A painful flat foot, or adult acquired flatfoot
deformity, is a progressive collapsing of the
arch of the foot that occurs as the posterior tibial tendon becomes insufficient due to various factors. Early stages may present with only pain along the posterior tibial tendon whereas advanced
deformity usually results in arthritis and rigidity of the rearfoot and ankle.
The cause of posterior tibial tendon insufficiency is not completely understood. The condition commonly does not start from one acute trauma but is a process of gradual degeneration of the soft
tissues supporting the medial (inner) side of the foot. It is most often associated with a foot that started out somewhat flat or pronated (rolled inward). This type of foot places more stress on the
medial soft tissue structures, which include the posterior tibial tendon and ligaments on the inner side of the foot. Children nearly fully grown can end up with flat feet, the majority of which are
no problem. However, if the deformity is severe enough it can cause significant functional limitations at that age and later on if soft tissue failure occurs. Also, young adults with normally aligned
feet can acutely injure their posterior tibial tendon from a trauma and not develop deformity. The degenerative condition in patients beyond their twenties is different from the acute injuries in
young patients or adolescent deformities, where progression of deformity is likely to occur.
Your feet tire easily or become painful with prolonged standing. It's difficult to move your heel or midfoot around, or to stand on your toes. Your foot aches, particularly in the heel or arch area,
with swelling along the inner side. Pain in your feet reduces your ability to participate in sports. You've been diagnosed with rheumatoid arthritis; about half of all people with rheumatoid
arthritis will develop a progressive flatfoot deformity.
Posterior Tibial Tendon Dysfunction is diagnosed with careful clinical observation of the patient?s gait (walking), range of motion testing for the foot and ankle joints, and diagnostic imaging.
People with flatfoot deformity walk with the heel angled outward, also called over-pronation. Although it is normal for the arch to impact the ground for shock absorption, people with PTTD have an
arch that fully collapses to the ground and does not reform an arch during the entire gait period. After evaluating the ambulation pattern, the foot and ankle range of motion should be tested.
Usually the affected foot will have decreased motion to the ankle joint and the hindfoot. Muscle strength may also be weaker as well. An easy test to perform for PTTD is the single heel raise where
the patient is asked to raise up on the ball of his or her effected foot. A normal foot type can lift up on the toes without pain and the heel will invert slightly once the person has fully raised
the heel up during the test. In early phases of PTTD the patient may be able to lift up the heel but the heel will not invert. An elongated or torn posterior tibial tendon, which is a mid to late
finding of PTTD, will prohibit the patient from fully rising up on the heel and will cause intense pain to the arch. Finally diagnostic imaging, although used alone cannot diagnose PTTD, can provide
additional information for an accurate diagnosis of flatfoot deformity. Xrays of the foot can show the practitioner important angular relationships of the hindfoot and forefoot which help diagnose
flatfoot deformity. Most of the time, an MRI is not needed to diagnose PTTD but is a tool that should be considered in advanced cases of flatfoot deformity. If a partial tear of the posterior tibial
tendon is of concern, then an MRI can show the anatomic location of the tear and the extensiveness of the injury.
Non surgical Treatment
Because of the progressive nature of PTTD, early treatment is advised. If treated early enough, your symptoms may resolve without the need for surgery and progression of your condition can be
arrested. In contrast, untreated PTTD could leave you with an extremely flat foot, painful arthritis in the foot and ankle, and increasing limitations on walking, running, or other activities. In
many cases of PTTD, treatment can begin with non-surgical approaches that may include. Orthotic devices or bracing. To give your arch the support it needs, your foot and ankle surgeon may provide you
with an ankle brace or a custom orthotic device that fits into the shoe. Immobilization. Sometimes a short-leg cast or boot is worn to immobilize the foot and allow the tendon to heal, or you may
need to completely avoid all weight-bearing for a while. Physical therapy. Ultrasound therapy and exercises may help rehabilitate the tendon and muscle following immobilization. Medications.
Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, help reduce the pain and inflammation. Shoe modifications. Your foot and ankle surgeon may advise changes to make with your shoes and
may provide special inserts designed to improve arch support.
Although non-surgical treatments can successfully manage the symptoms, they do not correct the underlying problem. It can require a life-long commitment to wearing the brace during periods of
increased pain or activity demands. This will lead a majority of patients to choose surgical correction of the deformity, through Reconstructive Surgery. All of the considerations that were extremely
important during the evaluation stage become even more important when creating a surgical plan. Generally, a combination of procedures are utilized in the same setting, to allow full correction of
the deformity. Many times, this can be performed as a same-day surgery, without need for an overnight hospital stay. However, one or two day hospital admissions can be utilized to help manage the
post-operative pain. Although the recovery process can require a significant investment of time, the subsequent decades of improved function and activity level, as well as decreased pain, leads to a
substantial return on your investment.