The posterior tibial tendon is one of the major supporting
structures of the foot. It functions to
help add stability to the arch, and assists in normal gait fuction. Posterior tibial tendon dysfunction is a
condition caused by changes in the tendon, leading to a loss of this stability
and a flattening of the arch of the foot.
Posterior tibial tendon dysfunction, or PTTD, is often
referred to as “adult-acquired flatfoot”.
This is because PTTD is the most common cause of flatfootedness in
adults. The condition can occur in one
or both of the feet. PTTD is usually a
progressive condition, meaning that the arch will continue to flatten and the
symptoms will worsen over time if not addressed.
PTTD is most often attributed to overuse of the tendon,
although there may be other contributing factors. Inflammatory arthropathies such as rheumatoid
arthritis can contribute to it’s development, as well as injuries to the foot
and ankle, or other bony abnormalities of the foot.
Symptoms of PTTD may include pain, swelling, or redness
around the posterior tibial tendon. This
is located on the medial side of the foot and ankle. As the condition progresses, pain may also
develop in the arch of the foot or the ankle.
Arthritis of the joints of the foot and ankle may develop overtime,
leading to worsening symptoms.
The diagnosis of PTTD or adult-acquired flatfoot is largely
a clinical diagnosis. On physical
examination, the pain may be localized to one or more of the effected
areas. The arch of the foot will usually
appear flattened, and the forefoot may be abducted, or shifted laterally, in
relation to the rearfoot. This is known
as the “too many toes” sign, as the examiner will be able to see more of the
toes from behind the patient on the affected side than on the non-affected
side. Patients with PTTD may also have a
difficult time rising to their toes on the affected side, especially when asked
to rise to their toes using only one leg.
X-rays are typically taken to rule out other potential
causes of pain, such as arthritis, fractures, or dislocations. They also serve as a baseline study to
monitor the progression of the foot and ankle, should the symptoms worsen over
time. If a tear of the tendon is
suspected, an MRI may be useful in determining the extent of the tendon
tear.
Treatment for PTTD will typically begin with conservative
treatment. This will involve things such
as orthotics and other types of braces, anti-inflammatroy medications, and
periods of rest and ice. For patients
with a painful flare-up of symptoms, a period of immobilization may be
beneficial. This would involve the use
of a cast or immobilizing cast boot to protect the foot and ankle. If some of the symptoms are related to
arthritis of the nearby joints, such as the subtalar joint or ankle, a
cortisone injection may be beneficial to relieve some of the pain.
Surgical intervention may be warranted if conservative
treatment fails, or is deemed to not be helping enough in managing pain and
function. Surgical treatment will vary
depending on the symptoms, and the extent of foot and ankle deformity. For patients with symptoms isolated to the
tendon and not involving the surrounding joints, the foot and ankle surgeon may
recommend “cleaning up the tendon” and restoring as much normal anatomy as
possible to the tendon. This is a
procedure that is as minimally invasive as possible for these types of
complaints.
For patients with more advanced pathology, a variety of
approaches may be used. Surgical
techniques may involve repositioning the calcaneus (heel bone), shifting
tendons in the foot, and repositioning the bones and joints of the midfoot to
recreate a more functional foot. Of
course, these methods can vary greatly between patients, and depend on a number
of factors. Factors such as the
patient’s lower extremity anatomy, age, weight, and overall health status
should be considered in the pre-operative work-up.
Surgical reconstruction of the foot and ankle is not without
risk, and a thorough conversation should be had between the patient and doctor
before surgery can be considered. Time
off of work, time to heal, and post-operative expectations of all parties should
be discussed.
Central Florida Foot & Ankle Center, LLC
101 6th Street N.W.
Winter Haven, FL 33881
Phone: 863-299-4551
www.FLFootandAnkle.com
