Adult flatfoot may be due to multiple problems including a dysfunctional posterior tibial tendon (PTT), hypermobility and ligamentous laxity, or possibly a coalition that becomes symptomatic. For a vast majority of patients, posterior tibial tendon dysfunction (PTTD) is the cause of symptomatic flatfoot and is the main trigger of surgical reconstruction in flatfoot. The common presenting scenario for adult flatfoot is a case of unilateral flatfoot with pain. Patients will often confirm they ?always had flat feet? but have noticed increased pain and additional collapse in the past few months to years. They may also note increased swelling and a possible concern over one foot increasing in shoe size. After a comprehensive dermatologic, neurologic and vascular assessment, one should direct his or her attention to the musculoskeletal portion of the exam. It is key to examine the foot and leg as a whole in order to determine the proper procedure and consider each phase of the corrective surgery.
Several risk factors are associated with PTT dysfunction, including high blood pressure, obesity, diabetes, previous ankle surgery or trauma and exposure to steroids. A person who suspects that they are suffering from PTT dysfunction should seek medical attention earlier rather than later. It is much easier to treat early and avoid a collapsed arch than it is to repair one. When the pain first happens and there is no significant flatfoot deformity, initial treatments include rest, oral anti-inflammatory medications and, depending on the severity, a special boot or brace.
PTTD begins with a gradual stretching and loss of strength of the posterior tibial tendon which is the most important tendon supporting the arch of the human foot. Left untreated, this tendon will continue to lengthen and eventually rupture, leading to a progressive visible collapse of the arch of the foot. In the early stages, patients with PTTD will notice a pain and swelling along the inner ankle and arch. Many times, they are diagnosed with ?tendonitis? of the inner ankle. If the foot and ankle are not properly supported during this early phase, the posterior tibial tendon can rupture and devastating consequences will occur to the foot and ankle structure. The progressive adult acquired flatfoot deformity will cause the heel to roll inward in a ?valgus? or pronated direction while the forefoot will rotate outward causing a ?duckfooted? walking pattern. Eventually, significant arthritis can occur in the joints of the foot, the ankle and even the knee. Early diagnosis and treatment is critical so if you have noticed that one, or both, of your feet has become flatter in recent times come in and have it checked out.
The adult acquired flatfoot, secondary to posterior tibial tendon dysfunction, is diagnosed in a number of ways with no single test proven to be totally reliable. The most accurate diagnosis is made by a skilled clinician utilizing observation and hands on evaluation of the foot and ankle. Observation of the foot in a walking examination is most reliable. The affected foot appears more pronated and deformed compared to the unaffected foot. Muscle testing will show a strength deficit. An easy test to perform in the office is the single foot raise. A patient is asked to step with full body weight on the symptomatic foot, keeping the unaffected foot off the ground. The patient is then instructed to "raise up on the tip toes" of the affected foot. If the posterior tibial tendon has been attenuated or ruptured, the patient will be unable to lift the heel off the floor and rise onto the toes. In less severe cases, the patient will be able to rise on the toes, but the heel will not be noted to invert as it normally does when we rise onto the toes. X-rays can be helpful but are not diagnostic of the adult acquired flatfoot. Both feet - the symptomatic and asymptomatic - will demonstrate a flatfoot deformity on x-ray. Careful observation may show a greater severity of deformity on the affected side.
Non surgical Treatment
Initial treatment consists of supporting the medial longitudinal arch (running the length of the foot) to relieve strain on the medial soft tissues. The most effective way to relieve pain on the tendon is to use a boot or brace, and once tenderness and pain has resolved, an orthotic device. A boot, brace, or orthotic has not been shown to correct or even prevent the progression of deformity. Orthotics can alleviate symptoms and may slow the progression of deformity, particularly if mild. The deformity may progress despite orthotics.
If cast immobilization fails, surgery is the next alternative. Treatment goals include eliminating pain, halting deformity progression and improving mobility. Subtalar Arthroereisis, 15 minute outpatient procedure, may correct flexible flatfoot deformity (hyperpronation). The procedure involves placing an implant under the ankle joint (sinus tarsi) to prevent abnormal motion. Very little recovery time is required and it is completely reversible if necessary. Ask your Dallas foot doctor for more information about this exciting treatment possibility.