Non-Operative Protocol for Flatfoot Deformity

Physical Therapy Protocol

Stage 2 Acquired Adult Flatfoot Deformity (Posterior Tibial Tendon Dysfunction)

This is an outline of a non-operative protocol for treating Stage 2 Acquired Adult Flatfoot Deformity. The details of this protocol are reported in a research paper published in the January 2006 edition of Foot and Ankle International (Alvarez RG, Marini A, Schmitt C, Saltzman CL. Stage 1 and 2 Posterior Tibial Tendon Dysfunction Treated by a Structured Nonoperative Management Protocol:  An Orthosis and Exercise Program.  FAI Vol. 27(1): 1-8, Jan 2006).

What is Acquired Adult Flatfoot Deformity (Posterior Tibial Tendon Dysfunction)?

This condition is characterized by a symptomatic flatfoot deformity. Patients are typically symptomatic on the inside (medial) ankle but may also experience pain on the outside (lateral) hindfoot, due to bony impingement. This condition often becomes symptomatic (after many years of a flatfoot deformity) when the medial structures (including the posterior tibial tendon) stretch out and become incompetent. A Stage 2 deformity is characterized by the patient's inability to perform a single leg heel lift. This test, which requires the patient to stand on one leg and elevate the heel, requires a functional posterior tibial tendon to be completed. Typically in Stage 2 AAFD, the posterior tibial tendon is stretched out beyond it's working length, but is not actually ruptured.

Uniqueness of this treatment protocol

What is unique about this treatment protocol is that it is the first time that a study has actually shown that patients can regain function of their posterior tibial tendon after it has stretched out. Prior to this study, patients could only look to control their symptoms with bracing, or undergo surgical reconstruction. 88% of the study patients were satisfied, and 83% reported the ability to perform multiple single leg heel rises after an average of four months of the treatment protocol.

Key elements of the treatment protocol

The treatment protocol has two components:
  1. Bracing to protect and support the injured medial structures
  2. A high repetition, low resistance, strengthening program to gradually strengthen the posterior tibial tendon

Limitations of the protocol

The protocol does not address the underlying foot deformity, nor does it undo the damage that has already been done to the tendon. However, it can significantly improve symptoms and function. The implication of these limitations are that patients will be at risk for recurrence of symptoms, and they will likely have to do a scaled down version of the exercise regimen 3-4x per week for the rest of their lives, to minimize the risk of recurrent symptoms. In addition, patients that are looking to regularly perform high demand activities (ex. running) may find this difficult.

Which patients are NOT candidates for this protocol?

Any patient with a dysfunctional posterior tibial tendon where the tendon itself is not in continuity, is not a candidate for this protocol. Approximately 1 out of 10 patients with Stage 2 acquired adult flatfoot deformity fall into this category. To determine whether the posterior tibial tendon is intact, the patient is asked to invert the foot, and the tendon is palpated. If it is unclear whether the tendon is intact, an MRI can be ordered (Routine MRIs are NOT needed to diagnose this condition). The MRI will show a grossly abnormal posterior tibial tendon, but what is important is whether the tendon itself is in continuity.

The BRACING Component of the Treatment Protocol

Bracing is instituted to support the overloaded (and chronically injured) medial structures, including the stretched out posterior tibial tendon. For patients with Stage 2 deformities characterized by the inability to do a single heel rise, a custom mold AFO is recommended in the study. We have found that patients are often more comfortable in a custom molded Arizona Ankle Lacer. However, some patients find this too hot and we have recently been using the Aircast Posterior Tibial Ankle Lacer. This has been pretty successful, and has the advantage of being an over the counter device that patients can begin using right away. After a few months of the protocol, once they have regained some function in their posterior tibial tendon, patients may be transitioned to an over the counter orthotic with a medial arch support. Patients should wear their brace or orthotic any time they are walking.

The PHYSICAL THERAPY component of the treatment protocol

The physical therapy protocol is a high repetition, low resistance protocol. Walking and standing normally puts 2-4 x body weight through the posterior tibial tendon. These forces are initially far too high to allow the tendon to function, however, by starting at much lower forces, the tendon can be rehabilitated. The role of the physical therapist is to education and evaluate, not to supervise every exercise session. Patients need to do their exercise routine daily during the four months or more of the protocol, in order for it to be successful. The physical therapist will see the patient 8-10 times during this four month period, typically weekly for the first 4 weeks and then biweekly after that. Patients should follow up with their treating physician after 4-6 weeks to monitor their progress. After successful completion of the protocol, patients should continue performing a truncated version of their exercise routine 3x per week, indefinitely.

Phase 1

  • Sole to sole exercises (start at 4 sets of 10, increase daily until 12 sets of 25 can be performed). In this exercise, the patient sits with their feet dangling and inverts each foot, trying to bring the soles together. In doing this, the patient fires the posterior tibial tendon with only gravity as resistance.
  • Picking up a ball with the heels (alternative exercise). With the patient sitting and the feet dangling on the ground, a ball is placed between the feet and the patient picks up the ball by inverting each foot and trapping the ball in the arch of the foot (start at 4 sets of 10, increase daily until 12 sets of 25 can be performed). Some patients find this easier to do than the sole to sole exercises.

Phase 2

This phase starts when the patient can comfortably do 12 sets of 25 repetitions of one of the Phase 1 exercises, usually 10-14 days after the exercises program is started.
  • Continue Phase 1 routine as a warm up
  • Exercises against resistance. An exercise routine using a red exercise band as resistance is instituted. Inversion, eversion, and dorsiflexion is performed, although the inversion exercises are the most important. Movements are performed with a controlled eccentric return without rotating the leg. Start with 4 sets of 10 repetitions, and gradually increase the number of sets and repetitions until 10 sets of 20 repetitions (200 total) can be performed.
  • Double Leg Heel Rises. With the patient standing and holding on to a wall or a chair for balance, they should raise their heels off the ground in a controlled manner. The uninvolved leg should take 75-85% of the body weight. Patients should start at 4 sets of 5 repetitions, and progress to 10 sets of 20 repetitions.
Phase 2 will typically take 4-8 weeks to complete. Patients should progress gradually! If the patient has a flare-up of symptoms, they should back off their routine for a few days until the symptoms improve.

Phase 3

This phase begins when the patient can comfortably perform a total of 200 repetitions of the exercises against resistance, and the double leg heel rises as described in Phase 2.
  • Continue Phase 1 routine as a warm up
  • Exercises against resistance.  Continue the exercise routine using a stiffer exercise band as resistance, as with the Phase 2 exercises inversion, eversion, and dorsiflexion are performed, although the inversion exercises are the most important. Movements are performed with a controlled eccentric return without rotating the leg. Continue to focus on higher repetitions, working up to 200-300 repetitions total (ex 10 sets of 20-30 reps).
  • Double Leg Heel Rises. With the patient standing and holding on to a wall or a chair for balance, they should raise their heels off the ground in a controlled manner.  The uninvolved leg now takes only 50% of the body weight.  Patients should start at 4 sets of 5 repetitions and progress to 10 sets of 20 repetitions.
  • Single leg heel rises. Patient may attempt some single leg heel rises. This exercise should be done in a controlled manner.
  • Toe walking. Patient should attempt toe walking for 10 feet, keeping the knees straight. Gradually progress until 5 x 100 feet can be performed.
Phase 3 typically lasts 4-8 weeks.

Stabilization Protocol

After completing the Treatment protocol, the patient should develop a routine of double leg heel rises, exercises against resistance, and toe walking that takes 10-15 minutes to complete. They should perform this routine a minimum of 3 times.

Edited September 10th, 2015

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