What could be my problem?

Flat Foot – Adult Acquired or Posterior Tibial Tendon Dysfunction (PTTD)  

The posterior tibial tendon attaches the calf muscle to the bones on the inside of the foot and serves as one of its major supporting structures. The main function of this tendon is to hold up the arch and support the foot when walking.

PTTD is a condition caused by changes in the tendon, impairing it's ability to support the arch, and this results in flattening of the foot. PTTD is often called adult acquired flat foot because it is the most common type of flat foot developed during adulthood.  Although this condition typically in only one foot, some people may develop it in both feet.  PTTD is usually progressive, and it will keep getting worse, especially if it is not treated early.

What causes adult acquired flat feet?

  • Overuse of the posterior tibial tendon
  • Symptoms usually occur after activities that involve the tendon – running, walking, hiking or climbing stairs

When should I see a foot doctor about my flat feet?

  • Pain, swelling, flattening of the arch and an inward rolling of the ankle
  • Pain on the inside of the foot and ankle
  • Red, warm, swelling on the inside of the foot and ankle
  • Pain on the inside of the foot and ankle, the toes begin to turn outward and the ankle rolls inward
  • The arch flattens, pain on the outside of the foot below the ankle

What are my treatment options?

Non-Surgical Treatment Options

Because of the progressive nature of PTTD, early treatment is important. If treated early enough, your symptoms may be resolved without the need for surgery and progression of your condition can be resolved.

Untreated PTTD could leave you with an extremely flat foot, painful arthritis in the foot and ankle, or increasing limitations on walking, running, or other activities.

Non-surgical treatment options include:

  • Custom orthotics or ankle brace
  • Short-leg cast or boot
  • Physical therapy
  • Non-steroidal, anti-inflammatory drugs
  • Shoe modifications

Surgical Treatment Options

Surgery should only be done if the pain does not get better after six months of appropriate non-surgical treatment.  The type of surgery depends on where the tendonitis is located and how much the tendon is damaged.  Surgical reconstruction can be extremely complex.

  • Gastrocnemius Recession or Lengthening of the Achilles Tendon - This is a surgical lengthening of the calf muscles, and it is useful in patients who have limited ability to move the ankle up.  This procedure can prevent flat foot from returning, but does create some weakness with pushing off and climbing stairs.
  • Tenosynovectomy (cleaning the tendon) - This procedure is used when there is very mild disease, the shape of the foot has not changed, and there is pain and swelling over the tendon.  The foot surgeon will clean away and remove the inflamed tissue (synovium) surrounding the tendon.
  • Tendon Transfer - Tendon transfer can be done in flexible flatfoot to recreate the function of the damaged posterior tibial tendon. The term ‘flexible’ means that while the foot is flat when weight bearing (standing), the arch returns when not standing. In this procedure, the diseased tendon is removed and replaced with another tendon from the foot, or if the disease is not too significant in the tendon, the transferred tendon is attached to the preserved posterior tibial tendon.
  • Osteotomy (cutting and shifting bones) - An osteotomy can change the shape of a flexible flatfoot to recreate a more “normal” arch shape.  One or two bone cuts may be required, typically of the heel bone (calcaneus). If flatfoot is severe, a bone graft may be needed.  The bone graft will lengthen the outside of the foot.  Other bones in the middle of the foot may also be involved.  They may be cut or fused to help support the arch and prevent the flat foot from returning. Screws or plates hold the bones in place while they heal.
  • Fusion - Sometimes the flatfoot is stiff or there is also arthritis in the back of the foot.  In these cases, the foot will not be flexible enough to be treated successfully with bone cuts and tendon transfers.  Fusion (arthrodesis) of a joint or joints in the back of the foot is used to realign the foot and make it more normal shaped and remove any arthritis. Fusion involves removing any remaining cartilage in the joint.  Over time, this lets the body “glue” the joints together so that they become one large bone without a joint, which eliminates joint pain.  Screws or plates hold the bones in place while they heal.