A Guide To Conservative Care For Adult-Acquired Flatfoot

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Continuing Education Course #153 — June 2007

I am pleased to introduce the latest article, “A Guide To Conservative Care For Adult-Acquired Flatfoot,” in our CE series. This series, brought to you by the North American Center for Continuing Medical Education (NACCME), consists of complimentary CE activities that qualify for one continuing education contact hour (.1 CEU). Readers will not be required to pay a processing fee for this course.
Adult-acquired flatfoot (AAF) is among the most difficult conditions to treat successfully. Paul R. Scherer, DPM, discusses recent developments in the understanding of AAF, delineates the stages of AAF and reviews appropriate conservative treatments. He offers pearls from his clinical experience and discusses the relevant literature on this subject.
At the end of this article, you’ll find a nine-question exam. Please mark your responses on the enclosed postcard and return it to NACCME. This course will be posted on Podiatry Today’s Web site (www.podiatrytoday.com) roughly one month after the publication date. I hope this CE series contributes to your clinical skills.


Jeff A. Hall
Executive Editor
Podiatry Today

INSTRUCTIONS: Physicians may receive one continuing education contact hour (.1 CEU) by reading the article on pg. 84 and successfully answering the questions on pg. 90. Use the enclosed card provided to submit your answers or log on to www.podiatrytoday.com and respond via fax to (610) 560-0502.
ACCREDITATION: NACCME is approved by the Council on Podiatric Medical Education as a sponsor of continuing education in podiatric medicine.
DESIGNATION: This activity is approved for 1 continuing education contact hour or .1 CEU.
DISCLOSURE POLICY: All faculty participating in Continuing Education programs sponsored by NACCME are expected to disclose to the audience any real or apparent conflicts of interest related to the content of their presentation.
DISCLOSURE STATEMENTS: Dr. Scherer has disclosed that he is the CEO of ProLab Orthotics in Napa, Ca.
GRADING: Answers to the CE exam will be graded by NACCME. Within 60 days, you will be advised that you have passed or failed the exam. A score of 70 percent or above will comprise a passing grade. A certificate will be awarded to participants who successfully complete the exam.
EXPIRATION DATE: June 30, 2008
LEARNING OBJECTIVES: At the conclusion of this activity, participants should be able to:
• review key assessment and diagnostic tools for staging adult-acquired flatfoot (AAF);
• differentiate between the clinical presentations of the different stages of AAF;
• describe conservative treatment options for Stage I AAF;
• discuss the motivation behind the development of ankle-foot orthoses (AFOs) and the casting of the devices;
• cite conservative treatment options for Stage II AAF; and
• discuss the gauntlet type of AFO and its potential impact in treating Stage III AAF.

Sponsored by the North American Center for Continuing Medical Education.

A Guide To Conservative Care For Adult-Acquired Flatfoot
A Guide To Conservative Care For Adult-Acquired Flatfoot
A Guide To Conservative Care For Adult-Acquired Flatfoot
A Guide To Conservative Care For Adult-Acquired Flatfoot
A Guide To Conservative Care For Adult-Acquired Flatfoot
A Guide To Conservative Care For Adult-Acquired Flatfoot
By Paul R. Scherer, DPM

Given the challenges of treating the common condition of adult-acquired flatfoot, this author reviews the literature and shares insights from his clinical experience. He discusses the proper staging of this condition and offers pertinent pearls on the use of conservative therapy.

Aside from calcaneal fractures, adult-acquired flatfoot (AAF) may be the most difficult foot pathology to treat successfully. The complexity surrounding this pathology originates in the continued confusion about etiology, pathology, classification, pathomechanics and surgical and non-surgical treatment.

   Accordingly, let us take a closer look at the various classifications of AAF, which has previously been referred to as posterior tibial tendon dysfunction (PTTD), and discuss the pathomechanics, prognosis and treatment options for non-surgical care.

   The loss of the active and passive pull of the tibialis posterior tendon is strongly associated with the development of AAF but no one is quite sure of the entire pathomechanics of this clinical disaster.1 Added to the lack of understanding of the etiology is the mystery of why this problem seems to be increasing in prevalence over the last 20 years.2 Is it a result of the increased aging of the susceptible flatfooted population or are we as clinicians just starting to recognize the problem as an entity in itself?

   Although the tibialis posterior must play an important role in the deformity, authors have begun since 1999 to describe this clinical scenario as adult-acquired flatfoot since the dysfunction or non-function of the tendon alone cannot account for the character and severity of the deformity and foot disability.2

   In a previous article in Podiatry Today, Douglas Richie, Jr., DPM, postulated that “significant ligamentous rupture occurs” as the flattening of the longitudinal arch and disarticulation of the rearfoot develops along with the attenuation or complete destruction of the spring ligament, superficial deltoid, the plantar fascia and finally the long and short plantar ligaments.2 This may truly be the reason that repair or anastomosis of the tibialis posterior tendon alone is rarely effective in repairing the structural integrity of the foot. Recognizing that a multilevel and interrelated pathology is occurring is essential for the successful treatment of AAF, whether the treatment is surgical or non-surgical.

   The progression from simple weakness of the tibialis posterior through ligamentous disruption and finally rearfoot subluxation creates various stages of pathology that are probably best to approach as individual entities. Treating the more advanced stages with methods one would use in the initial stages is not effective. Conversely, treating the early stages with therapies one would employ for the advanced subluxations is probably unpredictable and unsuccessful as well. Which system of classification offers the most appropriate and simplest decision marking opportunities for the clinician?

   Although several authors attribute AAF to seropositive or seronegative arthropathies, the overwhelming majority are solely a local lower extremity phenomenon.3,4 Any valid classification should focus on this phenomenon as well as the contributing factors, such as obesity and gender, which seem to determine both the severity and accelerated progression of the deformity.

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