Posterior Tibial Tendon Dysfunction (PTTD) is a painful flatfoot
condition that affects adults,
primarily over the age of 50. Also known as Adult Acquired Flatfoot, this issue affects women more than men and is linked to obesity, hypertension and diabetes. Most people with PTTD have had flat
feet all of their lives. Then, for reasons not fully understood, one foot starts to become painful and more deformed.
Women are affected by Adult Acquired Flatfoot four times more frequently than men. Adult Flatfoot generally occurs in middle to older age people. Most people who acquire the condition already have
flat feet. One arch begins to flatten more, then pain and swelling develop on the inside of the ankle. This condition generally affects only one foot. It is unclear why women are affected more often
than men. But factors that may increase your risk of Adult Flatfoot include diabetes, hypertension, and obesity.
Posterior tibial tendon insufficiency is divided into stages by most foot and ankle specialists. In stage I, there is pain along the posterior tibial tendon without deformity or collapse of the arch.
The patient has the somewhat flat or normal-appearing foot they have always had. In stage II, deformity from the condition has started to occur, resulting in some collapse of the arch, which may or
may not be noticeable. The patient may feel it as a weakness in the arch. Many patients initially present in stage II, as the ligament failure can occur at the same time as the tendon failure and
therefore deformity can already be occurring as the tendon is becoming symptomatic. In stage III, the deformity has progressed to the extent where the foot becomes fixed (rigid) in its deformed
position. Finally, in stage IV, deformity occurs at the ankle in addition to the deformity in the foot.
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
Non surgical Treatment
Conservative treatment also depends on the stage of the disease. Early on, the pain and swelling with no deformity can be treated with rest, ice, compression, elevation and non-steroidal
anti-inflammatory medication. Usually OTC orthotic inserts are recommended with stability oriented athletic shoes. If this fails or the condition is more advanced, immobilization in a rigid walking
boot is recommended. This rests the tendon and protects it from further irritation, attenuation, or tearing. If symptoms are greatly improved or eliminated then the patient may return to a supportive
shoe. To protect the patient from reoccurrence, different types of devices are recommended. The most common device is orthotics. Usually custom-made orthotics are preferable to OTC. They are reserved
for early staged PTTD. Advanced stages may require a more aggressive type orthotic or an AFO (ankle-foot orthosis). There are different types of AFO's. One type has a double-upright/stirrup attached
to a footplate. Another is a gauntlet-type with a custom plastic interior surrounded be a lace-up leather exterior. Both require the use of a bulky type athletic or orthopedic shoes. Patient
compliance is always challenging with these larger braces and shoes.
If conservative treatments don?t work, your doctor may recommend surgery. Several procedures can be used to treat posterior tibial tendon dysfunction; often more than one procedure is performed at
the same time. Your doctor will recommend a specific course of treatment based on your individual case. Surgical options include. Tenosynovectomy. In this procedure, the surgeon will clean away
(debride) and remove (excise) any inflamed tissue surrounding the tendon. Osteotomy. This procedure changes the alignment of the heel bone (calcaneus). The surgeon may sometimes have to remove a
portion of the bone. Tendon transfer: This procedure uses some fibers from another tendon (the flexor digitorum longus, which helps bend the toes) to repair the damaged posterior tibial tendon.
Lateral column lengthening, In this procedure, the surgeon places a small wedge-shaped piece of bone into the outside of the calcaneus. This helps realign the bones and recreates the arch.
Arthrodesis. This procedure welds (fuses) one or more bones together, eliminating movement in the joint. This stabilizes the hindfoot and prevents the condition from progressing further.