From: Foot and Ankle Clinics of North America. Volume 17, Issue 2, June 2012, Pages 169–181

The RAM Classification: A Novel, Systematic Approach to the Adult-Acquired Flatfoot
The adult-acquired flatfoot (AAFF) is most commonly associated with dysfunction of the posterior tibial tendon (PTT) and presents clinically as a painful pes planus deformity.  From the time posterior tibial tendonitis was initially described in 1936 by Kulowski until 1983, little can be found throughout the literature pertaining to this topic aside from a few case series. In 1983, Johnson was the first to discuss the signs and symptoms that resulted from rupture of the PTT. He described a valgus deformity of the hindfoot and abduction deformity of the forefoot, which has since become the hallmark of this disorder. From this work, he established the “too many toes” sign and the inability to perform a single-leg heel rise as indicators of loss of PTT function.  Steven M. Raikin, MD, , Brian S. Winters, MD, Joseph N. Daniel, DO. Available online 27 April 2012.
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