Adult Acquired Flatfoot Deformity (AAFD)

Adult acquired flatfoot deformity (AAFD) is a progressive flattening of the arch of the foot that occurs as the posterior tibial tendon wears down. It has many other names such as posterior tibial tendon dysfunction, posterior tibial tendon insufficiency, and dorsolateral peritalar subluxation. This problem may progress from early stages with pain and swelling along the posterior tibial tendon to complete arch collapse and arthritis throughout the hindfoot (back of the foot) and ankle.

Anatomy

The posterior tibial muscle originates on the bones of the lower leg (tibia and fibula). This muscle then turns into the posterior tibial tendon, which passes behind the inside of the ankle and attaches to the navicular bone along the instep of the foot. The posterior tibial tendon plays a central role in maintaining the arch of the foot when you stand and walk.

In addition to tendons running across the ankle and foot joints, a number of ligaments span and stabilize these joints. The ligaments at the inside of the ankle also can become stretched and contribute to the progressive flattening of the arch.

Several muscles and tendons around the ankle and foot act to counter-balance the action of the posterior tibial tendon. Under normal circumstances, the result is a balanced ankle and foot with normal motion. When the posterior tibial tendon fails, the other muscles and tendons become relatively overpowering. These muscles then contribute to the progressive deformity seen with this disorder.

Symptoms

Patients with AAFD often experience pain, deformity, and/or swelling at the ankle or hindfoot. When the posterior tibial tendon does not work properly, a number of changes can occur to the foot and ankle. In early stages, symptoms often include pain and swelling along the posterior tibial tendon behind the inside of the ankle.

As the tendon fails over time, deformity of the foot and ankle may occur. This deformity can include:

• progressive flattening of the arch
• outward shifting of the heel so that it no longer is aligned underneath the rest of the leg
• rotational deformity of the forefoot
• tightening of the heel cord
• development of arthritis
• deformity of the ankle joint

At certain stages of this disorder, pain may shift from the inside to the outside of the ankle as the heel shifts outward and structures are pinched on the outside of the ankle.

A patient with AAFD of the left foot. You can see that the heel has shifted outward and is no longer aligned under the leg.

Causes

Posterior tibial tendon dysfunction is the most common cause of AAFD. Often there is no specific event or injury that starts the problem. More commonly, the tendon is injured from “wear and tear” over time. Posterior tibial tendon dysfunction occurs more commonly in patients who are born with a flat foot or who develop the condition for other reasons. With a relatively flat arch, more stress is placed on the posterior tibial tendon and also on the ligaments on the inside of the foot and ankle. The result is a progressive disorder. Weight also plays a role in the progression of this disorder. For overweight patients, significant weight loss may lead to some improvement of symptoms.

Diagnosis

The diagnosis of posterior tibial tendon dysfunction and AAFD usually is made from a combination of symptoms, physical exam and X-rays. Your foot and ankle orthopedic surgeon will look at the location of the pain, shape of your foot, flexibility of the hindfoot joints, and how you walk to make the diagnosis and assess how advanced the problem is.

Achilles Tendon Rupture Surgery

The goal of Achilles tendon rupture surgery is to reconnect the calf muscles with the heel bone to restore push-off strength. Regaining Achilles tendon function after an injury is critical for walking.

Diagnosis

Those best suited for surgical repair of an acute or chronic Achilles tendon rupture (tear) include healthy, active people who want to return to activities such as jogging, biking, or other sports. Even those who are less active may be candidates for surgical repair. Non-surgical treatment may also be an option. You should discuss the decision to have surgery with your foot and ankle orthopedic surgeon.

You should not have this surgery if you have an active infection or unhealthy skin at or around the site of the Achilles tendon rupture, or if you are not healthy enough to undergo surgery. Other concerns include diabetes, smoking, sedentary lifestyle, steroid use, and inability to follow postoperative instructions. Any health concerns should be discussed with your foot and ankle orthopedic surgeon.

Treatment

Surgery for an acute or chronic rupture of the Achilles tendon typically occurs in an outpatient setting. This means you will have surgery and go home the same day. Numbing medicine is placed into the leg around the nerves to help decrease pain after surgery. This is called a nerve block. You will then be put to sleep and placed in a position that gives the surgeon access to the ruptured tendon. Repair of an acute rupture usually takes between 30 minutes and one hour. Repair of a chronic rupture can take longer depending on the steps needed to fix the tendon.

There are a variety of ways to repair an Achilles tendon rupture. The most common method is an open repair. This starts with your surgeon making an incision on the back of the lower leg starting just above the heel bone. After the surgeon finds the two ends of the ruptured tendon, they sew these ends together with sutures and close the incision.

In most cases, Dr. Reed can repair your rupture through a percutaneous approach. He makes a small incision on the back of the lower leg at the site of the rupture. Then he will pass a series of needles with sutures attached through the skin and Achilles tendon and then bring them out through the small incision. He will then tie the sutures together. Talk to your foot and ankle orthopedic surgeon to determine the best surgical technique for your Achilles rupture.

Recovery

After surgery, you will be placed in a splint or cast from the toes to just below the knee. Typically you will not be allowed to walk or put weight on the involved leg. You can use crutches, a walker, knee scooter, or wheelchair to move around. Keeping the operated leg elevated above heart level will help decrease swelling and pain. If a nerve block has been given, you can expect the numbing sensation to last from 8-24 hours.

Patients typically are seen in the office two weeks after surgery. The splint or cast is removed and the surgical incision is evaluated. Stitches usually are removed at this time if they need to be removed at all. From 2-6 weeks, the postoperative protocol varies based on the surgeon’s preference. You may be allowed to begin weightbearing in a walking boot. Ankle motion is often allowed and encouraged. A cast is sometimes used instead of a boot.

At six weeks patients usually are allowed full weightbearing out of the cast or boot. You may start physical therapy to restore ankle range of motion. Your surgeon will gradually allow strengthening exercise for the calf muscles and Achilles as the tendon heals. Patients usually are able to return to full activity by six months, but it may be more than a year before they achieve full recovery.

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.

Potential complications specific to Achilles tendon surgery include wound infection and delayed wound healing. Re-rupture can also occur. There may be scarring of the tendon or thickening of the surgical scar. A nerve that gives sensation to the outside part of the foot can be stretched or injured during surgery, which can result in numbness or burning.

FAQs

What is the likelihood of success with Achilles tendon rupture surgery?

Surgical repair of an acute rupture usually does well. It is important to understand that even after a successful surgical repair the ultimate strength of the leg will likely be less than it was before the injury.

What is the risk of tendon re-rupture?

The risk of re-rupture after surgical repair is less than 5%. If re-rupture occurs, the tendon can be repaired again either directly or with other techniques that utilize other tissues and materials to reinforce the repair. Revision surgery is always more complex than the original surgery.

Achilles Tendon

The Achilles tendon is the largest tendon in your body. It connects the upper calf muscles to the back of the heel bone. Achilles tendinosis is a condition in which the Achilles tendon degenerates and becomes inflamed. Sometimes, it may also be called Achilles tendinitis. If you have Achilles tendinosis, your tendon can swell and become painful. This condition is common in athletes, runners, and people who have calf tightness. Achilles tendinosis may occur in the middle of the tendon (known as midsubstance Achilles tendinosis) or at the point where the tendon connects to the heel bone (known as insertional Achilles tendinosis).

Symptoms

You may see many changes when the Achilles tendon becomes inflamed. Many patients have pain and/or tightness in the tendon behind the ankle. Most of the time there is no trauma or injury, but rather a slow progression of pain. You may have difficulty climbing stairs or running. You also may have pain after sitting for long periods or after sleeping. Many patients notice a bump either in the tendon or right behind the heel bone. Some also get irritation from shoes rubbing against the bump and feel better when wearing backless shoes. Patients commonly have less pain while wearing a shoe with a low heel versus shoes that are flat.

Causes

Achilles and calf tightness are common causes of Achilles tendinosis. In addition, insertional Achilles tendinosis often is associated with a heel bone spur. This spur may rub against the Achilles tendon and lead to small tears. It is similar to a rope being rubbed against a sharp rock. This is also known as Haglund’s deformity. Pain and swelling occur as the cumulative effects of chronic wear and tear on the tendon.

Diagnosis

Your foot and ankle orthopedic surgeon will take a thorough history and perform an examination. It is common to have pain right on the tendon or at the back of the heel. You also may have swelling and thickening of the tendon. X-rays may be taken to see if there are any bone spurs. An MRI or ultrasound may be ordered to look for tears and further evaluate how much of the tendon is affected.

Treatment

Treatment depends on the length and severity of the symptoms. Many patients improve without surgery. Rest and oral medications may help reduce the swelling and pain. Heel cups can improve pain by taking some of the stress off of the Achilles tendon when walking. A walking boot or other brace may be recommended.

Often, formal physical therapy is recommended to work on stretching and improve mobility within the calf muscle. Other treatments may include ultrasound, massage, shockwave therapy, and topical nitroglycerin patches. Recently, platelet-rich plasma has been discussed as a treatment for Achilles tendinosis. This involves taking one’s own blood and isolating growth factors that are involved in healing. This serum is then injected into the inflamed tendon.

In some cases, surgery may be required. The specifics of the surgery depend upon the location and extent of the tendinosis.

FAQs

If I am treated without surgery for Achilles tendinosis will it come back?

While most patients will achieve lasting relief after treatment for Achilles tendinosis, symptoms may return. The risk decreases if the patient continues to do routine stretching even after the symptoms go away. However, athletes and runners in particular are at a slightly higher risk for this condition because of the high demands they put on the Achilles. These patients should pay close attention to stretching and shoe choice to prevent chronic recurrence.

What are the outcomes for those who have surgery for Achilles tendinosis?

Surgery can predictably return patients to activity. Success rates for Achilles tendinosis surgery are 80-90 percent. Some of the variability depends on the amount of tendon that is diseased at the time of surgery.

Patients improve with both conservative and operative management of Achilles tendinosis. Physical therapy has been shown to help most patients with this condition and should be tried before surgery is considered.

Achilles Tendon

The Achilles tendon is the largest tendon in your body. It connects the upper calf muscles to the back of the heel bone. When the Achilles tendon degenerates and becomes inflamed, it is called Achilles tendinitis or Achilles tendinosis.

If you have these conditions, your tendon can swell and become painful. They are common in athletes, runners, and people who have calf tightness. Achilles tendinosis may occur in the middle of the tendon (known as midsubstance Achilles tendinosis) or at the point where the tendon connects to the heel bone (known as insertional Achilles tendinosis).

For midsubstance Achilles tendinosis, surgery focuses on removing the diseased portion of the tendon. If most of the tendon is damaged, your foot and ankle orthopedic surgeon often will use the tendon that goes to the big toe to support the Achilles tendon after repair. Other procedures may include lengthening the Achilles tendon or calf muscles if they are too tight.

Surgery for insertional Achilles tendinosis is similar. Very often the diseased tissue is removed and the tendon is repaired back down to the heel bone. Surgeons often will shave down the bone spur and smooth it out so that it no longer has the ability to rub the Achilles tendon. Often there is a fluid-filled sac (bursa) that contributes to the pain and inflammation. This bursa frequently is removed during the surgery.

Diagnosis

Surgery may be an option for Achilles tendinitis or tendinosis if other treatments, including physical therapy, ultrasound, massage, and shock wave therapy, fail to bring pain relief.

Treatment

General anesthesia is commonly used. Regional anesthesia that numbs the leg also may be used. The patient is positioned face down on the operating table. Your surgeon will make an incision in the back of the ankle directly over the Achilles tendon. The diseased portion of the tendon is removed with a scalpel. If the problem involves the end of the tendon where it inserts on the heel bone, the tendon may be lifted off of the heel bone. The bump at the back of the bone is removed with a chisel or saw, and the tendon is repaired back down to the remaining bone. Some surgeons also perform a stretching of the calf muscles as part of the procedure. The incisions are sewn together. The leg is bandaged and then protected with a splint or boot brace.

Recovery

It may take up to a full year for symptoms to resolve completely. Often surgical patients will need several months in a protective boot and crutches before they can walk on their own. Physical therapy often is needed to help restore mobility and strength to the repaired tendon.

Surgery can predictably return patients to activity. Success rates for Achilles tendinosis surgery are 80-90%. Some of the variability depends on the amount of tendon that is diseased at the time of surgery.

Risks and Complications

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

After this surgery, patients can still have moderate pain. If the tendon is repaired there is still risk of future degeneration of the tendon as the patient ages. However, repeat surgery is rarely required. There is also a risk of Achilles tendon rupture.

FAQs

If I am treated without surgery for Achilles tendinosis will it come back?

While most patients will achieve lasting relief after treatment for Achilles tendinosis, symptoms may return. The risk decreases if the patient continues to do routine stretching even after the symptoms resolve. However, athletes and runners in particular are at a slightly higher risk for this condition because of the high demands they put on the Achilles. These patients should pay close attention to stretching, and shoe choice to prevent chronic recurrence.

Will I still have pain after surgery?

The majority of patients improve after having surgery. However, up to 20-30% of patients still report some pain after surgical treatment.

Tendon Transfer

A tendon transfer is moving a tendon from its normal, anatomic location to another area of the foot or ankle. Tendons typically are transferred in order to restore more normal movement to a foot and ankle that has lost function. A common problem is loss of the ability to raise the foot up, which is called foot drop. This can result from nerve or muscle damage due to stroke, injury, or other diseases. This muscular weakness or paralysis decreases movement and can lead to the foot becoming bent or twisted, making it difficult or painful to stand, walk, or wear shoes.

Some tendon transfers allow the ankle and foot to move up and down and regain some strength and motion. Others bring the foot into a position where it is easier to walk, stand, and wear shoes, but will not increase range of motion. Realigning the foot and ankle can also decrease pain by more evenly distributing pressure across the foot. In some cases, a tendon transfer may eliminate the need for a brace altogether.

Diagnosis

There are two common reasons your foot and ankle orthopedic surgeon may recommend a tendon transfer in the foot and ankle. One is a painful, flexible flatfoot. This develops when the posterior tibial tendon stretches and becomes nonfunctional or ruptures, which can cause the arch of the foot to drop. The foot then rolls inward, leading the patient to walk on the inside of their foot. This can cause discomfort.

The other reason is the loss of function of muscles in the lower leg and foot due to a neurological problem such as injury or disease. This can include weakness after a stroke, nerve damage after a surgery or accident, or a systemic disease causing weakness of the muscles such as Charcot-Marie-Tooth disease. These problems most typically weaken the muscles of the front and outside of the calf. This causes the foot to roll outward and the patient to walk on the outside of their foot. This can cause pain and weakness as well as bone fractures and looseness of the ligaments on the outside of the foot.

Tendon transfers usually are elective procedures. Any medical problems which make surgery more dangerous or difficult, such as a recent heart attack, stroke, blood clot, or infection, may require the procedure to be delayed or canceled.

Treatment

There are three requirements for tendon transfers to be successful:

1. The muscle that the tendon is attached to has to be functional. It must contract at the proper time during walking.
2. The soft tissue through which the tendon is to be transferred needs to be as normal as possible. Large areas of scarring or skin damage can make it difficult to transfer the tendon. It also can prevent the tendon from gliding along the correct path.
3. The joints that the tendon crosses need to be both mobile and stable.

Tendon transfers involve the cutting of the tendon at or near its normal insertion, rerouting it through the soft tissues either around or between the bones of the foot and ankle, and connecting it to another bone in the foot. When the transferred tendon is long enough, it can be passed through a tunnel drilled through the target bone and then sewn to itself. The tendon also can be brought into a bone tunnel and fastened with a screw made of metal or an absorbable plastic. An anchor with sutures attached to it also can be placed in the bone at the point the tendon is to be attached and the sutures used to sew the tendon to the anchor. The soft tissues are then closed and the patient is placed in a splint.

Recovery

Typically the splint stays on the patient’s leg for 10-14 days. At that point the splint and sutures are removed. The patient is then placed in a cast or a removable boot.

Patients typically are non-weightbearing for six weeks after surgery to allow the transferred tendon to heal to its new attachment. This can be longer or shorter depending on what is seen during surgery. After six weeks, patients usually start to bear more weight on the leg and are placed in a boot if they aren’t in one already. Patients are out of the cast or boot by 12 weeks after surgery.

Physical therapy usually is needed to regain the strength of the transferred muscle and to help the patient learn to walk more normally. The transferred muscle is weaker than it was in its original functional position because of the transfer. There may be some limitations in motion of the foot due to the tendon transfer, but the function regained by the transfer should outweigh the function lost.

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. Sometimes the tendon transfer does not heal into its new position. The implant could break or loosen, or there could be progression of the original neurologic condition requiring further surgery.

FAQs

Will my foot move normally after the tendon transfer?

It depends on which tendon transfer you have. Some tendon transfers act as a leash for the foot and simply hold it in proper alignment. This does not necessarily provide much movement for your ankle and foot. Other tendon transfers move functional muscles from one side of the foot to the other, and therefore the foot should have a more normal movement after these procedures. The goals for the surgery and recovery should be discussed with your foot and ankle orthopedic surgeon before proceeding with any procedure.