Key Insights On Conservative Care For Adult Flatfoot

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Author(s): 
Patrick DeHeer, DPM, FACFAS, FASPS, and Aaron Warnock, DPM

Formulating An Initial Treatment Plan

Coupling the patient’s history of present illness with the results of the clinical exam, the clinician should be able to formulate a proper treatment plan. It is paramount that the initial treatment plan seeks to relieve the patient’s pain and discomfort. We treat stage 1 and stage 2 posterior tibialis tendon dysfunction with night splints, low Dye strappings, Medrol Dosepaks and RICE (rest, ice, compression, elevation) therapy at initial contact.

   Night splints may be effective initial treatments as many clinicians’ treatment plans seem to under-address equinus. Van Boerum and colleagues showed that biomechanically, the deforming force of a tight triceps surae acts on the midfoot instead of the metatarsal heads during the propulsive phase of the gait cycle, which collapses the arch.1 With a collapsed arch, the authors note the foot rolls forward like a rocker bottom and loses the force that is necessary for efficient gait. This puts chronic stress on the posterior tibial tendon and puts the foot at risk for a pes planus foot type, which physicians must address.

   We instruct the patient to use the splints one or two hours a night for two to three months with augmentation one day a week for long-term care. The arch has the external support of low Dye strapping and usually stays in place for four to five days. We also prescribe a Medrol Dosepak and provide written instructions for RICE therapy. If the patient is unable to tolerate oral prednisone, we use Duexis (Horizon Pharma) or Mobic (Boehringer Ingelheim). The patient then presents to the office in one week for further evaluation.

   The majority of the patients do well with this initial treatment plan. Getting the patient’s initial symptomology under control allows the clinician not only to formulate a proper treatment plan but allows one to access the apex of the deformity and address the root cause of the pain.

   However, if the flatfoot deformity is severe, we may see at the next office visit that the initial treatment plan has been nullified. In these cases, we opt to place the patient in a controlled ankle motion (CAM) walker or a below-the-knee hard cast for four to six weeks or until symptoms subside. In our clinic, immobilization in a walking boot in conjunction with low Dye taping for two to four weeks has been effective in reducing many of our patients’ painful conditions and gets us to square one to move forward with long-term treatment. We do not use steroid injections into the tendon although some clinicians utilize this treatment modality.

What You Should Know About Orthotic Therapy

Once the initial symptomology is under control, we then employ external supportive devices to control the excessive pronation the patient is experiencing. Our first line of therapy is a custom orthotic that has a deep heel cup, an extra 1/8th inch of ethylene vinyl acetate (EVA) forefoot padding, and a perforated EVA top cover with a non-slip rubber bottom. This is a semi-rigid device.

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