Fidelia Renwick

Compelling Data Relating To The Foot

Hallux Valgus Treatment

Overview
Bunions Hard Skin Hallux Abducto Valgus, commonly called bunion, is a bony deformity affecting the angle of the joint at the base of the big toe. Some medical professionals believe that the condition is solely due to ill-fitting footwear, while others believe it is a genetic structural defect that can be exacerbated by shoes. Despite the varying opinions, the reality is that it is probably a combination of both factors. A bunion forms when pressure is applied to the side of the big toe, causing it to become inflamed and painful. The joint then protrudes, effectively making the foot wider. The second toe might then become displaced, which can cause a multitude of other issues like corn and callus development. The bunion joint will have a reduced range of motion and often ends up arthritic. The condition usually develops later in life.

Causes
Inflammatory joint diseases. Those who suffer from rheumatoid and psoriatic arthritis are at risk for bunions, although many times, those who suffer from bunions will mistakenly attribute the soreness in their feet to arthritis. Genetic and neuromuscular factors. Individuals with Down?s Syndrome are believed to be more prone to developing bunions; therefore, the gait and feet of such patients should be examined carefully and regularly so that any problems can be caught and treated early. Similarly, individuals of any age who have been diagnosed with Ehlers-Danlos or Marfan?s Syndrome, have also been shown to have a higher than average occurrence of bunions. Limb inequality. Individuals who have legs of unequal length often suffer from bunions on the longer limb due to the irregular mechanics of their walking or running gait.

Symptoms
In addition to the typical bump, signs of bunions can include red, calloused skin along the foot at the base of the big toe. With bunions, you may also develop calluses on the big toe, sores between the toes, ingrown toenail, and restricted motion of the toe. Some bunions are small and painless and some are large and extremely painful. Pressure from shoes worsens the problem.

Diagnosis
Bunions are readily apparent, you can see the prominence at the base of the big toe or side of the foot. However, to fully evaluate your condition, the Podiatrist may arrange for x-rays to be taken to determine the degree of the deformity and assess the changes that have occurred. Because bunions are progressive, they don't go away, and will usually get worse over time. But not all cases are alike, some bunions progress more rapidly than others. There is no clear-cut way to predict how fast a bunion will get worse. The severity of the bunion and the symptoms you have will help determine what treatment is recommended for you.

Non Surgical Treatment
Somtimes observation of the bunion is all that?s needed. A periodic exam and x-ray can determine if your bunion deformity is advancing. Measures can then be taken to reduce the possibility of permanent damage to your joint. In many cases, however, some type of treatment is needed. Conservative treatments may help reduce the pain of a bunion. These options include changes in shoe-wear. Wearing the right kind of shoes is very important. Choose shoes with a large toe box and avoid narrow high heeled shoes which may aggravate the condition. Padding. Pads can be placed over the area to reduce shoe pressure. Medication. Nonsteroidal anti-inflammatory drugs may help reduce inflammation and reduce pain. Injection therapy. Injection of steroid medication may be used to treat inflammation that causes pain and swelling especially if a fluid filled sac has developed about the joint. Orthotic shoe inserts. By controlling the faulty mechanical forces the foot may be stabilized so that the bunion becomes asymptomatic. Bunion Pain

Surgical Treatment
For patients who have arthritis of the big toe joint associated with a bunion deformity an osteotomy is not performed. The deformity is corrected through the joint either with a fusion of the joint or by removing a portion of the joint (an arthroplasty). Fusion of the big toe joint is an excellent operation since it corrects the deformity, prevents the bunion from returning and eliminates the arthritis simultaneously.

Overpronation Of The Feet

Overview

?Pes Planus? is the medical term for flat feet. It comes from Latin, Pes = foot and Planus = plain, level ground. Very few people suffer from this condition, as a true flat foot is very rare. Less than 5% of the population has flat feet. The majority of the Australian population, however, has fallen arches (an estimated 60-70% of the population) known in the medical profession as ?excess pronation? or over-pronation. Over-pronation means the foot and ankle tend to roll inwards and the arch collapses with weight-bearing. This is a quite a destructive position for the foot to function in and may cause a wide variety of foot, leg and lower back conditions.Over Pronation

Causes

In adults, the most common reason for the onset of Over-Pronation is a condition known as Post Tibial Tendonitis. This condition develops from repetitive stress on the main supporting tendon (Posterior Tibial Tendon) of the foot arch. As the body ages, ligaments and muscles can weaken. When this occurs the job of providing the majority of the support required by the foot arch is placed upon this tendon. Unfortunately, this tendon cannot bear the weight of this burden for too long. Eventually it fatigues under the added strain and in doing so the foot arch becomes progressively lower over a period of time.

Symptoms

Overpronation can negatively affect overall body alignment. The lowering of the longitudinal arch pulls the heel bone in, causing the leg, thigh bone and hip to rotate inwards, and an anterior tilt of the pelvis. Unnecessary strain to the ankles, knees, hips and back can result. Plantar fasciitis and inflammation, metatarsal pain, problems with the Achilles tendon, pain on the inside of the knee, and bursitis in the hip are just some of the conditions commonly associated with pronation.

Diagnosis

To easily get an idea of whether a person overpronates, look at the position and condition of certain structures in the feet and ankles when he/she stands still. When performing weight-bearing activities like walking or running, muscles and other soft tissue structures work to control gravity's effect and ground reaction forces to the joints. If the muscles of the leg, pelvis, and feet are working correctly, then the joints in these areas such as the knees, hips, and ankles will experience less stress. However, if the muscles and other soft tissues are not working efficiently, then structural changes and clues in the feet are visible and indicate habitual overpronation.Overpronation

Non Surgical Treatment

Overpronation is a condition in which the foot rolls excessively down and inward. The arch may elongate and collapse (or ?fall?) and the heel will lean inward. Overpronation should not be confused with pronation. Pronation is a normal motion of the foot during weight bearing and allows the foot to absorb shock as it contacts the ground.

Prevention

Many of the prevention methods for overpronation orthotics, for example, can be used interchangeably with treatment methods. If the overpronation is severe, you should seek medical attention from a podiatrist who can cast you for custom-made orthotics. Custom-made orthotics are more expensive, but they last longer and provide support, stability, and balance for the entire foot. You can also talk with a shoe specialist about running shoes that offer extra medial support and firm heel counters. Proper shoes can improve symptoms quickly and prevent them from recurring. Surgery can sometimes help cure and prevent this problem if you suffer from inherited or acquired pes planus deformity. Surgery typically involves stabilizing the bones to improve the foot?s support and function.

Therapy For Severs Disease

Overview

Sever?s disease is repetitive micro trauma or overuse of the heel in young athletes. Sever?s is caused by overloading the insertion of the Achilles tendon onto the calcaneus and the apophyseal growth plate. Active Children (7 to 15 years), particularly during the pubertal growth spurt or at the beginning of a sport season (e.g. gymnasts, basketball and football players), often suffer from this condition.

Causes

A big tendon called the Achilles tendon joins the calf muscle at the back of the leg to the heel. Sever?s disease is thought to occur because of a mismatch in growth of the calf bones to the calf muscle and Achilles tendon. If the bones grow faster than the muscles, the Achilles tendon that attaches the muscle to the heel gets tight. At the same time, until the cartilage of the calcaneum is ossified (turned into bone), it is a potential weak spot. The tight calf muscle and Achilles tendon cause a traction injury on this weak spot, resulting in inflammation and pain. Sever?s disease most commonly affects boys aged ten to 12 years and girls aged nine to 11 years, when growth spurts are beginning. Sever?s disease heals itself with time, so it is known as self-limiting. There is no evidence to suggest that Sever?s disease causes any long term problems or complications.

Symptoms

Patients with Severs disease typically experience pain that develops gradually in the back of the heel or Achilles region. In less severe cases, patients may only experience an ache or stiffness in the heel that increases with rest (especially at night or first thing in the morning). This typically occurs following activities which require strong or repetitive contraction of the calf muscles, such as running (especially uphill) or during sports involving running, jumping or hopping. The pain associated with this condition may also warm up with activity in the initial stages of the condition. As the condition progresses, patients may experience symptoms that increase during activity and affect performance. Pain may also increase when performing a calf stretch or heel raise (i.e. rising up onto tip toes). In severe cases, patients may walk with a limp, have difficulty putting their heel down, or be unable to weight bear on the affected leg. Pain may also increase on firmly touching the affected region and occasionally a bony lump may be palpable or visible at the back of the heel. This condition typically presents gradually overtime and can affect either one or both lower limbs.

Diagnosis

Sever?s disease can be diagnosed based on your history and symptoms. Clinically, your physiotherapist will perform a "squeeze test" and some other tests to confirm the diagnosis. Some children suffer Sever?s disease even though they do less exercise than other. This indicates that it is not just training volume that is at play. Foot and leg biomechanics are a predisposing factor. The main factors thought to predispose a child to Sever?s disease include a decrease in ankle dorsiflexion, abnormal hind foot motion eg overpronation or supination, tight calf muscles, excessive weight-bearing activities eg running.

Non Surgical Treatment

Depending on the Podiatrist's diagnosis and the severity of the pain, there are several treatment options available. Rest/ reduced activity: your child should reduce or stop any activity that causes pain, such as sports and running. This can be a difficult option, as children are normally quite willful in pursuit of their favorite pastimes! Over the counter anti-inflammatory drugs, such as ibuprofen (found in Nurofen), to help reduce pain and inflammation. Try to make sure your child does the recommended stretching exercises before sport/play. This will should help reduce the stress on the fascia tendon and relieve heel pain. The use of Orthotic insoles. Footactive Kids orthotics are made for children. They will help properly support the foot, help prevent over-pronation or improper gait restoring your child's foot the the correct biomechanical position. If you are in any doubt or your child's foot pain persists then please arrange an appointment with a Podiatrist or Physiotherapist. Please click here for more information on the use of orthotics for children.

Surgical Treatment

The surgeon may select one or more of the following options to treat calcaneal apophysitis. Reduce activity. The child needs to reduce or stop any activity that causes pain. Support the heel. Temporary shoe inserts or custom orthotic devices may provide support for the heel. Medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, help reduce the pain and inflammation. Physical therapy. Stretching or physical therapy modalities are sometimes used to promote healing of the inflamed issue. Immobilization. In some severe cases of pediatric heel pain, a cast may be used to promote healing while keeping the foot and ankle totally immobile. Often heel pain in children returns after it has been treated because the heel bone is still growing. Recurrence of heel pain may be a sign of calcaneal apophysitis, or it may indicate a different problem. If your child has a repeat bout of heel pain, be sure to make an appointment with your foot and ankle surgeon.

Dealing With An Achilles Tendon Rupture

Overview
Achilles Tendonitis Achilles tendon is a strong fibrous cord present behind the ankle that connects the calf muscles to heel bone. It is used when you walk, run and jump. When the Achilles tendon becomes thin, weak, or if it is not used, it may be susceptible to injury or damage. Achilles tendon rupture occurs most often in middle-aged athlete participating in sports that involve running, pivoting, and jumping. Recreational sports that may cause Achilles rupture include tennis, racquetball, basketball, and badminton.

Causes
Factors that may increase your risk of Achilles tendon rupture include some of the following. Age. The peak age for Achilles tendon rupture is 30 to 40. Sex. Achilles tendon rupture is up to five times more likely to occur in men than in women. Recreational sports. Achilles tendon injuries occur more often during sports that involve running, jumping, and sudden starts and stops, such as soccer, basketball and tennis. Steroid injections. Doctors sometimes inject steroids into an ankle joint to reduce pain and inflammation. However, this medication can weaken nearby tendons and has been associated with Achilles tendon ruptures. Certain antibiotics. Fluoroquinolone antibiotics, such as ciprofloxacin (Cipro) or levofloxacin (Levaquin), increase the risk of Achilles tendon rupture.

Symptoms
You may notice the symptoms come on suddenly during a sporting activity or injury. You might hear a snap or feel a sudden sharp pain when the tendon is torn. The sharp pain usually settles quickly, although there may be some aching at the back of the lower leg. After the injury, the usual symptoms are a flat-footed type of walk. You can walk and bear weight, but cannot push off the ground properly on the side where the tendon is ruptured. Inability to stand on tiptoe. If the tendon is completely torn, you may feel a gap just above the back of the heel. However, if there is bruising then the swelling may disguise the gap. If you suspect an Achilles tendon rupture, it is best to see a doctor urgently, because the tendon heals better if treated sooner rather than later. A person with a ruptured Achilles tendon may experience one or more of the following. Sudden pain (which feels like a kick or a stab) in the back of the ankle or calf, often subsiding into a dull ache. A popping or snapping sensation. Swelling on the back of the leg between the heel and the calf. Difficulty walking (especially upstairs or uphill) and difficulty rising up on the toes.

Diagnosis
The diagnosis is usually made on the basis of symptoms, the history of the injury and a doctor?s examination.

Non Surgical Treatment
Nonsurgical treatment involves extended casting, special braces, orthotics, and physical therapy. Avoids the normal complications and expenses of surgery. Some studies show the outcome is similar to surgery in regard to strength and function. There is risk of an over-lengthened tendon with inadequate tension. Extended immobilization can lead to more muscle weakness. Nonsurgical treatment has a higher incidence of re-rupture than surgical repair. Nonsurgical treatment is often used for nonathletes or for those with a general low level of physical activity who would not benefit from surgery. The elderly and those with complicating medical conditions should also consider conservative nonsurgical treatment. Achilles Tendonitis

Surgical Treatment
There are a variety of ways to repair an Achilles tendon rupture. The most common method is an open repair. This starts with an incision made on the back of the lower leg starting just above the heel bone. After the surgeon finds the two ends of the ruptured tendon, these ends are sewn together with sutures. The incision is then closed. Another repair method makes a small incision on the back of the lower leg at the site of the rupture. A series of needles with sutures attached is passed through the skin and Achilles tendon and then brought out through the small incision. The sutures are then tied together. The best surgical technique for your Achilles rupture will be determined by your orthopaedic foot and ankle surgeon.

Functional Leg-Length Discrepancy Pads

Overview

The majority of people in the world actually have some degree of leg length discrepancy, up to 2cm. One study found that only around 1/4 of people have legs of equal lengths. LLD of greater than 2cm is relatively rare, however, and the greater the discrepancy, the greater the chances of having a clinical problem down the road. A limp generally begins when LLD exceeds 2cm and becomes extremely noticeable above 3cm. When patients with LLD develop an abnormal gait, one of the debilitating clinical features can be fatigue because of the relatively high amount of energy needed to walk in the new, inefficient way. Poliomyelitis, or polio, as it is more commonly known, used to account for around 1/3 of all cases of LLD, but due to the effectiveness of polio vaccines, it now represents a negligible cause of the condition. Functional LLD, described above, usually involves treatment focused on the hip, pelvis, and/or lower back, rather than the leg. If you have been diagnosed with functional LLD or pelvic obliquity, please ask your orthopaedic surgeon for more information about treatment of these conditions.Leg Length Discrepancy

Causes

The causes of LLD are many, including a previous injury, bone infection, bone diseases (dysplasias), inflammation (arthritis) and neurologic conditions. Previously broken bones may cause LLD by healing in a shortened position, especially if the bone was broken in many pieces (comminuted) or if skin and muscle tissue around the bone were severely injured and exposed (open fracture). Broken bones in children sometimes grow faster for several years after healing, causing the injured bone to become longer. Also, a break in a child?s bone through a growth center (located near the ends of the bone) may cause slower growth, resulting in a shorter extremity. Bone infections that occur in children while they are growing may cause a significant LLD, especially during infancy. Bone diseases may cause LLD, as well; examples are neurofibromatosis, multiple hereditary exostoses and Ollier disease. Inflammation of joints during growth may cause unequal extremity length. One example is juvenile rheumatoid arthritis. Osteoarthritis, the joint degeneration that occurs in adults, very rarely causes a significant LLD.

Symptoms

LLD do not have any pain or discomfort directly associated with the difference of one leg over the other leg. However, LLD will place stress on joints throughout the skeletal structure of the body and create discomfort as a byproduct of the LLD. Just as it is normal for your feet to vary slightly in size, a mild difference in leg length is normal, too. A more pronounced LLD, however, can create abnormalities when walking or running and adversely affect healthy balance and posture. Symptoms include a slight limp. Walking can even become stressful, requiring more effort and energy. Sometimes knee pain, hip pain and lower back pain develop. Foot mechanics are also affected causing a variety of complications in the foot, not the least, over pronating, metatarsalgia, bunions, hammer toes, instep pain, posterior tibial tendonitis, and many more.

Diagnosis

The only way to decipher between anatomical and functional leg length inequalities (you can have both) is by a physical measurement and series of biomechanical tests. It is actually a simple process and gets to the true cause of some runner?s chronic foot, knee, hip and back pain. After the muscles are tested and the legs are measured it may be necessary to get a special X-ray that measures both of your thighs (Femurs) and legs (Tibias). The X-ray is read by a medical radiologist who provides a report of the actual difference down to the micrometer leaving zero room for error. Once the difference in leg length is known, the solution becomes clear.

Non Surgical Treatment

After the leg length discrepancy has been identified it can be categorized in as structural or functional and appropriate remedial action can be instigated. This may involve heel lifters or orthotics being used to level up the difference. The treatment of LLD depends on the symptoms being experienced. Where the body is naturally compensating for the LLD (and the patient is in no discomfort), further rectifying action may cause adverse effects to the biomechanical mechanism of the body causing further injury. In cases of functional asymmetry regular orthotics can be used to correct the geometry of the foot and ground contact. In structural asymmetry cases heel lifts may be used to compensate for the anatomic discrepancy.

Leg Length

Surgical Treatment

Surgery is another option. In some cases the longer extremity can be shortened, but a major shortening may weaken the muscles of the extremity. In growing children, lower extremities can also be equalized by a surgical procedure that stops the growth at one or two sites of the longer extremity, while leaving the remaining growth undisturbed. Your physician can tell you how much equalization can be attained by surgically halting one or more growth centers. The procedure is performed under X-ray control through very small incisions in the knee area. This procedure will not cause an immediate correction in length. Instead, the LLD will gradually decrease as the opposite extremity continues to grow and "catch up." Timing of the procedure is critical; the goal is to attain equal length of the extremities at skeletal maturity, usually in the mid- to late teens. Disadvantages of this option include the possibility of slight over-correction or under-correction of the LLD and the patient?s adult height will be less than if the shorter extremity had been lengthened. Correction of significant LLDs by this method may make a patient?s body look slightly disproportionate because of the shorter legs.

Acquired Flat Foot Surgery

Overview
Most flat feet are not painful, particularly those flat feet seen in children. In the adult acquired flatfoot, pain occurs because soft tissues (tendons and ligaments) have been torn. The deformity progresses or worsens because once the vital ligaments and posterior tibial tendon are lost, nothing can take their place to hold up the arch of the foot. The painful, progressive adult acquired flatfoot affects women four times as frequently as men. It occurs in middle to older age people with a mean age of 60 years. Most people who develop the condition already have flat feet. A change occurs in one foot where the arch begins to flatten more than before, with pain and swelling developing on the inside of the ankle. Why this event occurs in some people (female more than male) and only in one foot remains poorly understood. Contributing factors increasing the risk of adult acquired flatfoot are diabetes, hypertension, and obesity. Acquired Flat Feet

Causes
The posterior tibial tendon, which connects the bones inside the foot to the calf, is responsible for supporting the foot during movement and holding up the arch. Gradual stretching and tearing of the posterior tibial tendon can cause failure of the ligaments in the arch. Without support, the bones in the feet fall out of normal position, rolling the foot inward. The foot's arch will collapse completely over time, resulting in adult acquired flatfoot. The ligaments and tendons holding up the arch can lose elasticity and strength as a result of aging. Obesity, diabetes, and hypertension can increase the risk of developing this condition. Adult acquired flatfoot is seen more often in women than in men and in those 40 or older.

Symptoms
Pain and swelling behind the inside of your ankle and along your instep. You may be tender behind the inner ankle where the posterior tibial tendon courses and occasionally get burning, shooting, tingling or stabbing pain as a result of inflammation of the nerve inside the tarsal tunnel. Difficulty walking, the inability to walk long distances and a generalised ache while walking even short distances. This may probably become more pronounced at the end of each day. Change in foot shape, sometimes your tendon stretches out, this is due to weakening of the tendon and ligaments. When this occurs, the arch in your foot flattens and a flatfoot deformity occurs, presenting a change in foot shape. Inability to tip-toe, a way of diagnosing Posterior Tibial Tendon Dysfunction is difficulty or inability to ?heel rise? (stand on your toes on one foot). Your tibialis posterior tendon enables you to perform this manoeuvre effectively. You may also experience pain upon attempting to perform a heel rise.

Diagnosis
In diagnosing flatfoot, the foot & Ankle surgeon examines the foot and observes how it looks when you stand and sit. Weight bearing x-rays are used to determine the severity of the disorder. Advanced imaging, such as magnetic resonance imaging (MRI) and computed tomography (CAT or CT) scans may be used to assess different ligaments, tendons and joint/cartilage damage. The foot & Ankle Institute has three extremity MRI?s on site at our Des Plaines, Highland Park, and Lincoln Park locations. These extremity MRI?s only take about 30 minutes for the study and only requires the patient put their foot into a painless machine avoiding the uncomfortable Claustrophobia that some MRI devices create.

Non surgical Treatment
Orthotic or anklebrace, Over-the-counter or custom shoe inserts to position the foot and relieve pain are the most common non-surgical treatment option. Custom orthotics are often suggested if the shape change of the foot is more severe. An ankle brace (either over-the-counter or custom made) is another option that will help to ease tendon tension and pain. Boot immobilization. A walking boot supports the tendon and allows it to heal. Activity modifications. Depending on what we find, we may recommend limiting high-impact activities, such as running, jumping or court sports, or switching out high-impact activities for low-impact options for a period of time. Ice and anti-inflammatory medications. These may be given as needed to decrease your symptoms. Acquired Flat Foot

Surgical Treatment
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.

Posterior Tibial Tendon Insufficiency Disorder

Overview Posterior tibial tendon dysfunction is one of several terms to describe a painful, progressive flatfoot deformity in adults. Other terms include posterior tibial tendon insufficiency and adult acquired flatfoot. The term adult acquired flatfoot is more appropriate because it allows a broader recognition of causative factors, not only limited to the posterior tibial tendon, an event where the posterior tibial tendon looses strength and function. The adult acquired flatfoot is a progressive, symptomatic (painful) deformity resulting from gradual stretch (attenuation) of the tibialis posterior tendon as well as the ligaments that support the arch of the foot. Acquired Flat Feet 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 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 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 Although AAF is not reversible without surgery, appropriate treatment should address the patient?s current symptoms, attempt to reduce pain, and allow continued ambulation. In the early stages, orthotic and pedorthic solutions can address the loss of integrity of the foot?s support structures, potentially inhibiting further destruction.3-5 As a general principle, orthotic devices should only block or limit painful or destructive motion without reducing or restricting normal motion or muscle function. Consequently, the treatment must match the stage of the deformity. Flat Feet Surgical Treatment For patients with a more severe deformity, or significant symptoms that do not respond to conservative treatment, surgery may be necessary. There are several procedures available depending on the nature of your condition. Ligament and muscle lengthening, removal of inflamed tendon lining, transferring of a nearby tendon to re-establish an arch, and bone realignment and fusion are examples of surgical options to help with a painful flatfoot condition. Surgery can be avoided when symptoms are addressed early. If you are feeling ankle pain or notice any warmth, redness or swelling in your foot, contact us immediately. We can create a tailored treatment plan to resolve your symptoms and prevent future problems.