Coleen Barkle
Logic will get you from A to Z; imagination will get you everywhere.
Arch Pain All You Need To Understand
Overview


Arch pain occurs with an inflammation of the plantar arch or fascia. It is the thick membrane that covers and supports all the muscles of the sole of the foot from the heel bone to the base of the toes that is called plantar arch. When this membrane pulls excessively (constant strain), pain developes in the arch of the foot or heel.


Foot Arch Pain


Causes


The most common cause of arch pain is plantar fasciitis. Plantar fasciitis is inflammation of the fibrous band of tissue that connects the heel to the toes. Sufferers of plantar fasciitis typically feel pain early in the morning when they first get out of bed. Another common cause of arch pain is fallen arches or flat feet. Fallen arches result in the sole of the foot becoming flat so that the entire sole of the foot touches the ground. Fallen arches can lead to pain in the ankles, knees, feet, and even in the legs. While fallen arches are often inherited, for some it develops as a result of wear and tear on your feet. Wearing shoes without proper metatarsal support, or arch support, can overstretch the tendon that supports the arch causing the arch to flatten out.


Symptoms


The foot of a newborn with congenital vertical talus typically has a convex rocker-bottom shape. This is sometimes combined with an actual fold in the middle of the foot. The rare person who is diagnosed at an older age often has a "peg-leg" gait, poor balance and heavy calluses on the soles where the arch would normally be. If a child with congenital vertical talus has a genetic disorder, additional symptoms often are seen in other parts of the body.


Diagnosis


The doctor will examine your feet for foot flexibility and range of motion and feel for any tenderness or bony abnormalities. Depending on the results of this physical examination, foot X-rays may be recommended. X-rays are always performed in a young child with rigid flatfeet and in an adult with acquired flatfeet due to trauma.


Non Surgical Treatment


Rest and icing the swollen area are a good way to practice in-home treatment for mild foot arch pains. Anti inflammatory medications can also be applied to the area. It is important to reduce your activity to avoid worsening the arch pain. Wearing shoes that fit properly is important as well. Make sure to use shoes that are designed with adequate arch support to prevent over pronating. When running, avoid uneven surfaces, as this may contribute to your foot arch pain. Also, orthopedic pads or other padded heel cups and devices can be inserted into shoes to provide support and prevent more strain to the foot.


Foot Arch Pain


Surgical Treatment


Although most patients with plantar fasciitis respond to non- surgical treatment, a small percentage of patients may require surgery. If, after several months of non-surgical treatment, you continue to have heel pain, surgery will be considered. Your foot and ankle surgeon will discuss the surgical options with you and determine which approach would be most beneficial. No matter what kind of treatment you undergo for plantar fasciitis, the underlying causes that led to this condition may remain. Therefore, you will need to continue with preventive measures. Wearing supportive shoes, stretching, and using custom orthotic devices are the mainstays of long-term treatment for plantar fasciitis.


Prevention


People who run regularly should replace shoes every six months, more frequently if an avid runner. Avoid running or stepping on uneven surfaces. Try to be careful on rocky terrain or hills with loose gravel. Holes, tree stumps and roots are problems if you are trail running. If you have problems with the lower legs, a dirt road is softer than asphalt, which is softer than concrete. Try to pick a good surface if possible. However, if you're racing, be sure to train on the surface you'll eventually run on. Be careful running too many hills. Running uphill is a great workout, but make sure you gradually build this up to avoid injuries. Be careful when running downhill too fast, which can often lead to more injuries than running uphills. Prevent recurrent injuries. Athletes who have experienced ankle injuries previously may benefit from using a brace or tape to prevent recurrent ankle injuries.


Stretching Exercises


Point your toes. To ease foot pain and aching in your feet, lift one foot and roll it downward until the toes are pointed toward the ground. Then flex your foot. Repeat using the other foot. This exercise will help stretch out all the small muscles that are on the bottom of your feet, which can help relieve aching and improve blood circulation. Raise your heels. This exercise is good for relieving toe cramps caused by standing for hours in constricting shoes, says Kurtz. Bonus: It can also strengthen calf muscles and make them look more defined. Stand up and lift your heels so that you are standing on the balls of your feet. Hold for 10 seconds. Repeat 10 times. Squeeze your toes. To strengthen the toes and help alleviate foot pain from hammertoes (when a toe resembles a claw), separate your toes using corks or foam toe separators and then squeeze your toes together for five seconds. Repeat 10 times. Roll a ball. Want to create an instant massage for the bottom of your feet? Roll a golf ball or tennis ball under the ball of your foot. Apply light pressure for about two minutes. This exercise can be helpful for arch pain, cramps, and heel pain from plantar fasciitis. Stretch standing up. A weight-bearing, runners-type stretch can be helpful for foot pain in the arch. Stand up and place your toes against a wall; lean forward a little until you feel your arch stretch. Repeat using the other foot. Stretch sitting down. Sit barefoot and cross your left leg so that your ankle rests on your right thigh. Then hold your toes and bend them back toward your shin, stretching the band of tissue connecting the bottom of the heel to the ball. A University of Rochester study found that people living with plantar fasciitis had a 75 percent chance of having no pain within three to six months of performing this stretch three times daily. Give yourself a foot massage. Nothing spells pain relief like a good foot rub. Use the following technique recommended by Rhonda Crockett, a licensed massage therapist at Ohio State University?s Center for Integrative Medicine in Columbus. Start with your toes, using your thumb to massage them in circular motions. Then move to the arch under your foot and gradually work your way down to the heel, applying pressure with your fingers and palm of your hand. Use lotion to allow your hand to move smoothly over your foot. Relax in a warm bath with Epsom salts. The combination of warm water and Epsom salts will give you a double dose of pain relief and relaxation. Magnesium sulfate, the key compound in Epsom salts, has been found to relax muscles, reduce pain, and sedate the nervous system. Plus, warm water helps improve circulation in the feet and relieve muscle pain. Crockett recommends adding two cups of Epsom salts to a warm bath and soaking for 20 minutes.
What Are The Main Causes Of Posterior Tibial Tendon Dysfunction ?

Overview
Adult-acquired flatfoot or collapsed arch occurs because the large tendon on the inside of the ankle - the posterior tibial tendon - becomes stretched out and no longer supports the foot?s arch. In many cases, the condition worsens and and the tendon thickens, becoming painful, especially during activities. Flatfoot or collapsed arch is also known as posterior tibial tendon dysfunction. This condition is different than having flat feet since birth (known as congenital flatfoot), although sometimes these patients develop similar symptoms and require similar treatments.
Flat Foot

Causes
As discussed above, many health conditions can create a painful flatfoot. Damage to the posterior tibial tendon is the most common cause of AAFD. The posterior tibial tendon is one of the most important tendons of the leg. It starts at a muscle in the calf, travels down the inside of the lower leg and attaches to the bones on the inside of the foot. The main function of this tendon is to hold up the arch and support your foot when you walk. If the tendon becomes inflamed or torn, the arch will slowly collapse. Women and people over 40 are more likely to develop problems with the posterior tibial tendon. Other risk factors include obesity, diabetes, and hypertension. Having flat feet since childhood increases the risk of developing a tear in the posterior tibial tendon. In addition, people who are involved in high impact sports, such as basketball, tennis, or soccer, may have tears of the tendon from repetitive use. Inflammatory arthritis, such as rheumatoid arthritis, can cause a painful flatfoot. This type of arthritis attacks not only the cartilage in the joints, but also the ligaments that support the foot. Inflammatory arthritis not only causes pain, but also causes the foot to change shape and become flat. The arthritis can affect the back of the foot or the middle of foot, both of which can result in a fallen arch.

Symptoms
Symptoms of pain may have developed gradually as result of overuse or they may be traced to one minor injury. Typically, the pain localizes to the inside (medial) aspect of the ankle, under the medial malleolus. However, some patients will also experience pain over the outside (lateral) aspect of the hindfoot because of the displacement of the calcaneus impinging with the lateral malleolus. This usually occurs later in the course of the condition. Patients may walk with a limp or in advanced cases be disabled due to pain. They may also have noticed worsening of their flatfoot deformity.

Diagnosis
Clinicians need to recognize the early stage of this syndrome which includes pain, swelling, tendonitis and disability. The musculoskeletal portion of the clinical exam can help determine the stage of the disease. It is important to palpate the posterior tibial tendon and test its muscle strength. This is tested by asking patient to plantarflex and invert the foot. Joint range of motion is should be assessed as well. Stiffness of the joints may indicate longstanding disease causing a rigid deformity. A weightbearing examination should be performed as well. A complete absence of the medial longitudinal arch is often seen. In later stages the head of the talus bone projects outward to the point of a large "lump" in the arch. Observing the patient's feet from behind shows a significant valgus rotation of the heel. From behind, the "too many toes" sign may be seen as well. This is when there is abducution of the forefoot in the transverse plane allowing the toes to be seen from behind. Dysfunction of the posterior tibial tendon can be assessed by asking the patient to stand on his/her toes on the affected foot. If they are unable to, this indicates the disease is in a more advanced stage with the tendon possibly completely ruptured.

Non surgical Treatment
Orthoses (insoles, functional orthoses, ankle supports, braces, ankle foot orthoses (AFOs)) - are usually custom-made to increase the functional stability of the foot and improve the mechanical properties of the tendon as well as reducing the actual degree of strain on the tendon. This reduces pain and inflammation. Physiotherapy - exercises and physiotherapy are often used to increase mobility, strengthen the tendon itself, stretch your Achilles tendon as well as reduce pain. Once the tendon has been stretched (stage one), the heel starts rolling outwards. Total immobilisation in a cast may help the symptoms to subside and prevent progression of the deformity in a smaller percentage of patients. Long-term use of orthoses may help stop progression of the deformity and reduce pain without surgery. Non-surgical treatment is unlikely to prevent progression to stage three and four but may be chosen by some patients who either are unsuitable for surgery or prefer not to have surgery.
Adult Acquired Flat Feet

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.
Acquired Flat Foot Causes

Overview
Adults with an acquired flatfoot deformity may present not with foot deformity but almost uniformly with medial foot pain and decreased function of the affected foot (for a list of causes of an acquired flatfoot deformity in adults. Patients whose acquired flatfoot is associated with a more generalised medical problem tend to receive their diagnosis and are referred appropriately. However, in patients whose ?adult acquired flatfoot deformity? is a result of damage to the structures supporting the medial longitudinal arch, the diagnosis is often not made early. These patients are often otherwise healthier and tend to be relatively more affected by the loss of function resulting from an acquired flatfoot deformity. The most common cause of an acquired flatfoot deformity in an otherwise healthy adult is dysfunction of the tibialis posterior tendon, and this review provides an outline to its diagnosis and treatment.
Flat Foot

Causes
Posterior tibial tendon dysfunction is the most common cause of acquired adult flatfoot deformity. There is often no specific event that starts the problem, such as a sudden tendon injury. More commonly, the tendon becomes injured from cumulative wear and tear. Posterior tibial tendon dysfunction occurs more commonly in patients who already have a flat foot for other reasons. As the arch flattens, more stress is placed on the posterior tibial tendon and also on the ligaments on the inside of the foot and ankle. The result is a progressive disorder.

Symptoms
Most people will notice mild to extreme pain in their feet. Below outlines some signs and symptoms of AAFD. Trouble walking or standing for any duration. Pain and swelling on the inside of the ankle. Bump on the bottom of the foot. Ulcer or wound developing on the outer aspects of foot.

Diagnosis
Looking at the patient when they stand will usually demonstrate a flatfoot deformity (marked flattening of the medial longitudinal arch). The front part of the foot (forefoot) is often splayed out to the side. This leads to the presence of a ?too many toes? sign. This sign is present when the toes can be seen from directly behind the patient. The gait is often somewhat flatfooted as the patient has the dysfunctional posterior tibial tendon can no longer stabilize the arch of the foot. The physician?s touch will often demonstrate tenderness and sometimes swelling over the inside of the ankle just below the bony prominence (the medial malleolus). There may also be pain in the outside aspect of the ankle. This pain originates from impingement or compression of two tendons between the outside ankle bone (fibula) and the heel bone (calcaneus) when the patient is standing.

Non surgical Treatment
Initial treatment for most patients consists of rest and anti-inflammatory medications. This will help reduce the swelling and pain associated with the condition. The long term treatment for the problem usually involves custom made orthotics and supportive shoe gear to prevent further breakdown of the foot. ESWT(extracorporeal shock wave therapy) is a novel treatment which uses sound wave technology to stimulate blood flow to the tendon to accelerate the healing process. This can help lead to a more rapid return to normal activities for most patients. If treatment is initiated early in the process, most patients can experience a return to normal activities without the need for surgery.
Acquired Flat Foot

Surgical Treatment
Types of surgery your orthopaedist may discuss with you include arthrodesis, or welding (fusing) one or more of the bones in the foot/ankle together. Osteotomy, or cutting and reshaping a bone to correct alignment. Excision, or removing a bone or bone spur. Synovectomy, or cleaning the sheath covering a tendon. Tendon transfer, or using a piece of one tendon to lengthen or replace another. Having flat feet is a serious matter. If you are experiencing foot pain and think it may be related to flat feet, talk to your orthopaedist.
Will Adult Aquired FlatFeet Always Require Surgery Teatment ?

Overview
Acquired adult flatfoot deformity (AAFD) is a progressive flattening of the arch of the foot that occurs as the posterior tibial tendon becomes insufficient. It has many other names such posterior tibial tendon dysfunction, posterior tibial tendon insufficiency and dorsolateral peritalar subluxation. This problem may progress from early stages with pain along the posterior tibial tendon to advanced deformity and arthritis throughout the hindfoot and ankle.
Acquired Flat Foot

Causes
As discussed above, many different problems can create a painful flatfoot. Damage to the posterior tibial tendon is the most common cause of AAFD. The posterior tibial tendon is one of the most important tendons of the leg. It starts at a muscle in the calf, travels down the inside of the lower leg and attaches to the bones on the inside of the foot. The main function of this tendon is to support the arch of your foot when you walk. If the tendon becomes inflamed or torn, the arch will slowly collapse. Women and people over 40 are more likely to develop problems with the posterior tibial tendon. Other risk factors include obesity, diabetes, and hypertension. Having flat feet since childhood increases the risk of developing a tear in the posterior tibial tendon. In addition, people who are involved in high impact sports, such as basketball, tennis, or soccer, may have tears of the tendon from repetitive use. Inflammatory arthritis, such as rheumatoid arthritis, can cause a painful flatfoot. This type of arthritis attacks not only the cartilage in the joints, but also the ligaments that support the foot. Inflammatory arthritis not only causes pain, but also causes the foot to change shape and become flat. The arthritis can affect the back of the foot or the middle of foot, both of which can result in a fallen arch. An injury to the tendons or ligaments in the foot can cause the joints to fall out of alignment. The ligaments support the bones and prevent them from moving. If the ligaments are torn, the foot will become flat and painful. This more commonly occurs in the middle of the foot (Lisfranc injury), but can also occur in the back of the foot. Injuries to tendons of the foot can occur either in one instance (traumatically) or with repeated use over time (overuse injury). Regardless of the cause, if tendon function is altered, the forces that are transmitted across joints in the foot are changed and this can lead to increased stress on joint cartilage and ligaments. In addition to tendon and ligament injuries, fractures and dislocations of the bones in the midfoot can also lead to a flatfoot deformity. People with diabetes or with nerve problems that limits normal feeling in the feet, can have collapse of the arch or of the entire foot. This type of arch collapse is typically more severe than that seen in patients with normal feeling in their feet. In addition to the ligaments not holding the bones in place, the bones themselves can sometimes fracture and disintegrate without the patient feeling any pain. This may result in a severely deformed foot that is very challenging to correct with surgery. Special shoes or braces are the best method for dealing with this problem.

Symptoms
The first stage represents inflammation and symptoms originating from an irritated posterior tibial tendon, which is still functional. Stage two is characterized by a change in the alignment of the foot noted on observation while standing (see above photos). The deformity is supple meaning the foot is freely movable and a ?normal? position can be restored by the examiner. Stage two is also associated with the inability to perform a single-leg heel rise. The third stage is dysfunction of the posterior tibial tendon is a flatfoot deformity that becomes stiff because of arthritis. Prolonged deformity causes irritation to the involved joints resulting in arthritis. The fourth phase is a flatfoot deformity either supple (stage two) or stiff (stage 3) with involvement of the ankle joint. This occurs when the deltoid ligament, the major supporting structure on the inside of the ankle, fails to provide support. The ankle becomes unstable and will demonstrate a tilted appearance on X-ray. Failure of the deltoid ligament results from an inward displacement of the weight bearing forces. When prolonged, this change can lead to ankle arthritis. The vast majority of patients with acquired adult flatfoot deformity are stage 2 by the time they seek treatment from a physician.

Diagnosis
Observation by a skilled foot clinician and a hands-on evaluation of the foot and ankle is the most accurate diagnostic technique. Your Dallas foot doctor may have you do a walking examination (the most reliable way to check for the deformity). During walking, the affected foot appears more pronated and deformed. Your podiatrist may do muscle testing to look for strength deficiencies. During a single foot raise test, the foot doctor will ask you to rise up on the tip of your toes while keeping your unaffected foot off the ground. If your posterior tendon has been attenuated or ruptured, you will be unable to lift your heel off the floor. In less severe cases, it is possible to rise onto your toes, but your heel will not invert normally. X-rays are not always helpful as a diagnostic tool for Adult Flatfoot because both feet will generally demonstrate a deformity. MRI (magnetic resonance imaging) may show tendon injury and inflammation, but can?t always be relied on for a complete diagnosis. In most cases, a MRI is not necessary to diagnose a posterior tibial tendon injury. An ultrasound may also be used to confirm the deformity, but is usually not required for an initial diagnosis.

Non surgical Treatment
Orthoses (insoles, functional orthoses, ankle supports, braces, ankle foot orthoses (AFOs)) - are usually custom-made to increase the functional stability of the foot and improve the mechanical properties of the tendon as well as reducing the actual degree of strain on the tendon. This reduces pain and inflammation. Physiotherapy - exercises and physiotherapy are often used to increase mobility, strengthen the tendon itself, stretch your Achilles tendon as well as reduce pain. Once the tendon has been stretched (stage one), the heel starts rolling outwards. Total immobilisation in a cast may help the symptoms to subside and prevent progression of the deformity in a smaller percentage of patients. Long-term use of orthoses may help stop progression of the deformity and reduce pain without surgery. Non-surgical treatment is unlikely to prevent progression to stage three and four but may be chosen by some patients who either are unsuitable for surgery or prefer not to have surgery.
Flat Feet

Surgical Treatment
If cast immobilization fails, surgery is the next alternative. Treatment goals include eliminating pain, halting deformity progression and improving mobility. Subtalar Arthroereisis, 15 minute outpatient procedure, may correct flexible flatfoot deformity (hyperpronation). The procedure involves placing an implant under the ankle joint (sinus tarsi) to prevent abnormal motion. Very little recovery time is required and it is completely reversible if necessary. Ask your Dallas foot doctor for more information about this exciting treatment possibility.
How To Cure Flat Feet In Adults

Overview
This condition is characterized by a progressive flattening or falling of the arch. It is often referred to as posterior tibial tendon dysfunction (PTTD) and is becoming a more commonly recognized foot problem. Since the condition develops over time, it is typically diagnosed in adulthood. It usually only develops in one foot although it can affect both. Since it is progressive, it is common for symptoms to worsen, especially when it is not treated early. The posterior tibial tendon attaches to the bones on the inside of your foot and is vital to the support structure within the foot. With PTTD, changes in the tendon impair its ability to function normally. The result is less support for the arch, which in turn causes it to fall or flatten. A flattening arch can cause the heel to shift out of alignment, the forefoot to rotate outward, the heel cord to tighten, and possible deformity of the foot. Common symptoms include pain along the inside of the ankle, swelling, an inward rolling of the ankle, pain that is worse with activity, and joint pain as arthritis sets in.
Flat Feet

Causes
There are a number of theories as to why the tendon becomes inflamed and stops working. It may be related to the poor blood supply within the tendon. Increasing age, inflammatory arthritis, diabetes and obesity have been found to be causes.

Symptoms
Symptoms shift around a bit, depending on what stage of PTTD you?re in. For instance, you?re likely to start off with tendonitis, or inflammation of the posterior tibial tendon. This will make the area around the inside of your ankle and possibly into your arch swollen, reddened, warm to the touch, and painful. Inflammation may actually last throughout the stages of PTTD. The ankle will also begin to roll towards the inside of the foot (pronate), your heel may tilt, and you may experience some pain in your leg (e.g. shin splints). As the condition progresses, the toes and foot begin to turn outward, so that when you look at your foot from the back (or have a friend look for you, because-hey-that can be kind of a difficult
maneuver to pull off) more toes than usual will be visible on the outside (i.e. the side with the pinky toe). At this stage, the foot?s still going to be flexible, although it will likely have flattened somewhat due to the lack of support from the posterior tibial tendon. You may also find it difficult to stand on your toes. Finally, you may reach a stage in which your feet are inflexibly flat. At this point, you may experience pain below your ankle on the outside of your foot, and you might even develop arthritis in the ankle.

Diagnosis
Looking at the patient when they stand will usually demonstrate a flatfoot deformity (marked flattening of the medial longitudinal arch). The front part of the foot (forefoot) is often splayed out to the side. This leads to the presence of a ?too many toes? sign. This sign is present when the toes can be seen from directly behind the patient. The gait is often somewhat flatfooted as the patient has the dysfunctional posterior tibial tendon can no longer stabilize the arch of the foot. The physician?s touch will often demonstrate tenderness and sometimes swelling over the inside of the ankle just below the bony prominence (the medial malleolus). There may also be pain in the outside aspect of the ankle. This pain originates from impingement or compression of two tendons between the outside ankle bone (fibula) and the heel bone (calcaneus) when the patient is standing.

Non surgical Treatment
Footwear has an important role, and patients should be encouraged to wear flat lace-up shoes, or even lace-up boots, which accommodate orthoses. Stage I patients may be able to manage with an off the shelf orthosis (such as an Orthaheel or Formthotics). They can try a laced canvas ankle brace before moving to a casted orthosis. The various casted, semirigid orthoses support the medial longitudinal arch of the foot and either hold the heel in a neutral alignment (stage I) or correct the outward bent heel to a neutral alignment (stage II). This approach is meant to serve several functions: to alleviate stress on the tibialis posterior; to make gait more efficient by holding the hindfoot fixed; and thirdly, to prevent progression of deformity. Devices available to do this are the orthosis of the University of California Biomechanics Laboratory, an ankle foot orthosis, or a removable boot. When this approach has been used, two thirds of patients have good to excellent results.
Acquired Flat Feet

Surgical Treatment
If initial conservative therapy of posterior tibial tendon insufficiency fails, surgical treatment is considered. Operative treatment of stage 1 disease involves release of the tendon sheath, tenosynovectomy, debridement of the tendon with excision of flap tears, and repair of longitudinal tears. A short-leg walking cast is worn for 3 weeks postoperatively. Teasdall and Johnson reported complete relief of pain in 74% of 14 patients undergoing this treatment regimen for stage 1 disease. Surgical debridement of tenosynovitis in early stages is believed to possibly prevent progression of disease to later stages of dysfunction.
Posterior Tibial Tendon Dysfunction Orthotic Treatment

Overview
Have you noticed that the medial arch of your foot is becoming flatter when you walk? You may be developing adult acquired flat foot. This condition is typically caused by a problem with a tendon on the medial side of your foot called the Posterior Tibial Tendon that is not functioning well. You may experience pain in the inner side of your foot when you walk. The affected foot appears to roll outwards (the sole of the foot is trying to face outwards) when you walk. This is called over-pronation of the foot. The back of your heel may start to point outwards (heel valgus). Over time you may lose the ability to tip toe on that foot as the posterior tibial tendon stretches out and it may eventually tear.
Adult Acquired Flat Feet

Causes
There are numerous causes of acquired Adult Flatfoot, including, trauma, fracture, dislocation, tendon rupture/partial rupture or inflammation of the tendons, tarsal coalition, arthritis, neuroarthropathy and neurologic weakness. The most common cause of acquired Adult Flatfoot is due to overuse of a tendon on the inside of the ankle called the posterior tibial tendon. This is classed as - posterior tibial tendon dysfunction. What are the causes of Adult Acquired flat foot? Trauma, Fracture or dislocation. Tendon rupture, partial tear or inflammation. Tarsal Coalition. Arthritis. Neuroarthropathy. Neurological weakness.

Symptoms
PTTD begins with a gradual stretching and loss of strength of the posterior tibial tendon which is the most important tendon supporting the arch of the human foot. Left untreated, this tendon will continue to lengthen and eventually rupture, leading to a progressive visible collapse of the arch of the foot. In the early stages, patients with PTTD will notice a pain and swelling along the inner ankle and arch. Many times, they are diagnosed with ?tendonitis? of the inner ankle. If the foot and ankle are not properly supported during this early phase, the posterior tibial tendon can rupture and devastating consequences will occur to the foot and ankle structure. The progressive adult acquired flatfoot deformity will cause the heel to roll inward in a ?valgus? or pronated direction while the forefoot will rotate outward causing a ?duckfooted? walking pattern. Eventually, significant arthritis can occur in the joints of the foot, the ankle and even the knee. Early diagnosis and treatment is critical so if you have noticed that one, or both, of your feet has become flatter in recent times come in and have it checked out.

Diagnosis
It is of great importance to have a full evaluation, by a foot and ankle specialist with expertise in addressing complex flatfoot deformities. No two flat feet are alike; therefore, "Universal" treatment plans do not exist for the Adult Flatfoot. It is important to have a custom treatment plan that is tailored to your specific foot. That starts by first understanding all the intricacies of your foot, through an extensive evaluation. X-rays of the foot and ankle are standard, and MRI may be used to better assess the quality of the PT Tendon.

Non surgical Treatment
Non-surgical treatment includes rest and reducing your activity until the pain improves. Orthotics or bracing help support the tendon to reduce its pull along the arch, thus reducing pain. In moderate to severe cases, a below knee cast or walking boot may be needed to allow the tendon to rest completely and heal. Physical therapy is an integral part of the non-surgical treatment regimen to reduce inflammation and pain. Anti-inflammatory medication is often used as well. Many times evaluation of your current shoes is necessary to ensure you are wearing appropriate shoe gear to prevent re-injury.
Acquired Flat Foot

Surgical Treatment
Surgery should only be done if the pain does not get better after a few months of conservative treatment. The type of surgery depends on the stage of the PTTD disease. It it also dictated by where tendonitis is located and how much the tendon is damaged. Surgical reconstruction can be extremely complex. Some of the common surgeries include. Tenosynovectomy, removing the inflamed tendon sheath around the PTT. Tendon Transfer, to augment the function of the diseased posterior tibial tendon with a neighbouring tendon. Calcaneo-osteotomy, sometimes the heel bone needs to be corrected to get a better heel bone alignment. Fusion of the Joints, if osteoarthritis of the foot has set in, fusion of the joints may be necessary.
How To Fix Flat Feet In Adults

Overview
Noticed that your foot is getting flatter and more painful? Do you have difficulty walking or performing exercise activity without leg and arch pain? Have you heard the term "fallen arches"? All of these things refer to a condition known as posterior tibial tendon dysfunction. This is an inflammation and overuse syndrome of one of the long tendons that pass from the leg around the inside of the ankle and attaches to the inside arch of the foot. The posterior tibial tendon?s job is to help support the arch and allow for more efficient gait.
Flat Feet

Causes
There are numerous causes of acquired adult flatfoot, including fracture or dislocation, tendon laceration, tarsal coalition, arthritis, neuroarthropathy, neurologic weakness, and iatrogenic causes. The most common cause of acquired adult flatfoot is posterior tibial tendon dysfunction.

Symptoms
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.

Diagnosis
Looking at the patient when they stand will usually demonstrate a flatfoot deformity (marked flattening of the medial longitudinal arch). The front part of the foot (forefoot) is often splayed out to the side. This leads to the presence of a ?too many toes? sign. This sign is present when the toes can be seen from directly behind the patient. The gait is often somewhat flatfooted as the patient has the dysfunctional posterior tibial tendon can no longer stabilize the arch of the foot. The physician?s touch will often demonstrate tenderness and sometimes swelling over the inside of the ankle just below the bony prominence (the medial malleolus). There may also be pain in the outside aspect of the ankle. This pain originates from impingement or compression of two tendons between the outside ankle bone (fibula) and the heel bone (calcaneus) when the patient is standing.

Non surgical Treatment
Conservative treatment is indicated for nearly all patients initially before surgical management is considered. The key factors in determining appropriate treatment are whether acute inflammation and whether the foot deformity is flexible or fixed. However, the ultimate treatment is often determined by the patients, most of whom are women aged 40 or older. Compliance can be a problem, especially in stages I and II. It helps to emphasise to the patients that tibialis posterior dysfunction is a progressive and chronic condition and that several fittings and a trial of several different orthoses or treatments are often needed before a tolerable treatment is found.
Adult Acquired Flat Feet

Surgical Treatment
If initial conservative therapy of posterior tibial tendon insufficiency fails, surgical treatment is considered. Operative treatment of stage 1 disease involves release of the tendon sheath, tenosynovectomy, debridement of the tendon with excision of flap tears, and repair of longitudinal tears. A short-leg walking cast is worn for 3 weeks postoperatively. Teasdall and Johnson reported complete relief of pain in 74% of 14 patients undergoing this treatment regimen for stage 1 disease. Surgical debridement of tenosynovitis in early stages is believed to possibly prevent progression of disease to later stages of dysfunction.
What Are The Causes Of A Ruptured Achilles Tendon?



Overview
Achilles Tendonitis
The Achilles tendon is the large cord like structure on the back of the leg just above the heel. It is the largest tendon in the body and has a tremendous amount of force transmitted through it during walking, running and jumping activities. The Achilles tendon is prone to injury, including rupture during periods of increased stress and activity. Common activities causing injury include running, basketball, baseball, football, soccer, volleyball and tennis. These activities require jumping and pushing forces that are possible due to the strength of the calf musculature and the ability of the Achilles tendon to endure this stress. Men from the ages of 30-50 are the most commonly injured during weekend athletic activities.

Causes
As with any muscle or tendon in the body, the Achilles tendon can be torn if there is a high force or stress on it. This can happen with activities which involve a forceful push off with the foot, for example, in football, running, basketball, diving, and tennis. The push off movement uses a strong contraction of the calf muscles which can stress the Achilles tendon too much. The Achilles tendon can also be damaged by injuries such as falls, if the foot is suddenly forced into an upward-pointing position, this movement stretches the tendon. Another possible injury is a deep cut at the back of the ankle, which might go into the tendon. Sometimes the Achilles tendon is weak, making it more prone to rupture. Factors that weaken the Achilles tendon are as follows. Corticosteroid medication (such as prednisolone) - mainly if it is used as long-term treatment rather than a short course. Corticosteroid injection near the Achilles tendon. Certain rare medical conditions, such as Cushing's syndrome, where the body makes too much of its own corticosteroid hormones. Increasing age. Tendonitis (inflammation) of the Achilles tendon. Other medical conditions which can make the tendon more prone to rupture; for example, rheumatoid arthritis, gout and systemic lupus erythematosus (SLE), lupus. Certain antibiotic medicines may slightly increase the risk of having an Achilles tendon rupture. These are the quinolone antibiotics such as ciprofloxacin and ofloxacin. The risk of having an Achilles tendon rupture with these antibiotics is actually very low, and mainly applies if you are also taking corticosteroid medication or are over the age of about 60.

Symptoms
The classic sign of an Achilles' tendon rupture is a short sharp pain in the Achilles' area, which is sometimes accompanied by a snapping sound as the tendon ruptures. The pain usually subsides relatively quickly into an aching sensation. Other signs that are likely to be present subsequent to a rupture are the inability to stand on tiptoe, inability to push the foot off the ground properly resulting in a flat footed walk. With complete tears it may be possible to feel the two ends of tendon where it has snapped, however swelling to the area may mean this is impossible.

Diagnosis
During the clinical examination, the patient will have significantly reduced ankle plantar flexion strength on the involved side. When the tendon is palpated with one finger on either side, the tendon can be followed from the calcaneus to where it "disappears" in the area of the rupture and to where it then returns 2 to 3 cm proximal to the rupture. If the injury is recent, the patient indicates that her pain is localized at the site of the rupture. The defect eventually fills with blood and edema and the skin over the area becomes ecchymotic.

Non Surgical Treatment
Non-surgical treatment typically involves wearing a brace or cast for the first six weeks following the injury to allow time for the ends of the torn tendon to reattach on their own. Over-the-counter medications, such as ibuprofen or aspirin, may be taken during this time to reduce pain and swelling. Once the tendon has reattached, physical therapy will be needed to strengthen the muscles and tendon. A full recovery is usually made within four to six months.
Achilles Tendinitis

Surgical Treatment
There are two types of surgery to repair a ruptured Achilles tendon. In open surgery, the surgeon makes a single large incision in the back of the leg. In percutaneous surgery, the surgeon makes several small incisions rather than one large incision. In both types of surgery, the surgeon sews the tendon back together through the incision(s). Surgery may be delayed for about a week after the rupture, to let the swelling go down.
Achilles Tendon Rupture Surgery Cast



Overview
Achilles Tendon
The Achilles tendon is the thickest and strongest tendon in the human body. It plays a very important role in most sport activities and is particularly vulnerable to overloading from repetitive running and jumping. The Achilles tendon forms a joint distal tendon for the gastrocnemius and the soleus muscles. These muscles combine to form the triceps surae muscle. Athletes who sustain Achilles tendon ruptures most frequently are those who participate in ball sports that demand rapid changes of direction and quick, reactive jumps (e.g., tennis, squash, badminton, and soccer), in addition to runners and jumpers in track and field. Sometimes a patient with a ruptured tendon has a history of long-term pain localized to the tendon, but more often the rupture occurs without warning. Such ruptures are often caused by degenerative changes in the tendon (tendinosis), usually in the segment of the tendon that has the worst blood supply. This segment extends from 2 to 6 cm proximal to the insertion of the tendon onto the calcaneus.

Causes
The Achilles tendon usually ruptures as a result of a sudden forceful contraction of the calf muscles. Activities such as jumping, lunging, or sprinting can cause undue stress on the Achilles tendon and cause it to rupture. Often there is a background of Achilles tendinitis. Direct trauma to the area, poor flexibility or weakness of the calf muscles or of the Achilles tendon and increasing age are some of the other factors that are associated with an Achilles tendon rupture.

Symptoms
When the Achilles tendon ruptures a loud bang or popping sound may be heard. The person may feel that they have been hit or kicked in the back of the lower leg and often they will look over their shoulder to see who or what has hit them. This is quickly followed by the sudden onset of sharp pain in the tendon and a loss of strength and function. If a complete rupture has occurred it may not be possible to lift the heel off the ground or point the toes. Often the degree of pain experienced, or lack of it, can be inversely proportional to the extent of the injury, ie a partial rupture may in fact be more painful than a complete rupture.

Diagnosis
The diagnosis is usually made on the basis of symptoms, the history of the injury and a doctor's examination. The doctor may look at your walking and observe whether you can stand on tiptoe. She/he may test the tendon using a method called Thompson's test (also known as the calf squeeze test). In this test, you will be asked to lie face down on the examination bench and to bend your knee. The doctor will gently squeeze the calf muscles at the back of your leg, and observe how the ankle moves. If the Achilles tendon is OK, the calf squeeze will make the foot point briefly away from the leg (a movement called plantar flexion). This is quite an accurate test for Achilles tendon rupture. If the diagnosis is uncertain, an ultrasound or MRI scan may help. An Achilles tendon rupture is sometimes difficult to diagnose and can be missed on first assessment. It is important for both doctors and patients to be aware of this and to look carefully for an Achilles tendon rupture if it is suspected.

Non Surgical Treatment
The best treatment for a ruptured Achilles tendon often depends on your age, activity level and the severity of your injury. In general, younger and more active people often choose surgery to repair a completely ruptured Achilles tendon while older people are more likely to opt for nonsurgical treatment. Recent studies, however, have shown fairly equal effectiveness of both operative and nonoperative management. Nonsurgical treatment. This approach typically involves wearing a cast or walking boot with wedges to elevate your heel; this allows the ends of your torn tendon to heal. This method can be effective, and it avoids the risks, such as infection, associated with surgery. However, the likelihood of re-rupture may be higher with a nonsurgical approach, and recovery can take longer. If re-rupture occurs, surgical repair may be more difficult.
Achilles Tendon

Surgical Treatment
Unlike other diseases of the Achilles tendon such as tendonitis or bursitis, Achilles tendon rupture is usually treated with surgical repair. The surgery consists of making a small incision in the back part of the leg, and using sutures to re-attach the two ends of the ruptured tendon. Depending on the condition of the ends of the ruptured tendon and the amount of separation, the surgeon may use other tendons to reinforce the repair. After the surgery, the leg will be immobilized for 6-8 weeks in a walking boot, cast, brace, or splint. Following this time period, patients work with a physical therapist to gradually regain their range of motion and strength. Return to full activity can take quite a long time, usually between 6 months and 1 year.
Partial Achilles Tendon Rupture Rehabilitation Time



Overview
Achilles Tendonitis
Your Achilles tendon is a large band of tissue in the back of your ankle. It connects your calf muscles to your heel bone. The tendon helps you point your foot downward, rise on your toes, and push off when you walk. You use it almost every time you move. But repeated stress can make the tendon more prone to injury. It may become inflamed and develop small tears (tendonitis). A complete tear through the tendon is known as an Achilles tendon rupture.

Causes
An Achilles tendon rupture is often caused by overstretching the tendon. This typically occurs during intense physical activity, such as running or playing basketball. Pushing off from the foot while the knee is straight, pivoting, jumping, and running are all movements that can overstretch the Achilles tendon and cause it to rupture. A rupture can also occur as the result of trauma that causes an over-stretching of the tendon, such as suddenly tripping or falling from a significant height. The Achilles tendon is particularly susceptible to injury if it is already weak. Therefore, individuals who have a history of tendinitis or tendinosis are more prone to a tendon rupture. Similarly, individuals who have arthritis and overcompensate for their joint pain by putting more stress on the Achilles tendon may also be more susceptible to an Achilles tendon rupture.

Symptoms
Following are a few of the symptoms usually associated with an Achilles tendon rupture. Sudden, severe pain, swelling, bruising, difficulty walking. Sometimes a gap may be felt in the tendon. The most common ways an Achilles tendon rupture is diagnosed are clinical history (presenting symptoms). Thompson or Simmonds? test, positive if when squeezing the calf there is no foot movement (passive planter flextion). O?Brien?s test, needles are placed into the tendon; tendon is intact if when the foot is moved up and down, the needle hub moves in the same direction as the toes (opposite direction of the tendon) Ultrasound and MRI, because these technologies involve an added expense, they are usually employed only to confirm the diagnosis.

Diagnosis
Your doctor diagnoses the rupture based on symptoms, history of the injury and physical examination. Your doctor will gently squeeze the calf muscles, if the Achilles tendon is intact, there will be flexion movement of the foot, if it is ruptured, there will be no movement observed.

Non Surgical Treatment
Not every torn Achilles tendon needs an operation. Recent studies have shown that even a conservative treatment, i.e. immobilizingt the leg can lead to satisfactory healing successes. This requires, however, that the patient is fitted with a cast (immobilization splint) and/or a special boot for a period of approximately 6 - 8 weeks. After that, the boot must be worn during the day for about two more weeks. An intensive physiotherapy will start after about six weeks to train the calf muscles so that the initial coordination can be restored. Running training on flat ground can be started again after another 10 - 12 weeks. Studies show that the danger of a recurring torn tendon is higher after a conservative treatment opposed to an operative treatment. Depending on the type of treatment, about 10 - 15 percent of those affected can expect at some point to again suffer from a tear of the Achilles tendon. Moreover, in the non-operated cases, we see more often a significant permanent weakness of the footprint, particularly restricting the ability to participate in sports.
Achilles Tendonitis

Surgical Treatment
The surgical repair of an acute or chronic rupture of the Achilles tendon typically occurs in an outpatient setting. This means the patient has surgery and goes home the same day. Numbing medicine is often placed into the leg around the nerves to help decrease pain after surgery. This is called a nerve block. Patients are then put to sleep and placed in a position that allows the surgeon access to the ruptured tendon. Repair of an acute rupture often takes somewhere between 30 minutes and one hour. Repair of a chronic rupture can take longer depending on the steps needed to fix the tendon.
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