The Treatments And Causes

Overview
PTTD is most commonly seen in adults and referred to as "adult acquired flatfoot". Symptoms include pain and swelling along the inside arch and ankle, loss of the arch height and an outward sway of the foot. If not treated early, the condition progresses to increased flattening of the arch, increased inward roll of the ankle and deterioration of the posterior tibial tendon. Often, with end stage complications, severe arthritis may develop. How does all this happen? In the majority of cases, it is overuse of the posterior tibial tendon that causes PTTD. And it is your inherited foot type that may cause a higher possibility that you will develop this condition.

Causes
Posterior tibial tendon dysfunction is the most common cause of acquired adult flatfoot. Sometimes this can be a result of specific trauma, but usually the tendon becomes injured from wear and tear over time. This is more prevalent in individuals with an inherited flat foot but excessive weight, age, and level of activity are also contributing factors.

Symptoms
In many cases, adult flatfoot causes no pain or problems. In others, pain may be severe. Many people experience aching pain in the heel and arch and swelling along the inner side of the foot.

Diagnosis
Perform a structural assessment of the foot and ankle. Check the ankle for alignment and position. When it comes to patients with severe PTTD, the deltoid has failed, causing an instability of the ankle and possible valgus of the ankle. This is a rare and difficult problem to address. However, if one misses it, it can lead to dire consequences and potential surgical failure. Check the heel alignment and position of the heel both loaded and during varus/valgus stress. Compare range of motion of the heel to the normal contralateral limb. Check alignment of the midtarsal joint for collapse and lateral deviation. Noting the level of lateral deviation in comparison to the contralateral limb is critical for surgical planning. Check midfoot alignment of the naviculocuneiform joints and metatarsocuneiform joints both for sag and hypermobility.

Non surgical Treatment
Non-surgical treatment consists of custom orthoses and or special bracing devices along with supportive measures aimed at reducing the symptoms. While non-surgical treatment helps the majority of patients with PTTD, progressive cases may require surgical treatment including soft tissue tendon transfers, osteotomies and lastly fusion.

Surgical Treatment
In cases where cast immobilization, orthoses and shoe therapy have failed, surgery is the next alternative. The goal of surgery and non-surgical treatment is to eliminate pain, stop progression of the deformity and improve mobility of the patient. Opinions vary as to the best surgical treatment for adult acquired flatfoot. Procedures commonly used to correct the condition include tendon debridement, tendon transfers, osteotomies (cutting and repositioning of bone) and joint fusions. (See surgical correction of adult acquired flatfoot). Patients with adult acquired flatfoot are advised to discuss thoroughly the benefits vs. risks of all surgical options. Most procedures have long-term recovery mandating that the correct procedure be utilized to give the best long-term benefit. Most flatfoot surgical procedures require six to twelve weeks of cast immobilization. Joint fusion procedures require eight weeks of non-weightbearing on the operated foot - meaning you will be on crutches for two months. The bottom line is, Make sure all of your non-surgical options have been covered before considering surgery. Your primary goals with any treatment are to eliminate pain and improve mobility. In many cases, with the properly designed foot orthosis or ankle brace, these goals can be achieved without surgical intervention.