Monthly Archives: March 2015

Flat Feet In Adults (Adult Aquired Flat Foot)

Overview

Adult flatfoot (adult acquired flatfoot) or posterior tibial tendon dysfunction (PTTD) is a common pathology presented to foot and ankle specialists. PTTD is characterized by a valgus (everted) hindfoot, flattening of the longitudinal arch of the foot (collapse) and abduction of the forefoot. This is a progressive deformity that begins flexible and can become rigid over time. The posterior tibial tendon (PT) is one of the main supporting structures of the foot arch. Changes within this tendon cause flattening of the foot. There are four stages of this deformity that begins flexible and progressives, with no treatment, to a rigid deformity and with time may involve the ankle joint. Patients usually present with pain in the foot or ankle stating the ankle is rolling. Its also common for patients to state they have difficulty walking barefoot. Pain is exacerbated after physical activities. Pain is usually isolated to the inside of the foot along the course of the PT tendon.Flat Feet


Causes

Damage to the posterior tendon from overuse is the most common cause for adult acquired flatfoot. Running, walking, hiking, and climbing stairs are activities that add stress to this tendon, and this overuse can lead to damage. Obesity, previous ankle surgery or trauma, diabetes (Charcot foot), and rheumatoid arthritis are other common risk factors.


Symptoms

The symptoms of PTTD may include pain, swelling, a flattening of the arch, and an inward rolling of the ankle. As the condition progresses, the symptoms will change. For example, when PTTD initially develops, there is pain on the inside of the foot and ankle (along the course of the tendon). In addition, the area may be red, warm, and swollen. Later, as the arch begins to flatten, there may still be pain on the inside of the foot and ankle. But at this point, the foot and toes begin to turn outward and the ankle rolls inward. As PTTD becomes more advanced, the arch flattens even more and the pain often shifts to the outside of the foot, below the ankle. The tendon has deteriorated considerably and arthritis often develops in the foot. In more severe cases, arthritis may also develop in the ankle.


Diagnosis

Posterior Tibial Tendon Dysfunction is diagnosed with careful clinical observation of the patient?s gait (walking), range of motion testing for the foot and ankle joints, and diagnostic imaging. People with flatfoot deformity walk with the heel angled outward, also called over-pronation. Although it is normal for the arch to impact the ground for shock absorption, people with PTTD have an arch that fully collapses to the ground and does not reform an arch during the entire gait period. After evaluating the ambulation pattern, the foot and ankle range of motion should be tested. Usually the affected foot will have decreased motion to the ankle joint and the hindfoot. Muscle strength may also be weaker as well. An easy test to perform for PTTD is the single heel raise where the patient is asked to raise up on the ball of his or her effected foot. A normal foot type can lift up on the toes without pain and the heel will invert slightly once the person has fully raised the heel up during the test. In early phases of PTTD the patient may be able to lift up the heel but the heel will not invert. An elongated or torn posterior tibial tendon, which is a mid to late finding of PTTD, will prohibit the patient from fully rising up on the heel and will cause intense pain to the arch. Finally diagnostic imaging, although used alone cannot diagnose PTTD, can provide additional information for an accurate diagnosis of flatfoot deformity. Xrays of the foot can show the practitioner important angular relationships of the hindfoot and forefoot which help diagnose flatfoot deformity. Most of the time, an MRI is not needed to diagnose PTTD but is a tool that should be considered in advanced cases of flatfoot deformity. If a partial tear of the posterior tibial tendon is of concern, then an MRI can show the anatomic location of the tear and the extensiveness of the injury.


Non surgical Treatment

The adult acquired flatfoot is best treated early. Accurate assessment by your doctor will determine which treatment is suitable for you. Reduce your level of activity and follow the RICE regime. R – rest as often as you are able. Refrain from activity that will worsen your condition, such as sports and walking. I – ice, apply to the affected area, ensure you protect the area from frostbite by applying a towel over the foot before using the ice pack. C – compression, a Tubigrip or elasticated support bandage may be

applied to relieve symptoms and ease pain and discomfort. E – elevate the affected foot to reduce painful swelling. You will be prescribed pain relief in the form of non-steroidal antiinflammatory medications (if you do not suffer with allergies or are asthmatic). Immobilisation of your affected foot – this will involve you having a below the knee cast for four to eight weeks. In certain circumstances it is possible for you to have a removable boot instead of a cast. A member of the foot and ankle team will advise as to whether this option is suitable for you. Footwear is important – it is advisable to wear flat sturdy lace-up shoes, for example, trainers or boots. This will not only support your foot, but will also accommodate orthoses (shoe inserts).

Adult Acquired Flat Foot


Surgical Treatment

Surgical correction is dependent on the severity of symptoms and the stage of deformity. The goals of surgery are to create a more functional and stable foot. There are multiple procedures available to the surgeon and it may take several to correct a flatfoot deformity. Usually surgical treatment begins with removal of inflammatory tissue and repair of the posterior tibial tendon. A tendon transfer is performed if the posterior tibial muscle is weak or the tendon is badly damaged. The most commonly used tendon is the flexor digitorum longus tendon. This tendon flexes or moves the lesser toes downward. The flexor digitorum longus tendon is utilized due to its close proximity to the posterior tibial tendon and because there are minimal side effects with its loss. The remainder of the tendon is sutured to the flexor hallucis longus tendon that flexes the big toe so that little function is loss.

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The Leading Causes And Treatment Plans For Achilles Tendonitis Pain

Overview

Achilles TendonAchilles Tendonitis is an inflammation of the Achilles tendon, which attaches the calf muscles (gastrocnemius and soleus) to the heel bone (calcaneus). Pain can be felt on the back of the heel at the attachment of the tendon, along the length of the tendon, or at the base of the calf where the tendon attaches to the muscle. Swelling is not always present with this injury, but it may occur in severe cases.

Causes

Achilles tendonitis is an overuse injury. Too much too soon is the common cause of overuse injuries, however other factors can contribute to developing the condition. An increase in activity, either distance, speed or a sudden change to running up hills. As a rule of thumb distance runners should increase their mileage by no more than 10% per week. A change of footwear or training surface for example suddenly running on soft sand can cause the heel to drop lower than normal making the tendon stretch further than it is used to. Weak calf muscles can tighten or go into partial spasm which again increases the strain on the achilles tendon by shortening the muscle. Running up hills – the achilles tendon has to stretch more than normal on every stride. This is fine for a while but will mean the tendon will fatigue sooner than normal. Overpronation or feet which roll in when running can place an increased strain on the achilles tendon. As the foot rolls in (flattens) the lower leg also rotates inwards which places twisting stresses on the tendon. Wearing high heels constantly shortens the tendon and calf muscles. When exercising in flat running shoes, the tendon is stretched beyond its normal range which places an abnormal strain on the tendon.

Symptoms

Symptoms include pain in the heel and along the tendon when walking or running. The area may feel painful and stiff in the morning. The tendon may be painful to touch or move. The area may be swollen and warm. You may have trouble standing up on one toe.

Diagnosis

Confirming Achilles tendonitis may involve imaging tests. X-rays provide images of the bones of the foot and leg. Magnetic resonance imaging (MRI) is useful for detecting ruptures and degeneration of tissue. Ultrasound shows tendon movement, related damage, and inflammation.

Nonsurgical Treatment

Use the R.I.C.E method of treatment when you first notice the pain. Although rest is a key part of treating tendonitis, prolonged inactivity can cause stiffness in your joints. Move the injured ankle through its full range of motion and perform gentle calf and ankle stretches to maintain flexibility. If self-care doesn’t work, it’s important to get the injury treated because if the tendon continues to sustain small tears through movement, it can rupture under excessive stress. Your doctor may suggest a temporary foot insert that elevates your heel and may relieve strain on the tendon. Other possible treatments include special heel pads or cups to wear in your shoes to cushion and support your heel, or a splint to wear at night. Physical therapy may also help allow the tendon to heal and repair itself over a period of weeks.

Achilles Tendon

Surgical Treatment

Surgery is considered the last resort. It is only recommended if all other treatment options have failed after at least six months. In this situation, badly damaged portions of the tendon may be removed. If the tendon has ruptured, surgery is necessary to re-attach the tendon. Rehabilitation, including stretching and strength exercises, is started soon after the surgery. In most cases, normal activities can be resumed after about 10 weeks. Return to competitive sport for some people may be delayed for about three to six months.

Prevention

Do strengthening and stretching exercises to keep calf muscles strong and flexible. Keep your hamstring muscles flexible by stretching. Warm up and stretch adequately before participating in any sports. Always increase the intensity and duration of training gradually. Do not continue an exercise if you experience pain over the tendon. Wear properly fitted running and other sports shoes, including properly fitted arch supports if your feet roll inwards excessively (over-pronate).

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