Another common term for this condition is Posterior Tibial Tendon Dysfunction
(PTTD). There is a cause-effect relationship between
pronation, flatfoot deformity and subsequent tenosynovitis of the posterior tibial tendon. Mechanical irritation of the tendon may lead to synovitis, partial tearing and eventually full rupture of
the tendon. Other structures, including ligaments and the plantar fascia, have also been shown to contribute to the arch collapsing. As the deformity progresses, these structures have been shown to
attenuate and rupture as well. In later stages, subluxation of various joints lead to a valgus rearfoot and transverse plane deformity of the forefoot. These deformities can become fixed and
irreducible as significant osteoarthritis sets in.
As discussed above, many different problems can create a painful flatfoot. Damage to the posterior tibial tendon is the most common cause of AAFD. The posterior tibial tendon is one of the most
important tendons of the leg. It starts at a muscle in the calf, travels down the inside of the lower leg and attaches to the bones on the inside of the foot. The main function of this tendon is to
support the arch of your foot when you walk. If the tendon becomes inflamed or torn, the arch will slowly collapse. Women and people over 40 are more likely to develop problems with the posterior
tibial tendon. Other risk factors include obesity, diabetes, and hypertension. Having flat feet since childhood increases the risk of developing a tear in the posterior tibial tendon. In addition,
people who are involved in high impact sports, such as basketball, tennis, or soccer, may have tears of the tendon from repetitive use. Inflammatory arthritis, such as rheumatoid arthritis, can cause
a painful flatfoot. This type of arthritis attacks not only the cartilage in the joints, but also the ligaments that support the foot. Inflammatory arthritis not only causes pain, but also causes the
foot to change shape and become flat. The arthritis can affect the back of the foot or the middle of foot, both of which can result in a fallen arch. An injury to the tendons or ligaments in the foot
can cause the joints to fall out of alignment. The ligaments support the bones and prevent them from moving. If the ligaments are torn, the foot will become flat and painful. This more commonly
occurs in the middle of the foot (Lisfranc injury), but can also occur in the back of the foot. Injuries to tendons of the foot can occur either in one instance (traumatically) or with repeated use
over time (overuse injury). Regardless of the cause, if tendon function is altered, the forces that are transmitted across joints in the foot are changed and this can lead to increased stress on
joint cartilage and ligaments. In addition to tendon and ligament injuries, fractures and dislocations of the bones in the midfoot can also lead to a flatfoot deformity. People with diabetes or with
nerve problems that limits normal feeling in the feet, can have collapse of the arch or of the entire foot. This type of arch collapse is typically more severe than that seen in patients with normal
feeling in their feet. In addition to the ligaments not holding the bones in place, the bones themselves can sometimes fracture and disintegrate without the patient feeling any pain. This may result
in a severely deformed foot that is very challenging to correct with surgery. Special shoes or braces are the best method for dealing with this problem.
Some symptoms of adult acquired flat foot are pain along the inside of the foot and ankle, pain that increases with activity, and difficulty walking for long periods of time. You may experience
difficulty standing, pain on the outside of the ankle, and bony bumps on the top of the foot and inside the foot. You may also have numbness and tingling of the feet and toes (may result from large
bone spurs putting pressure on nerves), swelling, a large bump on the sole of the foot and/or an ulcer (in diabetic patients). Diabetic patients should wear a properly fitting diabetic shoe wear to
prevent these complications from happening.
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
Nonoperative therapy for posterior tibial tendon dysfunction has been shown to yield 67% good-to-excellent results in 49 patients with stage 2 and 3 deformities. A rigid UCBL orthosis with a medial
forefoot post was used in nonobese patients with flexible heel deformities correctible to neutral and less than 10? of forefoot varus. A molded ankle foot orthosis was used in obese patients with
fixed deformity and forefoot varus greater than 10?. Average length of orthotic use was 15 months. Four patients ultimately elected to have surgery. The authors concluded that orthotic management is
successful in older low-demand patients and that surgical treatment can be reserved for those patients who fail nonoperative 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.