Flatfoot may sound like a characteristic of a certain water animal rather than a human problem. Flatfoot
is a condition in which the arch
of the foot is fallen and the foot is pointed outward. In contrast to a flatfoot condition that has always been present, this type develops after the skeleton has reached maturity. There are several
situations that can result in fallen arches, including fracture, dislocation, tendon laceration, tarsal coalition, and arthritis. One of the most common conditions that can lead to this foot problem
is posterior tibial tendon dysfunction. The posterior tibial tendon attaches the calf muscle to the bones on the inside of the foot and is crucial in holding up and supporting the arch. An acute
injury or overuse can cause this tendon to become inflamed or even torn, and the arch of the foot will slowly fall over time.
As discussed above, many health conditions can create a painful flatfoot. Damage to the posterior tibial tendon is the most common cause of AAFD. The posterior tibial tendon is one of the most
important tendons of the leg. It starts at a muscle in the calf, travels down the inside of the lower leg and attaches to the bones on the inside of the foot. The main function of this tendon is to
hold up the arch and support your foot when you walk. If the tendon becomes inflamed or torn, the arch will slowly collapse. Women and people over 40 are more likely to develop problems with the
posterior tibial tendon. Other risk factors include obesity, diabetes, and hypertension. Having flat feet since childhood increases the risk of developing a tear in the posterior tibial tendon. In
addition, people who are involved in high impact sports, such as basketball, tennis, or soccer, may have tears of the tendon from repetitive use. Inflammatory arthritis, such as rheumatoid arthritis,
can cause a painful flatfoot. This type of arthritis attacks not only the cartilage in the joints, but also the ligaments that support the foot. Inflammatory arthritis not only causes pain, but also
causes the foot to change shape and become flat. The arthritis can affect the back of the foot or the middle of foot, both of which can result in a fallen arch.
Symptoms of pain may have developed gradually as result of overuse or they may be traced to one minor injury. Typically, the pain localizes to the inside (medial) aspect of the ankle, under the
medial malleolus. However, some patients will also experience pain over the outside (lateral) aspect of the hindfoot because of the displacement of the calcaneus impinging with the lateral malleolus.
This usually occurs later in the course of the condition. Patients may walk with a limp or in advanced cases be disabled due to pain. They may also have noticed worsening of their flatfoot
First, both feet should be examined with the patient standing and the entire lower extremity visible. The foot should be inspected from above as well as from behind the patient, as valgus angulation
of the hindfoot is best appreciated when the foot is viewed from behind. Johnson described the so-called more-toes sign: with more advanced deformity and abduction of the forefoot, more of the
lateral toes become visible when the foot is viewed from behind. The single-limb heel-rise test is an excellent determinant of the function of the posterior tibial tendon. The patient is asked to
attempt to rise onto the ball of one foot while the other foot is suspended off the floor. Under normal circumstances, the posterior tibial muscle, which inverts and stabilizes the hindfoot, is
activated as the patient begins to rise onto the forefoot. The gastrocnemius-soleus muscle group then elevates the calcaneus, and the heel-rise is accomplished. With dysfunction of the posterior
tibial tendon, however, inversion of the heel is weak, and either the heel remains in valgus or the patient is unable to rise onto the forefoot. If the patient can do a single-limb heel-rise, the
limb may be stressed further by asking the patient to perform this maneuver repetitively.
Non surgical Treatment
Conservative (nonoperative) care is advised at first. A simple modification to your shoe may be all that???s needed. Sometimes purchasing shoes with a good arch support is sufficient. For other
patients, an off-the-shelf (prefabricated) shoe insert works well. The orthotic is designed specifically to position your foot in good alignment. Like the shoe insert, the orthotic fits inside the
shoe. These work well for mild deformity or symptoms. Over-the-counter pain relievers or antiinflammatory drugs such as ibuprofen may be helpful. If symptoms are very severe, a removable boot or cast
may be used to rest, support, and stabilize the foot and ankle while still allowing function. Patients with longer duration of symptoms or greater deformity may need a customized brace. The brace
provides support and limits ankle motion. After several months, the brace is replaced with a foot orthotic. A physical therapy program of exercise to stretch and strengthen the foot and leg muscles
is important. The therapist will also show you how to improve motor control and proprioception (joint sense of position). These added features help prevent and reduce injuries.
Surgical treatment should be considered when all other conservative treatment has failed. Surgery options for flatfoot reconstruction depend on the severity of the flatfoot. Surgery for a flexible
flatfoot deformity (flatfoot without arthritis to the foot joints) involves advancing the posterior tibial tendon under the arch to provide more support and decrease elongation of the tendon as well
as addressing the hindfoot eversion with a osteotomy to the calcaneus (surgical cut in the heel bone). Additionally, the Achilles tendon may need to be lengthened because of the compensatory
contracture of the Achilles tendon with flatfoot deformity. Flatfoot deformity with arthritic changes to the foot is considered a rigid flatfoot. Correction of a rigid flatfoot deformity usually
involves surgical fusion of the hindfoot joints. This is a reconstructive procedure which allows the surgeon to re-position the foot into a normal position. Although the procedure should be
considered for advanced PTTD, it has many complications and should be discussed at length with your doctor.