Treatment

Overview
Have you noticed the arch in your foot collapse over a fairly short period of time as an adult? Or Do you suffer from pain on the inside and sole of your arch? If it does, then you may be suffering from a condition known as adult acquired flat foot. As one of the main support structures of the foot?s arch, the tibilais posterior tendon, along with other muscles, tendons and ligaments, play a very important role in its mechanical function.

Causes
There are multiple factors contributing to the development of this problem. Damage to the nerves, ligaments, and/or tendons of the foot can cause subluxation (partial dislocation) of the subtalar or talonavicular joints. Bone fracture is a possible cause. The resulting joint deformity from any of these problems can lead to adult-acquired flatfoot deformity. Dysfunction of the posterior tibial tendon has always been linked with adult-acquired flatfoot deformity (AAFD). The loss of active and passive pull of the tendon alters the normal biomechanics of the foot and ankle. The reasons for this can be many and varied as well. Diabetes, high blood pressure, and prolonged use of steroids are some of the more common causes of adult-acquired flatfoot deformity (AAFD) brought on by impairment of the posterior tibialis tendon. Overstretching or rupture of the tendon results in tendon and muscle imbalance in the foot leading to adult-acquired flatfoot deformity (AAFD). Rheumatoid arthritis is one of the more common causes. About half of all adults with this type of arthritis will develop adult flatfoot deformity over time. In such cases, the condition is gradual and progressive. Obesity has been linked with this condition. Loss of blood supply for any reason in the area of the posterior tibialis tendon is another factor. Other possible causes include bone fracture or dislocation, a torn or stretched tendon, or a neurologic condition causing weakness.

Symptoms
Pain and swelling around the inside aspect of the ankle initially. Later, the arch of the foot may fall (foot becomes flat), this change leads to walking to become difficult and painful, as well as standing for long periods. As the flat foot becomes established, pain may progress to the outer part of the ankle. Eventually, arthritis may develop.

Diagnosis
Observe forefoot to hindfoot alignment. Do this with the patient sitting and the heel in neutral, and also with the patient standing. I like to put blocks under the forefoot with the heel in neutral to see how much forefoot correction is necessary to help hold the hindfoot position. One last note is to check all joints for stiffness. In cases of prolonged PTTD or coalition, rigid deformity is present and one must carefully check the joints of the midfoot and hindfoot for stiffness and arthritis in the surgical pre-planning.

Non surgical Treatment
The adult acquired flatfoot is best treated early. Accurate assessment by your doctor will determine which treatment is suitable for you. Reduce your level of activity and follow the RICE regime. R - rest as often as you are able. Refrain from activity that will worsen your condition, such as sports and walking. I - ice, apply to the affected area, ensure you protect the area from frostbite by applying a towel over the foot before using the ice pack. C - compression, a Tubigrip or elasticated support bandage may be applied to relieve symptoms and ease pain and discomfort. E - elevate the affected foot to reduce painful swelling. You will be prescribed pain relief in the form of non-steroidal antiinflammatory medications (if you do not suffer with allergies or are asthmatic). Immobilisation of your affected foot - this will involve you having a below the knee cast for four to eight weeks. In certain circumstances it is possible for you to have a removable boot instead of a cast. A member of the foot and ankle team will advise as to whether this option is suitable for you. Footwear is important - it is advisable to wear flat sturdy lace-up shoes, for example, trainers or boots. This will not only support your foot, but will also accommodate orthoses (shoe inserts).

Surgical Treatment
Surgery is usually performed when non-surgical measures have failed. The goal of surgery is to eliminate pain, stop progression of the deformity and improve a patient?s mobility. More than one technique may be used, and surgery tends to include one or more of the following. The tendon is reconstructed or replaced using another tendon in the foot or ankle The name of the technique depends on the tendon used. Flexor digitorum longus (FDL) transfer. Flexor hallucis longus (FHL) transfer. Tibialis anterior transfer (Cobb procedure). Calcaneal osteotomy - the heel bone may be shifted to bring your heel back under your leg and the position fixed with a screw. Lengthening of the Achilles tendon if it is particularly tight. Repair one of the ligaments under your foot. If you smoke, your surgeon may refuse to operate unless you can refrain from smoking before and during the healing phase of your procedure. Research has proven that smoking delays bone healing significantly.