Help!!! One of my feet is now flat!!!
Tibialis Posterior Dysfunction & Adult Acquired Flat-foot deformity
Several times a year I have patients who present to my Gold Coast Podiatry clinics noticing one or both of their feet have become flat. They may or may not have pain but none the less are concerned because of the obvious change.
The most common cause of this is when the tibialis posterior tendon (main arch supporting tendon of the arch) becomes insufficient and arch supporting ligaments stretch or rupture. Without these important “cables” there is only one way for the arch to go……down!
Two common diagnoses are tibialis posterior dysfunction and/or adult acquired flat foot deformity.Two common diagnoses are tibialis posterior dysfunction and/or adult acquired flat foot deformity. #performbetter @pogophysio Click To Tweet
In helping explain both of these conditions there are 4 stages clinically that we look at as clinicians that helps guide treatment.
Stage 1 – may or may not see noticeable structural changes of the foot. Patient can raise heel off the ground. Primary symptom is tibialis posterior tendon tenosynovitis (pain on the medial side of the ankle).
Stage 2 – attenuation of tibialis posterior tendon, structural change, difficulty or inability to lift heel off the ground, loss of one or more critical ligaments in the hindfoot, joints that are still flexible and the rear-foot Valgus deformity is reducible, negative Jack’s test (bending of the big toe), positive first metatarsal rise test with supinatus deformity that is reducible.
Stage 3 – deformity becomes rigid, cannot raise heel off the ground, positive metatarsal rise test with supinatus that is NOT reducible, cannot reduce the rear-foot Valgus deformity in stance
Stage 4 – as stage 3 but with valgus deformity of Talo-crural joint (viewed on weight bearing xray)
After the correct stage of the condition has been diagnosed then the appropriate treatment plan can be put in place. Like most conditions there are a number of factors that need to be addressed to complete the overall picture. It is important to understand that because of the failure of those structures holding up the arch we need to compensate for this by using external forces via the use of foot orthotics or more commonly an ankle-foot orthoses (AFO).
Other common treatment modalities used especially in the earlier stages include:
- Physical Therapy – to strengthen the tibialis posterior tendon and the other supporting tendons and muscles. Proprioception exercises to aid in ligament integrity. Mobility work of foot joints to help take any excessive strain off ligaments.
- Correct footwear recommendations – A stability shoe that helps counter-act the shift of the weight due to the flattening of the feet.
- Starting to address Over-weight or Obesity issues with the GP – the heavier a patient is the more strain on tendons and ligaments.
If there is failure of slowing the progression of flattening of the foot or the failure of improving of symptoms then a surgical opinion is recommended. The surgeon may look at repairing the tendon and/or reconstructing the arch of the foot. As always this should be considered as a last option once other interventions have been exhausted.
If you have further questions please contact me.
BSc (Biomed), BHlthSc (Pod)
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