Adult acquired flat foot
was first described in the late 1960s as something that occurred after trauma, as a result of a tear to
the tibial posterior tendon. However, by 1969 two doctors called Kettlekamp and Alexander described cases in which no trauma had taken place. They referred to the condition as "tibial posterior
tendon dysfunction" and this became known as the most common type of adult acquired flat foot.
Several risk factors are associated with PTT dysfunction, including high blood pressure, obesity, diabetes, previous ankle surgery or trauma and exposure to steroids. A person who suspects that they
are suffering from PTT dysfunction should seek medical attention earlier rather than later. It is much easier to treat early and avoid a collapsed arch than it is to repair one. When the pain first
happens and there is no significant flatfoot deformity, initial treatments include rest, oral anti-inflammatory medications and, depending on the severity, a special boot or brace.
Symptoms shift around a bit, depending on what stage of PTTD you?re in. For instance, you?re likely to start off with tendonitis, or inflammation of the posterior tibial tendon. This will make the
area around the inside of your ankle and possibly into your arch swollen, reddened, warm to the touch, and painful. Inflammation may actually last throughout the stages of PTTD. The ankle will also
begin to roll towards the inside of the foot (pronate), your heel may tilt, and you may experience some pain in your leg (e.g. shin splints). As the condition progresses, the toes and foot begin to
turn outward, so that when you look at your foot from the back (or have a friend look for you, because-hey-that can be kind of a difficult
maneuver to pull off) more toes than usual will be visible on the outside (i.e. the side with the pinky toe). At this stage, the foot?s still going to be flexible, although it will likely have
flattened somewhat due to the lack of support from the posterior tibial tendon. You may also find it difficult to stand on your toes. Finally, you may reach a stage in which your feet are inflexibly
flat. At this point, you may experience pain below your ankle on the outside of your foot, and you might even develop arthritis in the ankle.
Clinicians need to recognize the early stage of this syndrome which includes pain, swelling, tendonitis and disability. The musculoskeletal portion of the clinical exam can help determine the stage
of the disease. It is important to palpate the posterior tibial tendon and test its muscle strength. This is tested by asking patient to plantarflex and invert the foot. Joint range of motion is
should be assessed as well. Stiffness of the joints may indicate longstanding disease causing a rigid deformity. A weightbearing examination should be performed as well. A complete absence of the
medial longitudinal arch is often seen. In later stages the head of the talus bone projects outward to the point of a large "lump" in the arch. Observing the patient's feet from behind shows a
significant valgus rotation of the heel. From behind, the "too many toes" sign may be seen as well. This is when there is abducution of the forefoot in the transverse plane allowing the toes to be
seen from behind. Dysfunction of the posterior tibial tendon can be assessed by asking the patient to stand on his/her toes on the affected foot. If they are unable to, this indicates the disease is
in a more advanced stage with the tendon possibly completely ruptured.
Non surgical Treatment
Orthoses (insoles, functional orthoses, ankle supports, braces, ankle foot orthoses (AFOs)) - are usually custom-made to increase the functional stability of the foot and improve the mechanical
properties of the tendon as well as reducing the actual degree of strain on the tendon. This reduces pain and inflammation. Physiotherapy - exercises and physiotherapy are often used to increase
mobility, strengthen the tendon itself, stretch your Achilles tendon as well as reduce pain. Once the tendon has been stretched (stage one), the heel starts rolling outwards. Total immobilisation in
a cast may help the symptoms to subside and prevent progression of the deformity in a smaller percentage of patients. Long-term use of orthoses may help stop progression of the deformity and reduce
pain without surgery. Non-surgical treatment is unlikely to prevent progression to stage three and four but may be chosen by some patients who either are unsuitable for surgery or prefer not to have
Flatfoot reconstruction (osteotomy). This is often recommended for flexible flatfoot condition. Flatfoot reconstruction involves cutting and shifting the heel bone into a more neutral position,
transferring the tendon used to flex the lesser toes (all but the big toe) to strengthen the posterior tibial tendon, and lengthening the calf muscle. Fusion (also known as triple arthrodesis).
Fusion involves fusing, or making stiff, three joints in the back of the foot the subtalar, talonavicular, and calcaneocuboid joints, to realign the foot and give it a more natural shape. Pins or
screws hold the area in place until it heals. Fusion is often recommended for a rigid flatfoot deformity or evidence of arthritis. Both of these surgeries can provide excellent pain relief and