Adult flatfoot, also known as flatfoot valgus, is a foot deformity characterized by collapse of the medial arch, abduction of the forefoot, and valgus of the hindfoot. This condition can be asymptomatic or cause pain and functional impairment, making appropriate management by podiatrists essential. This comprehensive guide explores the pathophysiological aspects, diagnostic methods, and different treatment options for adult flatfoot.
Introduction to adult flat feet
Flatfoot valgus in adults results from a failure of the foot's supporting structures, leading to a progressive collapse of the plantar arch. This deformity is often associated with posterior tibial tendon insufficiency and tendon retractions that aggravate the mechanical imbalance of the foot. Although flatfoot can appear at any age, it is particularly common in adults over 45-50 years of age.
Patients may complain of pain in the ankle or midfoot, which worsens when walking on uneven surfaces or carrying heavy loads. The condition can progress to severe joint stiffness and deformities if not treated adequately.
Pathophysiology of adult flatfoot
Adult flatfoot is characterized by collapse of the medial arch, often associated with injury to the plantar talocalcaneal ligament (spring ligament) and posterior tibial tendon. This deformity leads to poor distribution of mechanical forces during gait, worsening the condition over time. Patients may also have hypermobility of the first metatarsal and retraction of the triceps surae and peroneal tendons, contributing to worsening hindfoot valgus.
The exact causes of adult flatfoot can vary, including traumatic, neurological, or inflammatory factors, as well as anatomical predispositions such as the relative length of the talus to the calcaneus.
Diagnosis of adult flat feet
The diagnosis of adult flatfoot is based on a detailed clinical examination, supplemented by imaging techniques to assess the severity of the deformity and identify the damaged structures.
Clinical examination
The physical examination includes observation of the patient's posture and gait, focusing on forefoot abduction, hindfoot valgus, and medial arch collapse. Specific tests, such as the bipodal and monopodal toe stand test, help assess posterior tibial tendon function and reducibility of the deformity. The Jack test and Hintermann test are also used to analyze medial arch flexibility and hindfoot stability.
Imaging
Weight-bearing radiographs are essential to visualize bony deformities, such as medial arch collapse and forefoot abduction. MRI is particularly useful to assess the condition of tendons and ligaments, while CT may be necessary in cases of rigid flat feet to detect the presence of osteoarthritis or synostoses.
Evolutionary and etiological assessment
The evolutionary assessment of adult flatfoot allows classification of the deformity according to the reducibility and severity of symptoms. Flatfoot can be reducible or fixed, with different implications for treatment. In adolescents and young adults, flatfoot is often reducible, while in adults over 45-50 years of age, the deformity tends to be more rigid.
The Bluman classification is commonly used to categorize adult flatfoot into four stages, ranging from tendinopathy without visible deformity to tibiotarsal osteoarthritis associated with severe deformity.
Treatments for flat feet in adults
Treatment for adult flatfoot depends on the stage of the deformity and the presence of symptoms. It may include conservative options such as rehabilitation and foot orthoses, as well as surgical interventions for more advanced cases.
1. Rehabilitation
Rehabilitation aims to correct tendon contractures and strengthen the supporting muscles of the foot, particularly the invertor muscles. Stretching exercises of the triceps surae and peroneus, as well as plantar muscle strengthening techniques, are essential to improve foot function and reduce pain.
2. Plantar orthoses
Foot orthoses play a crucial role in the treatment of reducible flat feet by providing medial arch support and correcting foot postural abnormalities. Orthoses should be fitted based on the results of clinical and baropodometric tests to provide maximum comfort and effectiveness.
3. Immobilization
In cases of acute pain crisis, temporary immobilization by casting or strapping may be necessary to reduce inflammation and allow tissue recovery. Immobilization is usually followed by progressive rehabilitation to restore mobility and muscle strength.
4. Surgery
Surgery is considered in cases of severe or nonreducible flat feet, where conservative treatments have failed to relieve symptoms. Surgical options include medial translation calcaneal osteotomy, lateral calcaneal lengthening osteotomy (Evans technique), and sinus tarsi endoprosthesis arthroplasty. These procedures aim to realign bony structures and correct mechanical imbalances in the foot.
Postoperative management and follow-up
Postoperative management is crucial for the long-term success of flatfoot surgery. Immobilization for 45 to 60 days is generally recommended, followed by rehabilitation to restore muscle and joint function. Custom foot orthoses may be necessary to maintain the corrections achieved and prevent recurrence.
Podiatrists should regularly monitor surgical patients to adjust orthotics and rehabilitation protocols based on progress. Particular attention should be paid to changes in foot function and the appearance of new pain or complications.
Adult flat feet represent a complex therapeutic challenge, requiring personalized and often multidisciplinary care. Podiatrists play a key role in the early diagnosis and management of this condition to prevent complications and improve patients' quality of life. Feel free to leave a comment below to share your experiences or ask questions about the management of adult flat feet.
