There is surgery for it.  Oftentimes, before you get to the surgery, the take-home point or the most important thing to do is maintain the flexibility of your foot.  Usually when I see people in stage 2, I tell them it’s important to keep the range of motion of your foot.  If you can keep the flexibility of your foot, then it’s easy to put a brace or arch support in, and a lot of times, your symptoms will be okay.  You start getting a lot of symptoms as your foot collapses, and you start getting a foot deformity where you cannot bring your foot back into the normal alignment for you to walk on it. Usually, as you start getting stiffer, you have more symptoms.  So, in stage 2, one of the first things I do with people is send them to physical therapy.  Physical therapy works hard on their range of motion, trying to get their flexibility back.

Then, depending on how their symptoms respond to that and some do not really want to wear brace long term, there is surgery to reconstruct the tendon. There’s different kinds of surgery, and I’m not going to go into too much detail as to what the surgery is.  The part of the surgery that people have to realize is that it’s not just a surgery where you go in and get fixed, and a week later you’re good.  It’s a surgery that reconstructs your arch.  For me, this is like doing a knee replacement or a hip replacement.  It’s a surgery that you come in the hospital for.  Usually, people stay in the hospital one night, and there is a recovery time involved with it.

You can either try to preserve the joint or preserve the motion in the joint where we do osteotomy where you cut some of the bones and re-align them.  Then, you fix and repair the tendon, and you transfer another tendon to augment it.  That generally works pretty well in younger people who have flexible feet.

As you get stiffer, if the foot is not passibly correctible, we start getting our correction by fusing some of the joints.  So, we’ll go in through the joints, put the bones back where they belong, usually put some screws in to hold it.  Then, we’ll let those joints fuse.  Your foot’s straight, still works where it up and down, but you lose some of the side-to-side motion.  So, we do those in people that become stiff and can’t get their motion back.

This is just an example of one of the ones with the osteotomy.  So, this shows, in the X-ray, the medial column of the foot’s been stabilized with some screws.  Then, we cut the heel bone, shifted it over, and fixed that with some screws.  Again, what you’re doing is re-aligning the arch, and what you can’t see is what we did with the tendon.  The tendon, we fixed, which is right along here.  It attaches on this bone, and once you make a new tendon, the soft tissues will help support the arch.

Then, in the fusions, you see a bunch of screws in this, but basically, we go through these joints.  The joints had collapsed through the subtalar joint, talonavicular joint.  Once those collapse, you go in through the joints, you bring the heel back under the talus and line up the medial column.  You scrape the joints out, you put screws in them, and it stays straight.  That’s a good way for correcting deformity.  You do lose a little bit of the side-to-side motion of your foot.

So, that’s flatfoot or posterior tibial disease in a nutshell.  Does anybody have any questions about that?  Yes?

[18:16]

I think it’s really important to keep your calves well-stretched out.  So, when you go walking or work out or things like that, every day you should work out your calves.  Certain people are more prone to it, people who have a lot of ligamentous laxity. Maintaining the side-to-side range of motion in your feet is important.  There’s not a lot of evidence to show that arch support makes a difference or prevents it, but I don’t know that that means they don’t work.  I just think we haven’t done the study well enough or you need a lot of people to show these make a difference, but arch supports intuitively help.  Probably the most important thing is keeping the mobility of your foot, supporting your arch, stretching the calves out, keeping your weight down helps.  Some people, again, there is a genetic component to it.  When you see patients, it’s amazing.  You’ll see people who have arthritis in their shoulders, hips, and knees, and they’re just genetically predisposed.  I think that’s the same way with tendons.  It’s really common to see both shoulders done, or they get this on both sides.  So, I think there’s a little bit of a genetic component that you really can’t change much.

Did you have a question over there?

[19:58]

I think it’s very common.  I think it’s oftentimes undiagnosed so we see it’s much more common in women.  Usually, the typical age is probably 50 to 65, and typically, a lot of people just have a swollen ankle that hurts.  I see people who have had sorts of testing.  I’ll see people tested for blood clots.  They get nerve test.  They get tested for all sorts of things, and I usually don’t see them.  I usually don’t see them until they start developing a deformity, but it’s diagnosed usually by a physical exam.  Again, it presents in the middle age and is much more common in women.

Yes?

[20:57]

No, venous insufficiency just relates to the blood flow out of the feet, and it doesn’t really have much to do with the ligaments or the bones or the musculoskeletal problem.  That’s more of a vascular problem, but that’s a really common of swelling around the ankles.  I think a lot of times people present with a lot of swelling around the ankles, and people say just that.  They say you have varicose veins or bad circulation in their legs, and there’s not much to do for it.  Usually, that doesn’t hurt a lot.  If you have pain that you can localize to one part of your foot that should tip you off that it’s more than venous insufficiency.  Now, you can have both.

Yes?

[21:56]

I think it contributes to your balance.  It’s kind of like the chicken or the egg. I think when you have this, you don’t have as good a balance.

Yes?

[22:15]

I don’t know that they’re really preventative.  I think they can make the condition not affect you as much, but again, I think there are some genetic factors and factors that have to do with the structure of your foot that make you more prone to get tendon failures. Just like people with fair skin are more like to get a sunburn, there’s people that have tendons and the way that they’re foot is that they’re more likely to have this.

Yes?

[22:57]

It depends on what operation you have so usually I tell people, “My main goal in your surgery is to have your foot straight, have it fit in a shoe, have you off pain medicine, and if you need an arch support, it’s just one of the over-the-counter ones like Dr. Scholl’s.”  Those are usually my goals of the surgery, but generally, especially if you do the fusion, you take away some of the side-to-side motion of your foot.  Some people don’t notice is that much because by the time they get the surgery, they’ve already lost that motion.  So, what you’re doing is you’re restoring the alignment of their foot, and if you differentiate the foot from ankle, what you’re trying to do is line the foot up in the best possible mechanical alignment so your ankle joint doesn’t wear out.

Another application I see fairly commonly is people who have knee replacements.  If you have knock knees, you bend like this for a long time, and then they replace your knee.  They straighten out your knee, and this puts more stress on your foot.  Sometimes, your foot didn’t really hurt before, but now it hurts because the alignment in your knee is different.  The emphasis is restoring the alignment so that it’s in the best mechanical position so that it will last the longest.

Yes?

[24:43]

So, the question was, “If the tendon is injured does it ever go back to normal?”  I think there’s two ways to look at it.  If you’re young and you have a normal foot and you have an injury, oftentimes, that may calm.  If the tendon stretches out and degenerates, usually no matter what you do, the tendon is not going to heal.  So, every once in a while I get someone who’s younger and has an acute injury and you diagnose a posterior tibial tear.  Even in those cases, you rarely just repair it.  You usually augment it with something.

Yes, sir?

[25:45]

He asked if you see the condition in runners.  It’s probably not as much.  It’s much more common in the sedentary, middle aged females, but runners can certainly get tendonitis of their posterior tibial tendon.  Again, runners, depending on how serious they are, they will usually do stretching, keep their feet mobile, and you can usually get it to calm down with arch support.

Okay, so we’ll go on to Achilles tendinosis.  Everybody knows where your Achilles tendon is?  It’s on the back of your ankle and inserts on the back of your heel.  There’s two areas that get involved.  One is where the Achilles attaches to your heel bone or your calcaneus.  That’s, by far, the most common type of tendinopathy.  The other one is up in the mid portion of the tendon.  That is more commonly seen in the active people.  That’s more common in the runners.

The nice thing about the foot and ankle is that it’s very superficial and it’s right under the skin.  Usually, if you know the anatomy and you can poke around and figure out what hurts, you can usually figure out what the problem is.  Again, it’s usually tender where it attached to the bone.  Oftentimes, this is not one where you need an MRI scan.  Usually, you just get a plain X-ray, and the most you’ll on an X-ray is the heel bone here.  You’ll see calcification going up into the tendon bone.  That’s typically what people refer to as a bone spur.  What a bone spur really is it’s where the tendon attaches to the bone, you have these microinjuries.  It’s wearing out, and your body’s trying to make it heal.  As your tries to heal it, it lays down calcium, and you get the bony overgrowth or what you feel is a spur.

A lot of times, what you’ll actually feel on your heel is soft tissue swelling.  You could really have a big bump on the back of your heel, and you’d think it’s all this bony spur.  Usually, it’s just soft tissue, and the spur usually isn’t that big.

So, in this, again, most of these first approaches is non-surgical.  So, we do a lot of physical therapy with the foot.  You want to modify what your activities are.  Usually, any anti-inflammatories like Motrin® or Aleve®.  Putting a heel lift into your shoe changes the movement of the muscle so sometimes that will relieve some pain.  For people who a bump on their heel, it raises your foot up in the show so the back of the shoe just hits you in a different spot.  Sometimes that will give you relief, but we do a lot of stretching.  You can get a pad, these gel pads, you can buy that.  It’s like a sock with a little gel sock in it.  You pull it on, and it has padding on the back of your heel so that your shoe doesn’t rub against it.