Pronation is the term used to describe a natural movement of the foot when walking. When the gait is normal, the heel strikes the ground first. As weight is transferred forward, the arch of the foot flattens and the foot rolls slightly inwards. Body weight is then placed on the ball of the foot and toes, and the foot straightens and turns outwards as the toes push off. Overpronation occurs when the foot rolls inward too far. This causes all the muscles and tendons of the lower leg to twist excessively. Regular overpronation is believed to contribute to the development of many knee, lower leg and foot injuries such as heel spurs, plantar fasciitis, tendinitis and bunions. It is thought that as much as 60% of the population may overpronate.
You do not have to be a runner or athlete to suffer from overpronation. Flat feet can be inherited, and many people suffer from pain on a day-to-day basis. Flat feet can also be traumatic in nature and result from tendon damage over time. Wearing shoes that do not offer enough arch support can also contribute to overpronation.
Symptoms can manifest in many different ways. Here is a list of some of the common conditions associated with over-pronation in children. Achilles Pain. Ankle pain. Arch Pain. Low back pain. Heel Pain. Knee Pain (Runner's knee and Chondromalecia of the patella) Osgood Schlatter Disease (pain below the knee) Shin Splints (pain in the front of the lower leg) Over-pronation does not necessarily mean your child has "flat feet." Even though children's arches may be relatively high when they lie down or sit, over-pronation may not be seen until your child is standing. A certain amount of pronation is normal. During normal walking or running ("gait cycle"), the heel strikes the ground and the foot rolls inward to absorb shock and adapt to the surface. This gait cycle is even more important if the running surface is uneven.
Your healthcare provider will ask about your symptoms, medical history, and activities and examine your feet. Your provider may watch you walk or run. Check the motion of your feet when they strike the ground. Look at your athletic shoes to see if they show an abnormal pattern of wear.
Non Surgical Treatment
Studies have shown that the most effective way to dexrease a high Q angle and lower the biomechanical stresses on the knee joint is to prevent excessive pronation with custom-maflexible orthotics. One study found that using soft corrective orthotics was more effective in reduknee pain than a traditional exercise program. A more recent study showed that Q angle asymmetries, secondary to excessive pronation affecting knee alignment, can be effectivecontrolled or corrected utilizing custom-made, flexible orthotics. Another project involving meof a running club determined that 75% of those using orthotics eliminated or greatly reduced pain in the feet, ankles, shins, knees and hips
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.
Children with Sever's disease, which is also called calcaneal apophysitis, develop microfractures where the Achilles tendon inserts on the calcaneus, the large bone that makes up the heel of the foot. These microfractures cause pain, which can vary depending on the type of activity your child is doing, and is generally worse after activity and improves with rest. Sever's disease is more common in boys and typically occurs when a child is between 8 and 13 years old. Although it can affect both heels, it more commonly just affects one foot.
Mechanically, the heel takes a beating. And the apophyseal bone is located near the point of impact for the heel bone at heel strike and with most weight bearing activities. This includes running, jumping and walking. Heavy impact activities like soccer, football and gymnastics are commonly associated with this problem. In addition to this, there is traction on this apophyseal bone and the associated physeal line of growth cartilage. This traction on the apopysis (island of bone) along with the impact of weight bearing activities can lead to inflammation and pain. Tight Achilles and calf muscles also can contribute to this problem, and why stretching is discussed later.
The typical clinical presentation is an active child (aged 9-10 years) who complains of pain at the posterior heel that is made worse by sports, especially those involving running or jumping. The onset is usually gradual. Often, the pain has been relieved somewhat with rest and consequently has been patiently monitored by the patient, parents, coaches, trainers, and family physicians, in the expectation that it will resolve. When the pain continues to interfere with sports performance and then with daily activities, further consultation is sought. It should be kept in mind that failure to instruct patients and parents that continual pain, significant swelling or redness, and fever are not signs of Sever disease and therefore require further evaluation could result in failure to diagnose a condition with much more serious long-term consequences.
Radiography. Most of the time radiographs are not helpful because the calcaneal apophysis is frequently fragmented and dense in normal children. But they can be used to exclude other traumas. Ultrasonography. could show the fragmentation of secondary nucleus of ossification of the calcaneus in severs?s disease. This is a safe diagnostic tool since there is no radiation. This diagnostic tool can also be used to exclude Achilles tendinitis and/or retrocalcaneal bursitis.
Non Surgical Treatment
Ice the heel(s) well after exercise (until the area is cold and numb!) Stretch hamstring and calf muscles 2-3 times daily (exercises below) REST when pain becomes persistent or moderate (even if it means skipping games or practices.) Anti-inflammatory medication such as ibuprofen. If symptoms persist, your child may need to see a physical therapist for additional exercises, and/or an orthopedist for othotics or temporary casting/crutches if pain is severe. Sever?s disease is self-recovering, meaning that it will go away on its own when the heels are rested or when the bone is through growing. The condition is not expected to create any long-term disability, and expected to subside in 2-8 weeks. However, pain can recur, for example at the start of a new sports season, several times if it is not taken care of.
Recovery time will vary from patient to patient. Age, health, previous injuries, and severity of symptoms will affect recovery time. Your compliance with the stretching program and the other recommendations made by your doctor will also determine your healing time. Heel pain often completely resolves after a child?s heel bone has stopped its period of growth.
This condition is a progressive collapse of the tendons and ligaments that hold up the foot?s arch. This condition most commonly affects women. It typically occurs in only one foot, but in some cases, both feet are afflicted.
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 are minor and may go unnoticed, Pain dominates, rather than deformity. Minor swelling may be visible along the course of the tendon. Pain and swelling along the course of the tendon. Visible decrease in arch height. Aduction of the forefoot on rearfoot. Subluxed tali and navicular joints. Deformation at this point is still flexible. Considerable deformity and weakness. Significant pain. Arthritic changes in the tarsal joints. Deformation at this point is rigid.
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
Icing and anti-inflammatory medications can reduce inflammation and physical therapy can strengthen the tibial tendon. Orthotic inserts that go inside your shoes are a common way to treat and prevent flatfoot pain. Orthotics control the position of the foot and alleviate areas of pressure. In some cases immobilization in a cast or walking boot is necessary to relieve symptoms, and in severe cases surgery may be required to repair tendon damage.
Stage two deformities are less responsive to conservative therapies that can be effective in mild deformities. Bone procedures are necessary at this stage in order to recreate the arch and stabilize the foot. These procedures include isolated fusion procedures, bone grafts, and/or the repositioning of bones through cuts called osteotomies. The realigned bones are generally held in place with screws, pins, plates, or staples while the bone heals. A tendon transfer may or may not be utilized depending on the condition of the posterior tibial tendon. Stage three deformities are better treated with surgical correction, in healthy patients. Patients that are unable to tolerate surgery or the prolonged healing period are better served with either arch supports known as orthotics or bracing such as the Richie Brace. Surgical correction at this stage usually requires fusion procedures such as a triple or double arthrodesis. This involves fusing the two or three major bones in the back of the foot together with screws or pins. The most common joints fused together are the subtalar joint, talonavicular joint, and the calcaneocuboid joint. By fusing the bones together the surgeon is able to correct structural deformity and alleviate arthritic pain. Tendon transfer procedures are usually not beneficial at this stage. Stage four deformities are treated similarly but with the addition of fusing the ankle joint.
Overview Acquired adult flatfoot deformity (AAFD) is a progressive flattening of the arch of the foot that occurs as the posterior tibial tendon becomes insufficient. It has many other names such posterior tibial tendon dysfunction, posterior tibial tendon insufficiency and dorsolateral peritalar subluxation. This problem may progress from early stages with pain along the posterior tibial tendon to advanced deformity and arthritis throughout the hindfoot and ankle. Causes The cause of posterior tibial tendon insufficiency is not completely understood. The condition commonly does not start from one acute trauma but is a process of gradual degeneration of the soft tissues supporting the medial (inner) side of the foot. It is most often associated with a foot that started out somewhat flat or pronated (rolled inward). This type of foot places more stress on the medial soft tissue structures, which include the posterior tibial tendon and ligaments on the inner side of the foot. Children nearly fully grown can end up with flat feet, the majority of which are no problem. However, if the deformity is severe enough it can cause significant functional limitations at that age and later on if soft tissue failure occurs. Also, young adults with normally aligned feet can acutely injure their posterior tibial tendon from a trauma and not develop deformity. The degenerative condition in patients beyond their twenties is different from the acute injuries in young patients or adolescent deformities, where progression of deformity is likely to occur. 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 The history and physical examination are probably the most important tools the physician uses to diagnose this problem. The wear pattern on your shoes can offer some helpful clues. Muscle testing helps identify any areas of weakness or muscle impairment. This should be done in both the weight bearing and nonweight bearing positions. A very effective test is the single heel raise. You will be asked to stand on one foot and rise up on your toes. You should be able to lift your heel off the ground easily while keeping the calcaneus (heel bone) in the middle with slight inversion (turned inward). X-rays are often used to study the position, shape, and alignment of the bones in the feet and ankles. Magnetic resonance (MR) imaging is the imaging modality of choice for evaluating the posterior tibial tendon and spring ligament complex. Non surgical Treatment Because of the progressive nature of PTTD, early treatment is critical. If treated soon enough, symptoms may resolve without the need for surgery and progression of the condition can be stopped. If left untreated, PTTD may create an extremely flat foot, painful arthritis in the foot and ankle, and will limit your ability to walk, run, and other activities. Your podiatrist may recommend one or more of these non-surgical treatments to manage your PTTD. Orthotic devices or bracing. To give your arch the support it needs, your foot and ankle surgeon may recommend an ankle brace or a custom orthotic device that fits into your shoe to support the arch. Immobilization. A short-leg cast or boot may be worn to immobilize the foot and allow the tendon to heal. Physical therapy. Ultrasound therapy and stretching exercises may help rehabilitate the tendon and muscle following immobilization. Medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, help reduce the pain and inflammation. Shoe modifications. Your foot and ankle surgeon may recommend changes in your footwear. Surgical Treatment Surgery should only be done if the pain does not get better after a few months of conservative treatment. The type of surgery depends on the stage of the PTTD disease. It it also dictated by where tendonitis is located and how much the tendon is damaged. Surgical reconstruction can be extremely complex. Some of the common surgeries include. Tenosynovectomy, removing the inflamed tendon sheath around the PTT. Tendon Transfer, to augment the function of the diseased posterior tibial tendon with a neighbouring tendon. Calcaneo-osteotomy, sometimes the heel bone needs to be corrected to get a better heel bone alignment. Fusion of the Joints, if osteoarthritis of the foot has set in, fusion of the joints may be necessary.