A painful flat foot, or adult acquired flatfoot deformity, is a progressive collapsing of the arch of the foot that occurs as the posterior tibial tendon becomes insufficient due to various factors. Early stages may present with only pain along the posterior tibial tendon whereas advanced deformity usually results in arthritis and rigidity of the rearfoot and ankle.
There are multiple factors contributing to the development of this problem. Damage to the nerves, ligaments, and/or tendons of the foot can cause subluxation (partial dislocation) of the subtalar or talonavicular joints. Bone fracture is a possible cause. The resulting joint deformity from any of these problems can lead to adult-acquired flatfoot deformity. Dysfunction of the posterior tibial tendon has always been linked with adult-acquired flatfoot deformity (AAFD). The loss of active and passive pull of the tendon alters the normal biomechanics of the foot and ankle. The reasons for this can be many and varied as well. Diabetes, high blood pressure, and prolonged use of steroids are some of the more common causes of adult-acquired flatfoot deformity (AAFD) brought on by impairment of the posterior tibialis tendon. Overstretching or rupture of the tendon results in tendon and muscle imbalance in the foot leading to adult-acquired flatfoot deformity (AAFD). Rheumatoid arthritis is one of the more common causes. About half of all adults with this type of arthritis will develop adult flatfoot deformity over time. In such cases, the condition is gradual and progressive. Obesity has been linked with this condition. Loss of blood supply for any reason in the area of the posterior tibialis tendon is another factor. Other possible causes include bone fracture or dislocation, a torn or stretched tendon, or a neurologic condition causing weakness.
Posterior tibial tendon insufficiency is divided into stages by most foot and ankle specialists. In stage I, there is pain along the posterior tibial tendon without deformity or collapse of the arch. The patient has the somewhat flat or normal-appearing foot they have always had. In stage II, deformity from the condition has started to occur, resulting in some collapse of the arch, which may or may not be noticeable. The patient may feel it as a weakness in the arch. Many patients initially present in stage II, as the ligament failure can occur at the same time as the tendon failure and therefore deformity can already be occurring as the tendon is becoming symptomatic. In stage III, the deformity has progressed to the extent where the foot becomes fixed (rigid) in its deformed position. Finally, in stage IV, deformity occurs at the ankle in addition to the deformity in the foot.
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
This condition may be treated with conservative methods. These can include orthotic devices, special shoes, and bracing. Physical therapy, rest, ice, and anti-inflammatory medication may be prescribed to help relieve symptoms. If the condition is very severe, surgical treatment may be needed.
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.