If you have been looking at your feet lately, swearing that they just don’t look the way they used to, you may be right! Our feet change shape and size throughout our lives and many things can look different over time. These changes over time can be seen in the skin, in the nails and even the structure of the foot. We commonly see patients in our office who relate that the arch of their foot isn’t as high as it used to be. We have many women in our office for foot concerns that relates their foot changed over the course of one or a few pregnancies. Even our male population will relate that their arch has changed over time.
The changes that occur do not usually happen so quickly that we notice a difference from one day to the next – though that is possible. Rather, the changes occur gradually and we just don’t pay that much attention to our feet every day. If you are having pain in your feet that you didn’t have before, this is another sign that your foot structure is changing. It could just be the straw that broke the camel’s back when one day you realize you have a bump by your big toe or that your footprint isn’t the same as it used to be.
One common problem with the feet is called adult acquired flatfoot. This is also referred to as posterior tibial tendon dysfunction. What in the world does that mean? Well, this is a condition whereby over a course of time our foot structure can become more flat appearing than it used to be. The reason why this happens can be chronic overuse, meaning you are on your feet a lot with inadequate support. Also, some foot structures exist when we are younger but exaggerate over time and with activity.
So what exactly is happening here? With adult acquired flatfoot, the arch lowers. Sometimes this is exaggerated between rest and weightbearing. There is a tendon that starts in the inner calf area and travels around the back of your inner ankle bone and inserts at the high point of the arch. This tendon is called the posterior tibial tendon. In some patients there is a tendency to overuse this tendon due to foot structure and with some patients who have an increased body mass index, the knee position can be altered and this can lead to the arch collapsing as well. Over time, the posterior tibial tendon becomes attenuated (stretched out) and this allows the foot to collapse more.
Adult acquired flatfoot is usually not discovered just be looking at the feet. Like I said, we tend to neglect our feet if they aren’t causing any pain. People we see with posterior tibial tendinitis often come in to see us because the posterior tibial tendon has hit a breaking point, whereby it becomes inflamed and painful. This pain can be just a feeling of fatigue and weakness in more mild cases or can be so painful that it is difficult to bear weight and walk on the foot.
At the first visit a patient has with us for pain like this, we start with a complete foot examination and digital x-rays. This provides information as to the severity of your condition as well as whether other conditions are at play that require addressing. In a majority of cases, a special ankle brace is recommended in order to reduce the overuse occurring on the tendon. We have our patients wear this brace during the day as well as to bed at night in order to rest the tendon as much as possible. Icing helps to reduce inflammation and pain and it is often accompanied by an oral anti-inflammatory. As the condition improves, we are able to transition slowly out of the support of the ankle brace and move into custom orthotics which help to reduce the amount of arch collapse occurring with daily activities. The custom orthotics significantly reduce the number of flare ups you may experience.
In some cases, if the pain is severe enough, our patients may be fitted for a walking boot. This walking boot provides further immobilization and protection compared to the ankle brace. Think of this as being a removable cast. It will encourage you to stay off your foot while the tendon recovers and heals. If pain and swelling necessitate use of a walking boot, a special temporary wrap is applied to the foot and ankle. This wrap provides relief of pain and swelling.
In the most severe cases, adult acquired flatfoot may not resolve with bracing, booting and/or custom orthotics. If this is the case, the next step is to further assess the health of the tendon with either MRI or diagnostic ultrasound. These two imaging studies provide us with information as to whether there is extra fluid inside the sheath of the tendon and if there are any tears in the tendon. In cases where extra fluid is present, this is a condition called tenosynovitis and can respond to steroid injections. In cases where a tear is present, further immobilization with a longer amount of time in the boot or (in some cases) a cast may be required. Depending upon the severity of the tear and if immobilization is successful determines whether surgical intervention is needed.
When it comes to surgery for adult acquired flatfoot, repair of the tendon and possible removal of a common occurring accessory bone can be performed. This in combination with custom orthotics may be enough to resolve the chronic pain. There are some situations where reconstruction of the foot is required. This is because if custom orthotics are not able to optimally correct the foot structure, the tendon can become inflamed, painful and even tear again.
If you are experiencing pain in your arch. If you feel your foot looks flatter than it once did. If you feel your foot is flatter than the other side. If your arch hurts, if your legs are fatigued after prolonged walking or standing. If you have swelling or redness or warmth along the inside of the arch and up the inside aspect of the leg, you may have posterior tibial tendon dysfunction and adult acquired flatfoot. Don’t wait to get started on treatment! The sooner you start treatment, the sooner your condition can improve and your life can resume normal activity. Call today!