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.
Adult Acquired Flat Foot

The most common cause of acquired adult flatfoot is posterior tibial tendon dysfunction. What causes adult acquired flat foot? Fracture or dislocation. Tendon laceration. Tarsal Coalition. Arthritis. Neuroarthropathy. Neurological weakness.

Depending on the cause of the flatfoot, a patient may experience one or more of the different symptoms here. Pain along the course of the posterior tibial tendon which lies on the inside of the foot and ankle. This can be associated with swelling on the inside of the ankle. Pain that is worse with activity. High intensity or impact activities, such as running, can be very difficult. Some patients can have difficulty walking or even standing for long periods of time. When the foot collapses, the heel bone may shift position and put pressure on the outside ankle bone (fibula). This can cause pain on the outside of the ankle. Arthritis in the heel also causes this same type of pain. Patients with an old injury or arthritis in the middle of the foot can have painful, bony bumps on the top and inside of the foot. These make shoewear very difficult. Occasionally, the bony spurs are so large that they pinch the nerves which can result in numbness and tingling on the top of the foot and into the toes. Diabetics may only notice swelling or a large bump on the bottom of the foot. Because their sensation is affected, people with diabetes may not have any pain. The large bump can cause skin problems and an ulcer (a sore that does not heal) may develop if proper diabetic shoewear is not used.

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
Stage one deformities usually respond to conservative or non-surgical therapy such as anti-inflammatory medication, casting, functional orthotics or a foot ankle orthosis called a Richie Brace. If these modalities are unsuccessful surgery is warranted.
Acquired Flat Foot

Surgical Treatment
Flatfoot reconstruction (osteotomy). This is often recommended for flexible flatfoot condition. Flatfoot reconstruction involves cutting and shifting the heel bone into a more neutral position, transferring the tendon used to flex the lesser toes (all but the big toe) to strengthen the posterior tibial tendon, and lengthening the calf muscle. Fusion (also known as triple arthrodesis). Fusion involves fusing, or making stiff, three joints in the back of the foot the subtalar, talonavicular, and calcaneocuboid joints, to realign the foot and give it a more natural shape. Pins or screws hold the area in place until it heals. Fusion is often recommended for a rigid flatfoot deformity or evidence of arthritis. Both of these surgeries can provide excellent pain relief and correction.


Rosaura Gosda

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