Some people have always had flat feet
from a young age. Unfortunately as people reach their fifties they will suddenly have one foot
with a flatter arch than the other foot. This situation is termed adult acquired flatfoot. Adult acquired flatfoot is a painful condition occurring in one foot. The common patient profile is a female
over the age of 50 with pre-existing flatfeet, high blood pressure, high cholesterol, diabetes and obesity. All of these underlying problems will lead to a weakening of the support structures of the
arch. If you have adult acquired flat foot you will not be able to lift your heel off the ground while standing on one leg. Adult acquired flatfoot may develop due to trauma or degeneration of major
tendons ankle & foot. Weakness or paralysis of leg muscles can also create a flatfoot deformity.
Rheumatoid arthritis This type of arthritis attacks the cartilage in the foot, leading to pain and flat feet. It is caused by auto-immune disease, where the body?s immune system attacks its own
tissues. Diabetes. Having diabetes can cause nerve damage and affect the feeling in your feet and cause arch collapse. Bones can also fracture but some patients may not feel any pain due to the nerve
damage. Obesity and/or hypertension (high blood pressure) This increases your risk of tendon damage and resulting flat foot.
The symptom most often associated with AAF is PTTD, but it is important to see this only as a single step along a broader continuum. The most important function of the PT tendon is to work in synergy
with the peroneus longus to stabilize the midtarsal joint (MTJ). When the PT muscle contracts and acts concentrically, it inverts the foot, thereby raising the medial arch. When stretched under
tension, acting eccentrically, its function can be seen as a pronation retarder. The integrity of the PT tendon and muscle is crucial to the proper function of the foot, but it is far from the lone
actor in maintaining the arch. There is a vital codependence on a host of other muscles and ligaments that when disrupted leads to an almost predictable loss in foot architecture and subsequent
Diagnostic testing is often used to diagnose the condition and help determine the stage of the disease. The most common test done in the office setting are weightbearing X-rays of the foot and ankle.
These assess joint alignment and osteoarthritis. If tendon tearing or rupture is suspected, the gold standard test would be MRI. The MRI is used to check the tendon, surrounding ligament structures
and the midfoot and hindfoot joints. An MRI is essential if surgery is being considered.
Non surgical Treatment
Medical or nonoperative therapy for posterior tibial tendon dysfunction involves rest, immobilization, nonsteroidal anti-inflammatory medication, physical therapy, orthotics, and bracing. This
treatment is especially attractive for patients who are elderly, who place low demands on the tendon, and who may have underlying medical problems that preclude operative intervention. During stage 1
posterior tibial tendon dysfunction, pain, rather than deformity, predominates. Cast immobilization is indicated for acute tenosynovitis of the posterior tibial tendon or for patients whose main
presenting feature is chronic pain along the tendon sheath. A well-molded short leg walking cast or removable cast boot should be used for 6-8 weeks. Weight bearing is permitted if the patient is
able to ambulate without pain. If improvement is noted, the patient then may be placed in custom full-length semirigid orthotics. The patient may then be referred to physical therapy for stretching
of the Achilles tendon and strengthening of the posterior tibial tendon. Steroid injection into the posterior tibial tendon sheath is not recommended due to the possibility of causing a tendon
rupture. In stage 2 dysfunction, a painful flexible deformity develops, and more control of hindfoot motion is required. In these cases, a rigid University of California at Berkley (UCBL) orthosis or
short articulated ankle-foot orthosis (AFO) is indicated. Once a rigid flatfoot deformity develops, as in stage 3 or 4, bracing is extended above the ankle with a molded AFO, double upright brace, or
patellar-tendon-bearing brace. The goals of this treatment are to accommodate the deformity, prevent or slow further collapse, and improve walking ability by transferring load to the proximal leg
away from the collapsed medial midfoot and heel.
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.