Flatfoot, PTCD, PCFD

Posterior Tibial Tendon Insufficiency
Adult Acquired Flatfoot Deformity
Progressive Collapsing Foot Deformity

The names attributed to this condition, such as Posterior Tibial Tendon Insufficiency (PTTI) or Adult Acquired Flatfoot Deformity (AAFD), have created misunderstanding for patients. For example, the name PTTI has been used because the posterior tibial tendon, located on the inner side of the hindfoot, is often what is first symptomatic. Unfortunately, usually at the same time or before, the ligaments which support the foot also fail. The ligaments are what hold the bones together in their correct alignment. Although it is not initially painful, ligament failure ultimately leads to the collapsing deformity of the foot by letting the bones shift more and more out of place. The collapse of the foot is the most significant and debilitating problem associated with this condition. As the collapsing deformity progresses, it becomes more and more symptomatic and patients find that the foot does not support them well. As the deformity continues to progress, patients will go from a limited ability to exercise to a limited ability to walk.

Another name that has been attributed to this condition is Adult Acquired Flatfoot Deformity (AAFD). This has also caused misunderstanding. Most patients with this condition have had a flatfoot for most, if not all of their adult life. Their flatfoot was initially present for years but asymptomatic or minimally symptomatic, as is the case for most flatfeet. Over time and most often without an accident, the flatfoot changes into a collapsing foot. This is a progressive condition that, unless stopped, leads to a severe, painful and progressive problem interfering with simple ambulation.

Why does this occur in certain flatfeet? Standing CAT (CT) scans have offered a clue: not all flatfeet are alike. Some flatfeet have a different angulation at the subtalar joint which places abnormal stress on the posterior tibial tendon and hindfoot/midfoot ligaments. The subtalar joint is located just below the ankle joint. Over years, this abnormal stress leads to gradual failure of the posterior tibial tendon and the ligaments. Unfortunately, no orthotic or brace stops this progressive failure.

The key to treatment is to make the foot as stable and normal functioning as possible. The bony alignment must be surgically corrected in such a way that deformity will not recur, yet preserve as much of the normal range of motion and strength in the foot. This often requires a tendon transfer and repositioning osteotomies to realign bones to correct the deformity. In more severe cases, osteotomies alone are not successful and fusion of joints is necessary. To avoid fusion of major joints, such as the subtalar and talonavicular joints (Figure 1), ligament reconstruction (Figure 2) can be done in properly selected cases. These joints are what provide the side-to-side motion (inversion and eversion) of the foot, which is an important function for comfortable walking, especially on uneven ground. Fusion of the subtalar joint causes some loss of this motion; fusion of the talonavicular joint causes loss of all of this motion.

Repair of these ligaments alone is not effective as the tissue is degenerated, similar to how the posterior tibial tendon becomes degenerated and weak and less amenable to repair alone. However, a key ligament called the spring ligament can be reconstructed. This procedure, called a Spring Ligament Reconstruction, is a technique which I help develop and have published on. This procedure can be used in severe cases to avoid major fusions, and in less severe cases to avoid overstiffening the foot. Its success has been documented.^{2,21,26,27,29,40,41} I am presently working on a submission with more patients and long term results which are very favorable (see patient testimonial and images below).

In recent years, I have been the invited guest at the largest association of foot and ankle orthopaedic surgeons, the AOFAS (Association of Orthopaedic Foot and Ankle Surgeons), as well as other associations (see my talks below, including a talk I was asked to give, "Why they call me Mr. Flatfoot"). The invitations have been to give talks on how to best restore these feet to the most normal function. This involves judging precisely the amount of correction. A good example of this is an osteotomy called lateral column lengthening. This osteotomy can overstiffen the foot or not provide enough correction if not judged properly. Ref.²² How to avoid or minimize this problem of over or undercorrection is something I have published on, and I have commonly been successful achieving very good function.^15,16,22,28 (See patient testimonial and images below)

This patient has correction that has allowed him to continue surfing which requires good motion and not much stiffness. He has held up without under or overcorrection and has excellent function.

There are different stages of PTTI (AAFD, PCFD) which are determined by the type and severity of deformity. Stage 1 describes a patient with a longstanding flatfoot who has developed symptoms from degeneration/possible tearing of the tendon but no deformity is present other than the flatfoot the patient has had in adulthood. The largest stage is Stage 2, which is characterized by a flexible deformity from the condition. In this stage the foot can be manipulated into a normal position when the patient is not putting weight on the foot and even into what is described as inversion, the motion normally created by swinging the foot inward through the hindfoot (subtalar and talonavicular joints). There are different grades of severity within Stage 2. Stage 3 is characterized by fixed deformity meaning that the foot cannot be manipulated into enough correction and inversion. Fusion of the talonavicular joint and possibly other joints is most often necessary. In Stage 4, the condition progresses to the ankle with failure of the biggest ligament of the foot and ankle, the deltoid ligament. Deltoid ligament failure causes a tilting deformity in the ankle, which over time leads to ankle arthritis. Therefore, now the patient has a very significant problem in the foot and the ankle. Fortunately, I have developed a deltoid ligament reconstruction which has shown long-term success (see patient testimonials and images below)

If at all possible, it is best not to wait long before correcting your foot if your foot is in Stage 2, 3, or 4. Patients commonly do not go through Stage 1 as the ligaments often fail concurrently with the tendon, rather than before. Therefore, a patient most often starts in Stage 2 and gradually collapses the foot during that stage. The speed of progression varies considerably, sometimes fairly quickly over months, other times somewhat slower. As the deformity progresses, it becomes less and less possible to correct the foot back to as normal function as it would have if the surgery was done earlier. No matter what stage you are in, I will do everything I can to make your foot as normal as possible. But try not to wait too long; the condition is definitely progressive and waiting means starting off with a worse foot.

In order to treat early Stage 2 deformity, procedures such as a posterior calcaneal osteotomy (medial heel slide) and flexor tendon transfer will be used to correct hindfoot alignment and augment or reconstruct a failing posterior tibial tendon. If there is more deformity in the subtalar and talonavicular joints (joints in the hindfoot and proximal midfoot), another procedure such as lateral column lengthening mentioned above may need to be done. This procedure is a key part of my expertise. I have developed trial blocks in 1 mm increments to intraoperatively judge the correct amount of lengthening necessary while still allowing good remaining motion for the best function.²² (See video below of a patient’s motion postoperatively)

Flatfoot deformity is complicated and there are many joints in the foot that can be affected. If part of your Achilles tendon (gastrocnemius tendon) is too tight it may need to be lengthened without lengthening the whole Achilles tendon to take stress off the foot joints. If the first metatarsal bone (the bone going from the midfoot to the base of the big toe) is elevated, it can be corrected with a bone wedge to reposition it (see images below). In more severe cases, a proximal fusion (first tarsometatarsal fusion) is done which fortunately results in minimal stiffness. These procedures are important and are common, but do not always have to be done.

Our goal is also to make your recovery as speedy and best as possible to get you to the best functioning foot. Some patients can be put in a removable boot at 3-4 weeks after surgery, and begin weight-bearing at 5-6 weeks. This can vary depending on how fast you heal and what procedures need to be done. The hindfoot and midfoot fusions such as subtalar and talonavicular fusion take somewhat longer to heal, while the medial calcaneal osteotomy and lateral column lengthening heal faster, usually by 5-6 weeks.

I have spent considerable time studying and publishing how to best treat this condition. I have published more than 50 articles and even more presentations at meetings. But that is not what is key. What is much more important is to use skill and experience to give every patient the best result and most up to date treatment.

Recovery Guidelines

0-2 weeks

Elevate your foot 80 to 90% of the time but get up 6 to 8 times a day, 15-20 minutes at a time to mobilize, go to the bathroom and do other things. It is good for you to get up but for short periods of time. Always sit by the side of the bed first and make sure you are not dizzy before you get up. You can also do upper body exercises.

2-6 weeks

A few days after your 2 week visit, you can get out more and do less elevation. For the first 2 or 3 days after the visit, continue to elevate the foot 80 to 90% of the time but after that, as you feel better, you can have the foot down for 1-2 hours at a time. By 4 weeks usually the foot can be dependent nearly all the time depending on how the foot is feeling and the amount of swelling. At the 3-4 week time period, you can be taken out of the short leg fiberglass cast and put in a removable boot. At this point you can start appropriate exercises which will be shown to you. Whenever you are walking, the boot must be on and you must not bear weight on that foot.

6-10 weeks

During this time period partial weight-bearing will begin with progression to full weight-bearing. Formal physical therapy can also be started. If no fusion has been done at the subtalar or talonavicular joints, partial weight-bearing usually starts after the CAT (CT) scan at the 6 week visit. For those patients with a subtalar fusion or talonavicular fusion, weight-bearing starts a usually a few weeks later as those fusions heal slower than osteotomies. A CT scan is done at 8-9 weeks for subtalar or talonavicular fusions (no scans at 6 weeks) and weight-bearing started at that time.

10-12 weeks

Progress with walking, including some walking out of the boot in an athletic type shoe at home. By 12-14 weeks, no more boot!

Flatfoot Publications

1. de Cesar Netto, C., Godoy-Santos, A.L., Saito, G.H., Lintz, F., Siegler, S., O’Malley, M.J., Deland, J.T. and Ellis, S.J., 2019. Subluxation of the Middle Facet of the Subtalar Joint as a Marker of Peritalar Subluxation in Adult Acquired Flatfoot Deformity: A Case-Control Study. JBJS, 101(20), pp.1838-1844.

2. Brodell Jr, J. D., MacDonald, A., Perkins, J. A., Deland, J. T., & Oh, I. (2019). Deltoid-spring ligament reconstruction in adult acquired flatfoot deformity with medial peritalar instability. Foot & ankle international, 40(7), 753-761.

3. Conti MS, Garfinkel JH, Kunas GC, Deland JT, Ellis SJ. Postoperative Medial Cuneiform Position Correlation With Patient-Reported Outcomes Following Cotton Osteotomy for Reconstruction of the Stage II Adult-Acquired Flatfoot Deformity. Foot Ankle Int. 2019 Jan 18:1071100718822839.

4. Conti MS, Jones MT, Savenkov O, Deland JT, Ellis SJ. Outcomes of Reconstruction of the Stage II Adult-Acquired Flatfoot Deformity in Older Patients. Foot Ankle Int. 2018 Sep;39(9):1019-1027.

5. Kunas GC, Do HT, Aiyer A, Deland JT, Ellis SJ. Contribution of Medial Cuneiform Osteotomy to Correction of Longitudinal Arch Collapse in Stage IIb Adult-Acquired Flatfoot Deformity. Foot Ankle Int. 2018 Apr;39(8):885-893.

6. Conti MS, Jones MT, Savenkov O, Deland JT, Ellis SJ. Outcomes of Reconstruction of the Stage II Adult-Acquired Flatfoot Deformity in Older Patients. Foot Ankle Int. 2018 May;1-9.

7. Kunas GC, Do HT, Aiyer A, Deland JT, Ellis SJ. Contribution of Medial Cuneiform Osteotomy to Correction of Longitudinal Arch Collapse in Stage IIb Adult-Acquired Flatfoot Deformity. Foot Ankle Int. 2018 Apr;39(8):885-893.

8. Sunders SM, Ellis SJ, Demetracopoulos CA, Marinescu A, Burkett J, Deland JT. Comparative Outcomes Between Step-Cut Lengthening Calcaneal Osteotomy vs Traditional Evans Osteotomy for Stage IIB Adult-Acquired Flatfoot Deformity. Foot Ankle Int. 2017 Oct;39(1):18-27.

9. Code EA, Williamson ER, Burket JC, Deland JT, Ellis SJ. Correlation of Talar Anatomy and Subtalar Joint Alignment on Weightbearing Computed Tomography with Radiographic Flatfoot Parameters. Foot Ankle Int. 2016 Aug;37(8):874-81.

10. Soukup DS, Macmahon A, Burket JC, Yu JM, Ellis SJ, Deland JT. Effect of Obesity on Clinical and Radiographic Outcomes Following Reconstruction of Stage II Adult Acquired Flatfoot Deformity. Foot Ankle Int. 2016 Mar;37(3)245-54.

11, Demetracopoulos CA, Nair P, Malzberg A, Deland JT. Outcomes of a Stepcut Lengthening Calcaneal Osteotomy for Adult-Acquired Flatfoot Deformity. Foot Ankle Int. 2015 Jul;36(7):749-55.

12. Conti MS, Ellis SJ, Chan YJ, Do HT, Deland JT. Optimal Position of the Heel Following Reconstruction of the Stage II Adult-Acquired Flatfoot Deformity. Foot ankle Int. 2015 August;36(8):919-27.

13. Chan JY, Greenfield ST, Soukup DS, Do HT, Deland JT, Ellis SJ. Contribution of Lateral Column Lengthening to Correction of Forefoot Abduction in Stage IIb Adult Acquired Flatfoot Deformity Reconstruction. Foot Ankle Int. 2015 Jul 27.

14. Haleem AM, Pavlov H, Bogner E, Sofka C, Deland JT, Ellis SJ. Comparison of deformity with respect to the talus in patients with posterior tibial tendon dysfunction and controls using multiplanar weight-

bearing imaging or conventional radiography. J Bone Joint Surg Am. 2014 Apr 16;96(8):e63

15. Baxter JR, Demetracopoulos CA, Prado MP, Gilbert SL, Tharmviboonsri T, Deland JT. Graft Shape Affects Midfoot Correction and Forefoot Loading Mechanics in Lateral Column Lengthening Osteotomies. Foot Ankle Int. 2014 Jul 31.

16. Vosseller JT, Ellis SJ, O’Malley MJ, Elliott AJ, Levine DS, Deland JT, Roberts MM. Autograft and allograft unite similarly in lateral column lengthening for adult acquired flatfoot deformity.. HSS J. 2013 Feb;9(1):6-11.

17. Vulcano E, Deland JT, Ellis SJ. Approach and treatment of the adult acquired flatfoot deformity. Curr Rev Musculoskelet Med. 2013 Jun 94.

18. Mani SB, Brown HC, Nair P, Chen L, Do HT, Lyman S, Deland JT, Ellis SJ. Validation of the Foot and Ankle Outcome Score in adult acquired flatfoot deformity. Foot Ankle Int. 2013 Aug;34(8):1140-6.

19. Mani SB, Brown HC, Nair P, Chen L, Do HT, Lyman S, Deland JT, Ellis SJ. Validation of the Foot and Ankle Outcome Score in Adult Acquired Flatfoot Deformity. Foot Ankle Int. 2013;34(8):1140-6.

20. Chan JY, Williams BR, Nair P, Young E, Sofka C, Deland JT, Ellis SJ. The contribution of medializing calcaneal osteotomy on hindfoot alignment in the reconstruction of the stage II adult acquired flatfoot deformity. Foot Ankle Int.2013;34(2):159-66.

21. Deland JT. Spring Ligament Complex and Flatfoot Deformity:Curse or Blessing? Foot Ankle Int. 2012:33(3)

22. Ellis SJ, Williams BR, Garg R, Campbell G, Pavlov H, Deland JT. Incidence of plantar lateral foot pain before and after the use of trial metal wedges in lateral column lengthening. Foot Ankle Int.2011;32(7):665-73

23 Ellis, S J., Williams, B R., Wagshul, A D., Pavlov, H., Deland, J.T. 2010, Deltoid ligament reconstruction with peroneus longus autograft in flatfoot deformity. Foot Ankle Int 2010 ; 31 (9): 781-789

24. Oh I, Williams BR, Ellis SJ, Kwon DJ, Deland JT. Reconstruction of the symptomatic idiopathic flatfoot in adolescents and young adults. Foot Ankle Int. 2011;32(3):225-32

25. Ellis SJ, Deyer T, Williams BR, Yu JC, Lehto S, Maderazo A, Pavlov H, Deland JT. Assessment of lateral hindfoot pain in acquired flatfoot deformity using weightbearing multiplanar imaging. Foot Ankle Int 2010;31(5):361-7.

26. Williams BR, Ellis SJ, Pavlov H, Deland JT. Reconstruction of the Spring Ligament using a Peroneus Longus Autograft Tendon Transfer. Foot Ankle Int 2010; 31(7):567-577.

27. Williams BR; Ellis, SJ; Deland, JT. Spring ligament reconstruction in posterior tibial tendon insufficiency. Current Orthopaedic Practice 2010; 21(3):268-272.

28. Ellis SJ, Yu JC, Johnson H, Elliott AA, O’Malley MJ,Deland JT. Plantar Pressures in Patients with and without Lateral Foot Pain after Lateral Column Lengthening. J Bone Joint Surg Am 2010; 92(1):81-92.

29. Ellis SJ, Williams BR, Yu JC, Deland JT Spring Ligament Reconstruction for Advanced Flatfoot Deformity with the Use of an Achilles Allograft. Operative Techniques in Orthopaedics 2010; 20:175-182.

30. Williams BR, Ellis SJ, Yu JC, Deland JT Stage IV Adult-Acquired Flatfoot Deformity Deltoid Ligament Reconstruction. Operative Techniques in Orthopaedics 2010; 20:183-189.

31. Ellis SJ, Yu JC, Williams BR, Lee C,Chiu YL,Deland,JT. New radiographic parameters assessing forefoo abduction in the adult acquired flatfoot deformity. Foot Ankle Int 2009; 30(12):1168-1176.

32. Deland JT. Adult-acquired Flatfoot Deformity, J Am Acad Orthop Surg 2008;16(7):399-406.

33. Deland JT,Hamilton WG. Posterior tibial tendon tears in dancers. Clin Sports Med 2008;27(2):289-94.

34. Tellisi N, Lobo M, O’Malley MJ, Kennedy JG, Elliott AJ, Deland JT. Functional outcome after surgical reconstruction of posterior tibial tendon insufficiency in patients under 50 years. Foot Ankle Int 2008;29(12):1179-83, 2008

35. Deland JT, Page A, Sung I-H, O’Malley MJ, Inda D, Choung S: Posterior Tibial Tendon Insufficiency Results at Different Stages. HSS Journal 2006; 2(2):157-160.

36. Deland JT, de Asla, RJ, Segal A. Reconstruction of the Chronically Failed Deltoid Ligament: A New Technique, Foot Ankle Int 2004; 25(11):795-799.

37. Sung I-H, Choi C-HC, Hwang K-T, Deland JT. Medial Structures of the Posterior Calcaneal Osteotomy: Anatomical Study. J. of Korean Orthop. Assoc.2004; 39(4):517-21.

38. Deland JT, de Asla, RJ., Sung, I-H, Ernberg, L.A., Potter, H.G.Posterior Tibial Tendon Insufficiency: Which Ligaments are Involved? Foot Ankle Int 2005; 26(6):427-435.

39. Sung I-H, Lee S, Otis JC, Deland JT. Medial Displacement Calcaneal Osteotomy – Biomechanical Effect on Calcaneal Inversion. J of Korean Orthop. Assoc. 2002;37(6):777-780.

40. Kyungjin C, Lee S, Otis JC, Deland JT. Anatomical reconstruction of the spring ligament using peroneus longus tendon graft. Foot Ankle Int 2003;24(5):430-436.

41. Deland JT. The Adult Acquired Flatfoot and Spring Ligament Complex, Pathology and Implications for Treatment. Foot Ankle Clin 2001;6(1)129-135.

42. Song SJ, Deland JT: Outcome Following Addition of Peroneus Brevis Tendon Transfer For Treatment of Acquired Posterior Tibial Tendon Insufficiency. Foot Ankle Int 2001; 22(4):301-4.

43. Song S, Lee S, O’Malley M, Otis JC, Sung IH, Deland JT Deltoid Ligament Strain After Correction of Flatfoot Deformity by Triple Arthrodesis. Foot Ankle Int 2000;21(7): 573-577.

44. Sung IH, Lee S, Otis JC, Deland JT. Posterior Tibial Tendon Force Requirement in Early Heel Rise After Calcaneal Osteotomies. Foot Ankle Int 2000;23(9):842-846.

45. Deland JT, Page AE, Kenneally SM. Posterior Calcaneal Osteotomy with Wedge: Cadaveric Testing of a New Procedure for Insufficiency of the Posterior Tibial Tendon.Foot Ankle Int 1999;20(5):290-295.

46. Otis JC, Deland JT, Kenneally SM, Chang V. Medial Arch Strain after Displacement Calcaneal Osteotomy: An Invitro Study, Foot Ankle Int 1999;20(4):222-226.

47. Otis JC, Deland JT, Kenneally S, Chang V. Medial Arch Strain After Lateral Column Lengthening: An Invitro Study. Foot Ankle Int 1999;20(12):797-802.

48. Dyal CM, Feder J, Deland JT, Thompson FM. Pes Planus in Patients with Posterior Tibial Tendon Insufficiency: Asymptomatic Versus Symptomatic Foot. Foot Ankle Int 1997; 18(2):85-88.

49. Deland JT, Lee K, Otis J, Hogel S. Lateral Column Lengthening with Calcaneocuboid Fusion: Range of Motion in the Triple Joint Complex. Foot Ankle Int 1995;16(11):729-733.

50. Davis WH, Sobel M, Deland JT, DiCarlo EF, Torzilli P, Deng X, Geppert MJ, Patel MB.The Gross, Histological and Microvascular Anatomy and Biomechanical Testing of the Spring Ligament Complex. Foot Ankle Int 1996;17(2):95-102.

51. O’Malley MJ, Deland JT, Lee KT. Selective Hindfoot Arthrodesis for Correction of the Adult Acquired Flatfoot

52. Deland JT, Davis WH, Torzilli P, Sobel M, Bohne WHO, Patel MB. Anatomy and Biomechanical Testing of the Spring Ligament Complex. Orthop Trans 1994;18(1):55-56.

53. Davis WH, Deland JT, Sobel M, Thompson FM, et al.The Histology of the Spring Ligament: Normal and Pathologic. Orthop Trans 1994;18(1):61.

54. Deland JT. Posterior Tibial Tendon Insufficiency: Soft-Tissue Reconstruction. Operative Tech Orthop 1992; 2(3):157-161.

55. Deland JT, Arnoczky SP, Thompson FM. Adult Acquired Flatfoot Deformity at the Talonavicular Joint: Reconstruction of the Spring Ligament in an In-Vitro Model. Foot and Ankle 1992; 13(6):327-333.

• Deland JT: My Most Challenging Cases. Scientific Programming of “O Pé Plano”course presentation. Brazilian Association of Medicine and Surgery of Ankle and Foot. São Paulo, Brazil. Dec 6 and 7, 2019.
• Deland JT: Subtalar Fusion in the Treatment of the Flatfoot. Scientific Programming of “O Pé Plano”course presentation. Brazilian Association of Medicine and Surgery of Ankle and Foot. São Paulo, Brazil. Dec 6 and 7, 2019.
• Deland JT: Medial Ligaments Reconstruction – Surgical Techniques and Indications, Pearls and Pitfalls. Scientific Programming of “O Pé Plano”course presentation. Brazilian Association of Medicine and Surgery of Ankle and Foot. São Paulo, Brazil. Dec 6 and 7, 2019.
• Deland JT: Midfoot Procedures and Approach of the First Ray . Scientific Programming of “O Pé Plano”course presentation. Brazilian Association of Medicine and Surgery of Ankle and Foot. São Paulo, Brazil. Dec 6 and 7, 2019.
• Deland JT: The Correlation Between Lateral Column Lengthening and Hindfoot Valgus Correction. Scientific Programming of “O Pé Plano”course presentation. Brazilian Association of Medicine and Surgery of Ankle and Foot. São Paulo, Brazil. Dec 6 and 7, 2019.
• Deland JT: Why do they call me Mr. Flatfoot. Scientific Programming of “O Pé Plano”course presentation. Brazilian Association of Medicine and Surgery of Ankle and Foot. São Paulo, Brazil. Dec 6 and 7, 2019.
• Deland JT: Is Lateral Column Lengthening Dead? Association of Orthopaedic Foot and Ankle Surgeons (AOFAS) Specialty Day2019. March, 2019.
• Deland JT: My approach to the management of the severe flatfoot deformity. 13th Biennial Canadian Orthopaedic Foot and Ankle Symposium. April, 2018.
• Deland JT: Panel member: Navicular trauma, Lesser toes, Hallux valgus, Tendon disorders. Moderator and panel member: Flatfoot. Moderator: Ankle arthritis I. AOFAS Surgical Complications of the Foot and Ankle Course. Durham NC, May 16-18, 2013.
• J.T. Deland: Spring Ligament Complex in Flatfoot Deformity: Curse or blessing? Podium Presentation.Summer Meeting of the American Orthopedic Foot and Ankle Society. Denver CO, July 15, 2011
• J.T. Deland: Treatment of the Adolescent Flexible Flatfoot, Specialty Day (Pediatric), AAOS, 2011.

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