Often considered solely a product of genetics, flatfoot rarely carries with it the stigma of presenting over time. The truth, however, is that flatfoot
does not discriminate on the basis of age and can become an issue in the form of adult-acquired flatfoot. Like its congenital
cousin, adult-acquired flatfoot deformity is one that, in causing structural damage to the foot (and particularly to the posterior tibial tendon), creates an imbalance that may result in any number
of symptoms, including inflammation, pain, stiffness, limited mobility, and even arthritis.
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.
Symptoms are minor and may go unnoticed, Pain dominates, rather than deformity. Minor swelling may be visible along the course of the tendon. Pain and swelling along the course of the tendon. Visible
decrease in arch height. Aduction of the forefoot on rearfoot. Subluxed tali and navicular joints. Deformation at this point is still flexible. Considerable deformity and weakness. Significant pain.
Arthritic changes in the tarsal joints. Deformation at this point is rigid.
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
Icing and anti-inflammatory medications can reduce inflammation and physical therapy can strengthen the tibial tendon. Orthotic inserts that go inside your shoes are a common way to treat and prevent
flatfoot pain. Orthotics control the position of the foot and alleviate areas of pressure. In some cases immobilization in a cast or walking boot is necessary to relieve symptoms, and in severe cases
surgery may be required to repair tendon damage.
In cases of PTTD that have progressed substantially or have failed to improve with non-surgical treatment, surgery may be required. For some advanced cases, surgery may be the only option. Surgical
treatment may include repairing the tendon, tendon transfers, realigning the bones of the foot, joint fusions, or both. Dr. Piccarelli will determine the best approach for your specific case. A
variety of surgical techniques is available to correct flexible flatfoot. Your case may require one procedure or a combination of procedures. All of these surgical techniques are aimed at relieving
the symptoms and improving foot function. Among these procedures are tendon transfers or tendon lengthening procedures, realignment of one or more bones, or insertion of implant devices. Whether you
have flexible flatfoot or PTTD, to select the procedure or combination of procedures for your particular case, Dr. Piccarelli will take into consideration the extent of your deformity based on the
x-ray findings, your age, your activity level, and other factors. The length of the recovery period will vary, depending on the procedure or procedures performed.