From the Clinic; "My foot was becoming flatter... but it wasn't just fallen arches."

Many people notice changes in the shape of their feet as they get older.

Often they assume it's simply part of ageing or that they have "fallen arches."

Sometimes that's true.

But occasionally a flattening foot is a sign that one of the most important tendons in the foot is beginning to fail.

This patient is a good example of why recognising the early signs can make a significant difference to long-term outcomes.

Patient presentation

A patient attended my clinic complaining of gradually worsening pain along the inside of their ankle and foot.

Initially, the symptoms only occurred after longer walks, but over several months they became noticeable during everyday activities.

The patient had also started to notice that one foot appeared flatter than the other and that shoes no longer seemed to fit quite as comfortably.

Family members had commented that the foot appeared to be "rolling inwards" when walking.

Assessment

Pain on the inside of the ankle can originate from several different structures.

During the assessment I carefully examined the patient's walking pattern, foot posture, joint movement, muscle strength and tendon function.

Particular attention was paid to the tibialis posterior tendon, which plays a vital role in supporting the arch of the foot and controlling foot motion during walking.

Clinical examination demonstrated tenderness along the course of the tibialis posterior tendon together with weakness during single-leg heel raise testing. The affected foot demonstrated early collapse of the medial arch compared with the opposite side.

Diagnostic ultrasound was performed to assess the tendon.

The scan demonstrated thickening of the tibialis posterior tendon with loss of its normal organised fibre appearance, consistent with tendinopathy. Importantly, there was no evidence of a full-thickness tendon rupture.

These findings correlated closely with the patient's symptoms and examination, allowing a confident diagnosis to be made.

The diagnosis explained

The tibialis posterior tendon acts like one of the body's natural support cables.

Its job is to help maintain the arch of the foot while controlling movement during walking and running.

When the tendon becomes overloaded over a prolonged period, it can gradually weaken.

As the tendon loses strength, the arch begins to collapse, placing increasing strain on surrounding joints and ligaments.

If left untreated, this process can progress from a painful tendon problem to a more significant change in foot shape known as Progressive Collapsing Foot Deformity (previously called Adult Acquired Flatfoot).

Fortunately, when identified early, many patients respond well to conservative treatment.

What we did

After discussing the diagnosis, we reviewed why the tendon had become overloaded.

Rather than simply treating the painful area, we considered the mechanics of the entire foot and lower limb.

The patient was reassured that the tendon remained intact and that surgery was not required at this stage.

Instead, treatment focused on improving tendon function while reducing the forces contributing to the overload.

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The treatment plan

Treatment centred around reducing stress on the tibialis posterior tendon while encouraging gradual recovery.

We discussed appropriate footwear, activity modification and a progressive strengthening programme designed specifically for the tendon.

Because changes in foot mechanics were contributing to the problem, custom foot orthoses were also recommended to improve load distribution and reduce stress on the tendon during walking.

The patient was advised that recovery from tendon injuries often takes several months and that consistency with rehabilitation is far more important than expecting rapid improvement.

Regular follow-up appointments were arranged to monitor symptoms, tendon function and foot posture.

What can we learn from this?

Pain along the inside of the ankle should never be ignored.

Whilst many patients assume they simply have "flat feet", the underlying problem may actually be a tendon that is struggling to cope with the demands being placed upon it.

Recognising the condition early often allows successful treatment without surgery.

The longer the tendon continues to weaken, the greater the risk that changes in foot shape become permanent.

My specialist thoughts

One of the most satisfying parts of treating tibialis posterior dysfunction is helping patients understand that they don't simply have "flat feet."

They have a reason why their foot is changing.

Once we identify the tendon responsible, treatment becomes much more logical.

Rather than trying random insoles or simply resting the foot, we can build a programme that protects the tendon, restores strength and improves the way the foot functions.

In my experience, early diagnosis is one of the biggest factors influencing long-term outcome. The sooner we recognise the problem, the greater the opportunity to prevent progression and keep patients active without the need for surgery.

About the author

Mr Liam Stapleton MSc, PGCert, PGDip, FFPM RCPS(Glas), FRCPodM

Mr Liam Stapleton is a Consulting Podiatrist, Independent Prescriber and Specialist in Podiatric Sports Medicine. He has completed postgraduate qualifications in Independent Prescribing, Musculoskeletal Ultrasound, Advanced Clinical Practice, the Theory of Podiatric Surgery, and Podiatric Sports Medicine. His clinical practice focuses on the diagnosis and management of complex foot and ankle conditions, combining detailed clinical assessment with diagnostic ultrasound to provide accurate diagnosis and evidence-based treatment.

If you're struggling with persistent foot or ankle pain and would like a specialist assessment, including diagnostic ultrasound where appropriate, appointments can be booked with Kent Sports Podiatry at clinics across Kent.