Overview
Adult Acquired Flatfoot occurs when the arch of your foot collapses after your skeleton has stopped growing, usually resulting in the foot falling inward with the toes pointing out. This allows your entire sole to touch the ground when you stand, instead of just the outside area. Arches fall for many reasons, including arthritis, injury to the supporting tendons or bones, nerve problems, diabetic collapse, pregnancy, aging, and obesity. A fallen arch doesn?t have to be painful-though as it develops and worsens, it can lead to strain and weakness in the feet that could allow for more uncomfortable foot problems later. Diabetics can develop serious complications from their fallen arches, and need to have their condition evaluated and treated.
Causes
Flat footedness, most people who develop the condition already have flat feet. With overuse or continuous loading, a change occurs where the arch begins to flatten more than before, with pain and swelling developing on the inside of the ankle. Inadequate support from footwear may occasionally be a contributing factor. Trauma or injury, occasionally this condition may be due to fracture, sprain or direct blow to the tendon. Age, the risk of developing Posterior Tibial Tendon Dysfunction increases with age and research has suggested that middle aged women are more commonly affected. Other possible contributing factors - being overweight and inflammatory arthritis.
Symptoms
At first you may notice pain and swelling along the medial (big toe) side of the foot. This is where the posterior tibialis tendon travels from the back of the leg under the medial ankle bone to the foot. As the condition gets worse, tendon failure occurs and the pain gets worse. Some patients experience pain along the lateral (outside) edge of the foot, too. You may find that your feet hurt at the end of the day or after long periods of standing. Some people with this condition have trouble rising up on their toes. They may be unable to participate fully in sports or other recreational activities.
Diagnosis
Starting from the knee down, check for any bowing of the tibia. A tibial varum will cause increased medial stress on the foot and ankle. This is essential to consider in surgical planning. Check the gastrocnemius muscle and Achilles complex via a straight and bent knee check for equinus. If the range of motion improves to at least neutral with bent knee testing of the Achilles complex, one may consider a gastrocnemius recession. If the Achilles complex is still tight with bent knee testing, an Achilles lengthening may be necessary. Check the posterior tibial muscle along its entire course. Palpate the muscle and observe the tendon for strength with a plantarflexion and inversion stress test. Check the flexor muscles for strength in order to see if an adequate transfer tendon is available. Check the anterior tibial tendon for size and strength.
Non surgical Treatment
This condition may be treated with conservative methods. These can include orthotic devices, special shoes, and bracing. Physical therapy, rest, ice, and anti-inflammatory medication may be prescribed to help relieve symptoms. If the condition is very severe, surgical treatment may be needed.

Surgical Treatment
If conservative treatment fails surgical intervention is offered. For a Stage 1 deformity a posterior tibial tendon tenosynovectomy (debridement of the tendon) or primary repair may be indicated. For Stage 2 a combination of Achilles lengthening with bone cuts, calcaneal osteotomies, and tendon transfers is common. Stage 2 flexible PTTD is the most common stage patients present with for treatment. In Stage 3 or 4 PTTD isolated fusions, locking two or more joints together, maybe indicated. All treatment is dependent on the stage and severity at presentation with the goals and activity levels of the patient in mind. Treatment is customized to the individual patient needs.
Adult Acquired Flatfoot occurs when the arch of your foot collapses after your skeleton has stopped growing, usually resulting in the foot falling inward with the toes pointing out. This allows your entire sole to touch the ground when you stand, instead of just the outside area. Arches fall for many reasons, including arthritis, injury to the supporting tendons or bones, nerve problems, diabetic collapse, pregnancy, aging, and obesity. A fallen arch doesn?t have to be painful-though as it develops and worsens, it can lead to strain and weakness in the feet that could allow for more uncomfortable foot problems later. Diabetics can develop serious complications from their fallen arches, and need to have their condition evaluated and treated.

Causes
Flat footedness, most people who develop the condition already have flat feet. With overuse or continuous loading, a change occurs where the arch begins to flatten more than before, with pain and swelling developing on the inside of the ankle. Inadequate support from footwear may occasionally be a contributing factor. Trauma or injury, occasionally this condition may be due to fracture, sprain or direct blow to the tendon. Age, the risk of developing Posterior Tibial Tendon Dysfunction increases with age and research has suggested that middle aged women are more commonly affected. Other possible contributing factors - being overweight and inflammatory arthritis.
Symptoms
At first you may notice pain and swelling along the medial (big toe) side of the foot. This is where the posterior tibialis tendon travels from the back of the leg under the medial ankle bone to the foot. As the condition gets worse, tendon failure occurs and the pain gets worse. Some patients experience pain along the lateral (outside) edge of the foot, too. You may find that your feet hurt at the end of the day or after long periods of standing. Some people with this condition have trouble rising up on their toes. They may be unable to participate fully in sports or other recreational activities.
Diagnosis
Starting from the knee down, check for any bowing of the tibia. A tibial varum will cause increased medial stress on the foot and ankle. This is essential to consider in surgical planning. Check the gastrocnemius muscle and Achilles complex via a straight and bent knee check for equinus. If the range of motion improves to at least neutral with bent knee testing of the Achilles complex, one may consider a gastrocnemius recession. If the Achilles complex is still tight with bent knee testing, an Achilles lengthening may be necessary. Check the posterior tibial muscle along its entire course. Palpate the muscle and observe the tendon for strength with a plantarflexion and inversion stress test. Check the flexor muscles for strength in order to see if an adequate transfer tendon is available. Check the anterior tibial tendon for size and strength.
Non surgical Treatment
This condition may be treated with conservative methods. These can include orthotic devices, special shoes, and bracing. Physical therapy, rest, ice, and anti-inflammatory medication may be prescribed to help relieve symptoms. If the condition is very severe, surgical treatment may be needed.

Surgical Treatment
If conservative treatment fails surgical intervention is offered. For a Stage 1 deformity a posterior tibial tendon tenosynovectomy (debridement of the tendon) or primary repair may be indicated. For Stage 2 a combination of Achilles lengthening with bone cuts, calcaneal osteotomies, and tendon transfers is common. Stage 2 flexible PTTD is the most common stage patients present with for treatment. In Stage 3 or 4 PTTD isolated fusions, locking two or more joints together, maybe indicated. All treatment is dependent on the stage and severity at presentation with the goals and activity levels of the patient in mind. Treatment is customized to the individual patient needs.