Why Conservative Treatment Is The Standard Of Care For Adult-Acquired Flatfoot
- Doug Richie Jr. DPM FACFAS
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There has been recent discussion on this Web site regarding the need or the effectiveness of conservative care prior to recommending or performing bunionectomy surgery (see http://bit.ly/f9x9MM ). I am in agreement with those who believe that conservative care is not necessary before performing bunion surgery in adults. When it comes to children and adolescents, I have seen improvement of symptoms and sometimes improvement of deformity with functional foot orthotic therapy. Therefore, I recommend conservative treatment for this group of patients before performing surgery.
For the adult-acquired flatfoot, there is also some controversy about the effectiveness of conservative care. I once sat on a panel of experts at an international surgical conference where a noted orthopedic foot and ankle surgeon stated that conservative care was a waste of time and that early operative intervention for the adult-acquired flatfoot was mandatory. That was six years ago and now there is a growing body of evidence that the opinion of this surgeon is incorrect.
To validate my position, I direct the readers to the recent issue of the Journal of Foot and Ankle Surgery, which contains two excellent articles on posterior tibial tendon dysfunction (PTTD). In one article by Chhabra and colleagues from Johns Hopkins Hospital, the authors elegantly describe and illustrate the pathologic magnetic resonance imaging (MRI) findings of PTTD and correlate these findings to clinical staging of this disorder.1 This article represents the finest demonstration of the progressive nature of PTTD reported in the literature to date.
The cascade of ligamentous failure, followed by displacement of osseous structures in the hindfoot, underscores the fact that PTTD or adult-acquired flatfoot is not a static deformity, but is a progressive injury. Interventions to treat this disorder must be based upon the stage of the injury and the level of damage to key anatomic structures. There is no single intervention that will work every time. One can perform clinical tests that will detect the level of ligament disruption that occurs after initial attenuation of the posterior tibial tendon. I provided a detailed description of these tests in a chapter in Clinics in Podiatric Medicine and Surgery published in 2007.2
Since adult-acquired flatfoot is a progressive disorder and not a static deformity, one can tailor non-surgical interventions to the condition depending upon the stage of progression. With the advent of advanced rehabilitation techniques and modification of traditional ankle foot orthosis design, non-operative treatments now show a better than 50 percent chance of success in alleviating symptoms and avoiding surgery in adult-acquired flatfoot.
Underscoring this fact is the newly published article in the Journal of Foot and Ankle Surgery by Nielsen and colleagues at the Western Pennsylvania Hospital podiatric residency training program.3 This study reveals an 87.5 percent successful non-surgical treatment of 64 patients diagnosed with adult-acquired flatfoot. The treatment regimen included bracing with either a low articulating ankle foot orthosis, a walking boot, a foot orthosis and physical therapy. The authors concluded that the low articulating ankle foot orthosis was particularly effective in relieving the symptoms of PTTD and adult-acquired flatfoot.
With this recent publication by Nielsen and co-workers, there are now nine studies in the literature documenting a remarkable effectiveness of non-surgical treatment of adult-acquired flatfoot. The authors summarize these previous studies in their paper.3 There is growing evidence that at least 50 percent of patients with PTTD or adult-acquired flatfoot can avoid surgery if they are properly braced and receive physical therapy. Several of these studies have documented that patients can discontinue their brace within one year and continue to be treated with foot orthoses alone.
With this body of evidence, it is clear that conservative, non-operative treatment is the standard of care before patients with adult-acquired flatfoot undergo surgery. With the known medical risks that accompany most patients with this disorder, and with the challenging nature of the surgery itself, taking the conservative route should be an easy decision for any practitioner.
1. Chhabra A, Soldatos T, Chalian M et al. 3-tesla magnetic resonance imaging evaluation of posterior tibial tendon dysfunction with relevance to clinical staging. J Foot Ankle Surg. 2011; 50(3):320-328.
2. Richie DH Jr. Biomechanics and clinical analysis of the adult acquired flatfoot. Clin Podiatr Med Surg. 2007; 24(4):617-644.
3. Nielsen MD, Dodson EE, Shadrick DL, Catanzariti AR, Mendicino RW, Malay DS. Nonoperative care for the treatment of adult-acquired flatfoot deformity. J Foot Ankle Surg. 2011; 50(3):311-314.