is a general term used to describe a person whose
arches are slowly dropping to the ground, aka fallen arches. Adult-acquired flatfoot deformity can be caused by several factors, but the most common is abnormal functioning of the posterior tibial
tendon in the foot and ankle. The posterior tibial tendon is the primary tendon that supports the arch. If this tendon begins to elongate from a sustained, gradual stretch over a long period of time,
then the arch will progressively decrease until full collapse of the arch is noted on standing. What makes this tendon elongated? Biomechanical instability of the foot such as over-pronation or an
accessory bone at the insertion site of the tendon are the primary causes for posterior tibial tendon dysfunction.
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.
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.
The diagnosis of tibialis posterior dysfunction is essentially clinical. However, plain radiographs of the foot and ankle are useful for assessing the degree of deformity and to confirm the presence
or absence of degenerative changes in the subtalar and ankle articulations. The radiographs are also useful to exclude other causes of an acquired flatfoot deformity. The most useful radiographs are
bilateral anteroposterior and lateral radiographs of the foot and a mortise (true anteroposterior) view of the ankle. All radiographs should be done with the patient standing. In most cases we see no
role for magnetic resonance imaging or ultrasonography, as the diagnosis can be made clinically.
Non surgical Treatment
PTTD is a progressive condition. Early treatment is needed to prevent relentless progression to a more advanced disease which can lead to more problems for that affected foot. In general, the
treatments include rest. Reducing or even stopping activities that worsen the pain is the initial step. Switching to low-impact exercise such as cycling, elliptical trainers, or swimming is helpful.
These activities do not put a large impact load on the foot. Ice. Apply cold packs on the most painful area of the posterior tibial tendon frequently to keep down the swelling. Placing ice over the
tendon immediately after completing an exercise helps to decrease the inflammation around the tendon.
Nonsteroidal Anti-inflammatory Medication (NSAIDS). Drugs, such as arcoxia, voltaren and celebrex help to reduce pain and inflammation. Taking such medications prior to an exercise activity helps to
limit inflammation around the tendon. However, long term use of these drugs can be harmful to you with side effects including peptic ulcer disease and renal impairment or failure. Casting. A short
leg cast or walking boot may be used for 6 to 8 weeks in the acutely painful foot. This allows the tendon to rest and the swelling to go down. However, a cast causes the other muscles of the leg to
atrophy (decrease in strength) and thus is only used if no other conservative treatment works. Most people can be helped with orthotics and braces. An orthotic is a shoe insert. It is the most common
non-surgical treatment for a flatfoot and it is very safe to use. A custom orthotic is required in patients who have moderate to severe changes in the shape of the foot. Physiotherapy helps to
strengthen the injured tendon and it can help patients with mild to moderate disease of the posterior tibial tendon.
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.