Flat Feet

About Flatfoot

The posterior tibial tendon is one of the major supporting structures of the foot. Posterior tibial tendon dysfunction (PTTD) is a condition caused by changes in the tendon, affecting its ability to hold up and support the arch.This has also been referred to as Adult Acquired Flatfoot (AAFF) because it is the most common type of flatfoot developed during adulthood. This condition usually involves only one foot but has been shown to develop in both feet for some patients. PTTD is usually progressive (continues to worsen) if it is not treated early.

Flexible flatfoot is one of the most common types of flatfoot in childhood and continues into adulthood. It typically occurs in both feet and progresses in severity throughout the adult years. As the condition worsens, the soft tissues (tendons and ligaments) of the arch may stretch/tear and can become painful and inflamed.

Flexible refers to the foot position when standing, meaning the foot is flat during weight bearing and returns to normal when non weight bearing.

Rigid refers to the foot staying in a flat position during weight bearing and non weight bearing with little to no movement of the joints. This is the end stage of flatfoot and usually encompasses arthritic joints throughout the foot and sometimes the ankle.

Other characteristics seen with flatfoot include:

• Forefoot abduction which includes the toes and front part of the foot pointing outward
• Heel values which includes the heel tilting toward the outside and the ankle moving towards the inside
• Equinus which includes a tight Achilles Tendon and causes the heel to lift off the ground earlier during ambulation
• Bunions as well as hammertoes may develop secondary to flatfoot.

Causes

• Overuse of the posterior tibial tendon
• Genetic/Hereditary
• Genu Valgum (knock knees)
• Obesity
• Previous Trauma/Injury
• Compensation due to pathology in the ankle, knee, or hip
• Over-pronation with the ankle moving inward and the foot moving outward

Diagnosis

In diagnosing flatfoot (Flexible, PTTD, Rigid) your surgeon will examine the foot and observes how it looks when you stand as well as when you sit. Your surgeon gently press on areas of the foot and ankle to determine areas of discomfort.

X-rays are usually taken to determine the severity of the disorder. If PTTD or flexible flatfoot is determined an MRI may be ordered to determine the extend of the pathology as well as evaluate the joints and soft tissues in the foot. If rigid flatfoot is determined a CT scan may be ordered to evaluate the extent of the arthritis in the foot/ankle. The advanced imaging will also assist in surgical planning should surgery be warranted.

If you are diagnosed with flexible flatfoot but you do not have any symptoms, your surgeon will explain what you might expect in the future.

Non-Surgical Treatment

If you experience symptoms with flexible flatfoot, your surgeon may recommend nonsurgical treatment options.

Due to the progressive nature of PTTD, early treatment is advised. If treated early sometimes your symptoms may resolve without the need for surgical intervention and further progression of your condition. However, untreated PTTD could leave you with an extreme flatfoot, painful arthritis in the foot and ankle, and severe limitations with daily activities. Often times if no treatment has been initiated conservative and non surgical approaches may assist in the limitations.

Rigid flatfoot develops secondary to progressive flexible flatfoot or PTTD symptoms. Severe flatfoot and arthritis of the foot and ankle is the result which limits daily activities. Often times if no treatment has been initiated conservative and non surgical approaches may assist in the limitations.

• Activity modifications. Cut down on activities that induce pain and avoid prolonged walking and/or standing.
• Weight loss. If you are obsee/overweight, try to lose weight. Too much weight on your arches will aggravate your symptoms.
• Immobilization/Rest. Immobilization may involve the use of a short leg cast or removable walking boot to limit the deformity and reduce the forces through the foot and ankle. It may be necessary to completely avoid weightbearing.
• Ice. Apply an ice pack to the painful area as well as behind the knee placing a thin towel between the ice and the skin. Use ice for 20 minutes and then wait at least 40 minutes before icing again.
• Medications. Nonsteroidal anti-inflammatory drugs (NSAIDs) may be helpful in reducing the pain and inflammation in the early stage of the conditions.
• Orthotic devices. Your surgeon may provide you with custom orthotic devices for your shoes to give more support to the arches and prevent over-pronation or gait abnormalities to control the motion of the foot.
• Shoe modifications. Wearing rigid or semi-rigid shoes that support the arches is important for anyone who has flatfoot.
• Ankle Foot Orthoses (AFO) devices. Your surgeon may recommend advanced bracing to modify your walking while also supporting your arches.
• Bracing Devices. Your surgeon may recommend other forms of bracing to limit the motion of the foot and ankle as well as support the arch.
• Physical therapy. Physical therapy may include strengthening exercises, soft-tissue massage, mobilization, ambulation education, stretching, and ultrasound therapy to reduce inflammation.

Surgery

If non-surgical approaches fail to adequately relieve the pain and other symptoms, surgery may be necessary. Your surgeon will select the best procedure to repair the flexible flatfoot, PTTD, or Rigid flatfoot. A variety of surgical techniques are available to correct these conditions and improve foot and ankle function.