Adult acquired flatfoot
is a progressive disorder that involves a compromise of soft tissue
supports of the medial arch. The condition most commonly affects middle aged women and is characterized by lowering of the arch, turning out of the forefoot, and a sideways angulation of the heel.
There are five stages of the disorder that becomes progressively disabling. The end stage can potentially compromise the ankle joint along with the joints in the hindfoot.
Flat footedness, most people who develop the condition already have flat feet. With overuse or continuous loading, a change occurs where the arch begins to flatten more than before, with pain and
swelling developing on the inside of the ankle. Inadequate support from footwear may occasionally be a contributing factor. Trauma or injury, occasionally this condition may be due to fracture,
sprain or direct blow to the tendon. Age, the risk of developing Posterior Tibial Tendon Dysfunction increases with age and research has suggested that middle aged women are more commonly affected.
Other possible contributing factors - being overweight and inflammatory arthritis.
Pain along the inside of the foot and ankle, where the tendon lies. This may or may not be associated with swelling in the area. Pain that is worse with activity. High-intensity or high-impact
activities, such as running, can be very difficult. Some patients can have trouble walking or standing for a long time. Pain on the outside of the ankle. When the foot collapses, the heel bone may
shift to a new position outwards. This can put pressure on the outside ankle bone. The same type of pain is found in arthritis in the back of the foot. Asymmetrical collapsing of the medial arch on
the affected side.
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
Options range from shoe inserts, orthotics, bracing and physical therapy for elderly and/or inactive patients to reconstructive surgical procedures in those wishing to remain more active. These
treatments restore proper function and alignment of the foot by replacing the damaged muscle tendon unit with an undamaged, available and expendable one, lengthening the contracted Achilles tendon
and realigning the Os Calcis, or heel bone, while preserving the joints of the hindfoot. If this condition is not recognized before it reaches advanced stages, a fusion of the hindfoot or even the
ankle is necessary. Typically this is necessary in elderly individuals with advanced cases that cannot be improved with bracing.
Surgery should only be done if the pain does not get better after a few months of conservative treatment. The type of surgery depends on the stage of the PTTD disease. It it also dictated by where
tendonitis is located and how much the tendon is damaged. Surgical reconstruction can be extremely complex. Some of the common surgeries include. Tenosynovectomy, removing the inflamed tendon sheath
around the PTT. Tendon Transfer, to augment the function of the diseased posterior tibial tendon with a neighbouring tendon. Calcaneo-osteotomy, sometimes the heel bone needs to be corrected to get a
better heel bone alignment. Fusion of the Joints, if osteoarthritis of the foot has set in, fusion of the joints may be necessary.