Review Question - QID 211726

The patient is an elderly individual with an adult-acquired flatfoot deformity. She has a flexible deformity and is unable to perform a single-leg heel raise, which is consistent with stage II posterior tibial tendon insufficiency (PTTI). The optimal initial management for patients with this stage of pathology is orthotic management with either a molded University of California Biomechanics Laboratory (UCBL) orthotic (Figure C) or an ankle-foot orthosis (AFO).

PTTI is the most common cause of adult-acquired flatfoot deformity. It occurs more commonly in women and often presents in the sixth decade of life. The pathogenesis is secondary to attenuation and tenosynovitis of the posterior tibial tendon, which leads to progressive medial arch collapse. The treatment for PTTI is stage-dependent. Nonoperative management with orthotics is the initial treatment for patients with stage II, III and IV disease, or for patients who are otherwise poor operative candidates. Failure of nonoperative management is an indication for surgery, which is typically a combination of tendon transfers, hindfoot osteotomies and soft-tissue balancing. Arthrodesis is reserved for the more advanced stages of PTTI.

Chao et al. performed a prospective evaluation of the use of a variety of braces for the management of stage II and III PTTI. Their study cohort included 49 patients (53 feet) with a mean patient age of 66 years at the initiation of treatment. Patients with a rigid deformity were managed with a molded ankle-foot orthosis, and those with a flexible deformity were managed with a University of California Biomechanics Laboratory (UCBL) shoe insert with medial posting. 67% of patients had good to excellent functional outcomes. The average period of orthoses use was 14.9 months. The authors concluded that patients with both stage II and III PTTI can be treated initially by aggressive bracing, and that surgical management should be reserved for patients who do not respond to this modality.

Pinney et al. performed a current concepts review on the various treatment options for acquired adult flatfoot deformity. They state that the goal of bracing is to support the medial arch of the foot and minimize the hindfoot valgus. They note that the UCBL is an effective orthotic choice for patients with a flexible deformity, and is an appropriate first-line orthotic option for patients with stage II PTTI. They do note, however, that the orthotic may be uncomfortable for patients with a rigid deformity and that there exists the possibility for skin breakdown if used for a rigid deformity.

Lin et al. performed a retrospective study of the use of a double upright ankle-foot orthosis (DUAFO) for stage II PTTI. Their study cohort consisted of 32 patients (33 feet) with a mean age of 57.6 years at the initiation of treatment. At a mean follow-up of 8.6 years, 69.7% of patients were brace-free, 15.2% were still brace-dependent and 15.2% had gone on to require a surgical intervention. The authors concluded that treatment of stage II PTTI with a DUAFO was an effective nonsurgical treatment option, with a majority of patients able to avoid surgery and ween out of brace wear.

Figure A depicts a right-sided flatfoot deformity, with the classic "too many toes" sign consistent with talonavicular uncoverage. Figure B depicts a rocker bottom shoe. Figure C depicts a molded University of California Biomechanics Laboratory (UCBL) orthotic.

Incorrect Answers:

Answer 1: This depicts a rocker bottom shoe, which has no role in the treatment of PTTI. This orthotic is typically used to manage patients with ankle or subtalar arthritis or calcaneal ulcers.
Answer 3: Physical therapy with a focus on gastrocsoleus complex eccentric strengthening would be the appropriate initial management for a patient with insertional Achilles tendinopathy, not stage II PTTI.
Answers 4 and 5: Surgery should be reserved for patients who fail a trial of aggressive bracing. It is not the appropriate initial management for patients with stage II PTTI.