Does Adult Aquired Flat Feet Need To Have Surgical Teatment ?

Overview


Adult acquired flatfoot is a very serious condition that can lead to many secondary deformities, not only within the foot but also in the knees, hips and back. This presentation discusses a new scientifically proven procedure that may be able to help realign and fix this problem at its root.Adult Acquired Flat Foot






Causes


Posterior tibial tendon dysfunction is the most common cause of acquired adult flatfoot deformity. There is often no specific event that starts the problem, such as a sudden tendon injury. More commonly, the tendon becomes injured from cumulative wear and tear. Posterior tibial tendon dysfunction occurs more commonly in patients who already have a flat foot for other reasons. As the arch flattens, more stress is placed on the posterior tibial tendon and also on the ligaments on the inside of the foot and ankle. The result is a progressive disorder.






Symptoms


Patients will usually describe their initial symptoms as "ankle pain", as the PT Tendon becomes painful around the inside of the ankle joint. The pain will become more intense as the foot flattens out, due to the continued stretching and tearing of the PT Tendon. As the arches continue to fall, and pronation increases, the heel bone (Calcaneus) tilts into a position where it pinches against the ankle bone (Fibula), causing pain on both the inside and outside of the ankle. As the foot spends increased time in a flattened, or deformed position, Arthritis can begin to affect the joints of the foot, causing additional pain.






Diagnosis


Clinicians need to recognize the early stage of this syndrome which includes pain, swelling, tendonitis and disability. The musculoskeletal portion of the clinical exam can help determine the stage of the disease. It is important to palpate the posterior tibial tendon and test its muscle strength. This is tested by asking patient to plantarflex and invert the foot. Joint range of motion is should be assessed as well. Stiffness of the joints may indicate longstanding disease causing a rigid deformity. A weightbearing examination should be performed as well. A complete absence of the medial longitudinal arch is often seen. In later stages the head of the talus bone projects outward to the point of a large "lump" in the arch. Observing the patient's feet from behind shows a significant valgus rotation of the heel. From behind, the "too many toes" sign may be seen as well. This is when there is abducution of the forefoot in the transverse plane allowing the toes to be seen from behind. Dysfunction of the posterior tibial tendon can be assessed by asking the patient to stand on his/her toes on the affected foot. If they are unable to, this indicates the disease is in a more advanced stage with the tendon possibly completely ruptured.






Non surgical Treatment


Orthoses (insoles, functional orthoses, ankle supports, braces, ankle foot orthoses (AFOs)) - are usually custom-made to increase the functional stability of the foot and improve the mechanical properties of the tendon as well as reducing the actual degree of strain on the tendon. This reduces pain and inflammation. Physiotherapy - exercises and physiotherapy are often used to increase mobility, strengthen the tendon itself, stretch your Achilles tendon as well as reduce pain. Once the tendon has been stretched (stage one), the heel starts rolling outwards. Total immobilisation in a cast may help the symptoms to subside and prevent progression of the deformity in a smaller percentage of patients. Long-term use of orthoses may help stop progression of the deformity and reduce pain without surgery. Non-surgical treatment is unlikely to prevent progression to stage three and four but may be chosen by some patients who either are unsuitable for surgery or prefer not to have surgery.


Flat Foot






Surgical Treatment


If surgery is necessary, a number of different procedures may be considered. The specifics of the planned surgery depend upon the stage of the disorder and the patient?s specific goals. Procedures may include ligament and muscle lengthening, removal of the inflamed tendon lining, tendon transfers, cutting and realigning bones, placement of implants to realign the foot and joint fusions. In general, early stage disease may be treated with tendon and ligament (soft-tissue) procedures with the addition of osteotomies to realign the foot. Later stage disease with either a rigidly fixed deformity or with arthritis is often treated with fusion procedures. If you are considering surgery, your doctor will speak with about the specifics of the planned procedure.

What Will Cause Achilles Tendonitis ?

Overview


Achilles TendonThe Achilles tendon attaches your calf muscles to your heel. You use this tendon to jump, walk, run, and stand on the balls of your feet. Continuous, intense physical activity, like running and jumping, can cause inflammation of the Achilles. This is known as Achilles tendonitis (also spelled tendinitis). Achilles tendonitis can often be treated at home using simple strategies. However, if home treatment doesn?t work, it is important to see a doctor. If your tendonitis gets worse, it can lead to a tendon tear. You may need medication to ease the pain or a surgical repair.


Causes


As ?overuse? disorders, Achilles tendonitis and tendonosis are usually caused by a sudden increase of a repetitive activity involving the Achilles tendon. Such activity puts too much stress on the tendon too quickly, leading to micro-injury of the tendon fibers. Due to this ongoing stress on the tendon, the body is unable to repair the injured tissue. The structure of the tendon is then altered, resulting in continued pain. Achilles4Athletes are at high risk for developing disorders of the Achilles tendon. Achilles tendonitis and tendonosis are also common in individuals whose work puts stress on their ankles and feet, such as laborers, as well as in ?weekend warriors?-those who are less conditioned and participate in athletics only on weekends or infrequently. In addition, people with excessive pronation (flattening of the arch) have a tendency to develop Achilles tendonitis and tendonosis due to the greater demands placed on the tendon when walking. If these individuals wear shoes without adequate stability, their over-pronation could further aggravate the Achilles tendon.


Symptoms


There are several types of Achilles tendinitis symptoms, but all of them are closely related. People who suffer from Achilles tendon pain typically have swelling in the Achilles tendon, and that pain can be chronic as the microscopic tears in the area become more prevalent over time. The most intense pain is typically located just a few centimeters above the area where the tendon meets the heel. This area is called the watershed zone, and the amount of blood moving through it is what gives it the highest potential for injury, especially for athletes. Most of the Achilles tendinitis symptoms in people with the condition will happen immediately after they have been inactive for a fairly significant amount of time. That means that the most pain will generally be felt after sitting or lying down for an extended period, or right after waking up in the morning and getting moving. If you aren?t positive that you are suffering specifically from Achilles tendinitis symptoms, consult a doctor to make sure.


Diagnosis


When diagnosing Achilles tendinitis, a doctor will ask the patient a few questions about their symptoms and then perform a physical examination. To perform a physical exam on the Achilles tendon, the doctor will lightly touch around the back of the ankle and tendon to locate the source of the pain or inflammation. They will also test the foot and ankle to see if their range of motion and flexibility has been impaired. The doctor might also order an imaging test to be done on the tendon. This will aid in the elimination of other possible causes of pain and swelling, and may help the doctor assess the level of damage (if any) that has been done to the tendon. Types of imaging tests that could be used for diagnosing Achilles tendinitis are MRI (Magnetic resonance imaging), X-ray, Ultrasound.


Nonsurgical Treatment


Massage therapy improves blood flow to the muscles and tissues of the affected area while increasing range of motion and can prevent recurring injury. The healing process can be quickened using ultrasound heat therapy to improve blood flow to the affected area. Wearing a night brace keeps the leg flexed, preventing stiffening of the tendon, which would impair healing. Stretching exercises increase flexibility and allow the tendon to heal without shortening, a deformity resulting in chronic pain. Persistent Achilles pain may warrant the use of a cast or walking boot to be worn for 4-6 weeks stabilizing the tendon so it can heal. After removal of the cast or boot, physical therapy will be ordered to increase functionality of the affected limb. To reduce chronic inflammation of the tendon, corticosteroid injections may be prescribed. It?s important to note that this corticosteroid treatment increases the risk of tendon rupture. Ultrasound imaging may be used by the physician administering the steroid injection, in order to help visualize the affected area. When all other therapies have failed to or tendon rupture occurs, surgical intervention and repair of the muscles and tendons is the last treatment option.


Achilles Tendonitis


Surgical Treatment


Achilles tendon repair surgery is often used to repair a ruptured or torn Achilles tendon, the strong fibrous cord that connects the two large muscles in the back of your calf to your heel bone. These muscles (the gastrocnemius and the soleus) create the power needed to push off with your foot or rise up on your toes. Achilles tendon ruptures are quite common. Most happen during recreational activities that require sudden bursts of muscle power in the legs. Often a torn Achilles tendon can be diagnosed with a physical examination. If swelling is present, the orthopaedist may delay the Achilles tendon surgery until it subsides.


Prevention


To prevent Achilles tendonitis or tendonosis from recurring after surgical or non-surgical treatment, the foot and ankle surgeon may recommend strengthening and stretching of the calf muscles through daily exercises. Wearing proper shoes for the foot type and activity is also important in preventing recurrence of the condition.

What Exactly Brings About Heel Pain

Heel Discomfort


Overview


Plantar Fasciitis is a chronic pain in the heel that can just appear from nowhere but it is actually a long standing mechanical condition caused by prolonged stress on your foot. In most cases Plantar Fasciitis is a common, but very treatable, mechanical condition of the foot and responds positively to orthotics. A heel pain caused by prolonged stress on a ligament like structure in the arch that is very important in weigh-bearing activities. The tissue becomes damaged and needs to be helped to repair in order for the pain to go or subside to a manageable level. Orthotics for your feet can achieve this necessary healing for pain relief. It can be very painful, and even debilitating for sufferers.






Causes


Patients with tight calf muscles will suffer with excessive pulling of the muscle group on the back of the heel. This in turn creates pulling of other structures that are attached to the heel, including the Plantar Fascia. When the pulling continues for long enough, then inflammation will develop and lead to Plantar Fasciitis. This causes Heel Pain. It is extremely common for patients who increase their level of activity to develop Plantar Fasciitis. Boot camp, running, zumba, recreational walking or other quick movement sports such as tennis or touch football are typical causes of Heel Pain. The sharp increase in exercise is too much for the foot to cope with and the stress on the Plantar Fascia causes inflammation. The Heel Pain that is caused by this inflammation is known as Plantar Fasciitis.






Symptoms


The symptoms of plantar fasciitis are pain on the bottom of the heel, pain in the arch of the foot, pain that is usually worse upon arising, pain that increases over a period of months. People with plantar fasciitis often describe the pain as worse when they get up in the morning or after they’ve been sitting for long periods of time. After a few minutes of walking the pain decreases, because walking stretches the fascia. For some people the pain subsides but returns after spending long periods of time on their feet.






Diagnosis


If you see a doctor for heel pain, he or she will first ask questions about where you feel the pain. If plantar fasciitis is suspected, the doctor will ask about what activities you've been doing that might be putting you at risk. The doctor will also examine your foot by pressing on it or asking you to flex it to see if that makes the pain worse. If something else might be causing the pain, like a heel spur or a bone fracture, the doctor may order an X-ray to take a look at the bones of your feet. In rare cases, if heel pain doesn't respond to regular treatments, the doctor also might order an MRI scan of your foot. The good news about plantar fasciitis is that it usually goes away after a few months if you do a few simple things like stretching exercises and cutting back on activities that might have caused the problem. Taking over-the-counter medicines can help with pain. It's rare that people need surgery for plantar fasciitis. Doctors only do surgery as a last resort if nothing else eases the pain.






Non Surgical Treatment


Cortisone is a powerful anti-inflammatory and when injected directly into the heel it will work almost immediately. Bear in mind however, that the treatment does not address the root cause of the inflammation, and needs to be repeated every few months. Also note, these injections are quite painful, and most doctors today will consider other, less invasive treatment options first. ESWT (Extra Corporeal Shockwave Treatment). A specialist targets therapeutic shockwaves to the affected heel area. This will stimulate a healing response in the affected tissue and ligaments, resulting in reduced inflammation and pain. This treatment and may take from 3 to 4 months to be fully effective. Extracorpreal Shock Wave Therapy is the latest technology to treat chronic plantar fasciitis. It is a non-invasive treatment and highly recommended for people who have tried other treatment like cortisone-injections, accupuncture etc with little or no success. Electroacupuncture and standard acupuncture are used in the treatment of plantar fasciitis and other foot problems such as neuromas and nerve impingement, numbness in the toes etc. In some cases there is nerve entrapment within the foot combined with referred pain from other areas of the body. Some research suggests that acunpuncture can be effective in the treatment of heel pain. A trigger point is an irritable knot in the muscle tissue. When pressed trigger points are very tender and can cause pain in that specific spot or elsewhere in the body (referred pain). The response to pushing into the knot is a muscle twitch. The foot contains 126 muscles, tendons and ligaments, so there are plenty of 'hiding places' for trigger points. Trigger points in the calf muscles often refer pain directly to the bottom of the foot. Trigger point therapy of the lower leg and foot can therefore be successful in the treatment of plantar fasciitis.


Heel Pain






Surgical Treatment


Plantar fasciotomy is often considered after conservative treatment has failed to resolve the issue after six months and is viewed as a last resort. Minimally invasive and endoscopic approaches to plantar fasciotomy exist but require a specialist who is familiar with certain equipment. Heel spur removal during plantar fasciotomy has not been found to improve the surgical outcome. Plantar heel pain may occur for multiple reasons and release of the lateral plantar nerve branch may be performed alongside the plantar fasciotomy in select cases. Possible complications of plantar fasciotomy include nerve injury, instability of the medial longitudinal arch of the foot, fracture of the calcaneus, prolonged recovery time, infection, rupture of the plantar fascia, and failure to improve the pain. Coblation (TOPAZ) surgery has recently been proposed as alternative surgical approaches for the treatment of recalcitrant plantar fasciitis.






Stretching Exercises


Calf stretch. Lean forward against a wall with one knee straight and the heel on the ground. Place the other leg in front, with the knee bent. To stretch the calf muscles and the heel cord, push your hips toward the wall in a controlled fashion. Hold the position for 10 seconds and relax. Repeat this exercise 20 times for each foot. A strong pull in the calf should be felt during the stretch. Plantar fascia stretch. This stretch is performed in the seated position. Cross your affected foot over the knee of your other leg. Grasp the toes of your painful foot and slowly pull them toward you in a controlled fashion. If it is difficult to reach your foot, wrap a towel around your big toe to help pull your toes toward you. Place your other hand along the plantar fascia. The fascia should feel like a tight band along the bottom of your foot when stretched. Hold the stretch for 10 seconds. Repeat it 20 times for each foot. This exercise is best done in the morning before standing or walking.

What Exactly May Cause Painful Heel

Foot Pain


Overview


The plantar fascia is a thick band of connective tissue that runs along the underneath of the foot from the heel bone to the toes. At the heel it can also have fascial connections to the achilles tendon. Its job is to maintain the arch of the foot, it acts as a bowstring pulled between the heel and the toes. "Itis" as a suffix indicates inflammation, but with the plantar fascia there is still some controversy over what exactly happens to the tissue when it becomes painful.






Causes


Plantar fasciitis occurs because of irritation to the thick ligamentous connective tissue that runs from the heel bone to the ball of the foot. This strong and tight tissue contributes to maintaining the arch of the foot. It is also one of the major transmitters of weight across the foot as you walk or run. Therefore, the stress placed on the this tissue is tremendous.






Symptoms


The symptoms of plantar fasciitis include pain in the bottom of your foot, especially at the front or centre of the heel bone, pain that is worse when first rising in the morning (called "first-step pain"), when first standing up after any long period of sitting, or after increased levels of activity especially in non-supportive shoes. Seek medical advice about plantar fasciitis if you have heel pain or pain in the bottom of your foot, especially when you get up in the morning, that does not respond to treatment or if there is redness or bruising in the heel.






Diagnosis


Plantar fasciitis is usually diagnosed by a health care provider after consideration of a person’s presenting history, risk factors, and clinical examination. Tenderness to palpation along the inner aspect of the heel bone on the sole of the foot may be elicited during the physical examination. The foot may have limited dorsiflexion due to tightness of the calf muscles or the Achilles tendon. Dorsiflexion of the foot may elicit the pain due to stretching of the plantar fascia with this motion. Diagnostic imaging studies are not usually needed to diagnose plantar fasciitis. However, in certain cases a physician may decide imaging studies (such as X-rays, diagnostic ultrasound or MRI) are warranted to rule out other serious causes of foot pain. Bilateral heel pain or heel pain in the context of a systemic illness may indicate a need for a more in-depth diagnostic investigation. Lateral view x-rays of the ankle are the recommended first-line imaging modality to assess for other causes of heel pain such as stress fractures or bone spur development. Plantar fascia aponeurosis thickening at the heel greater than 5 millimeters as demonstrated by ultrasound is consistent with a diagnosis of plantar fasciitis. An incidental finding associated with this condition is a heel spur, a small bony calcification on the calcaneus (heel bone), which can be found in up to 50% of those with plantar fasciitis. In such cases, it is the underlying plantar fasciitis that produces the heel pain, and not the spur itself. The condition is responsible for the creation of the spur though the clinical significance of heel spurs in plantar fasciitis remains unclear.






Non Surgical Treatment


A steroid (cortisone) injection is sometimes tried if your pain remains bad despite the above 'conservative' measures. It may relieve the pain in some people for several weeks but does not always cure the problem. It is not always successful and may be sore to have done. Steroids work by reducing inflammation. Sometimes two or three injections are tried over a period of weeks if the first is not successful. Steroid injections do carry some risks, including (rarely) tearing (rupture) of the plantar fascia. Extracorporeal shock-wave therapy. In extracorporeal shock-wave therapy, a machine is used to deliver high-energy sound waves through your skin to the painful area on your foot. It is not known exactly how it works, but it is thought that it might stimulate healing of your plantar fascia. One or more sessions of treatment may be needed. This procedure appears to be safe but it is uncertain how well it works. This is mostly because of a lack of large, well-designed clinical trials. You should have a full discussion with your doctor about the potential benefits and risks. In studies, most people who have had extracorporeal shock-wave therapy have little in the way of problems. However, possible problems that can occur include pain during treatment, skin reddening, and swelling of your foot or bruising. Another theoretical problem could include the condition getting worse because of rupture of your plantar fascia or damage to the tissues in your foot. More research into extracorporeal shock-wave therapy for plantar fasciitis is needed. Other treatments. Various studies and trials have been carried out looking at other possible treatments for plantar fasciitis. Such treatments include injection with botulinum toxin and treatment of the plantar fascia with radiotherapy. These treatments may not be widely available. Some people benefit from wearing a special splint overnight to keep their Achilles tendon and plantar fascia slightly stretched. The aim is to prevent the plantar fascia from tightening up overnight. In very difficult cases, sometimes a plaster cast or a removable walking brace is put on the lower leg. This provides rest, protection, cushioning and slight stretching of the plantar fascia and Achilles tendon. However, the evidence for the use of splint treatment of plantar fasciitis is limited.


Painful Heel






Surgical Treatment


Surgery for plantar fasciitis can be very successful in the right patients. While there are potential complications, about 70-80% of patients will find relief after plantar fascia release surgery. This may not be perfect, but if plantar fasciitis has been slowing you down for a year or more, it may well be worth these potential risks of surgery. New surgical techniques allow surgery to release the plantar fascia to be performed through small incisions using a tiny camera to locate and cut the plantar fascia. This procedure is called an endoscopic plantar fascia release. Some surgeons are concerned that the endoscopic plantar fascia release procedure increases the risk of damage to the small nerves of the foot. While there is no definitive answer that this endoscopic plantar fascia release is better or worse than a traditional plantar fascia release, most surgeons still prefer the traditional approach.


What Leads To Heel Discomfort

Feet Pain


Overview


Plantar fasciitis, or better termed chronic plantar heel pain, is likely caused by a combination of heel Compression, from standing with weight distributed on the heels. Abnormal stress on the foot, from decreased ankle flexibility, pronation, or a high BMI. Footwear, particularly a rigid sole and toe spring, which interferes with foot muscle activity, restricts circulation, and hinders the plantar fascia’s ability to absorb forces. Contrary to popular belief, the condition is not caused by inflammation in the traditional sense, and supportive footwear is possibly more likely to contribute to the problem than help it. Plantar fasciitis doesn’t develop from overuse or too much stress on plantar fascia. It happens when the wrong kind of stress replaces the good kind of stress that the foot needs to remain healthy. The aim of treatment therefore should not be reducing stress on the arch. Instead, treatment should focus on changing the types of stresses being applied and encouraging normal function of the foot.






Causes


You're more likely to develop the condition if you're female, overweight or have a job that requires a lot of walking or standing on hard surfaces. You're also at risk if you walk or run for exercise, especially if you have tight calf muscles that limit how far you can flex your ankles. People with very flat feet or very high arches also are more prone to plantar fasciitis.






Symptoms


When plantar fasciitis occurs, the pain is typically sharp and usually unilateral (70% of cases).Heel pain worsens by bearing weight on the heel after long periods of rest. Individuals with plantar fasciitis often report their symptoms are most intense during their first steps after getting out of bed or after prolonged periods of sitting. Improvement of symptoms is usually seen with continued walking. Numbness, tingling, swelling, or radiating pain are rare but reported symptoms. If the plantar fascia continues to be overused in the setting of plantar fasciitis, the plantar fascia can rupture. Typical signs and symptoms of plantar fascia rupture include a clicking or snapping sound, significant local swelling, and acute pain in the sole of the foot.






Diagnosis


Most cases of plantar fasciitis are diagnosed by a health care provider who listens carefully to your description of symptoms. During an examination of your feet, your health care provider will have to press on the bottom of your feet, the area most likely to be painful in plantar fasciitis. Because the pain of plantar fasciitis has unique characteristics, pain upon rising, improvement after walking for several minutes, pain produced by pressure applied in a specific location on your foot but not with pressure in other areas, your health care provider will probably feel comfortable making the diagnosis based on your symptoms and a physical examination. Your health care provider may suggest that you have an X-ray of your foot to verify that there is no stress fracture causing your pain.






Non Surgical Treatment


Give your painful heel lots of rest. You may need to stay completely off your foot for several days when the pain is severe. Your healthcare provider may recommend or prescribe anti-inflammatory medicines, such as aspirin or ibuprofen. These drugs decrease pain and inflammation. Adults aged 65 years and older should not take non-steroidal anti-inflammatory medicine for more than 7 days without their healthcare provider’s approval. Resting your heel on an ice pack for a few minutes several times a day can also help. Try to cushion your foot. You can do this by wearing athletic shoes, even at work, for awhile. Heel cushions can also be used. The cushions should be worn in both shoes. They are most helpful if you are overweight or an older adult. Your provider may recommend special arch supports or inserts for your shoes called orthotics, either custom-made or off the shelf. These supports can be particularly helpful if you have flat feet or high arches. Your provider may recommend an injection of a cortisone-like medicine. Lose weight if needed. A night splint may be recommended. This will keep the plantar fascia stretched while you are sleeping. Physical therapy for additional treatments may be recommended. Surgery is rarely needed.


Painful Heel






Surgical Treatment


Surgery for plantar fasciitis can be very successful in the right patients. While there are potential complications, about 70-80% of patients will find relief after plantar fascia release surgery. This may not be perfect, but if plantar fasciitis has been slowing you down for a year or more, it may well be worth these potential risks of surgery. New surgical techniques allow surgery to release the plantar fascia to be performed through small incisions using a tiny camera to locate and cut the plantar fascia. This procedure is called an endoscopic plantar fascia release. Some surgeons are concerned that the endoscopic plantar fascia release procedure increases the risk of damage to the small nerves of the foot. While there is no definitive answer that this endoscopic plantar fascia release is better or worse than a traditional plantar fascia release, most surgeons still prefer the traditional approach.






Prevention


While there are no sure ways to prevent plantar fasciitis, these prevention tips may be helpful. Keep your weight under reasonable control. Wear comfortable, supportive shoes. Use care when starting or intensifying exercise programmes.
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