What Can Cause Adult Aquired Flat Foot ?

Overview
When we have foot pain, it isn?t always easy to pinpoint the source because we can?t visualize the structure of all the bones, muscles, and tendons on the inside. The posterior tibial tendon plays an important supportive role within the structure of the foot. It attaches to your calf muscle and then comes down along the inside of your ankle, connecting to the bones inside your foot at the other side. This tendon?s main function is to hold up your arch and support your foot during each and every movement. Every step, run, walk, or jump is made possible with the support from this crucial tendon. While it is designed to perform such an important role, it is vulnerable to stress and injury. A tear during a traumatic injury or stress from overuse can injure the tissues within the tendon. This kind of injury is referred to as posterior tibial tendon dysfunction (PTTD). A really hard fall during a sports game or exposure to a repetitive motion, such as the impact on feet during soccer, tennis, football or basketball, can cause an injury. Flat foot and flat feet in adults can exacerbate this condition. The tendon can experience small tears and become inflamed. If the inflammation is allowed to continue and worsen over time, it will weaken further and could rupture completely.

Causes
A person with flat feet has greater load placed on the posterior tibial tendon which is the main tendon unit supporting up the arch of the foot. Throughout life, aging leads to decreased strength of muscles, tendons and ligaments. The blood supply diminishes to tendons with aging as arteries narrow. Heavier, obese patients have more weight on the arch and have greater narrowing of arteries due to atherosclerosis. In some people, the posterior tibial tendon finally gives out or tears. This is not a sudden event in most cases. Rather, it is a slow, gradual stretching followed by inflammation and degeneration of the tendon. Once the posterior tibial tendon stretches, the ligaments of the arch stretch and tear. The bones of the arch then move out of position with body weight pressing down from above. The foot rotates inward at the ankle in a movement called pronation. The arch appears collapsed, and the heel bone is tilted to the inside. The deformity can progress until the foot literally dislocates outward from under the ankle joint.

Symptoms
Posterior tibial tendon insufficiency is divided into stages by most foot and ankle specialists. In stage I, there is pain along the posterior tibial tendon without deformity or collapse of the arch. The patient has the somewhat flat or normal-appearing foot they have always had. In stage II, deformity from the condition has started to occur, resulting in some collapse of the arch, which may or may not be noticeable. The patient may feel it as a weakness in the arch. Many patients initially present in stage II, as the ligament failure can occur at the same time as the tendon failure and therefore deformity can already be occurring as the tendon is becoming symptomatic. In stage III, the deformity has progressed to the extent where the foot becomes fixed (rigid) in its deformed position. Finally, in stage IV, deformity occurs at the ankle in addition to the deformity in the foot.

Diagnosis
Starting from the knee down, check for any bowing of the tibia. A tibial varum will cause increased medial stress on the foot and ankle. This is essential to consider in surgical planning. Check the gastrocnemius muscle and Achilles complex via a straight and bent knee check for equinus. If the range of motion improves to at least neutral with bent knee testing of the Achilles complex, one may consider a gastrocnemius recession. If the Achilles complex is still tight with bent knee testing, an Achilles lengthening may be necessary. Check the posterior tibial muscle along its entire course. Palpate the muscle and observe the tendon for strength with a plantarflexion and inversion stress test. Check the flexor muscles for strength in order to see if an adequate transfer tendon is available. Check the anterior tibial tendon for size and strength.

Non surgical Treatment
It is imperative that you seek treatment should you notice any symptoms of a falling arch or PTTD. Due to the progressive nature of this condition, your foot will have a much higher chance of staying strong and healthy with early treatment. When pain first appears, your doctor will evaluate your foot to confirm a flatfoot diagnosis and begin an appropriate treatment plan. This may involve rest, anti-inflammatory medications, shoe modifications, physical therapy, orthotics and a possible boot or brace. When treatment can be applied at the beginning, symptoms can most often be resolved without the need for surgery.

Surgical Treatment
Flatfoot reconstruction (osteotomy). This is often recommended for flexible flatfoot condition. Flatfoot reconstruction involves cutting and shifting the heel bone into a more neutral position, transferring the tendon used to flex the lesser toes (all but the big toe) to strengthen the posterior tibial tendon, and lengthening the calf muscle. Fusion (also known as triple arthrodesis). Fusion involves fusing, or making stiff, three joints in the back of the foot the subtalar, talonavicular, and calcaneocuboid joints, to realign the foot and give it a more natural shape. Pins or screws hold the area in place until it heals. Fusion is often recommended for a rigid flatfoot deformity or evidence of arthritis. Both of these surgeries can provide excellent pain relief and correction.

Fixing Flat Feet In Adults

Overview
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.

Causes
The posterior tibial tendon, which connects the bones inside the foot to the calf, is responsible for supporting the foot during movement and holding up the arch. Gradual stretching and tearing of the posterior tibial tendon can cause failure of the ligaments in the arch. Without support, the bones in the feet fall out of normal position, rolling the foot inward. The foot’s arch will collapse completely over time, resulting in adult acquired flatfoot. The ligaments and tendons holding up the arch can lose elasticity and strength as a result of aging. Obesity, diabetes, and hypertension can increase the risk of developing this condition. Adult acquired flatfoot is seen more often in women than in men and in those 40 or older.

Symptoms
Many patients with this condition have no pain or symptoms. When problems do arise, the good news is that acquired flatfoot treatment is often very effective. Initially, it will be important to rest and avoid activities that worsen the pain.

Diagnosis
Posterior Tibial Tendon Dysfunction is diagnosed with careful clinical observation of the patient?s gait (walking), range of motion testing for the foot and ankle joints, and diagnostic imaging. People with flatfoot deformity walk with the heel angled outward, also called over-pronation. Although it is normal for the arch to impact the ground for shock absorption, people with PTTD have an arch that fully collapses to the ground and does not reform an arch during the entire gait period. After evaluating the ambulation pattern, the foot and ankle range of motion should be tested. Usually the affected foot will have decreased motion to the ankle joint and the hindfoot. Muscle strength may also be weaker as well. An easy test to perform for PTTD is the single heel raise where the patient is asked to raise up on the ball of his or her effected foot. A normal foot type can lift up on the toes without pain and the heel will invert slightly once the person has fully raised the heel up during the test. In early phases of PTTD the patient may be able to lift up the heel but the heel will not invert. An elongated or torn posterior tibial tendon, which is a mid to late finding of PTTD, will prohibit the patient from fully rising up on the heel and will cause intense pain to the arch. Finally diagnostic imaging, although used alone cannot diagnose PTTD, can provide additional information for an accurate diagnosis of flatfoot deformity. Xrays of the foot can show the practitioner important angular relationships of the hindfoot and forefoot which help diagnose flatfoot deformity. Most of the time, an MRI is not needed to diagnose PTTD but is a tool that should be considered in advanced cases of flatfoot deformity. If a partial tear of the posterior tibial tendon is of concern, then an MRI can show the anatomic location of the tear and the extensiveness of the injury.

Non surgical Treatment
Nonoperative therapy for adult-acquired flatfoot is a reasonable treatment option that is likely to be beneficial for most patients. In this article, we describe the results of a retrospective cohort study that focused on nonoperative measures, including bracing, physical therapy, and anti-inflammatory medications, used to treat adult-acquired flatfoot in 64 consecutive patients. The results revealed the incidence of successful nonsurgical treatment to be 87.5% (56 of 64 patients), over the 27-month observation period. Overall, 78.12% of the patients with adult-acquired flatfoot were obese (body mass index [BMI] = 30), and 62.5% of the patients who failed nonsurgical therapy were obese; however, logistic regression failed to show that BMI was statistically significantly associated with the outcome of treatment. The use of any form of bracing was statistically significantly associated with successful nonsurgical treatment (fully adjusted OR = 19.8621, 95% CI 1.8774 to 210.134), whereas the presence of a split-tear of the tibialis posterior on magnetic resonance image scans was statistically significantly associated with failed nonsurgical treatment (fully adjusted OR = 0.016, 95% CI 0.0011 to 0.2347). The results of this investigation indicate that a systematic nonsurgical treatment approach to the treatment of the adult-acquired flatfoot deformity can be successful in most cases.

Surgical Treatment
Surgery should only be done if the pain does not get better after a few months of conservative treatment. The type of surgery depends on the stage of the PTTD disease. It it also dictated by where tendonitis is located and how much the tendon is damaged. Surgical reconstruction can be extremely complex. Some of the common surgeries include. Tenosynovectomy, removing the inflamed tendon sheath around the PTT. Tendon Transfer, to augment the function of the diseased posterior tibial tendon with a neighbouring tendon. Calcaneo-osteotomy, sometimes the heel bone needs to be corrected to get a better heel bone alignment. Fusion of the Joints, if osteoarthritis of the foot has set in, fusion of the joints may be necessary.