(AAF) is the term used to describe the
progressive deformity of the foot and ankle that, in its later stages, results in collapsed and badly deformed feet. Although the condition has been described and written about since the 1980s, AAF
is not a widely used acronym within the O&P community-even though orthotists and pedorthists easily recognize the signs of the condition because they treat them on an almost daily basis. AAF is
caused by a loss of the dynamic and static support structures of the medial longitudinal arch, resulting in an incrementally worsening planovalgus deformity associated with posterior tibial (PT)
tendinitis. Over the past 30 years, researchers have attempted to understand and explain the gradual yet significant deterioration that can occur in foot structure, which ultimately leads to painful
and debilitating conditions-a progression that is currently classified into four stages. What begins as a predisposition to flatfoot can progress to a collapsed arch, and then to the more severe
posterior tibial tendon dysfunction (PTTD). Left untreated, the PT tendon can rupture, and the patient may then require a rigid AFO or an arthrodesis fixation surgery to stabilize the foot in order
to remain capable of walking pain free.
Flat footedness, most people who develop the condition already have flat feet. With overuse or continuous loading, a change occurs where the arch begins to flatten more than before, with pain and
swelling developing on the inside of the ankle. Inadequate support from footwear may occasionally be a contributing factor. Trauma or injury, occasionally this condition may be due to fracture,
sprain or direct blow to the tendon. Age, the risk of developing Posterior Tibial Tendon Dysfunction increases with age and research has suggested that middle aged women are more commonly affected.
Other possible contributing factors - being overweight and inflammatory arthritis.
Depending on the cause of the flatfoot, a patient may experience one or more of the different symptoms here. Pain along the course of the posterior tibial tendon which lies on the inside of the foot
and ankle. This can be associated with swelling on the inside of the ankle. Pain that is worse with activity. High intensity or impact activities, such as running, can be very difficult. Some
patients can have difficulty walking or even standing for long periods of time. When the foot collapses, the heel bone may shift position and put pressure on the outside ankle bone (fibula). This can
cause pain on the outside of the ankle. Arthritis in the heel also causes this same type of pain. Patients with an old injury or arthritis in the middle of the foot can have painful, bony bumps on
the top and inside of the foot. These make shoewear very difficult. Occasionally, the bony spurs are so large that they pinch the nerves which can result in numbness and tingling on the top of the
foot and into the toes. Diabetics may only notice swelling or a large bump on the bottom of the foot. Because their sensation is affected, people with diabetes may not have any pain. The large bump
can cause skin problems and an ulcer (a sore that does not heal) may develop if proper diabetic shoewear is not used.
Although you can do the "wet test" at home, a thorough examination by a doctor will be needed to identify why the flatfoot developed. Possible causes include a congenital abnormality, a bone fracture
or dislocation, a torn or stretched tendon, arthritis or neurologic weakness. For example, an inability to rise up on your toes while standing on the affected foot may indicate damage to the
posterior tibial tendon (PTT), which supports the heel and forms the arch. If "too many toes" show on the outside of your foot when the doctor views you from the rear, your shinbone (tibia) may be
sliding off the anklebone (talus), another indicator of damage to the PTT. Be sure to wear your regular shoes to the examination. An irregular wear pattern on the bottom of the shoe is another
indicator of acquired adult flatfoot. Your physician may request X-rays to see how the bones of your feet are aligned. Muscle and tendon strength are tested by asking you to move the foot while the
doctor holds it.
Non surgical Treatment
Treatment depends very much upon a patient?s symptoms, functional goals, degree and specifics of deformity, and the presence of arthritis. Some patients get better without surgery. Rest and
immobilization, orthotics, braces and physical therapy all may be appropriate. With early-stage disease that involves pain along the tendon, immobilization with a boot for a period of time can
relieve stress on the tendon and reduce the inflammation and pain. Once these symptoms have resolved, patients are often transitioned into an orthotic that supports the inside aspect of the hindfoot.
For patients with more significant deformity, a larger ankle brace may be necessary.
If initial conservative therapy of posterior tibial tendon insufficiency fails, surgical treatment is considered. Operative treatment of stage 1 disease involves release of the tendon sheath,
tenosynovectomy, debridement of the tendon with excision of flap tears, and repair of longitudinal tears. A short-leg walking cast is worn for 3 weeks postoperatively. Teasdall and Johnson reported
complete relief of pain in 74% of 14 patients undergoing this treatment regimen for stage 1 disease. Surgical debridement of tenosynovitis in early stages is believed to possibly prevent progression
of disease to later stages of dysfunction.