Surgery For Flat Feet In Adults

posted on 21 Apr 2015 01:40 by vazquezmzatycfytp
Overview
Tendons do a lot of work. In fact, a great deal of what happens when you walk can be related to tendons tugging and pulling in appropriate ways in their proper places. With this in mind, it?s hardly surprising that on occasion, (probably because we too often forget to send them ?Thank you? cards), tendons may decide that they?ve had it. They may buck their responsibilities, shirk their work, and in all other ways cease to function properly. And that may mean bad news for you. Take the posterior tibial tendon: it runs from the bottom of the calf, goes right under that bump on the inside of the ankle (the medial malleolus) and ends up attaching itself to a bone on the inside of the middle of your foot (the navicular bone). It?s the main tendon that keeps the arch of your foot in place, and it helps a bunch in walking, too. Over time, though, we tend to put a lot of stress on this faithful tendon, especially if we?ve put on extra weight, or do a lot of activities that stress it out, walking, running, hiking, or climbing stairs. Sometimes athletes (who do a lot of that walking and running stuff) may put so much stress on the tendon that it tears suddenly. But for many of us, damage may take place gradually (i.e. the tendon stretches out) until the tendon tells us that it flat out quits. (It sometimes doesn?t even give two weeks notice.) In short, you may develop posterior tibial tendon dysfunction (PTTD). Acquired Flat Feet

Causes
Adult acquired flatfoot is caused by inflammation and progressive weakening of the major tendon that it is responsible for supporting the arch of the foot. This condition will commonly be accompanied by swelling and pain on the inner portion of the foot and ankle. Adult acquired flatfoot is more common in women and overweight individuals. It can also be seen after an injury to the foot and ankle. If left untreated the problem may result in a vicious cycle, as the foot becomes flatter the tendon supporting the arch structure becomes weaker and more and more stretched out. As the tendon becomes weaker, the foot structure becomes progressively flatter. Early detection and treatment is key, as this condition can lead to chronic swelling and pain.

Symptoms
Initially, flatfoot deformity may not present with any symptoms. However, overtime as the tendon continues to function in an abnormal position, people with fallen arches will begin to have throbbing or sharp pain along the inside of the arch. Once the tendon and soft tissue around it elongates, there is no strengthening exercises or mechanism to shorten the tendon back to a normal position. Flatfoot can also occur in one or both feet. If the arch starts to slowly collapse in one foot and not the other, posterior tibial dysfunction (PTTD) is the most likely cause. People with flatfoot may only have pain with certain activities such as running or exercise in the early phase of PTTD. Pain may start from the arch and continue towards the inside part of the foot and ankle where the tendon courses from the leg. Redness, swelling and increased warmth may also occur. Later signs of PTTD include pain on the outside of the foot from the arch collapsing and impinging other joints. Arthritic symptoms such as painful, swollen joints in the foot and ankle may occur later as well due to the increased stress on the joints from working in an abnormal position for a long period of time.

Diagnosis
Perform a structural assessment of the foot and ankle. Check the ankle for alignment and position. When it comes to patients with severe PTTD, the deltoid has failed, causing an instability of the ankle and possible valgus of the ankle. This is a rare and difficult problem to address. However, if one misses it, it can lead to dire consequences and potential surgical failure. Check the heel alignment and position of the heel both loaded and during varus/valgus stress. Compare range of motion of the heel to the normal contralateral limb. Check alignment of the midtarsal joint for collapse and lateral deviation. Noting the level of lateral deviation in comparison to the contralateral limb is critical for surgical planning. Check midfoot alignment of the naviculocuneiform joints and metatarsocuneiform joints both for sag and hypermobility.

Non surgical Treatment
Non-surgical treatment includes rest and reducing your activity until the pain improves. Orthotics or bracing help support the tendon to reduce its pull along the arch, thus reducing pain. In moderate to severe cases, a below knee cast or walking boot may be needed to allow the tendon to rest completely and heal. Physical therapy is an integral part of the non-surgical treatment regimen to reduce inflammation and pain. Anti-inflammatory medication is often used as well. Many times evaluation of your current shoes is necessary to ensure you are wearing appropriate shoe gear to prevent re-injury. Flat Feet

Surgical Treatment
Until recently, operative treatment was indicated for most patients with stage 2 deformities. However, with the use of potentially effective nonoperative management , operative treatment is now indicated for those patients that have failed nonoperative management. The principles of operative treatment of stage 2 deformities include transferring another tendon to help serve the role of the dysfunctional posterior tibial tendon (usually the flexor hallucis longus is transferred). Restoring the shape and alignment of the foot. This moves the weight bearing axis back to the center of the ankle. Changing the shape of the foot can be achieved by one or more of the following procedures. Cutting the heel bone and shifting it to the inside (Medializing calcaneal osteotomy). Lateral column lengthening restores the arch and overall alignment of the foot. Medial column stabilization. This stiffens the ray of the big toe to better support the arch. Lengthening of the Achilles tendon or Gastrocnemius. This will allow the ankle to move adequately once the alignment of the foot is corrected. Stage 3 acquired adult flatfoot deformity is treated operatively with a hindfoot fusion (arthrodesis). This is done with either a double or triple arthrodesis - fusion of two or three of the joints in hindfoot through which the deformity occurs. It is important when a hindfoot arthrodesis is performed that it be done in such a way that the underlying foot deformity is corrected first. Simply fusing the hindfoot joints in place is no longer acceptable.
Tags: adult, aquired, flat, foot