Posterior Tibial Tendon Dysfunction Physical Therapy

Overview
Adult acquired flatfoot is one of the most common problems affecting the foot and ankle. Treatment ranges from nonsurgical methods, such as orthotics and braces to surgery. Your doctor will create a treatment plan for you based on what is causing your AAFD. Flat Foot

Causes
As discussed above, many different problems can create a painful flatfoot. Damage to the posterior tibial tendon is the most common cause of AAFD. The posterior tibial tendon is one of the most important tendons of the leg. It starts at a muscle in the calf, travels down the inside of the lower leg and attaches to the bones on the inside of the foot. The main function of this tendon is to support the arch of your foot when you walk. If the tendon becomes inflamed or torn, the arch will slowly collapse. Women and people over 40 are more likely to develop problems with the posterior tibial tendon. Other risk factors include obesity, diabetes, and hypertension. Having flat feet since childhood increases the risk of developing a tear in the posterior tibial tendon. In addition, people who are involved in high impact sports, such as basketball, tennis, or soccer, may have tears of the tendon from repetitive use. Inflammatory arthritis, such as rheumatoid arthritis, can cause a painful flatfoot. This type of arthritis attacks not only the cartilage in the joints, but also the ligaments that support the foot. Inflammatory arthritis not only causes pain, but also causes the foot to change shape and become flat. The arthritis can affect the back of the foot or the middle of foot, both of which can result in a fallen arch. An injury to the tendons or ligaments in the foot can cause the joints to fall out of alignment. The ligaments support the bones and prevent them from moving. If the ligaments are torn, the foot will become flat and painful. This more commonly occurs in the middle of the foot (Lisfranc injury), but can also occur in the back of the foot. Injuries to tendons of the foot can occur either in one instance (traumatically) or with repeated use over time (overuse injury). Regardless of the cause, if tendon function is altered, the forces that are transmitted across joints in the foot are changed and this can lead to increased stress on joint cartilage and ligaments. In addition to tendon and ligament injuries, fractures and dislocations of the bones in the midfoot can also lead to a flatfoot deformity. People with diabetes or with nerve problems that limits normal feeling in the feet, can have collapse of the arch or of the entire foot. This type of arch collapse is typically more severe than that seen in patients with normal feeling in their feet. In addition to the ligaments not holding the bones in place, the bones themselves can sometimes fracture and disintegrate without the patient feeling any pain. This may result in a severely deformed foot that is very challenging to correct with surgery. Special shoes or braces are the best method for dealing with this problem.

Symptoms
Pain and swelling around the inside aspect of the ankle initially. Later, the arch of the foot may fall (foot becomes flat), this change leads to walking to become difficult and painful, as well as standing for long periods. As the flat foot becomes established, pain may progress to the outer part of the ankle. Eventually, arthritis may develop.

Diagnosis
Examination by your foot and ankle specialist can confirm the diagnosis for most patients. An ultrasound exam performed in the office setting can evaluate the status of the posterior tibial tendon, the tendon which is primarily responsible for supporting the arch structure of the foot.

Non surgical Treatment
A painless flatfoot that does not hinder your ability to walk or wear shoes requires no special treatment or orthotic device. Other treatment options depend on the cause and progression of the flatfoot. Conservative treatment options include making shoe modifications. Using orthotic devices such as arch supports and custom-made orthoses. Taking nonsteroidal anti-inflammatory drugs such as ibuprofen to relieve pain. Using a short-leg walking cast or wearing a brace. Injecting a corticosteroid into the joint to relieve pain. Rest and ice. Physical therapy. In some cases, surgery may be needed to correct the problem. Surgical procedures can help reduce pain and improve bone alignment. Adult Acquired Flat Foot

Surgical Treatment
The indications for surgery are persistent pain and/or significant deformity. Sometimes the foot just feels weak and the assessment of deformity is best done by a foot and ankle specialist. If surgery is appropriate, a combination of soft tissue and bony procedures may be considered to correct alignment and support the medial arch, taking strain off failing ligaments. Depending upon the tissues involved and extent of deformity, the foot and ankle specialist will determine the necessary combination of procedures. Surgical procedures may include a medial slide calcaneal osteotomy to correct position of the heel, a lateral column lengthening to correct position in the midfoot and a medial cuneiform osteotomy or first metatarsal-tarsal fusion to correct elevation of the medial forefoot. The posterior tibial tendon may be reconstructed with a tendon transfer. In severe cases (stage III), the reconstruction may include fusion of the hind foot,, resulting in stiffness of the hind foot but the desired pain relief. In the most severe stage (stage IV), the deltoid ligament on the inside of the ankle fails, resulting in the deformity in the ankle. This deformity over time can result in arthritis in the ankle.