PTTD is a condition of degeneration and dysfunction in the tendon complex that helps control the medial arch of your foot. Essentially what happens is the complex is unable to do its job of
supporting the arch and supinating the foot, so a progressive flat foot develops (usually called adult acquired flat
). Initially pain and often swelling develops on the inside of the ankle and it will continue to get progressively worse. There are a number of stages of PTTD (3 Stages) and it needs to be
aggressively treated early on otherwise a surgical reconstruction of the arch will invariably be required. PTTD can develop into a very disabling condition if it is not dealt with properly and
promptly. As PTTD becomes more advanced, the arch flattens even more and the pain often shifts to the outside of the foot, below the ankle. Arthritis often develops in the foot and In more severe
cases, arthritis may also develop in the ankle.
Adult flatfoot typically occurs very gradually. If often develops in an obese person who already has somewhat flat feet. As the person ages, the tendons and ligaments that support the foot begin to
lose their strength and elasticity.
Some symptoms of adult acquired flat foot are pain along the inside of the foot and ankle, pain that increases with activity, and difficulty walking for long periods of time. You may experience
difficulty standing, pain on the outside of the ankle, and bony bumps on the top of the foot and inside the foot. You may also have numbness and tingling of the feet and toes (may result from large
bone spurs putting pressure on nerves), swelling, a large bump on the sole of the foot and/or an ulcer (in diabetic patients). Diabetic patients should wear a properly fitting diabetic shoe wear to
prevent these complications from happening.
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
Treatment depends very much upon a patient?s symptoms, functional goals, degree and specifics of deformity, and the presence of arthritis. Some patients get better without surgery. Rest and
immobilization, orthotics, braces and physical therapy all may be appropriate. With early-stage disease that involves pain along the tendon, immobilization with a boot for a period of time can
relieve stress on the tendon and reduce the inflammation and pain. Once these symptoms have resolved, patients are often transitioned into an orthotic that supports the inside aspect of the hindfoot.
For patients with more significant deformity, a larger ankle brace may be necessary.
A new type of surgery has been developed in which surgeons can re-construct the flat foot deformity and also the deltoid ligament using a tendon called the peroneus longus. A person is able to
function fully without use of the peroneus longus but they can also be taken from deceased donors if needed. The new surgery was performed on four men and one woman. An improved alignment of the
ankle was still evident nine years later, and all had good mobility 8 to 10 years after the surgery. None had developed arthritis.