Adult flatfoot (adult acquired flatfoot) or posterior tibial tendon dysfunction
(PTTD) is a common pathology presented to foot
and ankle specialists. PTTD is characterized by a valgus (everted) hindfoot, flattening of the longitudinal arch of the foot (collapse) and abduction of the forefoot. This is a progressive deformity
that begins flexible and can become rigid over time. The posterior tibial tendon (PT) is one of the main supporting structures of the foot arch. Changes within this tendon cause flattening of the
foot. There are four stages of this deformity that begins flexible and progressives, with no treatment, to a rigid deformity and with time may involve the ankle joint. Patients usually present with
pain in the foot or ankle stating the ankle is rolling. Its also common for patients to state they have difficulty walking barefoot. Pain is exacerbated after physical activities. Pain is usually
isolated to the inside of the foot along the course of the PT tendon.
As discussed above, many health conditions can create a painful flatfoot. Damage to the posterior tibial tendon is the most common cause of AAFD. The posterior tibial tendon is one of the most
important tendons of the leg. It starts at a muscle in the calf, travels down the inside of the lower leg and attaches to the bones on the inside of the foot. The main function of this tendon is to
hold up the arch and support your foot when you walk. If the tendon becomes inflamed or torn, the arch will slowly collapse. Women and people over 40 are more likely to develop problems with the
posterior tibial tendon. Other risk factors include obesity, diabetes, and hypertension. Having flat feet since childhood increases the risk of developing a tear in the posterior tibial tendon. In
addition, people who are involved in high impact sports, such as basketball, tennis, or soccer, may have tears of the tendon from repetitive use. Inflammatory arthritis, such as rheumatoid arthritis,
can cause a painful flatfoot. This type of arthritis attacks not only the cartilage in the joints, but also the ligaments that support the foot. Inflammatory arthritis not only causes pain, but also
causes the foot to change shape and become flat. The arthritis can affect the back of the foot or the middle of foot, both of which can result in a fallen arch.
Patients will usually describe their initial symptoms as "ankle pain", as the PT Tendon becomes painful around the inside of the ankle joint. The pain will become more intense as the foot flattens
out, due to the continued stretching and tearing of the PT Tendon. As the arches continue to fall, and pronation increases, the heel bone (Calcaneus) tilts into a position where it pinches against
the ankle bone (Fibula), causing pain on both the inside and outside of the ankle. As the foot spends increased time in a flattened, or deformed position, Arthritis can begin to affect the joints of
the foot, causing additional pain.
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
Nonoperative therapy for posterior tibial tendon dysfunction has been shown to yield 67% good-to-excellent results in 49 patients with stage 2 and 3 deformities. A rigid UCBL orthosis with a medial
forefoot post was used in nonobese patients with flexible heel deformities correctible to neutral and less than 10? of forefoot varus. A molded ankle foot orthosis was used in obese patients with
fixed deformity and forefoot varus greater than 10?. Average length of orthotic use was 15 months. Four patients ultimately elected to have surgery. The authors concluded that orthotic management is
successful in older low-demand patients and that surgical treatment can be reserved for those patients who fail nonoperative treatment.
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.