Do Hammertoes Cause Pain

Overview

A #LINK is a common and painful deformity in the three middle toes where they appear to always be bent. Causes of hammer toes include shoes that don?t fit properly, foot injuries, bunions and rheumatoid arthritis. Having toe joints sticking out can cause them to rub and a person may walk differently, risking other foot conditions, such as metatarsalgia. Hammer toes can be a serious problem in people with diabetes or Hammer toe poor circulation.

Causes

Footwear is actually the leading cause of this type of toe deformity so much so that people sometimes require hammer toe surgery to undo some of the damage. The most common problem is wearing shoes that are too short, too narrow or too tight. These shoes constricts the feet and force the toes into a bend position. Women are more at risk especially due to high heels. Footwear isn?t the only problem, poor foot posture can lead to muscle and even bone imbalances. This asymmetry can cause excessive strain on the toes either by forcing the toe into unnatural positions. Arthritis can also play a factor in the development of hammer toe, especially if the toe joint is stiff and incapable of a full range of motion.

Symptoms

A hammertoe may be present but not always painful unless irritated by shoes. One may have enlarged toe joints with some thickened skin and no redness or swelling. However, if shoes create pressure on the joint, the pain will usually range from pinching and squeezing to sharp and burning. In long standing conditions, the dislocated joints can cause the pain of arthritis.

Diagnosis

Hammer toes may be easily detected through observation. The malformation of the person’s toes begin as mild distortions, yet may worsen over time – especially if the factors causing the hammer toes are not eased or removed. If the condition is paid attention to early enough, the person’s toes may not be permanently damaged and may be treated without having to receive surgical intervention. If the person’s toes remain untreated for too long, however the muscles within the toes might stiffen even more and will require invasive procedures to correct the deformity.

Non Surgical Treatment

Wear wide shoes with plenty of room in the toes and resilient soles. Avoid wearing shoes with pointed toes. Commercially available felt pads or cushions may ease pressure from the shoe on the toe. Toe caps (small, padded sleeves that fit around the tip of the toe) may relieve the pain of hammer toe. Do toe exercises, to help toe muscles become stronger and more flexible.

Arch supports or an orthotic shoe insert prescribed by your doctor or podiatrist may help to redistribute weight on the foot. These devices do not cure the problem but may ease the symptoms of either hammer toe or mallet toe.

Surgical Treatment

Treatment of a severe hammertoe that has become rigid includes surgery. What is done during the surgery depends on how misshapen and inflexible the toe is. The surgeon may make a cut over your toe and release the tendon by cutting the tendon away from the bone. The surgeon may remove a small piece of bone from the toe. The surgeon may realign the tendons to reposition your toe or fasten the bones with pins. Sometimes the surgeon may have to join the bones in the toe. In this case, you will no longer be able to bend the toe, but the toe will be flat.

Prevention

If you notice the beginning signs of hammertoe, you may be able to prevent the tendons from tightening by wearing toe-friendly shoes, by flattening your toes regularly, and by soaking your feet every day in warm water, then stretching your toes and ankles by pointing your toes. Foot exercises also can help to maintain or restore the flexibility of the tendons. One simple exercise is to place a small towel on the floor and then pick it up using only your toes. You also can grasp at carpet with your toes or curl your toes up and down repeatedly.

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Hammertoe Treatments

Overview

Hammer toes are classified based on the mobility of the toe joints. There are two types. Flexible and rigid. In a flexible Hammer toe, the joint has the ability to move. This type of hammer toe can be straightened manually. A rigid hammer toe does not have that same ability to move. Movement is very limited and can be extremely painful. This sometimes causes foot movement to become restricted leading to extra stress at the ball-of-the-foot, and possibly causing pain and the development of corns and calluses.

Causes

The muscles of each toe work in pairs. When the toe muscles get out of balance, a hammer toe can form. Muscle imbalance puts a lot of pressure on the toe’s tendons and joints. This pressure forces the toe into a hammerhead shape. How do the toe muscles get out of hammertoe balance? There are three main reasons. Your genes, you may have inherited a tendency to develop hammer toes because your foot is slightly unstable – such as a flat foot. But high-arched feet can also get hammer toes. Arthritis. Injury to the toe: ill-fitting shoes are the main culprits of this cause. If shoes are too tight, too short, or too pointy, they push the toes out of balance. Pointy, high-heeled shoes put particularly severe pressure on the toes.

Symptoms

The most obvious sign of hammertoes are bent toes, other symptoms may include pain and stiffness during movement of the toe. Painful corns on the tops of the toe or toes from rubbing against the top of the shoe’s toe box. Painful calluses on the bottoms of the toe or toes. Pain on the bottom of the ball of the foot. Redness and swelling at the joints.

Diagnosis

Although hammertoes are readily apparent, to arrive at a diagnosis the foot and ankle surgeon will obtain a thorough history of your symptoms and examine your foot. During the physical examination, the doctor may attempt to reproduce your symptoms by manipulating your foot and will study the contractures of the toes. In addition, the foot and ankle surgeon may take x-rays to determine the degree of the deformities and assess any changes that may have occurred.

Non Surgical Treatment

Inserts in your shoes can be used to help relieve pressure on the toes from the deformity. Splints/Straps. These can be used to help re-align and stretch your toes and correct the muscle imbalance and tendon shortening. One of the most common types are toe stretchers like the yogatoe. Chiropody. A chiropodist can remove calluses or corns, areas of hard skin that have formed to make the foot more comfortable.Steroid injections can help to reduce pain and inflammation.

Surgical Treatment

There are several surgical techniques used to treat hammertoes. When the problem is less severe, the doctor will remove a small piece of bone at the involved joint and realign the toe joint. More severe hammer toes may need more complicated surgery.

Prevention

The key to prevention is to wear shoes that fit you properly and provide plenty of room for your toes. Here?s how to get the right fit. Have your feet properly measured. The best way to do this is to get someone to draw the outline of your foot while you stand barefoot with your full weight on it, then measure the outline at the widest point. Measure the soles of your shoes. Ideally, they should be as wide as your feet, but certainly no more than half an inch narrower. Length matters, too, of course: your shoes should be half an inch longer than your longest toe.

Bunions Causes Symptoms And Treatments

Overview

A bunion forms when the bursa (a sac of fluid at friction points between the tendons and bone in some areas and between bone and the skin in others) becomes inflamed along the edge of the joint at the base of the big toe. There are two types of bunions. The acute bunion causes the sharper pain. It develops from a bursitis, a sudden outcropping of a fluid-filled sac. An acute bunion can progress into the second type of bunion, the hallux valgus, a chronic but often painless deformity involving permanent rigidity of the bones. Bunions can form in any part of the foot but occur most often at the big toe joint, where the first metatarsal bone abuts the proximal phalanx of the big toe. Women are more likely than men to get bunions because of the misshapen footwear and elevated heels they wear.

Causes
People born with abnormal bones (congenital) in their feet. Inherited foot type. Foot injuries. Inflammatory or degenerative arthritis causing the protective cartilage that covers your big toe joint to deteriorate. Wearing high heels forces your toes into the front of your shoes, often crowding your toes. Wearing shoes that are too tight, too narrow or too pointed are more susceptible to bunions. Pain from arthritis may change the way you walk, making you more susceptible to bunions. Occupation that puts extra stress on your feet or job that requires you to wear ill-fitting shoes. The tendency to develop bunions may be present because of an inherited structural foot defect.
SymptomsThe most common symptoms associated with this condition are pain on the side of the foot. Shoes will typically aggravate bunions. Stiff leather shoes or shoes with a tapered toe box are the prime offenders. This is why bunion pain is most common in women whose shoes have a pointed toe box. The bunion site will often be slightly swollen and red from the constant rubbing and irritation of a shoe. Occasionally, corns can develop between the 1st and 2nd toe from the pressure the toes rubbing against each other. On rare occasions, the joint itself can be acutely inflamed from the development of a sac of fluid over the bunion called a bursa. This is designed to protect and cushion the bone. However, it can become acutely inflamed, a condition referred to as bursitis.

Diagnosis
Although bunions are usually obvious from the pain and unusual shape of the toe, further investigation is often advisable. Your doctor will usually send you for X-rays to determine the extent of the deformity. Blood tests may be advised to see if some type of arthritis could be causing the pain. Based on this evaluation, your doctor can determine whether you need orthopaedic shoes, medication, surgery or other treatment.

Non Surgical Treatment
There are two ways to treat this pathological foot conditions, conservatively and surgically. Conservative treatment is the first line treatment which consists of splints and orthotic care to reduce the causative factors. Realigning the foot with the aid of an orthotic helps prevent further degeneration and/or reduce symptoms of HAV in any stage of its deformity. Along with orthotic care, patients may require debridement of corns and calluses produced due to extra forces produced on the foot. Orthotics will also help the function of the big toe joint as it allows it to bend in the correct position. Footwear advice is also essential in the conservative care of bunions, HAV, there may be a need to change footwear, so it is able to fit properly and be compliment with orthotics. Surgical correction of bunions, HAV is available, however should only be considered when conservative care has failed to reduce the onset of bunions, HAV. It is only considered if there is a clear sign that it will induce a better quality of life for the patient.

Surgical Treatment
Bunion surgery is usually done as an out patient procedure, so the patient does not have to stay in hospital overnight although it is usually performed under a general anesthetic. The procedure involves the surgeon making a cut on the inside of the big toe joint and removing excess bone whilst also repositioning ligaments and tendons. The joint may be fixed with screws or wires, which may be dissolve, or may be removed at a later date or in some cases, remain in the foot permanently. After the operation the foot will be immobilized, often in a cast for 4 to 8 weeks to keep the bones in alignment. Crutches will usually be issued to help the patient get around. After this period, the foot will be assessed to check the bones have healed correctly. At which point full weight bearing may be gradually introduced.

Prevention
The best way to prevent a bunion is to be proactive in the truest sense of the word. Go over your risk factors. If you know that you pronate or have any problem with the mechanics of your foot, talk with a podiatric physician about the correct types of shoes and/or orthoses for you. If you are not sure whether you have such a problem, the podiatric professional can analyze your foot, your stride and the wear pattern of your shoes, and give you an honest evaluation. Has anyone in your family complained of bunions? Does your job involve a lot of standing, walking or other stress on your feet or toes? Do you exercise? If so, what kind of shoes do you wear for sports? For work? For school? Do you ever feel pain in your toes, or have you noticed a pronounced or increased redness on your big toe, or on the other side of your foot, near your little toe? Make sure you let the doctor know. Keep track of whether any relatives have suffered from arthritis or other joint problems, as well as anything else that might be relevant to your podiatric health. If you?ve suffered sports injuries previously, let the doctor know about that, too. In other words, try to give your health care professional the most honest and thorough background you can, so that he or she can make the best evaluation possible.

Overpronation Of The Foot Discomfort

Overview

The foot and ankle complex needs to pronate to make the muscles of the hips and legs work correctly. Many muscles that originate from the pelvis attach to both the upper and lower leg. For example, the gluteus maximus and tensor fascia latae (TFL) attach to the outside of the lower leg via the iliotibial band, while the abductors attach to the outside of the femur. When the foot pronates, the whole leg rotates inward toward the center line of the body. This inward rotation pulls the attachment of the glutes, TFL and abductors away from the origin of these muscles up on the pelvis which creates tension. Similarly, the muscles of the lower leg such as the peroneals, tibialis anterior and tibialis posterior originate on the lower leg and attach to the underside of the foot. When the foot flattens out, as it does in pronation, this pulls the insertion of these muscles away from their origin on the tibia. This action also creates tension in the muscles.

Causes

Acquired “Flat Feet” this develops over a period of time rather than at birth (unlike Congenital “Flat Feet”). In children, many different factors may contribute to the development of this condition such as the type of shoes that a child wears, a child’s sitting or sleeping positions or it may occur as some type of compensation for other abnormalities located further up the leg. Compensation may occur due to the rupture (tearing) of ligaments or tendons in the foot. One common reason for this condition is that the foot is compensating for a tight Achilles Tendon. If this tendon is tight it may cause the foot to point downward away from the body. This gives the body the perception that the affected leg is longer in length and the body attempts to compensate for the perceived additional length by flattening out the foot arch in an attempt to provide balance and stability.

Symptoms

Symptoms can manifest in many different ways. The associated conditions depend on the individual lifestyle of each patient. Here is a list of some of the conditions associated with Over Pronation. Hallux Abducto Valgus (bunions). Hallux Rigidus (stiff 1st toe). Arch Pain. Heel Pain (plantar fascitis). Metatarsalgia (ball of the foot pain). Ankle sprains. Shin Splints. Achilles Tendonitis. Osteochondrosis. Knee Pain. Corns & Calluses. Flat Feet. Hammer Toes.

Diagnosis

When you overpronate your foot rolls inwards causing the lower leg to rotate inwards too. It’s thought that this increases stress on the soft tissues of the lower leg causing pain and inflammation, or more commonly known as shin splints.

Non Surgical Treatment

When you see the doctor, he or she will likely perform a complete examination of your feet and watch you walk. The doctor will need to take x-rays to determine the cause of your flat feet. In some cases, further imaging may be needed, especially if your symptoms are severe and sudden in nature. Once you are properly diagnosed, your doctor will create an appropriate treatment plan. There are several options to correct overpronation, such as orthotics. In many cases, overpronation can be treated with non-surgical methods and over-the-counter orthotics. In severe cases, however, custom-made orthotics may work better. Orthotics provide arch support and therefore prevent collapse of the arch with weight bearing. They are made of materials such as spongy rubber or hard plastic. Your doctor will also want to examine your footwear to ensure they fit properly and offer enough medial support. Extra support and stability can be achieved with footwear that has a firm heel counter. If you are experiencing pain, you should be able to use over-the-counter pain medications such as ibuprofen to relieve symptoms.

Prevention

Massage and stretch the calves to increase dorsiflexion at the foot/ankle. Dorsiflexion is the bending at the ankle. By improving the dorsiflexion, one will have more flexibility at the ankle, which will allow the foot to over-pronate less. Massage the IT Band with a foam roller or tennis ball to quiet down the tightness throughout this part of the leg. The IT Band attaches from the glute maximus and runs down the side of the leg into the knee area. When the IT Band is tight it will accelerate the force of the leg moving inward, which will cause the foot to move inward as well. It is often that tightness through the IT Band that promotes over-pronation. Decreasing over-pronation, which is very prominent in runners, will help add endurance, speed and efficiency to your run and ultimately place less stress on your body.

What Causes Severs Disease?

Overview

Sever’s disease is a disorder of the growth plate of the calcaneus. Symptoms most often occur at the posterior (back of the heel) aspect of the growth plate but sometimes are experienced at the plantar aspect below the heel. The Achilles tendon attaches to the posterior aspect of the growth plate and the plantar fascia takes part of its origin from the plantar aspect. Sever?s disease occurs more often in boys than girls. The age of onset is usually between 8 to 12 years. Sever?s disease is believed to be caused by overuse. On x-ray the growth center first appears in girls between the ages of 4 to 6 years and boys aged 7 to 8 years. The centers fuse to the primary ossification center of the calcaneus in girls at approximately ages 12 to 14 on boys at ages 15 to 17.

Causes

With early puberty, the growth plate at the end of the heel develops, transforming cartilage cells into bone cells. This painful heel condition occurs during these growth spurts, when the heel bone grows more rapidly than the muscles and tendons of the leg. The discrepancy between rates of development causes excess pressure and tension to be placed upon the heel and it becomes less flexible. This condition affects active children the most. Due to the amount of exercise, more stress is placed upon the tendons which in turn causes more damage to the growth plate. The bone plates fully mature and harden by the time a child reaches the age of 15.

Symptoms

This syndrome can occur unilaterally or bilaterally. The incidence of bilaterally is approximately 60%. Common signs and symptoms include posterior inferior heel pain (over the medial and lateral surface of the bone). Pain is usually absent when the child gets up in the morning. Increased pain with weight bearing, running or jumping (= activity-related pain). The area often feels stiff. The child may limp at the end of physical activity. Tenderness at the insertion of the tendons (= an avascular necrosis of the arthropathy). Limited ankle dorsiflexion range secondary to tightness of the Achilles tendon. Hard surfaces and poor-quality or worn-out athletic shoes contribute to increased symptoms. The pain gradually resolves with rest. Reliability or validity of methods used to obtain the ankle joint dorsiflexion or biomechanical malalignment data are not commented upon, thus reducing the quality of the data. Although pain and limping are mentioned as symptomatic traits, there have been no attempts to quantify the pain or its effect on the individual.

Diagnosis

Children or adolescents who are experiencing pain and discomfort in their feet should be evaluated by a physician. In some cases, no imaging tests are needed to diagnose Sever?s disease. A podiatrist or other healthcare professional may choose to order an x-ray or imaging study, however, to ensure that there is no other cause for the pain, such as a fracture. Sever?s disease will not show any findings on an x-ray because it affects cartilage.

Non Surgical Treatment

The doctor will talk with you about the best treatment plan for your child. As instructed, your child will Ice the heel 3-4 times a day for 15-20 minutes at a time. Use an ice pack or bag of frozen peas, or something similar. Never put ice directly on your child’s skin. A thin cloth or towel should be between your child?s skin and the ice pack. Take anti-inflammatory medication, such as ibuprofen, as directed. Decrease the amount of running and jumping he or she does. Stretch the heels and calves, as instructed by the doctor. Regular stretching can help prevent Sever?s from coming back. Use a ?heel cup? or a cushioned shoe insert that takes pressure off the heel. In some cases, a cast is placed on the foot and worn for several weeks.

Heel Arch Pain Running

Overview

Pain across the bottom of the foot at any point between the heel and the ball of the foot is often referred to as “arch pain.” Although this description is non-specific, most arch pain is due to strain or inflammation of the plantar fascia (a long ligament on the bottom of the foot). This condition is known as plantar fasciitis and is sometimes associated with a heel spur. In most cases, arch pain develops from overuse, unsupportive shoes, weight gain, or acute injury. If arch pain persists beyond a few days, see a foot and ankle surgeon for treatment to prevent this condition from becoming worse.

Causes

There are a number of other medical conditions that can cause foot arch pain such as diabetes, arthritis and obesity. These can affect the position and strength of the bones, muscles, ligaments and tendons, leading to bottom of foot pain. It sounds simple but footwear plays an important role in how our feet feel. Foot arch pain is commonly caused by ill-fitting shoes, especially ones with little arch support or that are too tight. Footwear is particularly important if you are going to be spending long periods on your feet or for sporting activities such as running. Shoes should be supportive, comfortable, cushioned, provide the appropriate level of arch support and be the correct width.

Symptoms

Flat feet don’t usually cause problems, but they can put a strain on your muscles and ligaments (ligaments link two bones together at a joint). This may cause pain in your legs when you walk. If you have flat feet, you may experience pain in any of the following areas, the inside of your ankle, the arch of your foot, the outer side of your foot, the calf, the knee, hip or back, Some people with flat feet find that their weight is distributed unevenly, particularly if their foot rolls inwards too much (overpronates). If your foot overpronates, your shoes are likely to wear out quickly. Overpronation can also damage your ankle joint and Achilles tendon (the large tendon at the back of your ankle). See your GP if you or your child has flat feet and your feet are painful, even when wearing supportive, well-fitting shoes, shoes wear out very quickly, feet appear to be getting flatter, feet are weak, numb or stiff, Your GP may refer you to a podiatrist (foot specialist).

Diagnosis

The medical practitioner will examine how the muscles of your foot function. These tests may involve holding or moving your foot and ankle against resistance; you may also asked to stand, walk, or even run. Pain caused by movements may indicate the cause of the pain. The nerves in the foot will be tested to make sure no injury has occurred there. An x-ray, MRI, or bone scan of the foot and arch may be taken to determine if there are changes in the makeup of the bone.

Non Surgical Treatment

This is a common foot condition that can be easily treated. If you suffer from arch pain avoid high-heeled shoes whenever possible. Try to choose footwear with a reasonable heel, soft leather uppers, shock absorbing soles and removable foot insoles. When the arch pain is pronation related (flat feet), an orthotic designed with a medial heel post and proper arch support is recommended for treating the pain. This type of orthotic will control over-pronation, support the arch and provide the necessary relief. If the problem persists, consult your foot doctor.

Surgical Treatment

If pain or foot damage is severe, your doctor may recommend surgery. Procedures may include the following. Fusing foot or ankle bones together (arthrodesis). Removing bones or bony growths also called spurs (excision). Cutting or changing the shape of the bone (osteotomy). Cleaning the tendons’ protective coverings (synovectomy). Adding tendon from other parts of your body to tendons in your foot to help balance the “pull” of the tendons and form an arch (tendon transfer). Grafting bone to your foot to make the arch rise more naturally (lateral column lengthening).

Prevention

The best method for preventing plantar fasciitis is stretching. The plantar fascia can be stretched by grabbing the toes, pulling the foot upward and holding for 15 seconds. To stretch the calf muscles, place hands on a wall and drop affected leg back into a lunge step while keeping the heel of the back leg down. Keep the back knee straight for one stretch and then bend the knee slightly to stretch a deeper muscle in the calf. Hold stretch for 15 seconds and repeat three times.

Stretching Exercises

Calf Stretching in Bed. As you may already know, the first few steps out of bed in the morning can be the worst of the day. Those first few steps can be enough to reaggravate your condition putting you into a cycle of inflammation and pain. The best way to help break that cycle is to stretch your calf before taking those first steps in the morning. When the muscles in your calf are tight, they pull on the heel bone, making your plantar fascia very taut and prone to injury. To help loosen those muscles, take a towel or belt and loop it around the ball of your foot. Keeping your leg straight, gently pull towards your body until you feel a stretch in the lower part of your leg. Hold that for 30 seconds and repeat up to 5 times before taking your first step out of bed. Plantar Fascia Stretching. Loosening up the tissues that are irritated probably makes sense to you, but you may not know how to do so. Luckily, there?s a very simple way. All you have to do is pull your toes up with your hand until you feel a stretch along the ball of your foot. You may feel the stretch anywhere from the ball of your foot to your heel. Holding this position for 30 seconds a few times can make a world of difference in your pain levels. Calf Stretching. I know, it probably seems like overkill, but stretching out the muscles in the lower leg is an integral step to recovery. There are two main muscles in the lower leg that attach to the heel, so we?ll work on stretching them both out. Stand against a wall and slide one leg back, pushing the heel down towards the floor (first picture). When you feel a stretch in the lower part of your leg, hold it for 30 seconds. After those 30 seconds are up, bend your knees until a deeper stretch is felt a bit lower in the leg (second photo). Again, hold this stretch for 30 seconds and repeat this until you?ve done it 3 times on each leg. Who doesn?t love a good massage? I suppose you could pay for someone to rub out the tissues in the bottom of your foot, but if you?re looking for a cheaper alternative, look no further than the humble tennis ball. Placing a tennis ball on the ground and gently rolling it under foot for a few minutes can help loosen up your plantar fascia, making it much less likely to become irritated. Put enough pressure on the ball to get a deep massage. You may feel some soreness, but back off if you feel any pain.Tennis Ball Massage While using the tennis ball is great for keeping things loose, sometimes it?s worth doing some icing at the same time for some inflammation control. Freezing a water bottle and rolling it under your foot for 10 minutes at the end of the day can be a very effective way to keep inflammation in check while staying loose. It might not be the most comfortable thing in the world, but ?Brrr? is better than ?Ouch? any day. One thing to keep in mind is that while these tips have been proven to work, they?re not an instant fix. It can take a few weeks of consistency with them before your pain levels begin to change. If you?re not seeing any improvement after making an honest effort, it may be time to look into some different treatment methods with your doctor such as formal PT, orthotics, a weight-loss plan, or others.

What Can Cause Posterior Tibial Tendon Dysfunction ?

Overview
A more serious condition, according to ACFAS, is adult-acquired flatfoot, often cause by posterior tibial tendon dysfunction (PTTD). In this case, the tendon that supports the arch weakens and fails, leading to a rigid flatfoot where the arch stays flat even when you aren’t standing. It can lead to a loss of range of motion in the foot and ankle and pain in the arch. The ACFAS clinical guideline recommends that flatfoot caused by PTTD can be treated with custom shoe orthotics, soft casts, walking boots, physical therapy and non-steroidal anti-inflammatory medications. If there is no relief or the condition worsens, then the patient may be referred to surgery.

Causes
Flat feet causes greater pressure on the posterior tibial tendon than normal. As the person with flat feet ages, the muscles, tendons and ligaments weaken. Blood supplies diminish as arteries narrow. These conditions are magnified for obese patients because of their increased weight and atherosclerosis. Finally, the tendon gives out or tears. Most of the time, this is a slow process. Once the posterior tibial tendon and ligaments stretch, body weight causes the bones of the arch to move out of position. The foot rotates inward (pronation), the heel bone is tilted to the inside, and the arch appears collapsed. In some cases, the deformity progresses until the foot dislocates outward from the ankle joint.

Symptoms
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.

Diagnosis
First, both feet should be examined with the patient standing and the entire lower extremity visible. The foot should be inspected from above as well as from behind the patient, as valgus angulation of the hindfoot is best appreciated when the foot is viewed from behind. Johnson described the so-called more-toes sign: with more advanced deformity and abduction of the forefoot, more of the lateral toes become visible when the foot is viewed from behind. The single-limb heel-rise test is an excellent determinant of the function of the posterior tibial tendon. The patient is asked to attempt to rise onto the ball of one foot while the other foot is suspended off the floor. Under normal circumstances, the posterior tibial muscle, which inverts and stabilizes the hindfoot, is activated as the patient begins to rise onto the forefoot. The gastrocnemius-soleus muscle group then elevates the calcaneus, and the heel-rise is accomplished. With dysfunction of the posterior tibial tendon, however, inversion of the heel is weak, and either the heel remains in valgus or the patient is unable to rise onto the forefoot. If the patient can do a single-limb heel-rise, the limb may be stressed further by asking the patient to perform this maneuver repetitively.

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.

Surgical Treatment
Many operations are available for the treatment of dysfunction of the posterior tibial tendon after a thorough program of non-operative treatment has failed. The type of operation that is selected is determined by the age, weight, and level of activity of the patient as well as the extent of the deformity. The clinical stages outlined previously are a useful guide to operative care (Table I). In general, the clinician should perform the least invasive procedure that will decrease pain and improve function. One should consider the effects of each procedure, particularly those of arthrodesis, on the function of the rest of the foot and ankle.