Most flat feet are not painful, particularly those flat feet seen in children. In the adult acquired flatfoot
, pain occurs because soft
tissues (tendons and ligaments) have been torn. The deformity progresses or worsens because once the vital ligaments and posterior tibial tendon are lost, nothing can take their place to hold up the
arch of the foot. The painful, progressive adult acquired flatfoot affects women four times as frequently as men. It occurs in middle to older age people with a mean age of 60 years. Most people who
develop the condition already have flat feet. A change occurs in one foot where the arch begins to flatten more than before, with pain and swelling developing on the inside of the ankle. Why this
event occurs in some people (female more than male) and only in one foot remains poorly understood. Contributing factors increasing the risk of adult acquired flatfoot are diabetes, hypertension, and
There are multiple factors contributing to the development of this problem. Damage to the nerves, ligaments, and/or tendons of the foot can cause subluxation (partial dislocation) of the subtalar or
talonavicular joints. Bone fracture is a possible cause. The resulting joint deformity from any of these problems can lead to adult-acquired flatfoot deformity. Dysfunction of the posterior tibial
tendon has always been linked with adult-acquired flatfoot deformity (AAFD). The loss of active and passive pull of the tendon alters the normal biomechanics of the foot and ankle. The reasons for
this can be many and varied as well. Diabetes, high blood pressure, and prolonged use of steroids are some of the more common causes of adult-acquired flatfoot deformity (AAFD) brought on by
impairment of the posterior tibialis tendon. Overstretching or rupture of the tendon results in tendon and muscle imbalance in the foot leading to adult-acquired flatfoot deformity (AAFD). Rheumatoid
arthritis is one of the more common causes. About half of all adults with this type of arthritis will develop adult flatfoot deformity over time. In such cases, the condition is gradual and
progressive. Obesity has been linked with this condition. Loss of blood supply for any reason in the area of the posterior tibialis tendon is another factor. Other possible causes include bone
fracture or dislocation, a torn or stretched tendon, or a neurologic condition causing weakness.
The symptoms of PTTD may include pain, swelling, a flattening of the arch, and an inward rolling of the ankle. As the condition progresses, the symptoms will change. For example, when PTTD initially
develops, there is pain on the inside of the foot and ankle (along the course of the tendon). In addition, the area may be red, warm, and swollen. Later, as the arch begins to flatten, there may
still be pain on the inside of the foot and ankle. But at this point, the foot and toes begin to turn outward and the ankle rolls inward. As PTTD becomes more advanced, the arch flattens even more
and the pain often shifts to the outside of the foot, below the ankle. The tendon has deteriorated considerably and arthritis often develops in the foot. In more severe cases, arthritis may also
develop in the ankle.
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
Non-surgical treatment consists of custom orthoses and or special bracing devices along with supportive measures aimed at reducing the symptoms. While non-surgical treatment helps the majority of
patients with PTTD, progressive cases may require surgical treatment including soft tissue tendon transfers, osteotomies and lastly fusion.
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.