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Ätiologie, Pathogenese, Klinik, Diagnostik und konservative Therapie des adulten erworbenen Plattfußes

Etiology, pathogenesis, clinical features, diagnostics and conservative treatment of adult flatfoot

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Zusammenfassung

Hintergrund

Etwa jeder sechste Erwachsene weist eine Plattfußstellung auf. Die stadienhaft verlaufende Fußfehlstellung ruft bei ca. 10 % der Patienten behandlungsbedürftige Beschwerden hervor. Im unbehandelten Endstadium droht der Verlust der Gehfähigkeit. Die gezielte Therapie erfordert eine korrekte Einordnung des Krankheitsstadiums und umfasst ein breites Spektrum konservativer und operativer Maßnahmen.

Material und Methoden

Gezielte Literaturrecherche in den Datenbanken Pubmed und Medline sowie Erfahrungen aus eigener Praxis.

Diagnostik

Die Funktionseinschränkung der statischen (Springligamentkomplex) und dynamischen (Tibialis-posterior-Sehne) Stabilisatoren führt zu der charakteristischen Fußfehlstellung mit Abflachung der medialen Fußwölbung, valgischer Rückfußachse und Abduktionsstellung des Vorfußes. Im Spätstadium droht eine schwere sekundäre Arthrose im oberen und unteren Sprunggelenkkomplex. Neben der essenziellen klinischen Untersuchung liefern belastete Röntgenaufnahmen im dorsoplantaren und seitlichen Strahlengang objektivierbare Informationen über das Ausmaß der Fehlstellung (Meary-Winkel, Kite-Winkel) und der begleitenden Arthrose. Die „long axis hindfoot view“ erlaubt die Quantifizierung des Rückfußvalgus. Die MRT ist das Mittel der Wahl zur Beurteilung der Tibialis-posterior-Sehne und des Springligamentkomplexes.

Therapie

Die Therapie zielt auf die Schmerzreduktion, Wiederherstellung der Funktion und auf die Vermeidung einer sekundären Arthrose sowie degenerativer Sehnenveränderungen ab. Eine Zunahme der Deformität soll vermieden werden. Sie sollte daher alle drei Komponenten der Deformität – Rückfußvalgus, Vorfußabduktion und Abflachung der Längswölbung – ansprechen und korrigieren. In der akuten Phase ist die Tenosynovialitis der Tibialis-posterior-Sehne gut mit antiinflammatorischer Therapie, mechanischer Entlastung und Krankengymnastik zu behandeln. Langfristig führt sie aber selten zu einer dauerhaften Stabilisierung des Fußes.

Abstract

Background

On average, one in six adults is affected by an acquired flatfoot. This foot deformity is characterized by its progression of stages and in 10% of cases causes complaints that require treatment. Untreated, the loss of walking ability may result in the final stage. Correct staging is crucial to being able to offer a specific course of therapy including a wide spectrum of conservative and operative treatments.

Material and methods

This review is based on pertinent publications retrieved from a selective search in PubMed and Medline and on the authors’ clinical experience.

Diagnostics

The loss of function of static (spring ligament complex) and dynamic (tibialis posterior tendon) stabilizers causes the characteristic deformity with loss of the medial arch, hind foot valgus and forefoot abduction. In the late stage, severe secondary osteoarthritis in upper and lower ankle joints occurs and impedes walking ability. The essential physical examination is supplemented by weight-bearing dorsoplantar and lateral radiographs, which provide further information about axial malalignment (Meary’s angle, Kite‘s angle). The long axis hind foot view allows analysis of the hindfoot valgus. MRI provides further information about the integrity of the tibialis posterior tendon, spring ligament complex and cartilage damage.

Therapy

The therapy aims to reduce pain, regain function and avoid development of secondary osteoarthritis and degenerative tendon disorders. Progress of the deformity should be stopped. Therefore, the main aspects of the deformity—loss of medial arch, hindfoot valgus and forefoot abduction should be addressed and corrected. In the acute phase, tendovaginitis of the tibialis posterior tendon can be treated sufficiently by anti-inflammatory measures, relieving mechanical loads on the tendon and muscle and physiotherapy.

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Abbreviations

AFO:

„Arizona ankle-foot“

CNSM :

Ligamentum calcaneonaviculare superomediale

FDL :

Flexor digitorum longus

NSAR :

Nichtsteroidale Antirheumatika

OSG :

Oberes Sprunggelenk

SL :

Springligament

TP :

Tibialis posterior

UCBL :

University of California Berkeley Laboratory

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  1. Department für Orthopädie, Unfall- und Wiederherstellungschirurgie, Martin-Luther-Universität Halle-Wittenberg, Ernst-Grube Str. 40, 06120, Halle (Saale), Deutschland

    N. Gutteck, S. Schilde & K. S. Delank

  2. Orthopädische Klinik, Klinikum Dortmund, Dortmund, Deutschland

    D. Arbab

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Gutteck, N., Schilde, S., Delank, K.S. et al. Ätiologie, Pathogenese, Klinik, Diagnostik und konservative Therapie des adulten erworbenen Plattfußes. Orthopäde 49, 942–953 (2020). https://doi.org/10.1007/s00132-020-03995-5

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