There are four stages of posterior tibial tendon dysfunction. In the first stage the posterior tibial tendon is inflamed but has normal strength. There is little to no change in the arch of the foot. In stage two the tendon is partially torn or shows degenerative changes and as a result loses strength. There is considerable flattening of the arch without arthritic changes in the foot. Stage three results when the posterior tibial tendon is torn and not functioning. As a result the arch is completely collapsed with arthritic changes in the foot. Stage four is identical to stage three except that the ankle joint also becomes arthritic.
Adult flatfoot typically occurs very gradually. If often develops in an obese person who already has somewhat flat feet. As the person ages, the tendons and ligaments that support the foot begin to lose their strength and elasticity.
Patients often experience pain and/or deformity at the ankle or hindfoot. When the posterior tibial tendon does not work properly, a number of changes can occur to the foot and ankle. In the earlier stages, symptoms often include pain and tenderness along the posterior tibial tendon behind the inside of the ankle. As the tendon progressively fails, deformity of the foot and ankle may occur. This deformity can include progressive flattening of the arch, shifting of the heel so that it no longer is aligned underneath the rest of the leg, rotation and deformity of the forefoot, tightening of the heel cord, development of arthritis, and deformity of the ankle joint. At certain stages of this disorder, pain may shift from the inside to the outside aspect of the ankle as the heel shifts outward and structures are pinched laterally.
Although you can do the "wet test" at home, a thorough examination by a doctor will be needed to identify why the flatfoot developed. Possible causes include a congenital abnormality, a bone fracture or dislocation, a torn or stretched tendon, arthritis or neurologic weakness. For example, an inability to rise up on your toes while standing on the affected foot may indicate damage to the posterior tibial tendon (PTT), which supports the heel and forms the arch. If "too many toes" show on the outside of your foot when the doctor views you from the rear, your shinbone (tibia) may be sliding off the anklebone (talus), another indicator of damage to the PTT. Be sure to wear your regular shoes to the examination. An irregular wear pattern on the bottom of the shoe is another indicator of acquired adult flatfoot. Your physician may request X-rays to see how the bones of your feet are aligned. Muscle and tendon strength are tested by asking you to move the foot while the doctor holds it.
Non surgical Treatment
Treatment will vary depending on the degree of your symptoms. Generally, we would use a combination of rest, immobilization, orthotics, braces, and physical therapy to start. The goal is to keep swelling and inflammation under control and limit the stress on the tendon while it heals. Avoidance of activities that stress the tendon will be necessary. Once the tendon heals and you resume activity, physical therapy will further strengthen the injured tendon and help restore flexibility. Surgery may be necessary if the tendon is torn or does not respond to these conservative treatment methods. Your posterior tibial tendon is vital for normal walking. When it is injured in any way, you risk losing independence and mobility. Keep your foot health a top priority and address any pain or problems quickly. Even minor symptoms could progress into chronic problems, so don?t ignore your foot pain.
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.
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