What Is Posterior Tibial Tendon Dysfunction ?

Overview The posterior tibial tendon serves as one of the major supporting structures of the foot, helping it to function while walking. Posterior tibial tendon dysfunction (PTTD) is a condition caused by changes in the tendon, impairing its ability to support the arch. This results in flattening of the foot. PTTD is often called ?adult acquired flatfoot? because it is the most common type of flatfoot developed during adulthood. Although this condition typically occurs in only one foot, some people may develop it in both feet. PTTD is usually progressive, which means it will keep getting worse, especially if it isn?t treated early. 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 Observation by a skilled foot clinician and a hands-on evaluation of the foot and ankle is the most accurate diagnostic technique. Your Dallas foot doctor may have you do a walking examination (the most reliable way to check for the deformity). During walking, the affected foot appears more pronated and deformed. Your podiatrist may do muscle testing to look for strength deficiencies. During a single foot raise test, the foot doctor will ask you to rise up on the tip of your toes while keeping your unaffected foot off the ground. If your posterior tendon has been attenuated or ruptured, you will be unable to lift your heel off the floor. In less severe cases, it is possible to rise onto your toes, but your heel will not invert normally. X-rays are not always helpful as a diagnostic tool for Adult Flatfoot because both feet will generally demonstrate a deformity. MRI (magnetic resonance imaging) may show tendon injury and inflammation, but can?t always be relied on for a complete diagnosis. In most cases, a MRI is not necessary to diagnose a posterior tibial tendon injury. An ultrasound may also be used to confirm the deformity, but is usually not required for an initial diagnosis. Non surgical Treatment A patient who has acute tenosynovitis has pain and swelling along the medial aspect of the ankle. The patient is able to perform a single-limb heel-rise test but has pain when doing so. Inversion of the foot against resistance is painful but still strong. The patient should be managed with rest, the administration of appropriate anti-inflammatory medication, and immobilization. The injection of corticosteroids is not recommended. Immobilization with either a rigid below-the-knee cast or a removable cast or boot may be used to prevent overuse and subsequent rupture of the tendon. A removable stirrup-brace is not initially sufficient as it does not limit motion in the sagittal plane, a component of the pathological process. The patient should be permitted to walk while wearing the cast or boot during the six to eight-week period of immobilization. At the end of that time, a decision must be made regarding the need for additional treatment. If there has been marked improvement, the patient may begin wearing a stiff-soled shoe with a medial heel-and-sole wedge to invert the hindfoot. If there has been only mild or moderate improvement, a longer period in the cast or boot may be tried. Surgical Treatment For more chronic flatfoot pain, surgical intervention may be the best option. Barring other serious medical ailments, surgery is a good alternative for patients with a serious problem. There are two surgical options depending on a person?s physical condition, age and lifestyle. The first type of surgery involves repair of the PTT by transferring of a nearby tendon to help re-establish an arch and straighten out the foot. After this surgery, patients wear a non-weight bearing support boot for four to six weeks. The other surgery involves fusing of two or three bones in the hind foot below the ankle. While providing significant pain relief, this option does take away some hind foot side-to-side motion. Following surgery, patients are in a cast for three months. Surgery is an effective treatment to address adult-acquired flatfoot, but it can sometimes be avoided if foot issues are resolved early. That is why it is so important to seek help right away if you are feeling ankle pain. But perhaps the best way to keep from becoming flatfooted is to avoid the risk factors altogether. This means keeping your blood pressure, weight and diabetes in check.

Posterior Tibial Tendon Dysfunction

Overview
Collapsed arches occur in five percent of adults 40 years and older, especially those who are overweight or maintain sedentary lifestyles. At the onset of the condition, adult acquired flatfoot can be controlled with anti-inflammatory medications, physical therapy, taping, bracing, and orthotics. While most cases of adult-onset flatfoot require surgery, congenital flatfoot is an entirely different condition that is best treated with orthotics in children. Ninety percent of children born with flat feet will be fine with conservative treatment.

Causes
Many health conditions can create a painful flatfoot, an injury to the ligaments in the foot can cause the joints to fall out of alignment. The ligaments support the bones and prevent them from moving. If the ligaments are torn, the foot will become flat and painful. This more commonly occurs in the middle of the foot (Lisfranc injury), but can also occur in the back of the foot. In addition to ligament injuries, fractures and dislocations of the bones in the midfoot can also lead to a flatfoot deformity.

Symptoms
Not everyone with adult flatfoot has problems with pain. Those who do usually experience it around the ankle or in the heel. The pain is usually worse with activity, like walking or standing for extended periods. Sometimes, if the condition develops from arthritis in the foot, bony spurs along the top and side of the foot develop and make wearing shoes more painful. Diabetic patients need to watch for swelling or large lumps in the feet, as they may not notice any pain. They are also at higher risk for developing significant deformities from their flatfoot.

Diagnosis
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
There are many non-surgical options for the flatfoot. Orthotics, non-custom braces, shoe gear changes and custom braces are all options for treatment. A course of physical therapy may be prescribed if tendon inflammation is part of the problem. Many people are successfully treated with non-surgical alternatives.

Surgical Treatment
When conservative care fails to control symptoms and/or deformity, then surgery may be needed. The goal of surgical treatment is to obtain good alignment while keeping the foot and ankle as flexible as possible. The most common procedures used with this condition include arthrodesis (fusion), osteotomy (cutting out a wedge-shaped piece of bone), and lateral column lengthening. Lateral column lengthening involves the use of a bone graft at the calcaneocuboid joint. This procedure helps restore the medial longitudinal arch (arch along the inside of the foot). A torn tendon or spring ligament will be repaired or reconstructed. Other surgical options include tendon shortening or lengthening. Or the surgeon may move one or more tendons. This procedure is called a tendon transfer. Tendon transfer uses another tendon to help the posterior tibial tendon function more effectively. A tendon transfer is designed to change the force and angle of pull on the bones of the arch. It's not clear yet from research evidence which surgical procedure works best for this condition. A combination of surgical treatments may be needed. It may depend on your age, type and severity of deformity and symptoms, and your desired level of daily activity.