Flat Foot Problems In Adults

Overview Becoming flatfooted can be a real health issue for people. The advice from healthcare experts is to pay attention to foot pain, and when it happens, to seek help right away. In the last 20 years, adult-acquired flatfoot has become a more commonly recognized health issue. The cause is a dysfunction of the ankle tendon that attaches to the bones on the inside of your foot. The function of this posterior tibial tendon (PTT) is to maintain the foot arch and provide strength during push-off when you walk. When the PTT is not functioning correctly, you tend to lose your arch, or become more flatfooted. This problem occurs about three times more often in women than in men, especially after the age of 40. Initially, PTT dysfunction is associated with pain on the inside of the ankle, swelling and sometimes a limp. If left unchecked, the arch appears to collapse and the pain on the inside of the ankle worsens. Eventually, if left unchecked, patients will begin to feel pain on the outside of the ankle, too. Causes Women are affected by Adult Acquired Flatfoot four times more frequently than men. Adult Flatfoot generally occurs in middle to older age people. Most people who acquire the condition already have flat feet. One arch begins to flatten more, then pain and swelling develop on the inside of the ankle. This condition generally affects only one foot. It is unclear why women are affected more often than men. But factors that may increase your risk of Adult Flatfoot include diabetes, hypertension, and obesity. Symptoms Many patients with this condition have no pain or symptoms. When problems do arise, the good news is that acquired flatfoot treatment is often very effective. Initially, it will be important to rest and avoid activities that worsen the pain. Diagnosis The history and physical examination are probably the most important tools the physician uses to diagnose this problem. The wear pattern on your shoes can offer some helpful clues. Muscle testing helps identify any areas of weakness or muscle impairment. This should be done in both the weight bearing and nonweight bearing positions. A very effective test is the single heel raise. You will be asked to stand on one foot and rise up on your toes. You should be able to lift your heel off the ground easily while keeping the calcaneus (heel bone) in the middle with slight inversion (turned inward). X-rays are often used to study the position, shape, and alignment of the bones in the feet and ankles. Magnetic resonance (MR) imaging is the imaging modality of choice for evaluating the posterior tibial tendon and spring ligament complex. 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. Surgical Treatment Stage two deformities are less responsive to conservative therapies that can be effective in mild deformities. Bone procedures are necessary at this stage in order to recreate the arch and stabilize the foot. These procedures include isolated fusion procedures, bone grafts, and/or the repositioning of bones through cuts called osteotomies. The realigned bones are generally held in place with screws, pins, plates, or staples while the bone heals. A tendon transfer may or may not be utilized depending on the condition of the posterior tibial tendon. Stage three deformities are better treated with surgical correction, in healthy patients. Patients that are unable to tolerate surgery or the prolonged healing period are better served with either arch supports known as orthotics or bracing such as the Richie Brace. Surgical correction at this stage usually requires fusion procedures such as a triple or double arthrodesis. This involves fusing the two or three major bones in the back of the foot together with screws or pins. The most common joints fused together are the subtalar joint, talonavicular joint, and the calcaneocuboid joint. By fusing the bones together the surgeon is able to correct structural deformity and alleviate arthritic pain. Tendon transfer procedures are usually not beneficial at this stage. Stage four deformities are treated similarly but with the addition of fusing the ankle joint.

Tibialis Posterior Tendon Dysfunction Surgery

Overview
PTTD is a condition of degeneration and dysfunction in the tendon complex that helps control the medial arch of your foot. Essentially what happens is the complex is unable to do its job of supporting the arch and supinating the foot, so a progressive flat foot develops (usually called adult acquired flat foot). Initially pain and often swelling develops on the inside of the ankle and it will continue to get progressively worse. There are a number of stages of PTTD (3 Stages) and it needs to be aggressively treated early on otherwise a surgical reconstruction of the arch will invariably be required. PTTD can develop into a very disabling condition if it is not dealt with properly and promptly. As PTTD becomes more advanced, the arch flattens even more and the pain often shifts to the outside of the foot, below the ankle. Arthritis often develops in the foot and In more severe cases, arthritis may also develop in the ankle.

Causes
The posterior tibial tendon, which connects the bones inside the foot to the calf, is responsible for supporting the foot during movement and holding up the arch. Gradual stretching and tearing of the posterior tibial tendon can cause failure of the ligaments in the arch. Without support, the bones in the feet fall out of normal position, rolling the foot inward. The foot's arch will collapse completely over time, resulting in adult acquired flatfoot. The ligaments and tendons holding up the arch can lose elasticity and strength as a result of aging. Obesity, diabetes, and hypertension can increase the risk of developing this condition. Adult acquired flatfoot is seen more often in women than in men and in those 40 or older.

Symptoms
Some symptoms of adult acquired flat foot are pain along the inside of the foot and ankle, pain that increases with activity, and difficulty walking for long periods of time. You may experience difficulty standing, pain on the outside of the ankle, and bony bumps on the top of the foot and inside the foot. You may also have numbness and tingling of the feet and toes (may result from large bone spurs putting pressure on nerves), swelling, a large bump on the sole of the foot and/or an ulcer (in diabetic patients). Diabetic patients should wear a properly fitting diabetic shoe wear to prevent these complications from happening.

Diagnosis
Although you can do the "wet test" at home, a thorough examination by a doctor will be needed to identify why the flatfoot developed. Possible causes include a congenital abnormality, a bone fracture or dislocation, a torn or stretched tendon, arthritis or neurologic weakness. For example, an inability to rise up on your toes while standing on the affected foot may indicate damage to the posterior tibial tendon (PTT), which supports the heel and forms the arch. If "too many toes" show on the outside of your foot when the doctor views you from the rear, your shinbone (tibia) may be sliding off the anklebone (talus), another indicator of damage to the PTT. Be sure to wear your regular shoes to the examination. An irregular wear pattern on the bottom of the shoe is another indicator of acquired adult flatfoot. Your physician may request X-rays to see how the bones of your feet are aligned. Muscle and tendon strength are tested by asking you to move the foot while the doctor holds it.

Non surgical Treatment
Footwear has an important role, and patients should be encouraged to wear flat lace-up shoes, or even lace-up boots, which accommodate orthoses. Stage I patients may be able to manage with an off the shelf orthosis (such as an Orthaheel or Formthotics). They can try a laced canvas ankle brace before moving to a casted orthosis. The various casted, semirigid orthoses support the medial longitudinal arch of the foot and either hold the heel in a neutral alignment (stage I) or correct the outward bent heel to a neutral alignment (stage II). This approach is meant to serve several functions: to alleviate stress on the tibialis posterior; to make gait more efficient by holding the hindfoot fixed; and thirdly, to prevent progression of deformity. Devices available to do this are the orthosis of the University of California Biomechanics Laboratory, an ankle foot orthosis, or a removable boot. When this approach has been used, two thirds of patients have good to excellent results.

Surgical Treatment
Flatfoot reconstruction (osteotomy). This is often recommended for flexible flatfoot condition. Flatfoot reconstruction involves cutting and shifting the heel bone into a more neutral position, transferring the tendon used to flex the lesser toes (all but the big toe) to strengthen the posterior tibial tendon, and lengthening the calf muscle. Fusion (also known as triple arthrodesis). Fusion involves fusing, or making stiff, three joints in the back of the foot the subtalar, talonavicular, and calcaneocuboid joints, to realign the foot and give it a more natural shape. Pins or screws hold the area in place until it heals. Fusion is often recommended for a rigid flatfoot deformity or evidence of arthritis. Both of these surgeries can provide excellent pain relief and correction.