There are some things that gain value as they age. Antique dealers are always on the lookout for pieces that have a certain wear and tear look that will bring a high price tag. Our feet on the other
hand, don't always fair as well when they have experienced a lot of wear and tear. Cumulative stress and impact can cause your foot structure to weaken and become prone to injury, especially when you
have a flat foot. This is the case with a condition called posterior tibial tendon dysfunction
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.
Symptoms shift around a bit, depending on what stage of PTTD you?re in. For instance, you?re likely to start off with tendonitis, or inflammation of the posterior tibial tendon. This will make the
area around the inside of your ankle and possibly into your arch swollen, reddened, warm to the touch, and painful. Inflammation may actually last throughout the stages of PTTD. The ankle will also
begin to roll towards the inside of the foot (pronate), your heel may tilt, and you may experience some pain in your leg (e.g. shin splints). As the condition progresses, the toes and foot begin to
turn outward, so that when you look at your foot from the back (or have a friend look for you, because-hey-that can be kind of a difficult
maneuver to pull off) more toes than usual will be visible on the outside (i.e. the side with the pinky toe). At this stage, the foot?s still going to be flexible, although it will likely have
flattened somewhat due to the lack of support from the posterior tibial tendon. You may also find it difficult to stand on your toes. Finally, you may reach a stage in which your feet are inflexibly
flat. At this point, you may experience pain below your ankle on the outside of your foot, and you might even develop arthritis in the ankle.
Observe forefoot to hindfoot alignment. Do this with the patient sitting and the heel in neutral, and also with the patient standing. I like to put blocks under the forefoot with the heel in neutral
to see how much forefoot correction is necessary to help hold the hindfoot position. One last note is to check all joints for stiffness. In cases of prolonged PTTD or coalition, rigid deformity is
present and one must carefully check the joints of the midfoot and hindfoot for stiffness and arthritis in the surgical pre-planning.
Non surgical Treatment
Orthoses (insoles, functional orthoses, ankle supports, braces, ankle foot orthoses (AFOs)) - are usually custom-made to increase the functional stability of the foot and improve the mechanical
properties of the tendon as well as reducing the actual degree of strain on the tendon. This reduces pain and inflammation. Physiotherapy - exercises and physiotherapy are often used to increase
mobility, strengthen the tendon itself, stretch your Achilles tendon as well as reduce pain. Once the tendon has been stretched (stage one), the heel starts rolling outwards. Total immobilisation in
a cast may help the symptoms to subside and prevent progression of the deformity in a smaller percentage of patients. Long-term use of orthoses may help stop progression of the deformity and reduce
pain without surgery. Non-surgical treatment is unlikely to prevent progression to stage three and four but may be chosen by some patients who either are unsuitable for surgery or prefer not to have
The indications for surgery are persistent pain and/or significant deformity. Sometimes the foot just feels weak and the assessment of deformity is best done by a foot and ankle specialist. If
surgery is appropriate, a combination of soft tissue and bony procedures may be considered to correct alignment and support the medial arch, taking strain off failing ligaments. Depending upon the
tissues involved and extent of deformity, the foot and ankle specialist will determine the necessary combination of procedures. Surgical procedures may include a medial slide calcaneal osteotomy to
correct position of the heel, a lateral column lengthening to correct position in the midfoot and a medial cuneiform osteotomy or first metatarsal-tarsal fusion to correct elevation of the medial
forefoot. The posterior tibial tendon may be reconstructed with a tendon transfer. In severe cases (stage III), the reconstruction may include fusion of the hind foot,, resulting in stiffness of the
hind foot but the desired pain relief. In the most severe stage (stage IV), the deltoid ligament on the inside of the ankle fails, resulting in the deformity in the ankle. This deformity over time
can result in arthritis in the ankle.