Eight Tips For Conservative Treatment Of Adult-Acquired Flatfoot

I read with interest the recent Point-Counterpoint feature in Podiatry Today: “Is Conservative Care The Optimal Treatment Course For Adult-Acquired Flatfoot?”¹ I have previously written a DPM Blog on this subject.² The authors of the Point-Counterpoint provide some excellent material on staging and treatment of adult-acquired flatfoot. However, I am not sure if they actually answered the question: whether conservative treatment, in comparison to surgical treatment for adult acquired flatfoot, is really optimal?

To date, there are at least seven studies published in the medical literature documenting favorable outcomes with conservative treatment of adult-acquired flatfoot.^3–9 The studies of Augustine, Lin, Kraus and their respective colleagues all show significant improvement in American Orthopaedic Foot and Ankle Society (AOFAS) functional scoring with conservative treatment of adult-acquired flatfoot.^6–8 When you compare outcomes using the same AOFAS functional scoring, these studies of conservative treatment of adult-acquired flatfoot have outcomes almost identical to surgical treatment.^10,11 

Given the impressive evidence that conservative treatment for adult-acquired flatfoot can work, especially for stage 2 deformity, why would any clinician recommend surgery before attempting a conservative treatment first? Furthermore, given the surgical risk factors common in patients with adult-acquired flatfoot and the potential for significant complications from challenging flatfoot surgery, choosing a conservative treatment program first would be a no-brainer for any foot and ankle surgeon. Therefore, looking at functional scoring and risk of complications, conservative treatment of adult-acquired flatfoot would be optimal without question.

With this assumption in mind, let me share some pearls that I have learned using conservative treatment for adult-acquired flatfoot.

1. The single foot heel rise is the easiest and most reliable test to choose between foot orthotic therapy versus an ankle-foot orthotic (AFO) brace. Inability to perform this maneuver indicates ligamentous failure and the need for an AFO brace.
2. The patient must be willing to follow the treatment plan for up to one year and adhere to footwear and activity restrictions.
3. Motion control running shoes are preferred to match with the AFO brace. The Brooks Beast (men) and Brooks Ariel (women) are my favorites.
4. Patients must wear the AFO brace at all times during weightbearing, all day long, even indoors in the home setting.
5. A hinged, full ankle flexion AFO is preferred over gauntlet braces for Stage 2 and 3 adult-acquired flatfoot.
6. Practitioners should cast the patient with adult-acquired flatfoot with a neutral suspension technique and should correct all acquired forefoot supination deformity to optimize control of the brace.
7. For adult-acquired flatfoot, one can enhance the foot plate of the AFO device with a medial heel skive as well as a lateral flange to prevent forefoot abduction.
8. A functional rehabilitation program using the Kulig protocol is critical to success.⁴ The program should combine eccentric and concentric strengthening along with balance training.

I tell all my patients at the start of their conservative treatment program that there is at least a 50 percent chance that they will be able discontinue their brace within one year of treatment and remain relatively symptom-free for the rest of their lives if they follow this program. The studies validate this promise. This gives hope to the patient and helps ensure adherence with the requirements of the program.

In my experience, if patients are going to succeed with conservative care, they will experience significant relief of pain within one month of AFO bracing. Those patients who do not get relief of symptoms within that time have a guarded prognosis. Fortunately, in my experience, this is less common.

Despite early relief of symptoms, all patients with adult-acquired flatfoot should continue wearing the AFO brace for a minimum of four months and complete their rehabilitation program. Normally, complete recovery will not occur for nine to 12 months. At this time, the patient can move out of the AFO to a well-designed custom foot orthosis.

References

1. Scherer P, Visser HJ, Wolfe J. Point-Counterpoint: Is conservative care the optimal treatment course for adult-acquired flatfoot? Podiatry Today. 2017; 30(10):44–48.

2. Richie D. Why conservative treatment is the standard of care for adult-acquired flatfoot. Podiatry Today DPM Blog. Available at https://www.podiatrytoday.com/blogged/why-conservative-treatment-standard-care-adult-acquired-flatfoot . Published June 2, 2011.

3. Chao W, Wapner KL, Lee TH, Adams J, Hecht PJ. Non-operative management of posterior tibial tendon dysfunction. Foot Ankle Int. 1996; 17(12):736–41.

4. Kulig K, Reischl SF, Pomrantz AB, Burnfield JM, Mais-Requejo S, Thordarson DB, Smith RW. Nonsurgical management of posterior tibial tendon dysfunction with orthoses and resistive exercise: a randomized controlled trial. Phys Ther. 2009; 89(1):26-37

5. Alvarez RG, Marini A, Schmitt C, Saltzman CL. Stage I and II posterior tibial tendon dysfunction treated by a structured non-operative management protocol: an orthosis and exercise program. Foot Ankle Int. 2006; 27(1):2–8.

6. Augustin JF, Lin SS, Berberian WS, Johnson JE. Non-operative treatment of adult acquired flat foot with the Arizona brace. Foot Ankle Clin. 2003; 8(3):491–502.

7. Lin JL, Balbas J, Richardson EG. Results of non-surgical treatment of stage ii posterior tibial tendon dysfunction: a 7- to 10-year followup. Foot Ankle Int. 2008; 29(8):781-6.

8. Krause F, Bosshard A, Lehmann O, Weber M. Shell brace for stage II posterior tibial tendon insufficiency. Foot Ankle Int. 2008; 29(11):1095–1100.

9. Nielsen MD, Dodson EE, Shadrick DL, Catanzariti AR, Mendicino RW, Malay DS. Non-operative care for the treatment of adult-acquired flatfoot deformity. J Foot Ankle Surg. 2011; 50(3):311-314.

10. Myerson MS, Badekas A, Schon LC. Treatment of sage II posterior tibial tendon deficiency with flexor digitorum longus tendon transfer and calcaneal osteotomy. Foot Ankle Int. 2004; 25(7):445–450.

11. Van der Krans A, Louwerens JWK, Anderson P. Adult acquired flexible flatfoot, treated by calcaneocuboid distraction arthrodesis, posterior tibial tendon augmentation, and percutaneous Achilles tendon lengthening: A prospective outcome study of 20 patients. Acta Ortho. 2006; 77(1):156–63.