Acquired Adult Flatfoot Deformity Treatment Options

Acquired adult flatfoot deformity (AAFD) is a progressive flattening of the arch of the foot that occurs as the posterior tibial tendon becomes insufficient. It has many other names, such as posterior tibial tendon dysfunction, posterior tibial tendon insufficiency, and dorsolateral peritalar subluxation. This problem may progress from early stages with pain along the posterior tibial tendon to advanced deformity and arthritis throughout the hindfoot and ankle.

Treatment Options

Treatment depends very much upon a patient’s symptoms, functional goals, degree and specifics of deformity, and the presence of arthritis. Some patients recover without surgery. Rest and immobilization, orthotics, braces, and physical therapy all may be appropriate.

With early-stage disease that involves pain along the tendon, immobilization with a boot for a period of time can relieve stress on the tendon and reduce the inflammation and pain. Once these symptoms have resolved, patients are often transitioned into an orthotic that supports the inside aspect of the hindfoot. For patients with more significant deformity, a larger ankle brace may be necessary.

If surgery is necessary, a number of different procedures may be considered. The specifics of the planned surgery depend upon the stage of the disorder and the patient’s specific goals.

Procedures may include ligament and muscle lengthening, removal of the inflamed tendon lining, tendon transfers, cutting and realigning bones, placement of implants to realign the foot, and joint fusions. In general, early-stage disease may be treated with tendon and ligament procedures with the addition of osteotomies to realign the foot. Later-stage disease with either a rigidly fixed deformity or with arthritis is often treated with fusion procedures.

If you are considering surgery, your doctor will speak with you further about the specifics of the planned procedure.


​Anticipated recovery after treatment for AAFD varies considerably depending on the treatment. Nonoperative treatments usually involve the use of a boot until symptoms subside and then an orthotic or brace. Almost all surgical treatments require a period of immobilization and restricted weight bearing that can range from several weeks to several months. More involved procedures that include a tendon transfer, osteotomy, or fusion may require a longer period of recovery.


​Some studies have shown good outcomes with nonsurgical treatment of early-stage AAFD. In the appropriate patient using a brace and structured physical therapy, studies have shown success without surgery in a high percentage of patients. Nonsurgical treatments for more advanced stages of AAFD may slow the progression of the disorder and limit symptoms.

Modern surgical approaches typically involve a combination of procedures to realign the bone deformity, lengthen contracted muscles, substitute for the deficient posterior tibial tendon, or perform joint fusions. Most modern surgical treatments exceed 80 percent success rate.


​In addition to standard surgical risks such as infection, bleeding, and nerve injury, additional risks may accompany particular procedures. For example, procedures that require bone healing (osteotomy, fusion, etc.) can result in a failure to properly heal the bones. The overall complication rates for these procedures are low.

Frequently Asked Questions

​If I am being treated without surgery, will I have to wear the orthotic or brace for the rest of my life?

Traditionally, it has been thought that orthotics and/or braces will need to be used by a patient for the rest of his or her life. This device serves to supplement for the dysfunctional posterior tibial tendon and help realign the foot. Some studies, though, have suggested that adequate bracing and strengthening may allow the posterior tibial tendon to heal and therefore avoid permanent brace use. This may be the case in select situations.

*Source:  American Orthopaedic Foot & Ankle Society®