Causes And Treatment

Overview
For many adults, years of wear and tear on the feet can lead to a gradual and potentially debilitating collapse of the arch. However, a new treatment approach based on early surgical intervention is achieving a high rate of longterm success. Based on results of clinical studies of adults with flat feet, we now believe that reconstructive surgery in the early stages of the condition can prevent complications later on. Left untreated, the arch eventually will collapse, causing debilitating arthritis in the foot and ankle. At this end stage, surgical fusions are often required to stabilize the foot.

Causes
Overuse of the posterior tibial tendon is often the cause of PTTD. In fact, the symptoms usually occur after activities that involve the tendon, such as running, walking, hiking, or climbing stairs.

Symptoms
At first you may notice pain and swelling along the medial (big toe) side of the foot. This is where the posterior tibialis tendon travels from the back of the leg under the medial ankle bone to the foot. As the condition gets worse, tendon failure occurs and the pain gets worse. Some patients experience pain along the lateral (outside) edge of the foot, too. You may find that your feet hurt at the end of the day or after long periods of standing. Some people with this condition have trouble rising up on their toes. They may be unable to participate fully in sports or other recreational activities.

Diagnosis
Clinicians need to recognize the early stage of this syndrome which includes pain, swelling, tendonitis and disability. The musculoskeletal portion of the clinical exam can help determine the stage of the disease. It is important to palpate the posterior tibial tendon and test its muscle strength. This is tested by asking patient to plantarflex and invert the foot. Joint range of motion is should be assessed as well. Stiffness of the joints may indicate longstanding disease causing a rigid deformity. A weightbearing examination should be performed as well. A complete absence of the medial longitudinal arch is often seen. In later stages the head of the talus bone projects outward to the point of a large "lump" in the arch. Observing the patient's feet from behind shows a significant valgus rotation of the heel. From behind, the "too many toes" sign may be seen as well. This is when there is abducution of the forefoot in the transverse plane allowing the toes to be seen from behind. Dysfunction of the posterior tibial tendon can be assessed by asking the patient to stand on his/her toes on the affected foot. If they are unable to, this indicates the disease is in a more advanced stage with the tendon possibly completely ruptured.

Non surgical Treatment
A painless flatfoot that does not hinder your ability to walk or wear shoes requires no special treatment or orthotic device. Other treatment options depend on the cause and progression of the flatfoot. Conservative treatment options include making shoe modifications. Using orthotic devices such as arch supports and custom-made orthoses. Taking nonsteroidal anti-inflammatory drugs such as ibuprofen to relieve pain. Using a short-leg walking cast or wearing a brace. Injecting a corticosteroid into the joint to relieve pain. Rest and ice. Physical therapy. In some cases, surgery may be needed to correct the problem. Surgical procedures can help reduce pain and improve bone alignment.

Surgical Treatment
Good to excellent results for more than 80% of patients have been reported at five years' follow up for the surgical interventions recommended below. However, the postoperative recovery is a lengthy process, and most surgical procedures require patients to wear a plaster cast for two to three months. Although many patients report that their function is well improved by six months, in our experience a year is required to recover truly and gain full functional improvement after the surgery. Clearly, some patients are not candidates for such major reconstructive surgery.