What Is Flatfoot?
Flatfoot is often a complex disorder, with diverse symptoms and varying degrees of deformity and disability. There are several types of flatfoot, all of which have one characteristic in common: partial or total collapse (loss) of the arch. Other characteristics shared by most types of flatfoot include toe drift, in which the toes and front part of the foot point outward. The heel tilts toward the outside and the ankle appears to turn in. A tight Achilles tendon, which causes the heel to lift off the ground earlier when walking and may make the problem worse, bunions and hammertoes may develop as a result of a flatfoot.
Flexible flatfoot is one of the most common types of flatfoot. It typically begins in childhood or adolescence and continues into adulthood. It usually occurs in both feet and progresses in severity throughout the adult years. As the deformity worsens, the soft tissues (tendons and ligaments) of the arch may stretch or tear and can become inflamed. The term “flexible” means that while the foot is flat when standing (weightbearing), the arch returns when not standing.
Symptoms that may occur in some persons with flexible flatfoot include:
- Pain in the heel, arch, ankle or along the outside of the foot
- Rolled-in ankle (overpronation)
- Pain along the shin bone (shin splint)
- General aching or fatigue in the foot or leg
- Low back, hip or knee pain
In diagnosing flatfoot, the foot and ankle surgeon examines the foot and observes how it looks when you stand and sit. X-rays are usually taken to determine the disorder's severity. If you are diagnosed with flexible flatfoot, but you do not have any symptoms, your surgeon will explain what you might expect in the future.
If you experience symptoms with flexible flatfoot, the surgeon may recommend nonsurgical treatment options, including:
- Activity modifications. Cut down on activities that bring you pain and avoid prolonged walking and standing to give your arches a rest.
- Weight loss. If you are overweight, try to lose weight. Putting too much weight on your arches may aggravate your symptoms.
- Orthotic devices. Your foot and ankle surgeon can provide you with custom orthotic devices for your shoes to give more support to the arches.
- Immobilization. In some cases, it may be necessary to use a walking cast or to completely avoid weightbearing.
- Medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, help reduce pain and inflammation.
- Physical therapy. Ultrasound therapy or other physical therapy modalities may be used to provide temporary relief.
- Shoe modifications. Wearing shoes that support the arches is important for anyone who has flatfoot.
- Ankle Foot Orthoses (AFO) devices. Your foot and ankle surgeon may recommend advanced bracing to modify your walking and to support your arches.
When Is Surgery Necessary?
In some patients whose pain is not adequately relieved by other treatments, surgery may be considered. Many surgical techniques are available to correct flexible flatfoot, and one or a combination of procedures may be required to relieve the symptoms and improve foot function. In selecting the procedure or combination of procedures for your particular case, the foot and ankle surgeon will take into consideration the extent of your deformity based on the x-ray findings, your age, your activity level and other factors. The length of the recovery period will vary depending on the procedure or procedures performed.
Collapsed Arches or Posterior Tibial Tendon Dysfunction (PTTD)
What Is PTTD?
The posterior tibial tendon serves as one of the major supporting structures of the foot, helping it to function while walking. Posterior tibial tendon dysfunction (PTTD) is a condition caused by changes in the tendon, impairing its ability to support the arch. This results 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 occurs in only one foot, some people may develop it in both feet. PTTD is usually progressive, which means it will keep getting worse, especially if it is not treated early.
Overuse of the posterior tibial tendon is often the cause of PTTD. In fact, the symptoms usually occur after activities that involve the tendon, such as running, walking, hiking or climbing stairs.
The symptoms of PTTD may include pain, swelling, a flattening of the arch and an inward rolling of the ankle. As the condition progresses, the symptoms will change.
For example, when PTTD initially develops, 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 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. In more severe cases, arthritis may also develop in the ankle.
Because of the progressive nature of PTTD, early treatment is advised. If treated early enough, your symptoms may resolve without the need for surgery, and progression of your condition can be arrested.
In contrast, untreated PTTD could leave you with an extremely flat foot, painful arthritis in the foot and ankle and increasing limitations on walking, running or other activities.
In many cases of PTTD, treatment can begin with nonsurgical approaches that may include:
Orthotic devices or bracing. To give your arch the support it needs, your foot and ankle surgeon may provide you with an ankle brace or a custom orthotic device that fits into the shoe.
Immobilization. Sometimes a short-leg cast or boot is worn to immobilize the foot and allow the tendon to heal, or you may need to completely avoid all weightbearing for a while.
Physical therapy. Ultrasound therapy and exercises may help rehabilitate the tendon and muscle following immobilization.
Medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, help reduce the pain and inflammation.
Shoe modifications. Your foot and ankle surgeon may advise changes to your shoes and may provide special inserts designed to improve arch support.
When Is Surgery Needed?
In cases of PTTD that have progressed substantially or have failed to improve with nonsurgical treatment, surgery may be required. For some advanced cases, surgery may be the only option. Dr. Cottom will determine the best approach for you.