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Overview
Adult acquired flatfoot is often a complex disorder, with diverse symptoms and varying degrees of deformity and disability. There are several types of flatfoot, all of which have one characteristic in common-partial or total collapse (loss) of the arch. Other characteristics shared by most types of flatfoot include ?Toe drift,? where the toes and front part of the foot point outward. The heel tilts toward the outside and the ankle appears to turn in. A short Achilles tendon or calf muscle, which causes the heel to lift off the ground earlier when walking and may act as a deforming force. In addition, other deformities such bunions and hammertoes can occur and cause pain in people with flexible flatfoot. Health problems such as rheumatoid arthritis, diabetes and obesity can increase the risk of developing flatfoot and may (or may not) make it more difficult to treat. This article provides a brief overview of the problems that can result in AAFD. Further details regarding the most common conditions that cause an acquired flatfoot and their treatment options are provided in separate articles. Links to those articles are provided.

Causes
Adult acquired flatfoot is caused by inflammation and progressive weakening of the major tendon that it is responsible for supporting the arch of the foot. This condition will commonly be accompanied by swelling and pain on the inner portion of the foot and ankle. Adult acquired flatfoot is more common in women and overweight individuals. It can also be seen after an injury to the foot and ankle. If left untreated the problem may result in a vicious cycle, as the foot becomes flatter the tendon supporting the arch structure becomes weaker and more and more stretched out. As the tendon becomes weaker, the foot structure becomes progressively flatter. Early detection and treatment is key, as this condition can lead to chronic swelling and pain.

Symptoms
The symptoms of PTTD may include pain, swelling, a flattening of the arch, and inward rolling of the ankle. As the condition progresses, the symptoms will change. For example, later, as the arch begins to flatten, there may still be pain on the inside of the foot and ankle. But at this point, the foot and toes begin to turn outward and the ankle rolls inward. As PTTD becomes more advanced, the arch flattens even more and the pain often shifts to the outside of the foot, below the ankle. The tendon has deteriorated considerably and arthritis often develops in the foot. In more severe cases, arthritis may also develop in the ankle. Symptoms, which may occur in some persons with flexible flatfoot, include. Pain in the heel, arch, ankle, or along the outside of the foot. ?Turned-in? ankle. Pain associated with a shin splint. General weakness / fatigue in the foot or leg.

Diagnosis
There are four stages of adult-acquired flatfoot deformity (AAFD). The severity of the deformity determines your stage. For example, Stage I means there is a flatfoot position but without deformity. Pain and swelling from tendinitis is common in this stage. Stage II there is a change in the foot alignment. This means a deformity is starting to develop. The physician can still move the bones back into place manually (passively). Stage III adult-acquired flatfoot deformity (AAFD) tells us there is a fixed deformity. This means the ankle is stiff or rigid and doesn???t move beyond a neutral (midline) position. Stage IV is characterized by deformity in the foot and the ankle. The deformity may be flexible or fixed. The joints often show signs of degenerative joint disease (arthritis).

Non surgical Treatment
Flatfoot deformity can be treated conservatively or with surgical intervention depending on the severity of the condition. When people notice their arches flattening, they should immediately avoid non-supportive shoes such as flip-flops, sandals or thin-soled tennis shoes. Theses shoes will only worsen the flatfoot deformity and exacerbate arch pain. Next, custom orthotics are essential for people with collapsed arches. Over-the-counter insoles only provide cushion and padding to the arch, whereas custom orthotics are fabricated to specifically fit the patient?s foot and provide support in the arch where the posterior tibial tendon is unable to anymore. Use of custom orthotics in the early phases of flatfoot or PTTD can prevent worsening of symptoms and prevent further attenuation or injury to the posterior tibial tendon. In more severe cases of flatfoot deformity an ankle foot orthosis (AFO) such as a Ritchie brace is needed. This brace provides more support to the arch and hindfoot rather than an orthotic but can be bulky in normal shoegear. Additional treatment along with use of custom orthotics is use of non-steroidal anti-inflammatories (NSAIDS) such as Advil, Motrin, or Ibuprofen which can decrease inflammation to the posterior tibial tendon. If pain is severe, the patient may need to be placed in a below the knee air walker boot for several weeks which will allow the tendon to rest and heal, especially if a posterior tibial tendon tear is noted on MRI.

Surgical Treatment
For those patients with PTTD that have severe deformity or have not improved with conservative treatments, surgery may be necessary to return them to daily activity. Surgery for PTTD may include repair of the diseased tendon and possible tendon transfer to a nearby healthy tendon, surgery on the surrounding bones or joints to prevent biomechanical abnormalities that may be a contributing factor or both.