Dr. Sonam Ruit of Martin Foot and Ankle of York, Lancaster, Hanover and Shrewsbury, PA  has written an article on the following subject:

Adult Acquired Flat Foot Deformity (or Posterior Tibial Tendon Dysfunction)

by Sonam Ruit, D.P.M.

This is a flat foot deformity seen on adults due to progressive weakening of the tendon overlying the inside of the ankle known as posterior tibial tendon. This is an extremely important tendon of the foot and ankle, arising from the back of the leg and attaches to multiple sites in the foot, primarily at the inside hindfoot bone known as Navicular. It acts as a stirrup to hold the arch up and provides good inside ankle stability as well as restores our normal arch height. As this tendon weakens, the arch slowly starts to collapse, initially easily controlled with good custom orthotics and proper rehab of the weakened tendon. However as the tendon weakens and is left untreated for a long period of time, the foot then takes a more rigid form of flat foot along with associated arthritic changes due to malposition of the joints. This will lead to abnormal gait, increased pain, inflammation, fatigue, swelling along the tendon, as well as, along the arch, and joints of the ankle, hindfoot and mid foot.

Adult acquired flat foot deformity or PTTD has no single causation, rather it is multifactorial. Of many, the two primary causes are trauma (or acute rupture) of the posterior tibial tendon and chronic degeneration or progressive untreated childhood flatfoot and tight calf muscles. This then leads to chronic weakening (or slow loss) of tendon strength giving rise to complete rigid flat foot deformity at later ages. There are different stages of flat foot deformity, stage I, II, III and IV.  Stage I being mild and Stage IV being severe with degenerative arthritis and ankle involvement.

Early detection and treatment of posterior tibial tendon dysfunction can keep the deformity from progressing to further stages in the adult flat foot scheme. Conservative treatment is often able to decrease pain and the progression of flat foot deformity. Conservative treatments range from anti-inflammatory meds, biomechanical stabilization with proper custom molded orthotics, PTTD bracing, rehab to strengthen the posterior tibial tendon and calf stretching regimen. Slightly more symptomatic patients will also need temporary immobilization in a boot or casts and then will resume rehab and transition into regular shoes with orthotics. However, complex flat foot deformities that fail all conservative measures will require surgical intervention. There are a wide variety of surgical procedures and will depend on the severity of the deformity. Surgical procedures range from simple tendon augmentation, transfer, bone realignment to corrective fusion procedures along with release of the calf muscle. Therefore seeing the proper physician, getting early diagnosis and early treatment can make a huge impact in the quality of your life in the later years.

Sonam Ruit, D.P.M.

Martin Foot and Ankle's own Dr. Bronwyn Wilke has recently taken a trip with her husband, Eric, to Africa, where they hiked to the top of Mount Kilimanjaro. Kilimanjaro is the highest mountain in Africa and a goal for many to achieve climbing during their life time. African Travel Resource states, "The trek to the summit is a magnificent and spectacular 5 to 9 night undertaking, to rank amongst the greatest outdoor challenges on the planet." 

Dr. Wilke recently read a Blog article (see link below) about a group who also climbed Kilimanjaro.  But they did it barefoot.  Below are her reflections and comments about her wonderful adventure and what her feet experienced,  as well as her thoughts on climbing barefoot.

http://www.grindtv.com/outdoor/blog/32592/climbing+expedition+a%20ttains+summit+of+mt+kilimanjaro--barefooted/

Dr. Wilke writes:

Several months of shopping and then breaking in my boots.  Four and a half days up where the terrain included mud (in the rainforest), sand, rocks, shale and snow and ice up on the glacier.  Summit night -  I vividly remember the stinging, burning pain of the ice cold wind as it snuck into every crevice it could find.  I was extremely thankful for my waterproof north face boots, sock liners and smartwool socks.  Although it was as the sun was rising, I was very aware when the warmers in my boots and gloves cooled after reaching their 8 hour limit. A day and a half down initially sliding down the scree or loose gravel for four hours then again climbing over rocks and into the sand and mud of the rainforest. 

This is how my feet experienced 30 miles of climbing Mt. Kilimanjaro last month.  On the last day of the descent I can imagine going barefoot would have felt great, relieving the jamming of toes into the front end of my boots, sinking into the soft warm mud of the rainforest. Aside from those final hours, my boots were one of the most important pieces of equipment I had on the mountain (second only to my husband). Reading about barefoot climbers is amazing and risky. As a climber I am thoroughly impressed by their achievement. Clearly the Old Mutual Barefoot Kilimanjaro Team did their due diligence in preparing and toughening their feet.  As a physician I could not recommend this to anyone due to the associated risks of injury. A simple cut or scrape could prematurely end the climb - a devastating end to months of preparation and investment.  The risk of cold injury and frost bite in the extreme environment of the summit is significant and could result in loss of a digit or chronic pain.

Article written by Dr. Bronwyn Wilke, D.P.M

I recently read an article by a woman's fashion magazine listing shoes that every woman should have.  I was stunned that sneakers did not make the list!  A good solid walking/hiking athletic shoe is number one on my list of must have shoes.  Athletic shoes are the one line of shoegear that is focused on function and has research dedicated to product performance.  I appreciate that the basis of the article was fashion.  What woman doesn't have her glam moments?  But for every moment of glamour and less than practical shoe choices there is a moment of relief when the shoes are taken off.  If you've strutted in pumps you appreciate the NYC exec who runs to appointments in her suit and sneakers with her dress shoes in her purse.  If you have danced in peep toes or platforms you understand Kim William's character wearing sneakers under her wedding gown in "Father of the Bride".  No matter how gorgeous the shoe it cannot be sexy if you have to limp.  As a lover of stilletos, pumps, peep toes, sandals and boots I must draw attention to the unsung hero of every womans closet - the sneaker.  If you are having trouble finding a sneaker that is right for you, your foot health professional will give you guidance on foot deformity and appropriate sneaker choices.  Come see us in York, Lancaster, Shrewsbury, or Hanover.  We are Podiatrists that specialize in you.

Article written by:    Maria Kasper, D.P.M. and Sonam Ruit, D.P.M.

For all you Jeopardy fans, we have a few answers:

Question 1:  It is a large ropelike band of tissue that connects the calf muscle to the back of the heel.

 Answer 1:  What is the achilles tendon?

Question 2:  He is now called the "destroyer of evil" after injuring his leg while chasing a burgler from his hotel room.

   Answer 2: Who is Alex Trebek?

That is correct.....on Tues, the 71 yo Trebek chased a burgler from his San Franscio hotel room after she allegedly stole cash and jewlery from him.  Trebek was staying with his wife in the hotel room while hosting the National Geographic Geography Bee.  Unfortunately, during the incident, while chasing the burgler down the hall Trebeck snapped his Achilles tendon. 

He is likely to require surgery to repair the tendon.

Achilles tendonitis is a painful and often debilitating inflammation of the Achilles tendon (heel cord).  It is located in the back of the lower leg, attaches to the heel bone (calcaneus),  and connects the leg muscles to the foot. The Achilles tendon gives us the ability to rise up on our toes, facilitating the act of walking.  Achilles tendonitis can make walking almost impossible due to the pain associated with it.

            Who is more prone to Achilles tendon injuries or tendonitis?

Poorly conditioned athletes are at the highest risk for developing Achilles tendonitis. Participating in activities that involve sudden stops and starts and repetitive jumping (e.g., basketball, tennis, dancing) increases the risk for the condition. It often develops following sudden changes in activity level, training on poor surfaces, or wearing inappropriate footwear. Achilles tendonitis may be caused by a single incident of overstressing the tendon, or it may result from a series of stresses that produce small tears over time (overuse).

The condition also may develop in people who exercise infrequently and in those who are just beginning an exercise program.    It is important for people who are just starting to exercise to stretch properly, start slowly, and increase gradually.

Women who wear high-heeled shoes often and switch to sneakers for exercise also can develop Achilles tendonitis.  High heels have allowed the Achilles tendon and lower leg muscles to gradually adapt to a shortened and contracted position.  When this happens, wearing sneakers or flat shoes forces the Achilles tendon to stretch further than it is accustomed to, causing inflammation.  If high heels are worn every day, stretching should be done every morning and night to keep the Achilles tendon lengthened.

The symptoms associated with Achilles tendonitis and tendonosis include:

• Pain—aching, stiffness, soreness, or tenderness—within the tendon. This may occur anywhere along the tendon’s path, beginning with the narrow area directly above the heel upward to the region just below the calf muscle. Often pain appears upon arising in the morning or after periods of rest, then improves somewhat with motion but later worsens with increased activity.
• Tenderness , or sometimes intense pain, when the sides of the tendon are squeezed.  There is less tenderness, however, when pressing directly on the back of the tendon.
• When the disorder progresses to degeneration, the tendon may become enlarged and may develop nodules in the area where the tissue is damaged.

If damage to the tendon is minor, the injury may respond to a simple course of treatment known as RICE (rest, ice, compression, elevation).

Patients are advised to:

• RESTthe tendon by keeping off their feet as much as possible;
• Apply ICE packs for 20 minutes at a time every hour for a day or two to reduce swelling;
• COMPRESS the ankle and foot with a firmly (not tightly) wrapped elastic bandage; and
• ELEVATEthe foot whenever possible to minimize swelling.

A nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen may be used to reduce pain, swelling, and inflammation. if mild Achilles tendonitis does not respond to basic treatment, or if symptoms return with the resumption of physical activity, a flexible cast may be used to immobilize the foot and reduce swelling, and crutches may be used to keep weight off the foot. This treatment may be necessary for up to 6-8 weeks .  Martin Foot and Ankle can provide Physical therapy and rehabilitation, which is also very essential in the treatment and management of Achilles tendonitis, to gradually stretch the tendon before full activity is resumed. 

When conservative therapy fails for severe Achilles tendonitis, Martin Foot and Ankle may recommend surgery at their surgical center located on S. Queen St. in York, PA. Surgery involves removing the tendon's inflamed outer covering and reattaching the torn tissues. Following surgery, the patient is immobilized in a cast or splint for 2-3 weeks, and then undergoes passive range of motion physical therapy and progressive strengthening exercises for the next 4-6wks. Most activities can be resumed in 6–10 weeks and competitive sports usually can be resumed after 3–6 months.

How can we prevent such problems?

Proper conditioningand appropriate footwear are the best defense against Achilles tendonitis. People who engage in physical activity should always warm up and stretch properly before beginning the activity. If discomfort occurs, the activity should be discontinued immediately and ice should be applied to the affected area to relieve inflammation. If the problem persists or recurs, medical evaluation by a foot and ankle specialist is necessary. It may be advisable to consult a physical trainer to determine whether a flaw in technique is contributing to the problem as well.

Martin Foot and Ankle,

Podiatrist in Lancaster, PA, York, PA, Hanover, PA and Shrewsbury, PA