Adult acquired flatfoot

and tibialis posterior tendonopathy

Management guidelines

The available evidence is not sufficient to produce conclusive practice guidelines. In addition, many issues are not addressed in the existing literature at all.

We use the following guidelines in East Lancshire :

1. in the first instance, most patients are treated symptomatically, with analgesia and physiotherapy for tendon and joint pain and a corrective in-shoe orthosis for flexible planovalgus deformity
2. patients with severe or stiff deformities need accommodative orthoses, AFOs or braces
3. patients may need accommodative shoewear
4. patients who fail the above treatment will have deformity series radiographs and an MR scan
5. if these confirm tendonopathy they may be offered surgery using the following guidelines:
   • tendonopathy without deformity, Conti type 1 MR changes – debridement
   • tendonopathy without deformity, Conti type 2/3 MR changes – debridement and FDL transfer
   • tendonopathy with fully flexible mild/moderate planovalgus deformity – medial displacement calcaneal osteotomy, debridement and FDL transfer
   • tendonopathy with fully flexible severe planovalgus deformity – Evans calcaneal osteotomy, debridement and FDL transfer
   • tendonopathy with planovalgus deformity with subtalar but not midfoot stiffness – corrective subtalar fusion, debridement and FDL transfer
   • tendonopathy with midfoot but not subtalar stiffness – medial displacement calcaneal osteotomy, tendon debridement + transfer if required, medial column realignment OR (mainly for talonavicular joint pain or severe instability) talonavicular or double fusion
   • tendonopathy with generally stiff planovalgus deformity – triple fusion
6. patients with deformity but no tendonopathy may be managed similarly except
   • omitting soft tissue reconstructions
   • their pain is more likely to be due to OA so they are more likely to need fusions
   • patients with tarsometatarsal instability or OA may need realignment arthrodesis and their other surgery adjusted accordingly