Posts Tagged With: Adult Aquired Flat Foot

Acquired Flat Foot Tibialis Posterior Tenosynovitis

Overview
PTTD is a common condition treated by foot and ankle specialists. Although there is a role for surgical treatment of PTTD, conservative care often can prevent or delay surgical intervention. Decreasing inflammation and stabilizing the affected joints associated with the posterior tibial tendon can decrease pain and increase functional levels. With many different modalities available, aggressive nonoperative methods should be considered in the treatment of PTTD, including early immobilization, the use of long-term bracing, physical therapy, and anti-inflammatory medications. If these methods fail, proper evaluation and work-up for surgical intervention should be employed.
Flat Foot

Causes
Damage to the posterior tendon from overuse is the most common cause for adult acquired flatfoot. Running, walking, hiking, and climbing stairs are activities that add stress to this tendon, and this overuse can lead to damage. Obesity, previous ankle surgery or trauma, diabetes (Charcot foot), and rheumatoid arthritis are other common risk factors.

Symptoms
The symptoms of PTTD may include pain, swelling, a flattening of the arch, and inward rolling of the ankle. As the condition progresses, the symptoms will change. For example, later, as the arch begins to flatten, there may still be pain on the inside of the foot and ankle. But at this point, the foot and toes begin to turn outward and the ankle rolls inward. As PTTD becomes more advanced, the arch flattens even more and the pain often shifts to the outside of the foot, below the ankle. The tendon has deteriorated considerably and arthritis often develops in the foot. In more severe cases, arthritis may also develop in the ankle. Symptoms, which may occur in some persons with flexible flatfoot, include. Pain in the heel, arch, ankle, or along the outside of the foot. ?Turned-in? ankle. Pain associated with a shin splint. General weakness / fatigue in the foot or leg.

Diagnosis
Observation by a skilled foot clinician and a hands-on evaluation of the foot and ankle is the most accurate diagnostic technique. Your Dallas foot doctor may have you do a walking examination (the most reliable way to check for the deformity). During walking, the affected foot appears more pronated and deformed. Your podiatrist may do muscle testing to look for strength deficiencies. During a single foot raise test, the foot doctor will ask you to rise up on the tip of your toes while keeping your unaffected foot off the ground. If your posterior tendon has been attenuated or ruptured, you will be unable to lift your heel off the floor. In less severe cases, it is possible to rise onto your toes, but your heel will not invert normally. X-rays are not always helpful as a diagnostic tool for Adult Flatfoot because both feet will generally demonstrate a deformity. MRI (magnetic resonance imaging) may show tendon injury and inflammation, but can?t always be relied on for a complete diagnosis. In most cases, a MRI is not necessary to diagnose a posterior tibial tendon injury. An ultrasound may also be used to confirm the deformity, but is usually not required for an initial diagnosis.

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.
Acquired Flat Foot

Surgical Treatment
Stage two deformities are less responsive to conservative therapies that can be effective in mild deformities. Bone procedures are necessary at this stage in order to recreate the arch and stabilize the foot. These procedures include isolated fusion procedures, bone grafts, and/or the repositioning of bones through cuts called osteotomies. The realigned bones are generally held in place with screws, pins, plates, or staples while the bone heals. A tendon transfer may or may not be utilized depending on the condition of the posterior tibial tendon. Stage three deformities are better treated with surgical correction, in healthy patients. Patients that are unable to tolerate surgery or the prolonged healing period are better served with either arch supports known as orthotics or bracing such as the Richie Brace. Surgical correction at this stage usually requires fusion procedures such as a triple or double arthrodesis. This involves fusing the two or three major bones in the back of the foot together with screws or pins. The most common joints fused together are the subtalar joint, talonavicular joint, and the calcaneocuboid joint. By fusing the bones together the surgeon is able to correct structural deformity and alleviate arthritic pain. Tendon transfer procedures are usually not beneficial at this stage. Stage four deformities are treated similarly but with the addition of fusing the ankle joint.

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The Cause And Treatment For Adult Aquired FlatFeet

Overview

Most flat feet are not painful, particularly those flat feet seen in children. In the adult acquired flatfoot, pain occurs because soft tissues (tendons and ligaments) have been torn. The deformity progresses or worsens because once the vital ligaments and posterior tibial tendon are lost, nothing can take their place to hold up the arch of the foot. The painful, progressive adult acquired flatfoot affects women four times as frequently as men. It occurs in middle to older age people with a mean age of 60 years. Most people who develop the condition already have flat feet. A change occurs in one foot where the arch begins to flatten more than before, with pain and swelling developing on the inside of the ankle. Why this event occurs in some people (female more than male) and only in one foot remains poorly understood. Contributing factors increasing the risk of adult acquired flatfoot are diabetes, hypertension, and obesity.Acquired Flat Feet


Causes

Many health conditions can create a painful flatfoot, an injury to the ligaments in the foot can cause the joints to fall out of alignment. The ligaments support the bones and prevent them from moving. If the ligaments are torn, the foot will become flat and painful. This more commonly occurs in the middle of the foot (Lisfranc injury), but can also occur in the back of the foot. In addition to ligament injuries, fractures and dislocations of the bones in the midfoot can also lead to a flatfoot deformity.


Symptoms

The first stage represents inflammation and symptoms originating from an irritated posterior tibial tendon, which is still functional. Stage two is characterized by a change in the alignment of the foot noted on observation while standing (see above photos). The deformity is supple meaning the foot is freely movable and a ?normal? position can be restored by the examiner. Stage two is also associated with the inability to perform a single-leg heel rise. The third stage is dysfunction of the posterior tibial tendon is a flatfoot deformity that becomes stiff because of arthritis. Prolonged deformity causes irritation to the involved joints resulting in arthritis. The fourth phase is a flatfoot deformity either supple (stage two) or stiff (stage 3) with involvement of the ankle joint. This occurs when the deltoid ligament, the major supporting structure on the inside of the ankle, fails to provide support. The ankle becomes unstable and will demonstrate a tilted appearance on X-ray. Failure of the deltoid ligament results from an inward displacement of the weight bearing forces. When prolonged, this change can lead to ankle arthritis. The vast majority of patients with acquired adult flatfoot deformity are stage 2 by the time they seek treatment from a physician.


Diagnosis

The diagnosis of posterior tibial tendon dysfunction and AAFD is usually made from a combination of symptoms, physical exam and x-ray imaging. The location of pain, shape of the foot, flexibility of the hindfoot joints and gait all may help your physician make the diagnosis and also assess how advanced the problem is.


Non surgical Treatment

Orthotic or anklebrace, Over-the-counter or custom shoe inserts to position the foot and relieve pain are the most common non-surgical treatment option. Custom orthotics are often suggested if the shape change of the foot is more severe. An ankle brace (either over-the-counter or custom made) is another option that will help to ease tendon tension and pain. Boot immobilization. A walking boot supports the tendon and allows it to heal. Activity modifications. Depending on what we find, we may recommend limiting high-impact activities, such as running, jumping or court sports, or switching out high-impact activities for low-impact options for a period of time. Ice and anti-inflammatory medications. These may be given as needed to decrease your symptoms.

Adult Acquired Flat Foot


Surgical Treatment

When conservative care fails to control symptoms and/or deformity, then surgery may be needed. The goal of surgical treatment is to obtain good alignment while keeping the foot and ankle as flexible as possible. The most common procedures used with this condition include arthrodesis (fusion), osteotomy (cutting out a wedge-shaped piece of bone), and lateral column lengthening. Lateral column lengthening involves the use of a bone graft at the calcaneocuboid joint. This procedure helps restore the medial longitudinal arch (arch along the inside of the foot). A torn tendon or spring ligament will be repaired or reconstructed. Other surgical options include tendon shortening or lengthening. Or the surgeon may move one or more tendons. This procedure is called a tendon transfer. Tendon transfer uses another tendon to help the posterior tibial tendon function more effectively. A tendon transfer is designed to change the force and angle of pull on the bones of the arch. It’s not clear yet from research evidence which surgical procedure works best for this condition. A combination of surgical treatments may be needed. It may depend on your age, type and severity of deformity and symptoms, and your desired level of daily activity.

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