Adult Acquired Flatfoot Deformity

Adult acquired flatfoot deformity (AAFD) is a collapse of the arch of the foot. Flatfoot surgery addresses the bones, ligaments, and tendons that support the arch, often through a combination of procedures. The goals of the surgery are to improve the alignment of the foot and restore more normal pressure during standing and walking. This surgery can also reduce pain and improve walking ability.

Diagnosis

Patients with a painful flatfoot frequently mention ankle and/or foot pain and difficulty with daily activities. A foot and ankle orthopedic surgeon should do a complete evaluation of the foot, including a medical history, physical exam, and X-rays. Non-surgical treatments such as rest, immobilization, shoe inserts, braces, and physical therapy should be tried first. If these are unsuccessful, then surgery may be considered.

Patients who have diabetes or take oral steroids should be evaluated by their primary care physician to determine if surgery is safe. Obese patients and smokers are at higher risk for blood clots and wound problems. Full recovery from flatfoot surgery can take up to a year. Patients who are unable or unwilling to complete this process should not have this surgery.

Treatment

Surgery can be performed under regional anesthesia, which is numbing of the foot and ankle with a nerve or spinal block, or general anesthesia, which may require a breathing tube. A nerve block often is placed behind the knee to reduce pain after surgery.

Comprehensive surgical treatment for AAFD usually involves a combination of several procedures. Your foot and ankle orthopedic surgeon will develop a treatment plan based on your deformity and the surgeon’s preferences. The following procedures may be considered.

Achilles Lengthening

In AAFD, the Achilles tendon becomes tight and contracted. Almost every surgical procedure for AAFD includes some kind of Achilles tendon lengthening. There are multiple types, each with different benefits. The most commonly performed types are gastrocnemius recession and triple-cut/percutaneous Achilles tendon lengthening.

Medializing Calcaneal Osteotomy

Also called a heel slide, this procedure involves cutting the heel bone to shift it back into correct alignment under the leg. The bone is then held in place with screws, staples, or a plate.

Tendon Transfers

Typically the flexor digitorum longus (FDL) tendon, which flexes your toes, is transferred to help bring some strength back to the posterior tibial tendon. It is cut in the foot and transferred to the navicular bone. If the posterior tibial tendon is severely damaged, your surgeon may remove it altogether. Sometimes, tendon transfers on the outside of the foot are also done to help realign the forces working on the foot.

Ligament Repairs

The spring ligament and the deltoid ligament are two ligaments that help hold the correct alignment of the foot and ankle. In patients with severe disease, one or both ligaments may be torn. In some cases, your surgeon may recommend repair or reconstruction of one or both of these ligaments.

Lateral Column Lengthening

In this procedure, the calcaneus bone is cut on the outside of the foot and “lengthened” to help correct the foot deformity. This is typically done by inserting either a cadaver bone or a metal wedge into the cut bone to lengthen it. Often, screws or a plate are used to help hold the bones in position while they heal.

Cotton (Medial Cuneiform) Osteotomy

In this procedure, the medial cuneiform bone is cut through an incision on the top of your foot. Spreading the cut bone apart with a bone or metal wedge helps recreate an arch.

Midfoot Fusion

Some patients with arthritis and/or deformity of their midfoot may require a midfoot fusion. This may involve one or more of the multiple midfoot joints, including the tarsometatarsal joints or the naviculocuneiform joint. This procedure is also useful for restoring the arch.

Subtalar Fusion

This procedure is done for more severe deformities. The talus and the calcaneus bones are fused together, which allows the surgeon to correct more of the deformity.

Double or Triple Arthrodesis

This procedure is done for the most severe deformities or ones with arthritis. In a triple arthrodesis, three joints are fused: the subtalar, talonavicular, and calcaneocuboid joints. Often, just the subtalar and talonavicular joints are fused (double arthrodesis). The foot will be stiff after this surgery, but usually pain and alignment are improved and the foot feels more stable for walking.

X-ray views of a flatfoot before and after

Recovery

Patients may go home the day of surgery or they may require an overnight hospital stay. The leg will be placed in a splint or cast and should be kept elevated for the first two weeks. At that point, sutures are removed. A new cast or a removable boot is then placed. It is important that patients do not put any weight on the corrected foot for 6-8 weeks following the operation. In most cases, patients may begin bearing weight after the first 6-8 weeks and progress to full weightbearing by 10-12 weeks. For some patients, weightbearing requires additional time. After 12 weeks, patients usually can transition to wearing a shoe. Inserts and ankle braces often are used. Physical therapy may be recommended. Swelling and discomfort can last for months after surgery, and full recovery can take 1-2 years.

Risks and Complications

All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots.

Complications following flatfoot surgery may include wound breakdown or incomplete healing of the bones (nonunion). These complications often can be prevented with proper wound care and rehabilitation. Occasionally, patients may notice some discomfort due to prominent hardware. Removal of hardware can be done at a later time if this is an issue. The overall complication rates for flatfoot surgery are low.

FAQs

Will surgical correction of my flatfoot improve the cosmetic appearance of my foot?

Surgical correction of flatfoot is aimed primarily at reducing pain and restoring function. Although surgery likely will improve the cosmetic appearance of the foot, it is not a primary goal of treatment.

What activities will I be able to do following flatfoot surgery?

With proper correction and rehabilitation, many patients return to active lifestyles. Activities such as walking, biking, driving, and even golfing are well tolerated. It is less likely, however, that patients will be able to participate in very strenuous high impact activities requiring running, cutting, or jumping.

Fifth Metatarsal Fracture

The metatarsal bones are the long bones in the middle of the foot. Each metatarsal bone has a base, a shaft, a neck, and a head. The fifth metatarsal is the last bone at the outside of the foot, and most breaks of the fifth metatarsal occur at the base.

The majority of fifth metatarsal fractures are treated without surgery. However, certain situations may require surgical treatment. Surgery can be performed to help the bone heal in a correct position and return the patient to full function. Surgery may reduce the time needed for immobilization and improve the chance of healing compared to non-surgical treatment.

Diagnosis

The base of the fifth metatarsal is divided into three fracture zones.

• Zone 1 fractures are avulsion or chip fractures that occur at the tip of the base of the fifth metatarsal. These fractures typically are treated without surgery using a cast, boot, or hard-soled shoe and tend to heal within 6-8 weeks.
• Zone 2 fractures are known as Jones fractures. They occur at the intersection between the base and the shaft of the fifth metatarsal. These fractures are known to have a higher chance of not healing (nonunion). They also are at risk of refracture even after healing. Surgery is common for these fractures due to the risk for delayed healing or reinjury.
• Zone 3 fractures happen at the junction of the wide portion of the bone with the shaft of the fifth metatarsal. These typically are stress fractures, and may be associated with symptoms prior to the fracture, or with minimal trauma that still results in a fracture. Lengthy healing times and risk of refracture may be reasons for surgical repair in these fractures.

Surgery is not indicated in a fracture where there is an infection or severely damaged soft tissue. Zone 1 fractures that are not displaced do not require surgery, and most fifth metatarsal shaft fractures without significant displacement do not require surgery.

Treatments

There are many surgical options for fifth metatarsal fractures. One popular technique (for zone 2 and 3 fractures) is a surgery where a screw is placed lengthwise within the bone (intramedullary screw fixation). Fractures of the shaft of the metatarsal are fixed with a plate and screws. These procedures can be performed under general or regional anesthesia with the patient going home the same day.

Specific Techniques

The surgical incision for an intramedullary screw is typically no more than a stab incision at the base of the fifth metatarsal. An X-ray machine is used to guide the screw placement. The screw threads cross the fracture site and allow for the fracture ends to be squeezed together. If bone grafting is needed, such as in a chronic fracture that has failed non-operative treatment, then a separate incision may be needed over the fracture to insert the bone graft or bone graft substitute.

Screw fixation of a fifth metatarsal base fracture

Recovery

For the first 7-14 days after surgery, you may be allowed to weight bear through the heel but typically not through the front of the foot. This could last as long as six weeks (sometimes longer based on healing and other factors such as diabetes). Weight bearing in a removable walking boot is allowed after that. Patients can expect to return to full activity 3-4 months after a typical fracture.

This includes returning to sports. Some fractures may require bone grafting and have longer recoveries. The screw is not usually removed unless it causes discomfort.

Risks and Complications

All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots.

Some complications can result in the need for repeat surgery. The metatarsal fracture may not heal and can become a nonunion. Another rare but serious complication is a re-fracture after fixation. Some patients may be at greater risk for poor healing or re-fracture due to the shape of their foot. A high-arched foot or a heel that turns in can put extra pressure on the fifth metatarsal and may require other surgical procedures to change the architecture of the foot.

FAQs

If I have a zone 2 fracture of the base of the fifth metatarsal, will I jeopardize my chance of bone healing if I try non-operative treatment first?

Most of these breaks will go on to heal after 12 weeks with appropriate treatment. The nonunion rate of these fractures may still be as high as 15 to 20 percent. A fracture that fails to heal and is painful may require surgical repair. The surgery can be more difficult at that point and may require a bone graft.

If I have a fracture of the neck or shaft of the metatarsal, is there a need for surgery?

The need for surgery in these fracture types depends on the degree of deformity. Rotational deformity of the little toe, angulation of the shaft of the metatarsal with a change in the shape of the foot and shortening as a result of the fracture are a few of the reasons for surgical repair.

If I choose not to have surgery and use a walker boot for six weeks, are there any other treatments that can help accelerate healing?

There is some evidence that electromagnetic bone stimulation may be useful in increasing healing rates and reducing time for healing in zone 2 fractures of the base of the fifth metatarsal. However, more evidence is needed before these therapies can be recommended to all patients with such fractures.

Is there any role for PRP or stem cell injections?

This is a relatively new and not well researched area currently. No recommendation for these injections can currently be made; they are not typically covered by insurance and can be quite expensive without data to suggest that they improve results. However, you should be aware that even if the biology can be improved with injections, these will not alter the mechanics of the foot. An increasing number of orthopedic practices are providing these injections. You should speak with your foot and ankle orthopedic specialist who is best educated to evaluate the full spectrum of care including non-surgical and surgical options.

Shock Wave Therapy

Shock wave therapy is a non-invasive method that uses pressure waves to treat various musculoskeletal conditions. High-energy acoustic waves (shock waves) deliver a mechanical force to the body’s tissues.

Diagnosis

Shock wave therapy may treat conditions such as degenerated tendons (Achilles tendinitis), heel pain (plantar fasciitis), and tennis elbow (lateral epicondylitis).

Complications are rare with shock wave therapy. People who have poor sensation (neuropathy) or hypersensitivity in the target area should not have this procedure. Open sores also are a reason to avoid shock wave therapy. Shock wave therapy is not used in patients with heart conditions or seizures. It should not be used during pregnancy.

Treatment

A non-invasive probe is applied to the skin. An electrical charge creates an energy wave that is focused on the area of concern. The shock waves create a force on the tissues that may induce healing. It’s not clear why this approach to healing works for some people, but it may be that shock waves cause inflammation and improve blood flow to encourage the body to repair and heal itself.

Specific Technique

Shock wave therapy is an outpatient procedure. A probe is placed on the skin after a gel is applied to help conduct the shock waves. Therapy is more successful with active patient participation where the patient tells the therapist whether or not the probe is at the area of pain. One or more treatment sessions may be needed.

Recovery

Patients typically bear weight after treatment. Patients are advised to reduce the level of physical activity for 1-2 weeks after treatment. Shock wave therapy may give good outcomes for some tendon problems or chronic degenerative conditions. Examples include Achilles tendinitis and plantar fasciitis.

Risks and Complications

The main complications are pain and hypersensitivity at the site of treatment. These problems typically resolve with time. Pain and disability may persist when shock wave therapy is not successful.

Claw Toe

Claw toe is a common foot deformity in which your toes bend into a claw-like position, digging down into the soles of your shoes and creating painful calluses. People often blame claw toe on wearing shoes that squeeze your toes, such as shoes that are too short or high heels. However, claw toes often are the result of nerve damage caused by diseases like diabetes or alcoholism, which can weaken the muscles in your foot. Claw toes can get worse without treatment and may become a permanent deformity over time.

Symptoms

There are several signs of claw toe:

• Your toes are bent upward (extension) from the joints at the ball of the foot.
• Your toes are bent downward (flexion) at the middle joints toward the sole of your shoe.
• Sometimes your toes also bend downward at the top joints, curling under the foot.

Corns or calluses may develop over the top of the toe, under the end of the toe or under the ball of the foot.

Diagnosis

If you have symptoms of a claw toe, see your foot and ankle orthopedic surgeon for evaluation. You may need tests to rule out neurological disorders that can weaken your foot muscles, creating imbalances that bend your toes. Trauma and inflammation also can cause claw toe deformity.

Treatments

Non-surgical Treatment

Claw toe deformities are flexible at first, but they harden into place over time. If you have claw toe in early stages, your doctor may recommend a splint or tape to hold your toes in correct position.

Non-surgical treatments should be tried first to correct claw toe. Wear shoes with soft, roomy toe boxes and avoid tight shoes and high heels. Use your hands to stretch your toes and toe joints toward their normal positions. Exercise your toes by using them to pick up marbles or crumple a towel laid flat on the floor.

If you have claw toe in later stages and your toes are fixed in position, a special pad can redistribute your weight and relieve pressure on the ball of your foot. Try special “in depth” shoes that have an extra 3/8-inch depth in the toe box or ask a shoe repair shop to stretch a small pocket in the toe box to accommodate the deformity.

Surgical Treatment

If the above treatments don’t help, you may need surgery to correct the problem. The type of surgery often depends on the severity of the deformity. If the claw toe is still in the early stages or flexible (able to be manually corrected with passive stretching), your foot and ankle orthopedic surgeon may recommend a procedure to reroute a flexor tendon to the toe to correct the deformity. If the deformity has been present for a long time and is now rigid (not correctable), your surgeon may recommend a toe fusion.

Chronic Lateral Ankle Pain

Chronic lateral ankle pain is recurring pain on the outer side of the ankle often develops after an injury such as a sprained ankle. However, several other conditions also may cause chronic ankle pain.

Symptoms

Pain, usually on the outer side of the ankle, may be so intense that you have difficulty walking or participating in sports. In some cases, the pain is a constant, dull ache. Patients may also experience difficulty walking on uneven ground or in high heels, a feeling of giving way (instability), swelling, stiffness, tenderness, or repeated ankle sprains.

Causes

The most common cause for a persistently painful ankle is incomplete healing after an ankle sprain. When you sprain your ankle, the connecting tissue between the bones is stretched or torn. Without thorough and complete rehabilitation, the ligament or surrounding muscles may remain weak, resulting in recurrent instability. As a result, you may experience additional ankle injuries. Other causes of chronic ankle pain include:

• An injury to the nerves that pass through the ankle. The nerves may be stretched, torn, injured by a direct blow, or pinched under pressure (entrapment).
• A torn or inflamed tendon
• Arthritis of the ankle joint
• A fracture in one of the bones that make up the ankle joint
• An inflammation of the joint lining (synovium)
• The development of scar tissue in the ankle after a sprain. The scar tissue takes up space in the joint, putting pressure on the ligaments.

Prevention

Almost half of all people who sprain their ankle once will experience additional ankle sprains and chronic pain. You can help prevent chronic pain from developing by following these simple steps:

1. Follow your doctor’s instructions carefully and complete the prescribed physical rehabilitation program.
2. Do not return to activity until cleared by your physician.
3. When you do return to sports, use an ankle brace rather than taping the ankle. Bracing is more effective than taping in preventing ankle sprains.
4. If you wear high-top shoes, be sure to lace them properly and completely.

Diagnosis

The first step in identifying the cause of chronic ankle pain is taking a history of the condition. Your foot and ankle orthopedic surgeon may ask you several questions, including:

• Have you previously injured the ankle? If so, when?
• What kind of treatment did you receive for the injury?
• How long have you had the pain?
• Are there times when the pain worsens or disappears?

Because there are so many potential causes for chronic ankle pain, your doctor may do a number of tests to pinpoint the diagnosis, beginning with a physical examination. Your surgeon will feel for tender areas and look for signs of swelling. He or she will have you move your foot and ankle to assess range of motion and flexibility. Your surgeon also may test the sensation of the nerves and administer a local anesthetic to help pinpoint the source of the symptoms.

Your surgeon may order several X-ray views of your ankle joint. You also may need to get X-rays of the other ankle so the doctor can compare the injured and non-injured ankles. In some cases, additional tests such as a bone scan, CT scan or MRI may be needed.

Treatments

Treatment will depend on the final diagnosis and should be personalized to your individual needs. Both non-surgical and surgical treatments may be used. Non-surgical treatments include:

• Anti-inflammatory medications such as aspirin or ibuprofen to reduce swelling
• Physical therapy, including tilt-board exercises, directed at strengthening the muscles, restoring range of motion and increasing your perception of joint position
• An ankle brace or other support
• An injection of a steroid medication
• In the case of a fracture, immobilization to allow the bone to heal

If your condition requires it, or if conservative treatment doesn’t bring relief, your doctor may recommend surgery. Many surgical procedures can be done on an outpatient basis. Some procedures use arthroscopic techniques; other require open surgery. Rehabilitation may take 6-10 weeks to ensure proper healing.

Surgical treatment options include:

• Removing (excising) loose fragments
• Cleaning (debriding) the joint or joint surface
• Repairing or reconstructing the ligaments or transferring tendons