You will see many patients come into your office with flat feet. Being flexible and flat footed is in fact a relatively normal and common problem. The problem arises when it becomes painful and particularly when it prevents you from walking or preforming everyday activities.

Consider this case; Joan, a 65 year old lady who plays golf at the local club comes to see you. She tell you that her foot was asymptomatic until about a month ago when it became quite painful. She points mainly to the inside of the foot in this situation.

You ask her to stand up and she has the “too many toes sign”. This is a common sign and is usually an indication of failure of the tibialis posterior tendon. When you look at her foot from behind, it looks different from one foot to the other.

You ask her to stand on her toes and she can’t really do it partly because it is painful and partly because she can’t simply stand on her toes on the affected side. This is a common issue with tibialis posterior failure.

The correct thing to do in this situation is to take an x-ray standing. It should be done in the AP and lateral projections.

Quite commonly, people will settle down given an opportunity to rest in a boot. A boot of this sort will be given to her by a physiotherapist.

Sometimes anti-inflammatory medication is useful, as well as ice and local therapy.

If it fails to settle and Joan is still in pain and can’t seem to play golf still, then it would be wise to consider an MRI scan. Ultra sound is of limited use in this situation, it is advisable to obtain the correct diagnoses.

Of course, tibialis posterior dysfunction or rupture is not the only cause of the problem, she may have arthritis of the subtailor joint or other issues involving general tendons in the foot.

In any event, the most common issue here is tibialis posterior pathology. The tibialis posterior tendon has a poor blood supply, you may recall it stretches around the back and inserts into the molecular.

The tendon can stretch over a long period of time but can also spontaneously rupture. It may also be associated with an accessory bone.

In any event, if the matter fails to settle, she may have to have to see foot medical surgeon like myself to determine the next surgical step. As I suggested earlier, some settle down, however if it raptures completely, the matter will require surgery.

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