Adult Flatfoot

Many adults have a “normal” flatfoot that they may have had throughout their lives which is not painful and has never caused any limitations or disability. This requires no treatment and is a variant of the normal anatomy of the foot. If, however, tendon damage, foot fractures, neurological disorders, arthritis, or other conditions affect the foot later in life, the arch can "fall”, creating a flatfoot and pain of the foot and ankle. If the condition progresses, you may experience problems with walking, climbing stairs and wearing shoes. Evaluation for a flatfoot should be considered if your feet tire easily or become painful with prolonged standing, it's difficult to move your heel or midfoot around, to stand on your toes, your foot aches, particularly in the heel or arch area, with swelling along the inner side, pain in your feet reduces your ability to participate in sports, or you've been diagnosed with rheumatoid arthritis; about half of all people with rheumatoid arthritis will develop a progressive flatfoot deformity. A thorough examination is needed to identify why the flatfoot developed. For example, an inability to rise up on your toes while standing on the affected foot may indicate damage to the posterior tibial tendon (PTT), which supports the heel and forms the arch which is the most common reason for a flatfoot that develops in adulthood. If "too many toes" show on the outside of your foot when viewed from the rear, your shinbone (tibia) may be sliding off the anklebone (talus), another indicator of damage to the PTT.

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 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, and physical therapy.

In some cases, surgery may be needed to correct the problem. Surgical procedures can help reduce pain and improve bone alignment. The type of surgery varies with the underlying cause of the disorder, foot function, and expectations. Some of the surgical procedures may involve an arthrodesis, or welding (fusing) one or more of the bones in the foot/ankle together, osteotomy, or cutting and reshaping a bone to correct alignment of the foot, excision, or removing a bone or bone spur in the foot, synovectomy, or cleaning the sheath covering involved tendons, and tendon transfer, or using a piece of one tendon to lengthen or replace another that is not functioning. Other procedures may also be occasionally necessary and are dependent upon each individual case and cause. Dr. Vora has published and lectured extensively regarding this condition and has developed new ways to treat this condition that may allow correction of the foot while maintaining the joints of the foot, avoiding fusions and preserving mobility for some patients.

Posterior tibial tendon dysfunction
A problem of the posterior tibial tendon, one of the tendons in the foot, is the most common cause of a flatfoot that develops in adulthood. Tendons connect muscles to bones and stretch across joints, enabling you to bend that joint. One of the most important tendons in the lower leg is the posterior tibial tendon. This tendon starts in the calf, stretches down behind the inside of the ankle and attaches to bones in the middle of the foot. The posterior tibial tendon helps hold your arch up and provides support as you step off on your toes when walking. If this tendon becomes inflamed, over-stretched or torn, you may experience pain on the inner ankle and gradually lose the inner arch on the bottom of your foot, leading to flatfoot. Signs and symptoms of posterior tibial tendon dysfunction include pain and swelling on the inside of the ankle, loss of the arch and the development of a flatfoot, gradually developing pin on the outer side of the ankle or foot, weakness and an inability to stand on the toes, and / or tenderness over the midfoot, especially when under stress during activity.

Posterior tibial tendon dysfunction often occurs in women over 50 years of age and may be due to an inherent abnormality of the tendon. But there are several other risk factors, including obesity, diabetes, hypertension, previous surgery or trauma, such as an ankle fracture on the inner side of the foot, local steroid injections, inflammatory diseases such as Reiter's syndrome, rheumatoid arthritis, spondylosing arthropathy and psoriasis, and other conditions. Athletes who are involved in sports such as basketball, tennis, soccer or hockey may tear the posterior tibial tendon. The tendon may also become inflamed if excessive force is placed on the foot, such as when running on a banked track or road.

The diagnosis is based on both a history and a physical examination. As the condition progresses, the front of the affected foot will start to slide to the outside. From behind, it will look as though you have "too many toes" showing and your heel collapsing. You may also be asked to stand on your toes or to do a single heel rise: stand with your hands on the wall, lift the unaffected foot off the ground, and rise up on the toes of the other foot. Normally, the heel will rotate inward; the absence of this sign indicates posterior tibial tendon dysfunction. X-rays, an ultrasound or a magnetic resonance image (MRI) of the foot may be necessary in confirming the diagnosis.

Without treatment, the flatfoot that develops from posterior tibial tendon dysfunction may begin as a flexible problem (the joints still function properly) but then develop rigidity (the joints become stiff and arthritic). Pain may increase and spread to the outer side of the ankle because of the abnormal positioning of the bones. The way you walk may be affected and wearing shoes may be difficult. Treatments depend on how far the condition has progressed. In the early stages, posterior tibial tendon dysfunction can be treated with rest; nonsteroidal anti-inflammatory drugs such as aspirin or ibuprofen, and immobilization of the foot for 6 to 8 weeks with a rigid below-knee cast or boot to prevent overuse. After the cast is removed, shoe inserts such as a heel wedge or arch support may be helpful. If the condition is advanced, a custom-made ankle-foot orthosis or support may be necessary. If conservative treatments don't work, surgery may be necessary. Several procedures can be used to treat posterior tibial tendon dysfunction; often more than one procedure is performed at the same time. Your doctor will recommend a specific course of treatment based on your individual case. Surgical options include: tenosynovectomy, a procedure in which the inflamed tissue surrounding the tendon is cleaned away (debrided) and removed (excise), osteotomy, a procedure changes the alignment of the heel bone (calcaneus), tendon transfer, a procedure that uses some fibers from another tendon (the flexor digitorum longus, which helps bend the toes) to repair the damaged posterior tibial tendon, lateral column lengthening, a procedure which involves placing a wedge-shaped piece of bone graft on the outside of the calcaneus which helps realign the bones and recreates the arch, and / or an arthrodesis procedure, which involves welding (fusing) one or more bones together, eliminating movement in the joint. This stabilizes the hindfoot and prevents the condition from progressing further. These treatments are individualized for each patient based upon the degree of involvement of the foot and patient expectations. Dr. Vora is extensively experienced in the utilization of these techniques and has lectured and published on these treatment options and is interested in maintaining joint function during the correction of the flatfoot whenever possible to maximize function. Dr. Vora has published literature and lectured on this condition and has developed a model to study this condition and the associated treatments options.
 

Modified from the AAOS