Adult Acquired Flatfoot - Posterior Tibial Tendon Dysfunction (PTTD)

Left Adult Flat Foot

Adult Flat Foot

Posterior Tibial Tendon Dysfunction (PTTD) is typically caused by a problem with a tendon on the medial side of your foot called the Posterior Tibial Tendon that is not functioning well. As a result, the tendon may not be able to provide stability and support for the arch of the foot, resulting in flatfoot. 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.

The posterior tibial tendon attaches the calf muscle to the bones on the inside of the foot. The main function of the tendon is to hold up the arch and support the foot when walking.

Patient may experience pain in the inner side of the foot when walking. The affected foot appears to roll outwards (the sole of the foot is trying to face outwards) when walking. This is called over-pronation of the foot. And the back of the heel may start to point outwards (heel valgus). Over time, the ability to tip toe on that foot as the posterior tibial tendon stretches out may be lost and the tendon may eventually tear.

Collapse of Medial Arch

Collapse of Medial Arch

Symptom

Signs and Symptoms of Posterior Tibial Tendon Dysfunction (PTTD) include:

  • Loss of arch height.
  • Swelling to medial ankle (along the course of the tendon).
  • Inability to rise on the toes (single heel raise).
  • Pain to medial ankle where the tendon lies during weight bearing. This may or may not be associated with swelling in the area.
  • Lateral foot pain (sinus tarsi pain).
  • Inward rolling of the ankle with outward rolling of the heel bone.
  • Toes starting to point towards the outside.
  • Pain that is worse with activity. High-intensity or high-impact activities, such as running, can be very difficult. Some patients can have trouble walking or standing for a long time.

Posterior Tibial TendonCause

The posterior tibial tendon can be injured from:

  • Overuse.
  • Not wearing supportive shoes.
  • Foot sprain / trauma e.g.acute injury from a fall can tear the tendon or cause it to become inflamed.
  • Engaging in activities that involves the tendon: running, walking and climbing.

It is more common in women and in people older than 40 years of age. Additional risk factors include obesity, diabetes, and hypertension.

Treatment

PTTD is a progressive condition. Early treatment is needed to prevent relentless progression to a more advanced disease which can lead to more problems for that affected foot.

Non-Surgical Treatment

  • Rest:
    Reducing or even stopping activities that worsen the pain is the initial step.
    Switching to low-impact exercise such as cycling, elliptical trainers, or swimming is helpful.
    These activities do not put a large impact load on the foot.
  • Ice:
    Apply cold packs on the most painful area of the posterior tibial tendon frequently to keep down the swelling. Placing ice over the tendon immediately after completing an exercise helps to decrease the inflammation around the tendon.
  • Nonsteroidal Anti-inflammatory Medication (NSAIDS):
    Drugs, such as arcoxia, voltaren and celebrex help to reduce pain and inflammation. Taking such medications prior to an exercise activity helps to limit inflammation around the tendon. However, long term use of these drugs can be harmful to you with side effects including peptic ulcer disease and renal impairment or failure.
  • Casting:
    A short leg cast or walking boot may be used for 6 to 8 weeks in the acutely painful foot. This allows the tendon to rest and the swelling to go down. However, a cast causes the other muscles of the leg to atrophy (decrease in strength) and thus is only used if no other conservative treatment works.
  • Foot Insoles/Orthotics:
    Most people can be helped with orthotics and braces. An orthotic is a shoe insert. It is the most common non-surgical treatment for a flatfoot and it is very safe to use. A custom orthotic is required in patients who have moderate to severe changes in the shape of the foot. The custom orthotic is more costly, but it allows the doctor to better control the position the foot. Customised insoles are available at our clinic.
  • Physiotherapy:
    Physiotherapy helps to strengthen the injured tendon and it can help patients with mild to moderate disease of the posterior tibial tendon.

Surgical Treatment

Surgery should only be done if the pain does not get better after a few months of conservative treatment.

The type of surgery depends on the stage of the PTTD disease. It it also dictated by where tendonitis is located and how much the tendon is damaged.

Surgical reconstruction can be extremely complex.

Some of the common surgeries include:

  • Tenosynovectomy – removing the inflamed tendon sheath around the PTT.
  • Tendon Transfer – to augment the function of the diseased posterior tibial tendon with a neighbouring tendon.
  • Calcaneo-osteotomy – sometimes the heel bone needs to be corrected to get a better heel bone alignment.
  • Fusion of the Joints – if osteoarthritis of the foot has set in, fusion of the joints may be necessary.
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