Adult Flat Foot
Flat footedness is divided into acquired flat foot which is a condition which develops after we have attained maturity and congenital flat foot which is a common condition and often not of pathological significance. Adult flat foot has many potential causes which include dislocation and fractures, foot abnormalities, arthritic changes and neurological conditions. The commonest cause however of this foot problem is a dysfunction of one of the foot tendons, the posterior tibial muscle tendon. The methods by which the tibialis posterior tendon malfunctions are varied and ascribed to degeneration, inflammation or trauma.
Studies of this condition have revealed that it is more common in groups who are obese, diabetic, hypertensive, on steroid medication or had previous trauma or operations to the mid part of the foot. Patients with arthritic conditions, often called spondyloarthropathies, have typically a family history of psoriasis or inflammatory conditions and have a higher incidence of this condition. Older people without specific medical problems are also seen, pointing to a mechanical cause secondary to age related degenerative changes. This tendon problem is moderately commonly seen in patients with rheumatoid arthritis.
Underneath the medial malleolus of the ankle and for a short distance forwards exists a region of limited blood supply which impacts on the tendon running through this area, contributing to an explanation of why degenerative change might occur more readily here. The tibialis posterior tendon contributes to the stability of the medial foot arch which has both passive and active supports. The static, passive supports for the arch include the spring ligament (calcaneonavicular ligament), the long and short plantar ligaments and the plantar fascia. The spring ligament is a support for the talus or ankle bone and stops it migrating inwards or downwards.
The medial foot arch is most powerfully supported in an active manner by the tibialis posterior muscle via its tendon. Its contraction lifts the inside of the medial longitudinal arch of the foot and inwardly turns the foot. If the tendon is ruptured or damaged and this supporting influence is lost then the outward turning foot muscles can work without being opposed. This permits the foot to suffer three main consequences: the hindfoot areas turns outwards; the medial foot arch loses its height and the front part of the foot can also turn outwards.
The forefoot and the hindfoot combine to be a rigid and stable platform in gait and the tendon changes lead to a reduction or loss of this with a less efficient gait pattern. Because the tibialis posterior muscle's strong influence on the foot is diminished or removed by the tendon problems this allows the major calf muscles to act more at the ankle rather than further forward. Pressure on the talus or ankle bone leads it to move down and inwards which puts the spring ligament on a stretch and allows a collapse of the inside arch as the joints assume new positions.
When developing symptoms from acquired flat foot patients will complain of swelling and pain on the inside of the ankle and foot when they are standing on the foot. The arch may gradually reduce and the patient realise they are walking on the inner part of the foot instead of normally. There is a loss of strength as the patient pushes off in walking and they may limp, the changes in gait often reflected in abnormal patterns of wear underneath the shoes. Physiotherapy assessment of the foot initially involves comparing both feet in standing to see if the arch is different on either foot.
If the foot is seen from behind the heel it is typical to be able to see the two outer toes, and seeing more means the forefoot is turned outwards. The physiotherapist will measure the angle made by the lower leg in relation to that of the heel, an angle which is increased as the heel bone turns outwards, a position known as valgus. On going up on tiptoe a normal foot performs a slight inward deviation of the heel as the large calf muscles power up.
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