Adult Flatfoot

Hi, I'm Dr. Randale Sechrest, your host for eOrthopod.TV. And today we're talking remotely once again with Dr. Brett Fink. Dr. Fink is an orthopedic foot and ankle surgeon who practices at Community Orthopedic Specialists in Indianapolis, Indiana. Dr. Fink did his medical school training at Washington University in St. Louis. And from there, an orthopedic residency in the Portsmouth Naval Hospital. And from there completed two orthopaedic fellowships in foot and ankle surgery, one the University of Miami, and one at Boston University. Thanks for joining us this evening Dr. Fink.

Dr. Brett Fink: Thank you very much, Randale.

Dr. Randale Sechrest: Well, Dr. Fink, thanks for joining us this evening. And I thought today what we would discuss is a fairly common problem amongst adults, and that's the problem of fallen arches, or flatfoot. And sometimes we call that acquired flatfoot because as we age, this problem comes on. It's not something we're necessarily born with. And as I understand it, there are multiple different potential causes of flatfoot in the adult. So could you start out by giving us a little bit of an idea about some of those , um, different varieties of flatfoot and how they may present in your office.

Dr. Brett Fink: Yes, uh, flatfeet is one of the most common complaints that I get. And whether it's flatfeet in a child or flatfeet in an an adult, that's already had flatfeet, or even flat feet in an adult that that whose arches have fallen, which is probably one of the most difficult and frustrating problems for them. Um, when I see someone that comes in for flatfeet, certainly what what I begin with is trying to figure out when uh, the flatfeet began became a problem. Whether it was something they've always had or whether it's something that's worsened with time. Um, the flatfeet that are actually a problem that I often treat, are the type of flatfeet that began with some degree of arch, but then the feet rolled, or became flatter with time. And these can be quite painful.

Dr. Randale Sechrest: Well, in terms of flatfeet, what type of symptoms do you see in patients other than the fact that they just complain that their foot doesn't look right?

Dr. Brett Fink: Well, usually, um, in the very early stages they may come in just with swelling. And often they come in complaining of a sprain on the inside of the ankle. Now, an ankle sprain is usually a traumatic injury, and it usually happens on the outside of the ankle. But, when you get pain that's on the inside of the ankle, especially if it's associated with swelling, and there really hasn't been an injury, then that is something quite different. And that is often the beginning of a flatfoot. Over time, many times the flatfoot will begin to become more flat. And what the person will notice when they're looking at it from the top, is that the inside of the ankle appears to be bowed. Uh, the front of the foot appears to be pointing towards the outside. Um, and eventually as the foot becomes more and more flat, it can start to crush some of the bones on the outside, and people can begin to have pain on the outside of their ankle also.

Dr. Randale Sechrest: Now, is this something that occurs over a long period of time, or are you suggesting that , you know, you can one day wake up and notice that your foot is bowed in this way. Is this something that happens fairly quickly or slowly?

Dr. Brett Fink: It can happen in a variety of different ways. It can be something that seems to progress. That someone just gradually starts to develop more and more pain over a period of months,, or it can be something that happens over a period of just a couple weeks. Um, like I said, really very variable.

Dr. Randale Sechrest: And what typically brings that person into your office? Are they referred because they've complained of this, or is it the pain that brings them there, or just the deformity?

Dr. Brett Fink: Once again, a lot of times, you know, people have heard of fallen arches, they understand that when the foot changed in it's um, ah, posture that that's a bad thing. But oftentimes again, the family practitioners are kind of stumped by what they see as swelling that's occurred for no reason, sometimes it's diagnosed as gout. Other times it's, once again called a medial ankle sprain, or a sprain to the inside of the ankle – which is really very uncommon as a traumatic injury.

Dr. Randale Sechrest: Well, explain to us a little bit about the anatomy of the foot and a little bit about the arch itself. I mean are we always supposed to have an arch? Is flatfoot a normal finding in some people, or should we all be concerned if we don't have an arch?

Dr. Brett Fink: Well, just like many other things in our bodies. There's a wide spectrum of what's normal. People, it is normal to have good flexibility in the back of the ankle. You should be able to bring your toes up and point your toes down, and then turn your toes in a definite circle. If that's not present, then that's kind of unusual. Um, and people should have strength really to point their toes in any direction that they want to. If that's not present, then that's probably something, there's probably something wrong. Um, as far as the anatomy of the ankle is concerned, um, it's really quite complex, but we'll try to just stick with the structures are very important to this topic. 1) Is the ankle joint. Which again lies between the tibia bone, which is the shin bone, and the talus, which is the bone that the shin articulates with at the ankle. And that really acts like a hinge joint. It brings the toes up and it brings the toes down. Underneath this, in between that talus bone, and the calcaneus and the remainder of the mid foot, there is a joint called the subtalar joint, which allows the foot to adjust to uneven surfaces. And it's the joint that would be most, uh, active, when you turn your foot in a circle. There are tendons at each quadrant of the foot. The tendon in the front is the anterior tibialis tendon, the tendon in the back is the Achilles tendon. The tendon on the inside which is probably most instrumental and most important in the development of the flatfoot, is called the posterior tibial tendon. It acts to bring the toes in towards the inside of the foot, or um, more or less roll it into the position where you would, where you might sprain it. Uh, an action that doctors call inversion. And this tendon is instrumental in supporting the arch and is part of why people develop a flatfoot.

Dr. Randale Sechrest: So, that tendon, the posterior tibial tendon, um, is this a problem because they've ruptured it, or it's weakening, what's the problem with the posterior tibial tendon?

Dr. Brett Fink: Well, um, most of the time this is a degenerative condition. Meaning that it happens as we get older. It's more common in people that are obese. Probably because they put more strain on the tendon. It's also more common in people that begin life with a flatfoot. Because a flatfooted person uses this tendon a lot more significantly than someone with a more normal arch or a high arched foot. Um, probably what happens over time is that the tendon develops small tears that gradually uh, allow it to lengthen and then the tendon stops working because, or the muscle stops working because it's not really in the position to work like it's supposed to. It doesn't control the foot like it should. Um, but there is a lot that doctors and scientists don't know about the development of a flatfoot. Some of it may be because of inflammatory problems. Perhaps some which we haven't identified. Such as rheumatoid arthritis.

Dr. Randale Sechrest: Now, you mentioned the posterior tibial tendon as probably the most common, I think you said most common cause of acquired flatfoot that develops over time. Any other causes that can lead to a flatfoot that may mimic the posterior tibial tendon problem?

Dr. Brett Fink: Yes, there are a lot of causes of flatfoot. First, again you got to differentiate it from the person that just has flatfeet and pain. You know, a person with flatfeet can develop pain just like a person with a normal foot. And you've got to make sure that they don't have any of a variety of conditions that can go along with just normal foot pain. Um, but the things that can mimic an arch that has actually shifted, or a fallen arch, are things like mid foot arthritis, the joints at the top of the arch can become arthritic, uh, meaning that the joints are starting to break down, And as they become arthritic they become lose and the arch begins to sag. Now, this is a very common condition in um, in people once they get into their 60's and 70's, um, and it's just every bit as common as a fallen arch. Um, other things that can ah, cause this are ligament tears in the middle part of the foot, or fractures. There is a condition where one of the bones in the top of the foot will actually just, will more or less disintegrate, it's called Mueller-Weiss syndrome. Um, and ah in a person like that they can develop a collapsed arch very rapidly and it is, it is a disastrous condition. But easy to identify with an X-ray.

Dr. Randale Sechrest: Now, the arthritis that you mentioned in middle, and late middle age, um, that's just wear-and-tear arthritis? Or this that a rheumatoid variant, or some other type of arthritis that specifically affects the foot?

Dr. Brett Fink: Well, I think that people with rheumatoid arthritis tend to develop the type of arthritis that becomes very, ah very deformed. But it can be from an old trauma. If someone had had a mid foot injury in their 30's, over time this might deteriorate more rapidly than you would expect. And they could develop mid foot arthritis that would deform itself. Um, ah, osteoarthritis also can develop like that. But typically the people that really have the severe deformity have some other underlying diagnosis like rheumatoid arthritis or other types of inflammatory arthritis.

Dr. Randale Sechrest: Well, you know I think a lot of people always worry about shoe wear, and they worry about whether or not the shoe wear can contribute to some of these foot conditions. And in terms of of acquired flatfoot um any sort of relationship to the type of shoe wear people commonly wear that could cause acquired flatfoot?

Dr. Brett Fink: Well, as you know Randale, those uh, those studies are very difficult for people to do and I would have to say there's been no evidence that , that shoe wear contributes to this. Or that wearing arch supports for your whole life contributes to it. Um, my own personal belief, and I think I've talked to you about this before, is that um, shoe wear and arch supports actually contribute to the development of a flatfoot because they allow other supporting structures to become weak because they're not used in a more natural way. Um, if the ah small muscles in the foot, the intrinsic muscles, are allowed to become weak, because they've been over protected, then I think that puts extra stress on the posterior tibial tendon. And over time, I think it can lead to this. So, my advice for people who don't have a fallen arch and are trained to prevent a fallen arch, is to just walk as normally as possible and wear shoe wear that is comfortable to them. Now, I never, advocate that people wear the highly fashionable shoe wear that actually deforms the foot, but a simple tennis shoe or sandal is quite reasonable for both men and women. And, I think that it's very healthy for people to go barefoot for a period time during the day or during their week, whenever they find it convenient to be in that situation.

Dr. Randale Sechrest: Well, that's interesting. You know that's probably the first time I've actually heard that recommendation, you know as a preventative um, sort of a , a measure for foot problems. But that's very interesting. So you actually tell your patients to spend some period of time during the day, whether they have normal feet, or not, um, spend some period of the day actually going barefoot?

Dr. Brett Fink: Oh, yes. I think that that's just aside from this topic, and again, and completely unsubstantiated by any scientific evidence, because there really is no scientific study that's been done on these types of things. But I know, from looking at people's feet and from that that people that are barefoot, their foot is different than the people that overly protect their foot. The skin becomes thin, I think the muscles become weaker with shoe wear that is overly constrictive. Just as if you wore a cast on a broken arm, much too long, the arm would wither and become stiff. The same thing can happen to feet too. If I look at an elderly patient, or examine an elderly patient, I find their skin is quite thin and very fragile. And I wonder even how ah, the bones underneath are protected at all from the pressure of the ground. I think that part of that reason is because they no longer expose them to any stress.

Dr. Randale Sechrest: And what about sandals and that sort of thing? Are there any shoes, or shoe types that would sort of mimic bare foot walking that you would probably recommend over something that has a very good arch and a very good support?

Dr. Brett Fink: Well, the more flexible the shoe is, I think the more it mimics it. But, ah, to be honest with you, especially as far as the skin is concerned, anything that protects the plantar surface of the foot from that shearing stress, is going to make this the, the sole of the foot softer and more pliable and I think less able to uh, distribute weight and to bear normal pressure.

Dr. Randale Sechrest: Hum, interesting. I guess we should move on and talk a little bit about diagnosis. When you're seeing these patients who present to your office because they've noticed a sort of a progressive deformity of their foot and may have noticed the swelling that you've suggested, and the pain, how do you begin the evaluation of that patient?

Dr. Brett Fink: Well, really, a good physical examination and a history are probably give you 90% of the information that you need. Um, ah, defining where the pain is coming from will lead you to the structures that are really irritable. Typically in posterior tibial tendonitis, once again, the posterior tibial tendon lies behind the bone on the inside of the ankle. The portion of that bone is called the medial malleolus. And usually that portion of the tendon is inflamed, so if you walk your fingers back behind the inside of the ankle bone, you'll get, the first soft structure you'll hit is the posterior tibial tendon. And if that is tender, then you have posterior tibial tendonitis. Umm, other things that you check for are the, is the strength of the posterior tibial tendon. Cer5tainly if it's weak, and a person is not able to point their toe towards the inside, that's a sign that the tendon and the muscle may be very, very damaged. Um, the flexibility of the joints is important. Uh, one problem that some people do get, that can mimic a flatfoot is called tarsal coalition. Which is a situation where the bone in the back part of the foot actually fuse together, uh, or rather they don't separate when people are adolescents. Um, and that can make the foot flat and stiff. So, that's a slightly different condition. And then, the other types of things, like the mid foot arthritis, or the disintegration of that navicular bone in the foot that I talked to, the syndrome called Mueller-Weiss syndrome can be ruled out by a simple x-ray. And I always get these x-rays in a weight bearing position. Because this places the foot in it's kind of normal flat position. I get to see where the joints are loose and what ligaments might be damaged by doing te x-ray in that fashion. Um, I almost never get an MRI on first evaluation. Uh, once again, and we talked about this before also, my feeling is that MRIs in foot and ankle problems are almost always to find a surgical problems, and posterior tibial tendonitis is almost never initially a surgical problem. There are good non-operative ways of treating it. So, an MRI is something that I reserve for later in the treatment when non-operative problems, or non-operative solutions have failed to give people good relief. Um, other things, if I am suspicious of a inflammatory arthritis, I might get some test to look for inflammatory arthritis, but often if I have a high degree to this suspicion, I'll send my patients to a rheumatologist, who is a specialist in inflammatory conditions who often knows the right test to order to identify those. Ah, and that's my initial evaluation.

Dr. Randale Sechrest: Well, lets talk a little bit about treatment. After you've gone through your initial evaluations, and at least made a provisional diagnosis, and you feel like you have a pretty good handle on what's causing the patient's flatfoot deformity, how are you going to start in terms of treatment on that patient?

Dr. Brett Fink: Um, I think that probably the most important thing, is getting an idea of what – where the patient is at when I see them. Um, some people come in and they have relatively mild problems from the posterior tibial tendonitis, other people are nearly incapacitated when I first see them. If someone has mild problems and really no foot deformity, then I think an arch support may be helpful in that condition. And once again, I just said that that arch supports and orthopedic shoes are probably not good for a healthy foot, on the other hand, for a foot that's already developing problems, it can keep from stressing structures that are already sick and therefore can have some benefit in people that have already developed a fallen arch. If someone has very severe problems, the initial treatment may be putting them in a cast or a cast boot to allow the tendon to rest for a time so that we can start to begin a more concentrated rehab program. At some point along the way, we're going to want to become, to begin a strengthening program. And that will include the intrinsic muscles or the small muscles in the foot. We do, we strengthen these by doing things like heel lifts on a flat surface or on a chair, or on a stair. And when the tendon has become strong enough and can withstand it, we might even begin some exercises that actually stress the posterior tibial tendon. Actually moving the foot from an everted, or turned out position, to an inverted, or turned in position. To allow that muscle to be, or to allow the tendon to develop the resilience it needs in order to become pain free. Another important thing that we do in rehab, is to um, get ah people involved in a stretching program. Because often the hamstring and the Achilles tendons are very tight in people that have developed Achilles tendonitis. This may be one of the predisposing factors, Um, over the long run, there are times that Achilles tendonitis or that posterior tibial tendonitis is reversible. When it is reversible the goal is to return people to normal show wear and normal activity. When it's not reversible, when there's been some degree of falling of the arch that's not going to go back, then we might have to use a brace in order to support that arch and position it in a way that doesn't stress other structures so that they also become irritated and fail.

Dr. Randale Sechrest: Now, there's always been somewhat of a controversy about posterior tibial tendonitis in terms of whether this is an inflammatory condition or a condition of the tendon itself, where the tendon is just degenerative – do you think that it's one or the other, or is it a little of both? How do you sort of conceptualize that?

Dr. Brett Fink: Well, I think that there are a lot of inflammatory conditions that orthopedists and other doctors have not been able to identify yet. Um, women in general develop these problems much more frequently than men. Really all inflammatory conditions. And uh, in some way, like I said, I just don't think that we know all of them. And there are already a hundred or more inflammatory conditions that can develop problems with the joints. So, at time, you can identify them, at other times, you've just got to assume that they have an issue like this. And sometimes early on in a problem like rheumatoid arthritis, uh, it may be very difficult to diagnose it because all the clinical points that you use to make that diagnosis might not be present yet.

Dr. Randale Sechrest: Now in terms of medications. If you consider at least some of the tendon problem in posterior tibial tendonitis to be inflammatory, do you routinely have patients take an anti-inflammatory?

Dr. Brett Fink: I would have to say that my own personal bias towards anti-inflammatories is that they are mainly used in my practice as pain medications. Despite the term that they have been given, anti-inflammatory. Um, I don't think that they're very many conditions that there is good evidence that they have a significant effect. You know, they call some medications disease modifying medications, medications like Humara and Enbrel, anti-inflammatories I think are used mainly for symptoms. So, I would have to say that ah, if someone needs a mild pain medications or analgesic that anti-inflammatories are a great choice. If someone is really looking ah, for some type of long-term or permanent benefit, or curative property from these medications, I think that they're probably going to be disappointed.

Dr. Randale Sechrest: And what about cortisone? If there any place for any type of cortisone preparation? Whether it's injected or taken by mouth, or perhaps through a newer technique like iontophoresis where it's put on the skin and simply driven through the skin by some type of electrical current? Do you ever recommend any type of cortisone treatment?

Dr. Brett Fink: I think as far as uh, certainly, I send my patients to physical therapists and uh, when I send someone to a physical therapist as another healthcare practitioner and a very educated one, a physical therapist should be given some leeway to treat patients in any way that they feel might be helpful. So I rely on their experience for this, but I would have to say that my own biases that I'm skeptical that iontophoresis does much over the long run for posterior tibial tendonitis. Although some of those modalities, as they call iontophoresis, and ultrasound, do help people with pain, and therefore can make them more satisfied with their treatment with the physical therapist. I'm not sure that that there's been any evidence that it really makes a long-term difference. As far as oral cortisone, um, you know I think it has a place if you can convince yourself that the problem is going to be a short-term duration. There are a lot of side effects with oral cortisone, including problems that can actually permanently damage the joint. A problem called avascular necrosis of the hip has been reported even in short courses of cortisone, or oral cortisol. So I certainly, when I prescribe these medications, discus this with my patients and make sure that they understand that there's little evidence that it has any long-term benefits and it can damage ah, ah, people in a permanent fashion. And this is on top of the other more common problems with oral cortisone like mood disturbances, sometimes people feel very irritable, ah, and even aggressive on cortisone. And, and problems with diabetes which is probably very common in people with posterior tibial tendonitis. As far as the injectable steroids, I've got to say that I use them very, very rarely, and only with a great deal of caution. Because weight bearing tendons that have been injected with cortisone have been reported to ah, actually rupture. And if the, if you have a weak posterior tibial tendon, a tendon that is already suffering from some micro damage and inject it with cortisone, I think that there's a significant chance that it could break completely. And that would take something that was potentially non surgical and make it into a surgical problem. Um, further, these tendons that are weakened by cortisone, that rupture, are sometimes very difficult to repair properly. So in the interests of not doing that and making my patients worse, I really avoid it almost always.

Dr. Randale Sechrest: So, if I could paraphrase what we've been discussing in terms of the conservative treatment for, especially posterior tibial tendonitis or posterior tibial problems, your goal is to rehab this patient and try to regain some of the strength and the balance in the muscles and some of the contributing structures. Like you mentioned the Achilles and the hamstrings, even upstream have some effect on that. But your goal is to really strengthen the tendon over a period of time, strengthen the muscle, so that you re-balance the foot and hopefully get that patient back to a normal gait pair, a normal gait pattern with normal shoe wear. And I think you also mentioned that that in some cases that's just not feasible. And in some cases you are going to probably look at some type of support or orthotic or something to definitely try to support that tendon that's probably never going to return to normal strength. Is that pretty accurate?

Dr. Brett Fink: Yeah, yeah, I think that covers it pretty well. I would have to say that in general with forms of tendonitis, that the first stages are to get rid of the acute inflammation. That really horrible pain and the swelling that persists. Once you've started getting the tendon out of that inflammatory stage and into something that is starting to scar and repair itself, then you gradually introduce stress to it so that as it heals, it remodels and becomes a strong resilient tendon. Now some damage may have been done to the tendon that does not allow it to function fully, uh, or properly. Um, and in situations like that, then a brace may be a permanent way of supporting this so that it doesn't hurt.

Dr. Randale Sechrest: Well, let's move on and talk a little bit about when conservative treatment fails and you begin to have the discussion about surgery with these patients. What drives yo to that to that discussion? How long does it have to go on in terms of conservative treatment, and what symptoms would sort of force you to sit down and have that hard discussion with the patient about maybe it's time to consider surgery?

Dr. Brett Fink: Generally when I see, when I see patients for posterior tibial tendonitis, or really and form of tendonitis, I kind of gauge what their pain and their impairment is doing over a period of time. If it seems like they
re making progressive improvement, I've a hard time discussing or recommending surgery for them because they're improving. And who knows how far they'll improve? Uh, when my patients become frustrated or it becomes clear that they're really not going to improve, then that's when we start talking about surgery, um after therapy has been maximized. I would have to say that it generally takes about two months at least for my patients to have of undergone a serious and reasonable course of non operative treatment. So, uh, pain that fails to um resolve is a good reason to resolve I think is a good reason to ah do ah, um surgery. Or if the patient is not willing to wear a brace, because some people when you tell them, okay, here's a brace, you may have to wear it for the rest of your life, they are not willing to do that. And therefore um, that patient uh, there is really no reason to continue the rehab then because the best possible results that I can give them is going to be unsatisfactory to them.

Dr. Randale Sechrest: So lets talk a little bit about surgical options. What are our surgical options for posterior tibial tendon problems?

Dr. Brett Fink: Well, really, as far as posterior tibial problems are concerned, there are two types of surgery that you can do And there are the joints sparing procedures, which are hopefully used in the majroity of patients, and they really preserve the joints of the foot so that you have good flexibility when the procedure is done. And then there is the joint sacrificing procedures that involve stabilizing the foot by fusing the bones together. And in that situation the foot is you know, never quite the same,
it doesn't move in the same way it did before. So hopefully those are only used when the joints are very stiff, or when a patient is so overweight that they can't be expected that any surgical reconstruction of their can be expected to withstand that type of pressure.

Dr. Randale Sechrest: So, can you describe one of these joint sparing procedures? I assume you're talking about reconstructing the arch using a different tendon, or a tendon graft of some sort?

Dr. Brett Fink: Yes. Ah, first of all to some extent these procedures are all geared towards the individual problem. And there may be a varying degree of hindfoot deformity that is going on in several different places. Ah, the tendon, the posterior tibial tendon could be um reconstructable or it may be beyond salvage. The muscle may be so damaged that it doesn't work anymore. And on top of that, as the foot becomes flat, the front of the foot can become deformed, and so that may be something that has to be addressed separately. So, the problem is posterior tibial tendonitis, and so the reconstruction of that is taking the posterior tibial tendon and removing the damaged portion of the tendon and then reconstructing it using another tendon and commonly the tendon that's used is one that is directly behind the posterior tibial tendon. A tendon called the flexor digitorum longus. And it runs right behind the posterior tibial tendon and goes into the arch of the foot and goes to the small toes and gives a flexibility to the small toes. And what we do is that we actually cut this tendon and reinsert it where the posterior tibial tendon used to be and use it to bridge the gap of tendon that we've taken from the inside of the ankle. Now these procedures are almost always done with other bony procedures. And the whole idea behind these bony procedures is to reestablish the arch or balance the back of the foot. And one of the most common is called a medial calcaneal sliding osteotomy. And in this procedure they cut the heel bone and shift it towards the inside so that the ah, that flat foot is made less flat by bringing the heel underneath the tibia bone and more in line with the axis of weight through the ankle and hind foot. It's a little hard to describe, but it balances the foot so that this weakened posterior tibial tendon can more effectively counteract the tendons that are on the outside of the foot. Um, then, if there is a deformity of the front of the foot, that might have to be addressed separately in order to bring the toes down so that they all hit the ground in an appropriate position. And this may involve cutting bones in the middle part of the floor, or fusing joints in the middle part of the foot in order to brring, usually the big toe down to meet the floor after it's been deformed so long.

Dr. Randale Sechrest: So let's move on and talk a little bit about these other, more drastic procedures you're talking about – the joint sacrificing types of procedures, what do they consist of?

Dr. Brett Fink: Well, they almost always consist of um removing the cartilage from some of the joints in the back of the foot and stabilizing them by fusing the joints together. Actually removing the cartilage, exposing the bone on each side of the joint, pushing them together until they fuse together, just as a fracture would normal, would fuse in a a ah fractured bone. Um, this generally takes usually there are multiple joints that are addressed in this way. Typically it occurs, it is necessary in people that are overweight, or whose joints have become arthritic in the process of, in the process of becoming flat. And usually it takes between 6 and 12 months for this to actually occur to the point that you can actually start to walk on it. But it is a very reliable way of keeping the foot in it's proper alignment.

Dr. Randale Sechrest: So you sort of give up some flexibility and gain more of a rigid, but painless foot with these types of operations.

Dr. Brett Fink: Exactly. And it's more resilient. So that again, if someone weighs 300 pounds, and you um, try to do a soft tissue reconstruction, there just may not be enough strength in that ah, in the tissue that you're moving around in the back of there to keep the joints in their proper position. When you fuse them, the strength is much higher and therefore it's more likely that they're going to get a good result and they're not going to, and their deformity is not going to recur.

Dr. Randale Sechrest: A questions for you. How's successful are these operations? You know, I think that foot surgery in general, because people I think fail to recognize how complex the foot it. But these type of operations where you do multiple different steps, what's your experience in terms of the success rate and people having a good outcome?

Dr. Brett Fink: Well, the foot is never normal. I, I, when I counsel my patients I tell them that from the beginning. If they expect to have the foot that they had when they were twenty, I just am, I'm not able to do that. So, when we talk about good results, what we're talking about is a foot that works well with walking, doesn't hurt, unless it's really used more than normal everyday activities, for most people. Um, and I would have to say that probably the success rate is on the order of 70-80 percent. In some, to some degree, it depends on the degree of the deformity and the patients themselves. You know, whether they're a smoker, or have diabetes, or um, are um, or whether their bones are excessively osteopenic, they're too brittle and dense, and not very dense. So I would have to say, on the order of 70-80 percent of people are very happy with the result after a discussion of what is to be expected.

Dr. Randale Sechrest: Well, I think people, the take away from this is 70 or 80 percent to a lot of people may not sound like a great success rate, but, I think people need to understand that the foot is so complex, and these problems in my experience, are some of the most difficult problems that one can deal with in orthopaedic surgery. Um, so I think that people ought to understand that the 70-80 percent success rate is a pretty good track record for this type of an operation, for this type of a problem. So thanks for sharing that.

Dr. Brett Fink: I think that also that, that you have to understand that this isn't the type of procedure that you do for someone with just mild pain. It's something that you do for someone that is really practically disabled by this problem. And so, again, if someone is just having a mild degree of pain and at the end of a rehab protocol they just have some discomfort, ah, I generally would not recommend surgery for that patient. It's only for the person that is limited, can't do their normal, enjoy things, activities with their family, they can't be employable, those are they types of people where it's appropriate. The other thing that I reenforce with my patients is that this, that these operations, they're a 6-12 month recovery period. It really takes that long before people are uh, have recovered to the point that they're going to, that they're really not going to recover much from there. It takes a long time, people are swollen for a while. And I find that that is something that in spite of my discussions with them, really often doesn't come through.

Dr. Randale Sechrest: You know I think this has been a very thorough discussion of acquired flatfoot and I think patients are going to take a lot of useful information away from this discussion, but, I think as we close tonight, is there anything that you feel like, that patients need to know that we have not discussed up to this point.

Dr. Brett Fink: Um, I think that the best thing is to um not ignore a swollen, or painful ankle. Especially is someone with diabetes. To get it evaluated. To find a doctor or either a podiatrist or an orthopedic surgeon that is knowledgeable in these matters, and discuss it with them. And to find a doctor that is that is willing to take the time to go through the conservative treatment that should be done before jumping to surgery. Um, I think uh, if that is kept in mind, then people are going to be treated reasonably and won't have to do through surgeries that may be unnecessary.

Dr. Randale Sechrest: And I'm assuming from our discussion up to this point, that the sooner the better. That if you don't let this deformity continue to progress, that your options may be better if you deal with it earlier.

Dr. Brett Fink: Yeah, I think in general that's true. Um, certainly if people don't have,or have a significant problem that just doesn't seem to go away, I just never think it's a good idea to ignore it. Often, I you know, I look back, and I think, well, maybe I couldn't have done anything for them anyway, but there are times where you wish that you would have seen people a little bit earlier and maybe you could have gotten a better result.

Dr. Randale Sechrest: Well, great discussion tonight, I want to thank you again for joining us tonight, and sharing this information with patients. So I look forward to further discussions in the future on additional foot problems. Thanks a lot.

Dr. Brett Fink: I do too Randale, thank you.