Adult flatfoot
BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m295 (Published 24 February 2020) Cite this as: BMJ 2020;368:m295
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Dear Editor,
I read with the interest the 10 minute consult by Tang et al on flat foot1. It is a lovely article with plenty of value for most readers. As a practising rheumatologist, one commonly comes across flat foot (flexible) in outpatient clinics, and often the aetiology is hypermobility2,3. Although patients often present with pain in foot, they also often present with knee pain4. Patients with hypermobility will usually present with joint pain or dislocation. Patients at the severe end of the hypermobility spectrum tend to present in late teens or early 20s, but milder ones often present in middle age.
The scenario that the authors described of a 45 year old overweight woman would be a common age group for patients with hypermobility to present. This is an important diagnosis that needs to be looked for. Patients with hypermobility have other manifestations due to collagen disorders, and some will have Ehlers-Danlos syndrome or other conditions. These patients will benefit from specific interventions including physiotherapy, but are at risk of problems with multiple joints, and will never settle until the right interventions are made. There are no specific laboratory investigations for hypermobility – the diagnosis is clinical (Beighton score)5, and if this is not part of the differential diagnosis, the diagnosis is likely to be missed.
Another factor to consider is since flat foot is a rather common condition; it may not be the reason for symptoms. If patients have history of morning stiffness and positive metatarsal squeeze on ‘feel’ of metatarsophalangeal joints, consideration should be given to the possibility of inflammatory arthritis.
References:
1. Tang CYK, Ng KH, Lai J. Adult flat foot: 10 minute consultation. BMJ 2020; 386:m295.
2. Finsterbush A, Pogrund H. The hypermobility syndrome: musculoskeletal complaints in 100 consecutive cases of generalized joint hypermobility. Clin Orthop. 1982;168:124–127.
3. Hakim A, Graham R. Joint hypermobility. Best Practice and Research Clinical Rheumatology. Volume 17, Issue 6, December 2003, Pages 989-1004.
4. Al-Rawi Z, Nessan AH. Joint hypermobility in patients with chondromalacia patellae. Br J Rheumatol.1997;36:1324–1327.
5. Beighton P, Solomon L, Soskolne CL. Articular mobility in an African population. Ann Rheum Dis. 1973;32:413–418.
Competing interests: No competing interests
Dear Editor
A gem of an article, thank you and one I plan to discuss with our students as I see this problem often in general practice.
Locally we are fortunate to have a good walk in podiatry and physiotherapy service so I usually leave the management to them.
However I often sense negatively/pts dissatisfied with their non surgical tx. After reading this article I now feel more able to check if they fully understand the purpose of treatment, and if they know what they should be doing and so hopefully check and aid compliance.
I am trying to find the suggested further information on home exercises that is cited in the article, without any luck so far.
I would be very grateful if you could kindly forward me that link.
Kind regards
Nicola Enoch
nenoch@hotmail.com
GP from Neath .S Wales
Competing interests: No competing interests
Re: Adult flatfoot
Dear Editor
This article is well presented and the clinical pictures are very helpful for those in primary care who wish to learn more about the assessment and examination of the adult flat foot. I believe the article has missed some key points that would help the primary care community.
I find the acute adult flatfoot presentation and the subsequent management was poorly outlined in the article.
People who present with sudden postural arch changes (flattening) over a very short period (1-2 weeks) should be treated promptly. Those that are associated with pain and swelling at the medial arch tendon and ligaments (tibialis posterior, flexor hallucis and flexor digitorum longus and Lisfranc ligament) require an urgent referral for long term management and access to ankle orthosis and or below knee walker, this service will depend on local commissioning arrangements and maybe via Orthotist, Podiatry, Physiotherapy MSK services, and close liaison Orthopaedic services, if surgical input is required.
The presentation of Charcot Arthropathy was described as a cause of adult acquired flat foot in this article, however, the advice provided does not reflect current NICE guidelines. Immediate action should always be taken in people who present with an acute flatfoot and who also have peripheral neuropathy (diabetes being the most common form). Swelling and heat in the midfoot are the most common complaints, with pain either reported as absent or minor in comparison to the clinical presentation. Any presentation of a red hot swollen foot in someone with Diabetes needs to be referred to the diabetes foot service as per NICE recommendation (NG19) [1]. In addition, despite the advice in the article, X-ray is often negative in the early stages of Charcot Arthropathy and by the time X-ray changes have occurred joint damage is irreversible, which increases the risk of ulceration, infection, and amputation [2]. People who are suspected of this Charcot Arthropathy require urgent below-knee casting and minimal weight-bearing for a prolonged period [3].
I find key points describing the spectrum of the adult flat foot were missing from this article, namely congenital flatfoot, of which joint hypermobility plays an important role. I wholeheartedly agree with the response to this article by Dr Dubey Rheumatologist and that Hypermobility Spectrum Disorders (Ehlers Danlos Syndrome) should be considered in the slowly evolving symptomatic flatfoot. In light of this, I would recommend the Royal College of GPs Ehlers Danlos Syndrome toolkit as an additional resource [4].
The other key point raised in this article is that the classification of the adult flatfoot from a flexible to a rigid deformity over time. It was disappointing to see osteoarthritis was not included in this article to help the reader understand the pathological processes, despite the hindfoot and medial midfoot osteoarthritis being associated with the adult flatfoot deformity [5,6]. I note this is well described by Abousayed et al. (2016) systematic review of the adult flatfoot and the classifications systems [7].
Reference
1. https://www.nice.org.uk/guidance/ng19/chapter/recommendations#charcot-ar... [accessed 02.03.2020].
2. Mautone M, Naidoo P. What the radiologist needs to know about Charcot foot. Journal of medical imaging and radiation oncology. 2015 Aug;59(4):395-402.
3. Renner N, Wirth SH, Osterhoff G, Böni T, Berli M. Outcome after protected full weightbearing treatment in an orthopedic device in diabetic neuropathic arthropathy (Charcot arthropathy): a comparison of unilaterally and bilaterally affected patients. BMC musculoskeletal Disorders. 2016 Dec 1;17(1):504.
4. https://www.rcgp.org.uk/clinical-and-research/resources/toolkits/ehlers-... [accessed 02.03.2020]
5. Menz HB, Munteanu SE, Zammit GV, Landorf KB. Foot structure and function in older people with radiographic osteoarthritis of the medial midfoot. Osteoarthritis and cartilage. 2010 Mar 1;18(3):317-22.
6. Arnold JB, Marshall M, Thomas MJ, Redmond AC, Menz HB, Roddy E. Midfoot osteoarthritis: potential phenotypes and their associations with demographic, symptomatic and clinical characteristics. Osteoarthritis and cartilage. 2019 Apr 1;27(4):659-66.
7. Abousayed MM, Tartaglione JP, Rosenbaum AJ, Dipreta JA. Classifications in brief: Johnson and Strom classification of adult-acquired flatfoot deformity.
Competing interests: No competing interests