Adult-acquired flatfoot or collapsed arch occurs because the large tendon on the inside of the ankle - the posterior tibial tendon - becomes stretched out and no longer supports the foot?s arch. In many cases, the condition worsens and and the tendon thickens, becoming painful, especially during activities. Flatfoot or collapsed arch is also known as posterior tibial tendon dysfunction. This condition is different than having flat feet since birth (known as congenital flatfoot), although sometimes these patients develop similar symptoms and require similar treatments.
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.
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.
The history and physical examination are probably the most important tools the physician uses to diagnose this problem. The wear pattern on your shoes can offer some helpful clues. Muscle testing helps identify any areas of weakness or muscle impairment. This should be done in both the weight bearing and nonweight bearing positions. A very effective test is the single heel raise. You will be asked to stand on one foot and rise up on your toes. You should be able to lift your heel off the ground easily while keeping the calcaneus (heel bone) in the middle with slight inversion (turned inward). X-rays are often used to study the position, shape, and alignment of the bones in the feet and ankles. Magnetic resonance (MR) imaging is the imaging modality of choice for evaluating the posterior tibial tendon and spring ligament complex.
Non surgical Treatment
Options range from shoe inserts, orthotics, bracing and physical therapy for elderly and/or inactive patients to reconstructive surgical procedures in those wishing to remain more active. These treatments restore proper function and alignment of the foot by replacing the damaged muscle tendon unit with an undamaged, available and expendable one, lengthening the contracted Achilles tendon and realigning the Os Calcis, or heel bone, while preserving the joints of the hindfoot. If this condition is not recognized before it reaches advanced stages, a fusion of the hindfoot or even the ankle is necessary. Typically this is necessary in elderly individuals with advanced cases that cannot be improved with bracing.
Although non-surgical treatments can successfully manage the symptoms, they do not correct the underlying problem. It can require a life-long commitment to wearing the brace during periods of increased pain or activity demands. This will lead a majority of patients to choose surgical correction of the deformity, through Reconstructive Surgery. All of the considerations that were extremely important during the evaluation stage become even more important when creating a surgical plan. Generally, a combination of procedures are utilized in the same setting, to allow full correction of the deformity. Many times, this can be performed as a same-day surgery, without need for an overnight hospital stay. However, one or two day hospital admissions can be utilized to help manage the post-operative pain. Although the recovery process can require a significant investment of time, the subsequent decades of improved function and activity level, as well as decreased pain, leads to a substantial return on your investment.