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Year : 2020  |  Volume : 17  |  Issue : 2  |  Page : 94-98

Nonsurgical treatment of adult acquired flatfoot is effective: A narrative review

Department of Orthopedics, Indraprastha Apollo Hospital, New Delhi, India

Date of Submission16-Mar-2020
Date of Acceptance16-Apr-2020
Date of Web Publication18-Jun-2020

Correspondence Address:
Abhishek Vaish
Indraprastha Apollo Hospital, New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/am.am_15_20

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Adult acquired flatfoot is a common clinical condition having complex pathology-posterior tibial tendon insufficiency and failure of ligamentous and capsular structures of the foot. There still remains a controversy in the management algorithm of the flexible flat foot. Conservative management is considered as the initial treatment, surgery being offered only when the conservative measures fail. The paramount importance is to assess the functional outcomes of conservative treatment, as not enough publications exist to evaluate its importance. This study aims to analyze evidence of benefits with nonsurgical treatment of the adult acquired flat foot. Online databases such as PubMed, Google Scholar, and Scopus were systematically searched for nonsurgical treatment of adult acquired flat foot in November 2019. Keywords used were “Flatfoot,” “Adult,” and “Pes planus.” The Boolean operators used were (AND), (OR), and (NOT). Five studies that matched our criteria were analyzed to assess the nonoperative treatment of adult flat foot for this review. Patient satisfaction with nonoperative treatment ranged from 60.6% to 89%. Conservative treatment was successful in 83%–87.5% and only the remaining patients required surgery. All of these studies support the use of a conservative approach in the management of acquired flatfoot deformity in adults in the form of orthotics with or without physiotherapy. Conservative methods are the mainstay of the management for Stage I and II AAFFF (Adult Acquired Flexible Flat Foot) with satisfactory functional results. The patient education and a reasonable period of care are essential for good outcomes. Surgery is necessary for patients in whom conservative management has failed and in all patients with fixed deformities.

Keywords: Adult, conservative treatment, flat foot, flexible deformity, pes planus

How to cite this article:
Vaish A, Sitaula J, Vaishya R. Nonsurgical treatment of adult acquired flatfoot is effective: A narrative review. Apollo Med 2020;17:94-8

How to cite this URL:
Vaish A, Sitaula J, Vaishya R. Nonsurgical treatment of adult acquired flatfoot is effective: A narrative review. Apollo Med [serial online] 2020 [cited 2020 Jul 8];17:94-8. Available from: http://www.apollomedicine.org/text.asp?2020/17/2/94/287079

  Introduction Top

In flat foot (pes planus), there is a decrease in the medial longitudinal arch with hindfoot in valgus and forefoot in the abduction. Adult-onset flat foot is a common problem encountered in day to day practice and affects middle-aged women more frequently. A prevalence of 5%–14% is reported among the adult population.[1] Flat foot in an adult is usually asymptomatic initially but can be a significant source of pain around heel, calf and midfoot, deformity, and functional loss in the foot. The treatment of flat foot depends on the patient's symptoms, age, and level of activities.[2] Both conservative and surgical options are available.

We found very few recent studies in the literature on the conservative management of flat foot. Surgical options are increasing but some patients cannot be operated because of their comorbidities or socioeconomic concerns. Moreover, the prognosis of most patients with adult acquired flatfoot is favorable with conservative treatment and most of them may not need surgery. An initial period of immobilization followed by support can yield satisfactory results in symptomatic patients with success rates ranging from 67% to 90%.[3] Furthermore, the postoperative recovery is lengthy, and often the surgical procedures require a cast immobilization for 2 to 3 months. The purpose of this research is to review the functional outcomes of the adult flat foot with conservative treatment.

  Materials and Methods Top

Online databases such as PubMed, Google Scholar, and Scopus were systematically searched for nonsurgical treatment of adult acquired flat foot in November 2019. Only articles published after 2001 in English were reviewed. The study that did not report on foot was excluded. Keywords used were “Flatfoot,” “Adult,” “Pes planus,” “Flexible” and “Conservative.” The Boolean operators used were (AND), (OR), and (NOT). The full text was obtained and reviewed for the studies after meeting inclusion criteria [Figure 1]. Five studies that matched our criteria were analyzed to assess the nonoperative treatment of adult flat foot for this review.
Figure 1: A flowchart showing the process of selection of studies for conservative management of flat foot in adults

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  Results Top

The characteristics of various studies that were reviewed are shown in [Table 1].
Table 1: Studies examining the nonsurgical treatment of adult acquired flatfoot

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All of these studies included adults having symptoms of acquired flat foot-the age group ranged from 14 to 88 years.[3] The minimum sample size among the studies was 30. The duration of symptoms was from a median of 5 months [4] to 19.3 months.[7] The duration of treatment ranged from 6 weeks [5] to 14.9 months.[7]

The total number of patients who underwent conservative treatment of adult flat foot in these five studies was 211 (217 feet). Among the 196 patients that were included in the final study, there were 44 males (22.45%) and 152 females (77.55%). The median age was 50 and 60 years in the study of Alvarez et al.[3] and Jari et al.,[6] respectively. The mean age of the remaining studies was 48.62 years.[4],[5],[7] Only Alvarez et al. mentioned the side affected 47% right-sided involvement, 49% left-sided, and 4% bilateral.[3]

The diagnosis of the flat foot was clinical and imaging was not routinely used. However, in the study of Nielsen et al.,[4] 46.55% of patients underwent magnetic resonance imaging (MRI) and Jari et al. did MRI for only those patients who required surgery. A single support heel rise (SSHR) test was used by Alvarez et al. for the assessment before and after treatment. Similarly, Lin et al. used a single-limb heel-rise (SLHR) test. Staging of the severity of disease was done according to the Johnson and Strom classification.[6] Alvarez et al.[3] included Stage I and II, Lin et al.[7] Stage II, Bek et al.[5] Stage I, II, and III, and Jari et al.[6] included all four stages in their study. The duration of follow-up also varied in these studies. The maximum follow up being 10 years in the study by Lin et al.

Various forms of nonoperative treatment were used in these studies as shown in [Table 2]. The distribution of orthoses applied to the patients is shown in [Table 3].
Table 2: Nonoperative treatment modalities used in adult flat foot

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Table 3: Orthotic support used

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  Discussion Top

The natural history of the flat foot has not been fully understood, despite being a common clinical condition. It is assumed to be detrimental to function and associated with pain; left untreated adult acquired flat foot can progress to more severe stages that will require more extensive treatment. Early diagnosis is critical and can even help avoid surgery in some patients. However, it is not possible to predict which flat feet will, and will not, develop symptoms, or what the symptoms would be.

The current classification systems classify flat feet as normal, flexible, or rigid, as well as separating out tibialis posterior tendon dysfunction.[8] Various etiology of adult-acquired flatfoot deformity have been proposed including arthritic, neuromuscular, and traumatic conditions; however, posterior tibial tendon dysfunction (PTTD) remains the most common etiology [Table 4]. The adult acquired flat foot deformity has been classified into four stages [Table 5].[9]
Table 4: Etiology of adult-acquired flatfoot deformity

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Table 5: Stages of flatfoot deformity in adults

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Flat feet were more common in females in all of the studies. It may be because of foot anatomy-males have longer and broader feet whereas females have shorter feet but higher arches. The type of footwear may also play a role. For instance, females wearing high heel footwear. Hormonal changes during pregnancy may cause relaxation of ligaments in the ankle and the foot arch complex causing flat foot.

Different methods of conservative treatment of adult flat foot were used in these studies. Almost all of them used some form of the orthosis with or without physiotherapy. Alvarez et al.[3] used orthosis and a structured exercise program. A short articulated ankle-foot orthosis (SAAFO) was used if symptomatic for >3 months and a three-quarter-length foot orthosis if symptomatic for <3 months. Rehabilitation included isokinetic exercise, exercise band, heel raise, and toe-walking for specific muscles (posterior tibial, anterior tibial, peroneal, and gastroc-soleus).

Nielsen et al.[4] used physical therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), and corticosteroids as initial treatment. In the long term treatment foot orthosis, an arch and ankle brace, low-articulating ankle-foot orthosis, cast-boot, or shoe modification was used. Similarly, Jari et al.[6] used both orthosis and physiotherapy for the management of flat foot. Patients with Stage I or II diseases were referred for physiotherapy. Patients having correctable deformities were given University California Biomechanics Laboratory (UCBL) orthoses and patients having fixed deformities were treated with supportive or molded foot orthoses.

Other studies included the only orthosis with no formal physical therapy. Lin et al.[7] used DUAFO (Double Upright Ankle Foot Orthosis) and Bek et al.[5] used a medial wedge and medial arch support, UCBL orthosis, air cast, and ankle-foot orthosis.

The final outcome of these nonoperative treatments of the flat foot was assessed using various outcome measures: pain and function, different scoring methods, and patient satisfaction. Pain in foot and ankle was assessed using the visual analog scale (VAS, scale 0–10). Average VAS was 1 in the study of Alvarez et al.,[3] and 1.9 in Lin et al. 83% patients could perform a painless SSHR and 15% could perform SSHR with pain.[3] However, in the study of Lin et al., only 42.3% had a normal SLHR; 19.2% had weak SLHR and the rest 38.5% were unable to do SLHR. The foot function index (FFI)[10] includes three subscales: foot pain, disability, and activity limitation.[10] Following 6 weeks of orthotic use, there was a 50% decrease in pain and disability rates (Bek et al.). Furthermore, Lin et al. had an improved FFI of 18.4 (activity 11.4, pain 18.0, and disability 25.86). The average AOFAS hindfoot score was [11] 78.4 (subjective 42.6 and objective 35.7). Jari et al. showed that patients with advanced disease had a poor AOFAS scale - the median score was 71.5, 76, 3, and 36.5 in stage I, II, III and IV respectively. Lin et al. also used SF-36[12] and found that the SF-36 subscores for each category had no significant difference in any of the age groups when compared to the national norms.

One of the other important outcome measures is patient satisfaction. Alvarez in his study showed that there was 89% satisfaction with the treatment whereas 11% were dissatisfied and underwent surgery. 8.5% were unable to discontinue SAAFO and therefore, 80.5% of patients were successful both in avoiding surgery and staying brace free. Lin found that 69.7% were brace free and avoided surgery and were deemed treatment success. 15.2% were unable to wean from brace at the final follow-up, and another 15.2% went for surgery. Overall treatment satisfaction was satisfied in 60.6% cases, satisfied with minor reservations in 33.3%, partially satisfied in 3.0%, and unsatisfied in 3.0%. Jari, in his study demonstrated that 82% were satisfied with the treatment outcome.

Nonoperative treatment was found successful in studies conducted by Alvarez et al. (in 83%) and Nielsen et al. (in 87.5%) with minimal treatment failures, ranging from 6% to 12.5% in their studies, who required surgery. However, Jari and Bek reported surgical intervention in their 13.9% and 16.7% patients, respectively.

Three of the five reviewed studies were prospective [3],[5],[6] and two were retrospective.[4],[7] Alvarez et al. had definite criteria for the diagnosis of flat foot. The rehabilitation program was well structured. Outcome measures also included strength of muscle groups. However, their observational design had no control groups, and also they did not independently compare the effects of orthosis or rehabilitation in the conservative treatment. They had a relatively shorter follow-up period (minimum 1 year).

The study of Nielsen et al. was a retrospective cohort study. The included sample size was larger (when compared to other studies) and they had a detailed description of patient characteristics and treatment given in terms of age group, sex, weight, and comorbid conditions. Imaging (MRI) was also used for diagnosis. Although no specific outcome scoring system was used, they analyzed the success of nonsurgical treatment based on different independent variables such as age, sex, weight, duration of symptoms, MRI diagnosis of tear, and use of any brace. They also used medications such as NSAIDs and corticosteroids in the initial treatment.

Bek et al.[5] had a low sample size (the final outcome was studied in only 25 patients). They included I, II, and III stages of the disease and had a precise description of localization of pain. The outcome was measured using FFI, but they studied only foot pain and disability subsections of FFI; activity limitation was not used.

Jari et al.[6] had clinical diagnostic criteria and included all four stages of the disease. They studied the patient characteristics in different stages and the outcome was also measured in each disease stage. The median follow-up was only 24 months and the final outcome was carried out in only 28 patients. The staging of the disease was done by two independent observers, but the interobserver agreement was not analyzed statistically.

Lin et al.[7] also did a retrospective study, in which only stage II disease was included. The follow-up period was long 7–10 years. Five different questionnaires were administered to the patients and the range of motion of the subtalar joint.

Ashford et al.[13] performed a systematic review of four randomized trials of conservative interventions for mobile pes planus in adults involving 140 participants and found that there may be some benefit associated with the conservative interventions; however, the evidence is insufficient to determine which conservative treatment is the most appropriate for the management of pes planus in adults.

Another systematic review on foot orthoses for adults with flexible pes planus including 13 studies was done by Banwell et al.[14] There were 312 participants with the mean age of 28.39 years. They found good-to-moderate level evidence to support that foot orthosis improves physical function and low-level evidence that foot orthosis improves pain and positively impacts on rear foot kinematics.

There are some limitations to this study. This is a retrospective analysis of the published studies on this topic, with a heterogeneous patient population, methods of treatment and different evaluation methods. Due to the paucity of literature on this topic, only a limited number (five) of studies are available to evaluate. We suggest that more multicentric studies with a larger number of patients are required on this common clinical condition, so as to reach logical conclusions.

  Conclusions Top

Flat feet are more common in the female population and various etiologies of acquired flat foot in adults have been described and the most common pathology is PTTD. Conservative treatment is considered as effective as the initial line of management. However, no consensus exists as to which conservative treatment is the best for the management of adult flat foot. More than two-thirds of the patients are able to avoid surgery and remain brace-free after the initial conservative treatment. The patient education and a reasonable period of care are essential for good outcomes. Surgery is necessary for patients in whom conservative management has failed and in all patients with fixed deformities.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Abousayed MM, Alley MC, Shakked R, Rosenbaum AJ. Adult-acquired flatfoot deformity: Etiology, diagnosis, and management. JBJS Rev 2017;5:e7.  Back to cited text no. 1
Buonomo LJ, Klein JS, Keiper TL. Orthotic devices. Custom-made, prefabricated, and material selection. Foot Ankle Clin 2001;6:249-52.  Back to cited text no. 2
Alvarez RG, Marini A, Schmitt C, Saltzman CL. Stage I and II posterior tibial tendon dysfunction treated by a structured nonoperative management protocol: An orthosis and exercise program. Foot Ankle Int 2006;27:2-8.  Back to cited text no. 3
Nielsen MD, Dodson EE, Shadrick DL, Catanzariti AR, Mendicino RW, Malay DS. Nonoperative care for the treatment of adult-acquired flatfoot deformity. J Foot Ankle Surg 2011;50:311-4.  Back to cited text no. 4
Bek N, Öznur A, Kavlak Y, Uygur F. The effect of orthotic treatment of posterior tibial tendon insufficiency on pain and disability. Pain Clin 2003;15:345-50.  Back to cited text no. 5
Jari S, Roberts N, Barrie J. Non-surgical management of tibialis posterior insufficiency. Foot Ankle Surg 2002;8:197-201.  Back to cited text no. 6
Lin JL, Balbas J, Richardson EG. Results of non-surgical treatment of stage II posterior tibial tendon dysfunction: A 7- to 10-year follow-up. Foot Ankle Int 2008;29:781-6.  Back to cited text no. 7
Mankey MG. A classification of severity with an analysis of causative problems related to the type of treatment. Foot Ankle Clin 2003;8:461-71.  Back to cited text no. 8
Vulcano E, Deland JT, Ellis SJ. Approach and treatment of the adult acquired flatfoot deformity. Curr Rev Musculoskelet Med 2013;6:294-303.  Back to cited text no. 9
Budiman-Mak E, Conrad KJ, Roach KE. The foot function index: A measure of foot pain and disability. J Clin Epidemiol 1991;44:561-70.  Back to cited text no. 10
Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS, Sanders M. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int 1994;15:349-53.  Back to cited text no. 11
Ware J, Snoww K, Ma K. SF36 Health Survey: Manual and Interpretation Guide. Lincoln, RI: Quality Metric, Inc.; 1993. p. 30.  Back to cited text no. 12
Ashford R, Mathieson I, Rome K. Conservative interventions for mobile PesPlanus in adults: A systematic review. Rev Int Ciencias Podol 2016;10. [doi: 10.5209/rev_RICP.2016.v10.n2.52304].  Back to cited text no. 13
Banwell H, Mackintosh S, Thewlis D. Foot orthoses for adults with flexible pesplanus: A systematic review. J Foot Ankle Res 2014;7:23.  Back to cited text no. 14


  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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