This condition is characterized by a progressive flattening or falling of the arch. It is often referred to as posterior tibial tendon dysfunction (PTTD) and is becoming a more commonly recognized
foot problem. Since the condition develops over time, it is typically diagnosed in adulthood. It usually only develops in one foot although it can affect both. Since it is progressive, it is common
for symptoms to worsen, especially when it is not treated early. The posterior tibial tendon attaches to the bones on the inside of your foot and is vital to the support structure within the foot.
With PTTD, changes in the tendon impair its ability to function normally. The result is less support for the arch, which in turn causes it to fall or flatten. A flattening arch can cause the heel to
shift out of alignment, the forefoot to rotate outward, the heel cord to tighten, and possible deformity of the foot. Common symptoms include pain along the inside of the ankle, swelling, an inward
rolling of the ankle, pain that is worse with activity, and joint pain
Posterior tibial tendon dysfunction is the most common cause of acquired adult flatfoot deformity. There is often no specific event that starts the problem, such as a sudden tendon injury. More
commonly, the tendon becomes injured from cumulative wear and tear. Posterior tibial tendon dysfunction occurs more commonly in patients who already have a flat foot for other reasons. As the arch
flattens, more stress is placed on the posterior tibial tendon and also on the ligaments on the inside of the foot and ankle. The result is a progressive disorder.
In many cases, adult flatfoot causes no pain or problems. In others, pain may be severe. Many people experience aching pain in the heel and arch and swelling along the inner side of the foot.
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
It is imperative that you seek treatment should you notice any symptoms of a falling arch or PTTD. Due to the progressive nature of this condition, your foot will have a much higher chance of staying
strong and healthy with early treatment. When pain first appears, your doctor will evaluate your foot to confirm a flatfoot diagnosis and begin an appropriate treatment plan. This may involve rest,
anti-inflammatory medications, shoe modifications, physical therapy, orthotics and a possible boot or brace. When treatment can be applied at the beginning, symptoms can most often be resolved
without the need for surgery.
In cases where cast immobilization, orthoses and shoe therapy have failed, surgery is the next alternative. The goal of surgery and non-surgical treatment is to eliminate pain, stop progression of
the deformity and improve mobility of the patient. Opinions vary as to the best surgical treatment for adult acquired flatfoot. Procedures commonly used to correct the condition include tendon
debridement, tendon transfers, osteotomies (cutting and repositioning of bone) and joint fusions. (See surgical correction of adult acquired flatfoot). Patients with adult acquired flatfoot are
advised to discuss thoroughly the benefits vs. risks of all surgical options. Most procedures have long-term recovery mandating that the correct procedure be utilized to give the best long-term
benefit. Most flatfoot surgical procedures require six to twelve weeks of cast immobilization. Joint fusion procedures require eight weeks of non-weightbearing on the operated foot - meaning you will
be on crutches for two months. The bottom line is, Make sure all of your non-surgical options have been covered before considering surgery. Your primary goals with any treatment are to eliminate pain
and improve mobility. In many cases, with the properly designed foot orthosis or ankle brace, these goals can be achieved without surgical intervention.