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What Is The Cause And Treatment Of Adult Aquired Flat Feet

Overview

Posterior tibial tendon insufficiency (also called posterior tibial tendon dysfunction or adult acquired flatfoot) has been named literally after failure of the posterior tibial tendon. However, the condition is caused not only by the progressive failure of the posterior tibial tendon; it is also failure of associated ligaments and joints on the inner side of the ankle and foot. This results in collapse of the arch of the foot, along with the deformity which most often becomes the debilitating problem in its later stages. While at the beginning the common symptom is pain over the tendon in the inner part of the hindfoot and midfoot, later on it is the deformity that can threaten a person's ability to walk. Just as the tendon degenerates and loses its function, other soft tissue on the same inner side of the foot - namely the ligaments - degenerate and fail. Ligaments are responsible for holding bones in place, and when they fail, bones shift to places where they shouldn?t; deformity is the result. The deformity causes malalignment, leading to more stress and failure of the ligaments.Flat Foot



Causes

Posterior tibial tendon dysfunction is the most common cause of acquired adult flatfoot. Sometimes this can be a result of specific trauma, but usually the tendon becomes injured from wear and tear over time. This is more prevalent in individuals with an inherited flat foot but excessive weight, age, and level of activity are also contributing factors.



Symptoms

PTTD begins with a gradual stretching and loss of strength of the posterior tibial tendon which is the most important tendon supporting the arch of the human foot. Left untreated, this tendon will continue to lengthen and eventually rupture, leading to a progressive visible collapse of the arch of the foot. In the early stages, patients with PTTD will notice a pain and swelling along the inner ankle and arch. Many times, they are diagnosed with ?tendonitis? of the inner ankle. If the foot and ankle are not properly supported during this early phase, the posterior tibial tendon can rupture and devastating consequences will occur to the foot and ankle structure. The progressive adult acquired flatfoot deformity will cause the heel to roll inward in a ?valgus? or pronated direction while the forefoot will rotate outward causing a ?duckfooted? walking pattern. Eventually, significant arthritis can occur in the joints of the foot, the ankle and even the knee. Early diagnosis and treatment is critical so if you have noticed that one, or both, of your feet has become flatter in recent times come in and have it checked out.



Diagnosis

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

Conservative treatment is indicated for nearly all patients initially before surgical management is considered. The key factors in determining appropriate treatment are whether acute inflammation and whether the foot deformity is flexible or fixed. However, the ultimate treatment is often determined by the patients, most of whom are women aged 40 or older. Compliance can be a problem, especially in stages I and II. It helps to emphasise to the patients that tibialis posterior dysfunction is a progressive and chronic condition and that several fittings and a trial of several different orthoses or treatments are often needed before a tolerable treatment is found.

Adult Acquired Flat Foot



Surgical Treatment

If conservative treatment fails to provide relief of pain and disability then surgery is considered. Numerous factors determine whether a patient is a surgical candidate. They include age, obesity, diabetes, vascular status, and the ability to be compliant with post-operative care. Surgery usually requires a prolonged period of nonweightbearing immobilization. Total recovery ranges from 3 months to one year. Clinical, x-ray, and MRI examination are all used to select the appropriate surgical procedure.

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