Footworks December 2008
By Dr Alexandra Buk
Many adults complain of having painful feet due to “fallen arches.” But is it true that years of wear and tear on the feet can actually cause arches to flatten over time?
Flatfoot in adults is a complex disorder, with varying symptoms and degrees of severity. Although there are several types of flatfoot, they all have one characteristic in common – partial or total collapse of the arch.
Posterior tibial tendon dysfunction (PTTD) is an inflammation and overstretching of he posterior tibial tendon in the foot. An important function of this tendon is to help support the arch. In PTTD, the tendon’s ability to perform that job is impaired, often resulting in flattening of the foot.
PTTD is often called “adult-acquired flatfoot” because it is the most common type of flatfoot developed during adulthood. Although this condition typically appears only in one foot, some people may develop it in both feet. PTTD is usually progressive, which means it will keep getting worse-especially if it isn’t treated early.
The symptoms of PTTD include pain, swelling, flattening of the arch, and inward rolling of the ankle. As the condition progresses, the symptoms will change. When PTTD initially develops, typically there is pain on the inside of the foot and ankle, along the course of the tendon. In addition, the area may be red, warm and swollen. Later, as the arch begins to flatten, there may still be pain on the inside of the foot and ankle. But at this point, the foot and toes begin to turn outward and the ankle rolls inward. As PTTD becomes more advanced, the arch flattens out even more and the pain often shifts to the outside of the foot, below the ankle. The tendon has deteriorated considerably and arthritis often develops in the foot and ankle.
The most common cause of PTTD is overuse, and wearing shoes without enough arch support. The popular use of flip-flops and barefoot walking contribute to the condition as well. The symptoms usually occur after activities that involve the tendon, such as running, walking, hiking or climbing stairs.
In many cases of PTTD, treatment is non-surgical. The most important first step is to evaluate your shoes. The best choice is an athletic shoe that laces snugly in the arch. An oxford-type shoe that laces is another alternative. Try to avoid slip-on flat shoes, house slippers and walking barefoot or in stocking feet.
Additional arch support, or orthoses, are also beneficial and an important aspect of treatment. These range from off the shelf arch lifts to a custom-made device that is made from a mold of your foot. Often orthotic devices can be moved from one pair of shoes to another.
If a significant amount of “rolling in” is present, an ankle brace, called an ankle gauntlet, is usually recommended. This is a flexible splint that is worn on top of the sock and can fit into a standard athletic shoe. It allows up-and-down motion of the ankle but limits side-to-side movement. In more severe cases, a custom brace, or AFO (ankle foot orthosis) is prescribed. This rigid brace completely limits ankle and foot joint motion. Although initially difficult to tolerate, this type of brace may allow individuals with end-stage PTTD to walk without pain and avoid surgery.
In the early stages of PTTD, when inflammation is present and the tendon is warm and swollen, anti-inflammatory medications and immobilization or non-weightbearing may help slow or even avoid the breakdown of the joints and collapse of the arch. Unfortunately, patients will usually wait until this acute phase is over and collapse has already occurred prior to seeking treatment.
If severe deformity is present, and conservative measures including orthoses and braces are not enough, surgery is warranted. Treatment will involve repairing the tendon and realigning and fusing joints in the foot.