Observing the patient rising up on their toes as the calf muscle performs the tiptoe action to bring the weight over the metatarsal heads, we should see an inward deviation of the heel area. This will often be absent if the tendon of the posterior tibial muscle is not working well and the patient may not be able to achieve tiptoes, or can do so partially with pain. Palpation around the tendon insertion is the next action for the physiotherapist, searching for tenderness, swelling and pain in the areas. The muscle power will now be tested as the patient is asked to push the foot inwards against resistance.
The physiotherapist will palpate all along the tendon as its strength is being assessed to check it is not ruptured or deficient and then straighten the knee and measure how much dorsiflexion is achievable, typically twenty degrees or so. If the deformity has been present over time and the foot held in an out and down position then this movement can be lost as a tight contracture develops in the joints. This can also occur in the forefoot joints and the physio will move down to check this after the ankle area. Treatment may be appropriate if the patient is having difficulty with walking, managing shoes, pain and deformity.
A painless flat foot with relatively normal walking in regular shoes perhaps with insoles may be sufficient management for this condition. The conservative treatment of more acute dysfunction involves resting the area, anti-inflammatory medication, orthotics, braces and physiotherapy. Elderly people, who do not put high stresses through this area, may be successfully managed in this way without operation. The initial acute stage of this problem is indicated mostly by local pain, with a plaster of Paris cast an appropriate treatment for acute tendon inflammation. Weight bearing may be permitted if pain is not an issue.
Orthotics can then be used to support the foot once the acute stage has settled and physiotherapy employed to stretch out any tight joint movements and strengthen the muscle groups. As the dysfunction proceeds and the foot deformity is flexible but painful it may be necessary to control the motion of the hindfoot more closely using a ankle-foot orthosis (AFO) of some kind. Later if the deformity becomes more rigid then individually moulded braces, perhaps extending to the knee or beyond, can be employed. This kind of treatment is for patients who are not physically very active, with operative treatment held in reserve.
The initial surgical management of the more acute phase of this condition is done by a release of pressure from opening up the tendon sheath and cleaning up any irregularities in the tendon (debridement) and repairing tears. Immobilisation in a below knee cast for three weeks is a typical post-operative management, with the operation aimed at preventing further deterioration of the condition. Once the dysfunction proceeds to a more severe phase there are a very large number of surgical options, little agreed surgical process and a difficult job to ensure a good outcome.
Rupture of the tendon can be managed by trimming up the tendon stumps and performing a repair with the tendons end to end. Avulsion of the tendon from its attachment on the navicular can be managed by re-attaching the tendon to its bony insertion. Other tendons in the anatomical area can also be used to reinforce the tendon which is lacking, thereby increasing the tendon function. Osteotomy of various bones can be performed with the aim of restoring the normality of the interrelationships between the bones, allowing normal alignment, reduced stresses across the ligamentous structures and more chance for surgical changes to the soft tissues to cope.
The end result from successful surgery should be the creation of a non-painful foot which can adapt flat to the ground and wear normal footwear. Foot surgery can result in an over correction or an under correction of normal foot posture, with close attention needed to correctly restore the various joint relationships. In the initial phases surgery is aimed at preventing the move towards a tendon rupture.
The physiotherapist will palpate all along the tendon as its strength is being assessed to check it is not ruptured or deficient and then straighten the knee and measure how much dorsiflexion is achievable, typically twenty degrees or so. If the deformity has been present over time and the foot held in an out and down position then this movement can be lost as a tight contracture develops in the joints. This can also occur in the forefoot joints and the physio will move down to check this after the ankle area. Treatment may be appropriate if the patient is having difficulty with walking, managing shoes, pain and deformity.
A painless flat foot with relatively normal walking in regular shoes perhaps with insoles may be sufficient management for this condition. The conservative treatment of more acute dysfunction involves resting the area, anti-inflammatory medication, orthotics, braces and physiotherapy. Elderly people, who do not put high stresses through this area, may be successfully managed in this way without operation. The initial acute stage of this problem is indicated mostly by local pain, with a plaster of Paris cast an appropriate treatment for acute tendon inflammation. Weight bearing may be permitted if pain is not an issue.
Orthotics can then be used to support the foot once the acute stage has settled and physiotherapy employed to stretch out any tight joint movements and strengthen the muscle groups. As the dysfunction proceeds and the foot deformity is flexible but painful it may be necessary to control the motion of the hindfoot more closely using a ankle-foot orthosis (AFO) of some kind. Later if the deformity becomes more rigid then individually moulded braces, perhaps extending to the knee or beyond, can be employed. This kind of treatment is for patients who are not physically very active, with operative treatment held in reserve.
The initial surgical management of the more acute phase of this condition is done by a release of pressure from opening up the tendon sheath and cleaning up any irregularities in the tendon (debridement) and repairing tears. Immobilisation in a below knee cast for three weeks is a typical post-operative management, with the operation aimed at preventing further deterioration of the condition. Once the dysfunction proceeds to a more severe phase there are a very large number of surgical options, little agreed surgical process and a difficult job to ensure a good outcome.
Rupture of the tendon can be managed by trimming up the tendon stumps and performing a repair with the tendons end to end. Avulsion of the tendon from its attachment on the navicular can be managed by re-attaching the tendon to its bony insertion. Other tendons in the anatomical area can also be used to reinforce the tendon which is lacking, thereby increasing the tendon function. Osteotomy of various bones can be performed with the aim of restoring the normality of the interrelationships between the bones, allowing normal alignment, reduced stresses across the ligamentous structures and more chance for surgical changes to the soft tissues to cope.
The end result from successful surgery should be the creation of a non-painful foot which can adapt flat to the ground and wear normal footwear. Foot surgery can result in an over correction or an under correction of normal foot posture, with close attention needed to correctly restore the various joint relationships. In the initial phases surgery is aimed at preventing the move towards a tendon rupture.
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