial Tendon Dysfunction. Gait & Posture 27: 331 – 339, 2008. http://dx.doi.org/10.1016/j.gaitpost.2007.04.014

Rattanaprasert U; Smith R; Sullivan M; Gilleard W: Threedimensional kinematics of the forefoot, rearfoot, and leg without the function of tibialis posterior in comparison with normal during stance phase of walking. Clin Biomech. 14: 14 – 23, 1999.

Ringleb SI; Kavros SJ; Kotajarvi BR, et al.: Changes in gait associated with acute stage II posterior tibial tendon dysfunction. Gait & Posture. 25: 555 – 64, 2007. http://dx.doi.org/10.1016/j.gaitpost.2006.

Tome J; Flemister S; Nawoczenski D; Houck J: Comparison of Foot Kinematics Between Subjects with Posterior Tibial Tendon Dysfunction and Healthy Controls. Journal of Orthopaedic & Sports Physical Therapy. 36: 635 – 644, 2006.

Jeff R. Houck, PhD, PT; Christopher G. Neville, PT, PhD; Josh Tome, MS; Adolph S. Flemister, MD Ankle and Foot Kinematics Associated with Stage II PTTD During Stance. Foot & Ankle International/Vol. 30, No. 6/June 2009.

Healthy vs. PTD Walking KinematicsHealthy vs. PTD Walking Kinematics

• PTD:

– Rearfoot (RF relative to Leg):

• SP:

– ↓ plantar flexion at terminal stance.

• FP:

– no difference in rearfoot eversion/inversion.

• TP:

– ↑ abduction at terminal stance.

Rattanaprasert et al., 1999

Healthy vs. PTD Walking KinematicsHealthy vs. PTD Walking Kinematics

• PTD:– Forefoot (FF relative to RF):

• SP: – ↓ dorsiflexion in early stance, and

– marked ↑ in mid-late stance phase.

• FR: – marked ↑ in eversion velocity from heel strike to 20% stance.

• TP: – marked ↑ in FF abduction in terminal stance.

Rattanaprasert et al., 1999

Locking Mechanism of the Midtarsal Joint

Blackwood CB; Yuen TJ; Sangeorzan BJ; Ledoux WR:

The midtarsal joint locking mechanism. Foot Ankle Int. 26:

1074 – 80, 2005.

Leardini A; Benedetti MG; Berti L, et al.: Rear-foot, mid-

foot and fore-foot motion during the stance phase of gait.

Gait & Posture 25: 453 – 62, 2007.

MacWilliams BA; Cowley M; Nicholson DE: Foot

kinematics and kinetics during adolescent gait. Gait &

Posture 17: 214 – 24, 2003. BB

BB

Altered Sagittal Plane Motion in PTTD Patients

Excessive plantarflexion of the hindfoot (at the ankle) contributes to

arch lowering and First Ray dorsiflexion at midstance.

Jeff R. Houck, PhD, PT; Christopher G. Neville, PT, PhD; Josh Tome, MS; Adolph S.

Flemister, MD Ankle and Foot Kinematics Associated with Stage II PTTD During Stance. Foot & Ankle International/Vol. 30, No. 6/June 2009.

Unlocking the MTJ and increasing Foot Flexibility

Patients with PTTD display greater relative HF eversion

and FF dorsiflexion than controls across the stance phase of

gait, suggesting even greater foot flexibility. These abnormal

foot kinematics increase the length of the PT muscle and

reliance of the foot on ligaments for support during push

off.

Flemister AS; Neville CG; Houck J: The relationship between ankle, hindfoot, and

forefoot position and posterior tibial muscle excursion. Foot Ankle Int. 28: 448 – 55,

2007.

Neville C; Flemister A; Tome J; Houck J: Comparison of changes in posterior tibialis

muscle length between subjects with posterior tibial tendon dysfunction and healthy

controls during walking. Journal of Orthopaedic & Sports Physical Therapy 37: 661

– 9, 2007.

Adult Acquired Flatfoot Adult Acquired Flatfoot Stage II Disease: Critical ChangesStage II Disease: Critical Changes

- Progressive ligament rupture

- Loss of movement transfer

- Progressive ligament rupture

- Loss of movement transfer

Spring LigamentSpring Ligament

Interosseus Talocalcaneal LigamentInterosseus Talocalcaneal Ligament

SuperficialDeltoid Ligament(Tibiocalcaneal)

SuperficialDeltoid Ligament(Tibiocalcaneal)

Jonathan T. Deland, M.D.1; Richard J. de Asla, M.D.2; Il -Hoon Sung, M.D.3; Lauren A. Ernberg, M.D.1; Hollis G. Potter, M.D. Posterior Tibial Tendon Insufficiency: Which Ligaments are Involved? Foot & Ankle International/Vol. 26, No. 6/June 2005

Background: The purpose of this observational study was to

identify the pattern of ligament involvement using

standardized, high-resolution magnetic resonance imaging

(MRI) in a series of 31 consecutive patients diagnosed with

PTTI compared to an age matched control group without

PTTI.


Results: Statistically significant differences in frequency of pathology in the

PTTI group and controls were found for the superomedial calcaneonavicular

ligament (p < 0.0001), inferomedial calcaneonavicular ligament (p < 0.0001),

interosseous ligament (p = 0.0009), anterior component of the superficial deltoid (p

< 0.0001), plantar metatarsal ligaments (p = 0.0002) and plantar naviculocuneiform

ligament (p = 0.0006).

The ligaments with the most severe involvement were the spring ligament complex

(superomedial and inferomedial calcaneonavicular ligaments) and the talocalcaneal

interosseous ligament.

Conclusion: Ligament involvement is extensive in PTTI, and the spring

ligamentcomplex is the most frequently affected. Because ligament pathology in

PTTI is nearly as common as posterior tibial tendinopathy, treatment should seek

to protect or prevent progressive failure of these ligaments.


“All patients in the PTTI group had some degree

of MRI abnormality of the superomedial

calcaneonavicular ligament. MRI evidence of

pathology in this component of the spring

ligament complex was nearly as severe as that in

the posterior tibialtendon.”

Adult Acquired Flatfoot Adult Acquired Flatfoot Ligament Insufficiency:

Why does it matter?

Stages of TPDStages of TPDfrom Johnson & Strom, Modified by Myerson et al.

STAGE PATHOLOGY CLINICAL SIGNS REARFOOTSTAGE PATHOLOGY CLINICAL SIGNS REARFOOT

I.

II.

III.

IV.

Tenosynovitis Swelling, Tenderness Flexible

Attenuation or

Rupture

Archcollapse,FF abduction, too many toes can or cannot heelrise

Complete

Rupture

Lateral foot painincreased heel valguscannot heel rise

Flexible

Rigid

RigidValgus talo

crural jt.DJD of RearfootFibular Mall. Fx.

Newer Classification System for the Adult Acquired Flatfoot

Steven L. Haddad, MD; Mark S. Myerson, MD; Alastair Younger, MD; Robert B. Anderson,

MD; W. Hodge Davis, MD; Arthur Manoli, II, MD. Adult Acquired Flatfoot Deformity. Foot

& Ankle International/Vol. 32, No. 1/January 2011

Stage I: Tenosynovitis without deformity

In Stage I disease, the tendon is inflamed or partially ruptured, deformity is absent or minimal

and the overall continuity of the tendon is maintained, and is subdivided into three categories:

A. Inflammatory disease. Posterior tibial tendon (PTT) rupture that results from a

systemic disease such as rheumatoid arthritis and the other inflammatory arthritides

is recognized as a separate entity. In Stage IA, hindfoot anatomy is maintained and

the foot alignment is normal.

B. Partial PTT tear with normal hindfoot anatomy.

C. Partial PTT tear with hindfoot valgus. This is a slight deformity to distinguish it

from Stage II disease, and represents an incipient rupture.

AAF: Objective Criteria for Staging?AAF: Objective Criteria for Staging?

Stage II: Ruptured PTT and flexible flatfootStage II disease implies PTT tendon rupture, as evidenced on physical examination by a clinically

apparent flatfoot, weakness with inversion of the plantarflexed foot, and inability to single leg heel

rise. Because some patients exhibit several of the following features, some degree of overlap may

exist.

A. Hindfoot valgus. In Stage IIA, once the heel is reduced from valgus to neutral,

there is a minimal if any residual forefoot supination.

B. Flexible forefoot supination. In Stage IIB, reducing the hindfoot from valgus to

neutral results in forefoot supination, which is however flexible. If the ankle is

plantarflexed to relax the gastrocnemius muscle, the forefoot supination is corrected.

C. Fixed forefoot supination. In Stage IIC, because of long-standing hindfoot valgus,

adaptive changes have occurred in the frontal plane of the forefoot. Thus, although

the hindfoot deformity is supple and reducible to neutral, the forefoot deformity

becomes fixed once the heel is held reduced. In other words, when the ankle is

plantarflexed while the hindfoot is held reduced, the forefoot remains supinated.

Stage II: Ruptured PTT and flexible flatfoot (continued):

D. Forefoot abduction. This may occur at the transverse tarsal joint (most commonly)

or at the first tarsometatarsal (TMT) or naviculocuneiform joint. The first TMT joint

instability can be either a primary deformity or a result of TMT joint arthritis. The

simplest way to determine this distinction is through examination of the lateral foot

X-ray (XR) image for a gap at the plantar joint surface, which is present with

primary deformity. Primary deformity of the first TMT joint may also result in

secondary hindfoot deformity, including rupture of the PTT.

E. Medial ray instability. As in Stage IIC (fixed forefoot supination), the Stage IIE

foot retains forefoot supination with reduction of the valgus heel to neutral. This

persists even with ankle plantarflexion. This is due to instability of the medial column

i.e. at the talon-avicular, naviculocuneiform, or medial cuneiform-first metatarsal

joint, or a combination thereof. This situation is similar to IIA; however, after the

heel is corrected to neutral, the unstable medial ray will tend to dorsiflex, and this

dorsiflexion causes the foot to collapse into pronation and leads to painful subtalar

joint impingement.

Stage III: Rigid hindfoot valgus

Stage III disease is generally associated with a more advanced course of tendon rupture and

deformity and is typically characterized by rigid hindfoot valgus. Forefoot deformity may also be

present, and it usually consists of rigid forefoot abduction or instability at the first TMT joint.

A. Hindfoot valgus.

B. Forefoot abduction and or sagittal plane instability.

Stage IV: Ankle valgusStage IV disease occurs after chronic tendon rupture and is associated with deltoid ligament

rupture and medial ankle instability, leading to ankle (tibiotalar) joint valgus deformity. It often

occurs in the setting of previous triple arthrodesis. Several variants of this condition have been

seen; it may be associated with or without ankle instability and arthritis and a flexible or rigid

hindfoot.

A. Flexible ankle valgus.

B. Rigid ankle valgus. This is the more common presentation of

Stage IV disease.

Stages of TPDStages of TPDfrom Johnson & Strom, Modified by Myerson et al.from Johnson & Strom, Modified by Myerson et al.

STAGE PATHOLOGY CLINICAL SIGNS REARFOOTSTAGE PATHOLOGY CLINICAL SIGNS REARFOOT

I.

II.

III.

IV.

Tenosynovitis Swelling, Tenderness Flexible

Attenuation or

Rupture

Archcollapse,FF abduction, too many toes can or cannot heelrise

Complete

Rupture

Lateral foot painincreased heel valguscannot heel rise

Flexible

Rigid

RigidValgus talo

crural jt.

DJD of RearfootFibular Mall. Fx.

STUDIES OF CONSERVATIVE TREATMENT OF AAF

Chao W; Wapner KL; Lee TH; Adams J; Hecht PJ: Non-operative management of posterior tibial tendon dysfunction. Foot Ankle Int. 17(12): 736 – 41, 1996.Alvarez RG; Marini A; Schmitt C; Saltzman CL: Stage I and II posterior tibial tendon dysfunction treated by a structured non-operative management protocol: an orthosisand exercise program. Foot Ankle Int. 27(1): 2 – 8, 2006.Augustin JF; Lin SS; Berberian WS; Johnson JE: Non-operative treatment of adult acquired flat foot with the Arizona brace. Foot Ankle Clin. 8(3):491 – 502, 2003.Johnny L. Lin, MD; John Balbas, MD; E. Greer Richardson, MD.Results of Non-Surgical Treatment of Stage II Posterior Tibial Tendon Dysfunction: A 7- to 10-Year FollowupFoot & Ankle International/Vol. 29, No.8/August 2008Krause F, Bosshard A, Lehmann O, Weber M. Shell brace for stage II posterior tibialtendon insufficiency. Foot Ankle Int 29 (11): 1095-1100, 2008. Kulig K, Reischl SF, Pomrantz AB, Burnfield JM, Mais-Requejo S, Thordarson DB, Smith RW Nonsurgical management of posterior tibial tendon dysfunction with orthoses and resistive exercise: a randomized controlled trial. PHYS THER.2009; 89: 26-37Nielsen MD, Dodson EE, Shadrick DL, Catanzariti AR, Mendocino RW, Malay DS. Non-operative Care for the Treatment of Adult-acquired Flatfoot Deformity. Jour Foot Ankle Surg 50 (2011)311-314.

Chao W; Wapner KL; Lee TH; Adams J; Hecht PJ: Non-operative management of posterior tibial tendon dysfunction. Foot Ankle Int. 17(12): 736 – 41, 1996.

Chao et al. retrospectively studied the conservative

treatment of stage II and III disease. Stage II disease

was treated with the UCBL type orthotic while Stage

III disease was treated with the molded ankle foot

orthosis (MAFO). Forty-nine patients (53 feet)

participated with a mean follow up of 20.3 months.

Using a clinical scoring system, 69.7% of patients had

excellent/good results. Of these, 12.2% of patients

discontinued use of the brace because of improvement,

while 53.1% continued use of the brace at follow up

Augustin JF; Lin SS; Berberian WS; Johnson JE: Non-operative treatment of adult acquired flat foot with the Arizona brace. Foot Ankle Clin. 8(3):491 – 502, 2003.

Augustin et al. prospectively studied the use of a

short custom-molded AFO (“Arizona brace”) in

treatment of PTTD. Despite a short follow up period

(mean, 12 months), they found significant changes in

AOFAS, FFI, and SF-36 scores. The AOFAS score

increased from 37.7 to 70.7.

The FFI activity, pain, and disability scores improved

to 14.8, 29.3, and 32.3 respectively.

Alvarez RG; Marini A; Schmitt C; Saltzman CL: Stage I and II posterior tibial tendon dysfunction treated by a structured non-operative management protocol: an orthosis and exercise program. Foot Ankle Int. 27(1): 2 – 8, 2006.

The use of a structured exercise program in addition to an

orthosis for treatment of Stage I and II disease was reported.

A short articulated AFO (SAAFO) was used if symptoms were

present for greater than 3 months and a three-quarter-length foot

orthosis used if they were present less than 3 months. The median

treatment period was 129 days with a minimum followup of 1

year.

The average VAS was 1.0 after treatment. 89% were subjectively

satisfied with their treatment while 11% were dissatisfied and

went on to surgery. 8.5% were unable to wean from the SAAFO.

Therefore, 80.5% were successful in avoiding surgery and staying

brace free.

Short articulated posterior opening ankle-foot-orthosis with instep wrap and full length toeplate used in Alvarez study.

Three-quarter length TPE foot orthosis with a high medial and lateral trim

lines used in Alvarez study.

Johnny L. Lin, MD; John Balbas, MD; E. Greer Richardson, MD. Results of Non-Surgical Treatment of Stage II Posterior Tibial Tendon Dysfunction: A 7- to 10-Year Follow up Foot & Ankle International/Vol. 29, No.8/August 2008

Results: Thirty-three feet in 32 patients were included with an average

follow up of 8.6 years. Success defined as being brace-free and avoiding

surgery was 69.7%. Five patients (15.2%) were unable to completely wean

from a brace. Five patients went on to surgery. The mean AOFAS and FFI

score was 78.4 and 18.4, respectively. Compared to national norms, SF-36

sub scores for each age sub-category showed no significant difference in any

of the age groups (p < 0.05). Average VAS pain scale score was 1.9.

Satisfaction was rated as “satisfied” in 20 patients (60.6%), “satisfied with

minor reservations” in 11 patients (33.3%), partially satisfied in one (3.0%),

and “unsatisfied” in one (3.0%). None of the patients rated as “satisfied with

major reservations”.

Conclusion: Treatment of Stage II PTTD with a DUAFO has been

shown to be a viable alternative to surgery with a high likelihood of adequate

function, avoidance of surgery, and being brace-free at 7- to 10-year follow

up.

Johnny L. Lin, MD; John Balbas, MD; E. Greer Richardson, MD. Results of Non-Surgical Treatment of Stage II Posterior Tibial Tendon Dysfunction: A 7- to 10-Year Follow up Foot & Ankle International/Vol. 29, No.8/August 2008

Anterior view of a DUAFO with medial T-strap on a patient’s foot.

Patients able to discontinue brace:Chao 12 %Lin 67 %Alvarez 80%

Augustin AOFAS scores: 37.7 increased to 70.7

Lin AOFAS scores: 42.6 increased to 78.4

Patients able to discontinue brace:Chao 12 %Lin 67 %Alvarez 80%

Augustin AOFAS scores: 37.7 increased to 70.7

Lin AOFAS scores: 42.6 increased to 78.4

SUMMARY OF STUDIES OF AFO BRACING FOR PTTDSUMMARY OF STUDIES OF AFO BRACING FOR PTTD

Matthew D. Nielsen, Erin E. Dodson, Daniel L. Shadrick, Alan R. Catanzariti, DPM, RobertW. Mendicino, DPM, D. Scot Malay. Nonoperative Care for the Treatment of Adult-acquired Flatfoot Deformity. The Journal of Foot & Ankle Surgery 50 (2011) 311–314.

In this article, we describe the results of a retrospective cohort

study that focused on nonoperative measures, including

bracing, physical therapy, and anti-inflammatory medications,

used to treat adult-acquired flatfoot in 64 consecutive patients.

The results revealed the incidence of successful nonsurgical

treatment to be 87.5% (56 of 64 patients), over the 27-

month observation period.

SURGICAL OUTCOME FOR STAGE II PTTD

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. 25(7): 445 – 450, 2004.

The longest surgical outcome study of Stage II PTTD

was reported by Myerson et al. The mean follow up

was 5.2 years after calcaneal osteotomy and FDL

tendon transfer. The mean AOFAS score was 79

points. They also reported satisfaction rates of 91.5%,

pain relief in 97%, function in 94%, and ability to

wear shoes without modification or arch support in

84%.

Van der Krans, A; Louwerens, JWK; 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 Ortho. 77(1): 156 – 63, 2006.

The only use of the FFI for grading surgical

treatment of Stage II PTTD was Van der Krans et al.

They prospectively evaluated 20 patients after lateral

column distraction arthrodesis and FDL transfer

with an average follow up of 2.1 years using the FFI

and AOFAS hindfoot score. The average total

AOFAS and FFI was 79.2 and 22.1, respectively

Final Outcome: Surgery vs Non-Surgical Treatment

Augustin AOFAS score 70.7

Lin AOFAS score 78.4

Krause AOFAS score 82

Myerson* AOFAS score 79

Van der Krans* AOFAS score 79.2

*surgical treatment

SUMMARY

The Adult Acquired Flatfoot is a condition which represents a cascade of soft tissue failures leading to dysfunction of the foot and ankle during ambulation

No surgical intervention has proven to be more successful than conservative treatment of AAF, while complications from both treatment options are far more likely when surgery is performed compared to bracing

Progression of deformity and disability can be monitored by clinical exam and gait analysis

which can be partially supported by imaging studies

Intervention with ankle foot orthoses has become the gold standard of treatment in the United States before surgical intervention should be recommended

The majority of patients with Stage II deformity can be expected to be successfully treated with a combination of ankle bracing (AFO devices) and physical therapy. They can expect to

be free of wearing a brace within 12 months of start of treatment.

THE FLEXOR DIGITORUM LONGUS

TENDON TRANSFER: WHY DO WE DO IT?

Douglas Richie D.P.M. F.A.C.F.A.S

Seal Beach Podiatry Group Inc.

[email protected]

DIAGNOSIS: DIAGNOSIS:

Stage II Posterior Tibial Tendon Dysfunction Stage II Posterior Tibial Tendon Dysfunction

TREATMENT: TREATMENT:

Medial displacement calcaneal osteotomy with

flexor digitorum longus tendon transfer.

Medial displacement calcaneal osteotomy with

flexor digitorum longus tendon transfer.

First papers reporting success with the FDL

transfer as a solitary procedure for PTTD:

Mann, RA: Acquired flatfoot in adults. Clin. Orthop. 181:46 –51, 1983.

Johnson, KA: Tibialis posterior tendon rupture. Clin. Orthop.177:140 –147, 1983.

Johnson, KA; Strom, DE: Tibialis posterior tendon dysfunction. Clin. Orthop. 239:196 –206, 1989.

Studies which refute initial success with the FDL Transfer:

Funk, DA; Cass, JR; Johnson, KA: Acquired adult flat foot secondary to posterior tibial-tendon pathology. J. Bone Joint Surg. 68-A:95 –102, 1986.

Mann, RA; Thompson, FM: Rupture of the posterior tibial tendon causing flat foot. Surgical treatment. J. Bone Joint Surg. 67-A: 556–561, 1985.

“The FDL transfer alone does not consistently correct the valgusmalalignment. In one series it had a 50% failure rate at two years.' As a result, the standard teaching now recommends bony deformity correction in addition to a soft tissue procedure. Even with adequate deformity correction coupled with a standard medial soft tissue reconstruction, the FDL tendon

and resultant inversion force may still be significantly less than that of the normal posterior tibialis. The FDL has been shown to be on average one-half to one third the size of the PTT. This is most likely to be borderline adequate.”

Mlchelson, J., Conti, S., and Jahss, M.: Survivorship analysis of tendon transfer surgery for posterior tibia1 tendon rupture. Orthop. Trans., 16: 30, 1992.

Suzette J. Song, MD; Jonathan T. Deland, MD Outcome Following Addition of Peroneus Brevis Tendon Transfer to Treatment of Acquired Posterior Tibial Tendon Insufficiency Foot & Ankle InternationalNoi. 22, No. 4/April 2000

Sutherland, D.H.: An electromyographic study of the plantar flexors of the ankle in normal walking on the level. J. Bone Joint Surg., 48k66-71, 1966.


673:432, 1985


673:432, 1985

POWER AND EXCURSIONPOWER AND EXCURSION

5 cadaver specimens

Lower leg muscle dissection

Length and weight measurement

Why transfer the FDL ?Hou-en J. Hui, M.S.1; Timothy C. Beals, M.D.2; Nicholas A.T. Brown, Ph.D. Influence of Tendon Transfer Site on Moment Arms of the Flexor Digitorum Longus Muscle. Foot & Ankle International/Vol. 28, No. 4/April 2007

Background: Adult acquired flatfoot is a common condition that leads to significant morbidity.

Along with bony procedures to operatively treat this condition, transfer of the flexor digitorum

longus (FDL) tendon to the medial cuneiform or navicular is routinely performed. The goal of this

tendon transfer is to increase the capacity of the FDL to invert the hindfoot and control the

transverse tarsal joints. However, it is not known whether this biomechanical goal is met or

whether one transfer site produces a larger mechanical advantage compared to another site. The

purpose of this study was to calculate FDL muscle moment arms at the hindfoot with two

clinically relevant transfer locations to quantify the change in mechanical advantage of the FDL

after tendon transfer. Methods: In seven cadaver specimens, muscle moment arms of the FDL with

respect to hindfoot motion were measured using the tendon excursion method before and after the

FDL was transferred to the plantar aspect of the navicular and medial cuneiform. The position

and orientation of the foot and excursion of the FDL tendon were measured with an optoelectronic

measurement system. Results: The FDL moment arm did not increase after tendon transfer to

either the medial cuneiform or navicular when compared to its native site. There were significant

decreases in FDL moment arm when transferred from its native site to the medial cuneiform (56%

decrease, p = 0.018) and navicular (46% decrease, p = 0.026). Conclusions: In contrast to the

clinical proposition that FDL transfer to the navicular or medial cuneiform increases this muscle’s

mechanical advantage to invert the hindfoot, this cadaver study suggests that, to the contrary, FDL

muscle moment arms decrease after tendon transfer.

Hou-en J. Hui, M.S.1; Timothy C. Beals, M.D.2; Nicholas A.T. Brown, Ph.D. Influence of Tendon Transfer Site on Moment Arms of the Flexor Digitorum LongusMuscle. Foot & Ankle International/Vol. 28, No. 4/April 2007

“The FDL is operatively transferred to the plantar aspect of the

medial cuneiform or navicular tuberosity in patients with adult

acquired flatfoot in part to improve the capacity of the FDL to invert

the hindfoot.14,22 In this study, the capacity of the FDL to invert the

hindfoot was measured in terms of its muscle moment arm before

and after tendon transfer. For the two clinically relevant transfer

sites tested, there was no increase in moment arm in comparison to

the native FDL. On the contrary, the native FDL demonstrated a

larger mechanical advantage to invert the hindfoot than did the

transferred FDL, suggesting that given equal muscle force generated

at the two sites, the intact muscle provides a larger moment about

the hindfoot complex before transfer surgery.”


It is widely accepted if not well quantified3 that once transferred, muscles lose a grade in

strength26 and experience other post-transfer adaptations.16 Maximal isometric force can be

estimated by multiplying a muscle’s physiological cross sectional area (PCSA) by its peak

muscle stress (35 Ncm2).36 Using PCSA data from Wickiewicz et al.35 the PT (727N)

produces approximately four times the force of the FDL (177N). Further, assuming that the

loss of one grade of force is 20% of total force, the FDL might produce only 142 N after

transfer. Combining these estimates with average FDL muscle moment arms presented in

Table 2, the maximal capacity of the FDL to generate an inversion moment about the

hindfoot decreases from 3.5 Nm (19.6mm × 177N) to 1.2 Nm (8.7 mm × 142 N) and 1.5 Nm

(10.7 mm × 142 N) once transferred to the medial cuneiform and plantar aspect of the

navicular, respectively. Thus, rather than a 46% to 56% decrease in the FDL capacity to

generate muscle force based on changes in moment arm alone, it is possible that transferring

the FDL tendon to the medial cuneiform or navicular may reduce its capacity to invert or

resist eversion of the hindfoot during gait to 36% of its native

state. Further consideration of the exemplar data presented in Figure 2 suggests that the

results may be even more profound when the hindfoot is everted. This speculation has

further implications for the outcome of FDL tendon transfer surgery, particularly if the foot

remains in a pronated position.”


“Flexor digitorum longus transfer has been an integral part

of the treatment of adult acquired flatfoot for over 20 years.

It is unclear if patient satisfaction with such multifaceted

operative procedures used to treat adult acquired flatfoot is a

direct result of tendon transfer, PT debridement, or the

medial realignment of the limb through osteotomy or fusion.

This biomechanical cadaver study suggests that FDL transfer

does not increase the mechanical advantage and consequently

may not contribute to improved patient outcomes. In

contrast, FDL transfer to either the navicular or the medial

cuneiform may actually decrease its capacity to invert the

hindfoot once transferred from its native state.”


Table 2: FDL moment arm magnitudes in mm at neutral position

for corresponding surgery cases in accordance to specimen Native

Cuneiform Navicular

Specimen 1 18.5 15.1 13.7

Specimen 2 10.9 7.7 9.9

Specimen 3 20.0 17.7 18.1

Specimen 4 25.4 6.4 1.8

Specimen 5 15.6 8.8 9.4

Specimen 6 20.2 1.2 5.3

Specimen 7 26.9 4.2 16.6

Group Mean 19.6 ± 5.5 8.7 ± 5.8 10.7 ± 5.9

Transverse Plane Motion at the Ankle JointTransverse Plane Motion at the Ankle Joint

• In vivo kinematic study, 25 subjects • In vivo kinematic study, 25 subjects

• Static and dynamic conditions • Static and dynamic conditions

• Mean Ankle/STJ ROM: • Mean Ankle/STJ ROM:

27.2˚27.2˚ transverse planetransverse plane

7.6˚7.6˚ frontal planefrontal plane

• Ankle transverse ROM: >15˚• Ankle transverse ROM: >15˚

Nester CJ, Findlow AF, Bowker P. Bouden PD: Transverse Plane Motion at the Ankle Joint. Foot and Ankle Int. 24:164-168, 2003.


“…the ankle and subtalar joints contribute approximately equal amounts of transverse plane motion to the overall function of the ankle/subtalar complex.”

“…the ankle and subtalar joints contribute approximately equal amounts of transverse plane motion to the overall function of the ankle/subtalar complex.”




“The angulation of the ankle/subtalar axis to the transverse plane calculated from the data from the static study was consistently high, ranging from 53.2˚ to 88.9˚, and this reflects the predominance of transverse plane motion at the complex.”

“The angulation of the ankle/subtalar axis to the transverse plane calculated from the data from the static study was consistently high, ranging from 53.2˚ to 88.9˚, and this reflects the predominance of transverse plane motion at the complex.”




the adult acquired flatfootrichiebrace.com.au/pdf/adult acquired flatfoot.pdf · summary of the...

Documents