Post Tibial Tendon Dysfunction

Post-tibial tendon dysfunction (PTTD) is a painful condition. Without treatment, the collapsed flat foot that develops from PTTD eventually becomes rigid, and arthritis develops in the foot and ankle. Post tibial tendon dysfunction is usually progressive, which means it will keep getting worse, especially if it isn’t treated early. The place to get the right diagnosis and the very best treatment is from the experts at the Colorado Center of Orthopaedic Excellence in Colorado Springs, Colorado. Their experience with PTTD is unmatched.

OVERVIEW

The average adult takes 4,000 to 6,000 steps per day. Considering the weight and stress placed on the feet each day, it’s easy to see how approximately 80% of people will experience a foot-related problem at some point during their lives. Post-tibial tendon dysfunction is also known as posterior tibial tendonitis or posterior tibial tendon insufficiency and is most currently renamed progressive collapsing foot deformity (PCFD). It often occurs in women over 50 and may be due to an inherent abnormality of the tendon. Post tibial tendon dysfunction is the most common cause of adult-acquired flatfoot deformity. Although this condition typically occurs in only one foot, some people may develop it in both feet.

ABOUT TENDONS

Approximately 25% of the bones in the body are found in the feet. The foot is a complex mechanical structure of the human body composed of 33 joints, 26 bones, and over a hundred muscles, ligaments, and tendons that all work together to bear weight, allow for locomotion, and transmit force. Tendons are flexible, cord or rope-like bands of connective tissue that connect muscles to bones. They essentially work as levers to move one’s bones as muscles contract and expand. When one contracts (squeezes) the muscle, the tendon pulls the attached bone, causing it to move. When the tendon is injured or breaks down, it may no longer be able to support the arch, making specific movements difficult. These movements may include standing, walking, running, or standing on the toes.

WHAT IS POST-TIBIAL TENDON DYSFUNCTION?

One of the many tendons is the posterior tibial tendon. This tendon originates in the calf and extends down to the inner part of the ankle, where it is connected to the bone in the middle of the foot. Posterior tibial tendon dysfunction (PTTD) is a condition that leads to inflammation or a tear in the tendon. When the tendon is damaged, it can no longer support the arch of the inside of the foot. There are four posterior tibial tendon dysfunction stages:

Stage I: The tendon is stretched or injured but otherwise intact.
Stage II: The tendon is torn (ruptured) or not working properly. The foot is deformed.
Stage III: The foot is significantly deformed. There are degenerative changes to the connective tissue (cartilage) in the back of the foot.
Stage IV: There are degenerative changes to the ankle joint. In this stage, the ankle and foot both become deformed, and there may be arthritis in the ankle.

The inability of the tendon to support the arch of the foot leads to a condition known as a “flat foot.” The American Academy of Orthopedic Surgeons defines a flat foot as a condition in which the foot’s arch lies flat on the inner side and the foot points outwards. PTTD is often called adult-acquired flatfoot because it is the most common type of flatfoot developed during adulthood.

CAUSES

Overuse of the posterior tibial tendon is often the cause of PTTD.
People who participate in high-impact sports or activities, including football, basketball, soccer, track, tennis, and long-distance running, may tear the tendon from repeated use.
The tendon can be caused by damage from a fall or overuse.
Strong, repetitive forces can injure the posterior tibial tendon.
As one gets older, the tendon can break down.
In people with obesity, additional body weight can cause the tendon to break down faster.
Prior ankle, foot, or joint injuries can also cause the tendon to break down quickly.
Prior surgery is a cause.
Problems with the tendon can occur if one has diabetes, high blood pressure, or has over-abused steroid use.

SYMPTOMS

Pain and swelling along the ankle or inside of the foot

Pain when standing on toes
The ankle rolls inward
The area may be red, warm, and swollen
Difficulty walking on uneven surfaces
Difficulty walking up and down stairs or simply walking
A previous limp that gets worse
Unusual or uneven wear on shoes
A flattening of the arch and inward rolling of the ankle
As post-tibial tendon dysfunction becomes more advanced, the arch flattens even more, and the pain often shifts to the outside of the foot, below the ankle.
If the tendon has deteriorated considerably, arthritis often develops in the foot. In more severe cases, arthritis may also develop in the ankle.

NON-SURGICAL TREATMENTS

The treatment a surgeon recommends will depend on how far the condition has progressed. In the early stages, more conservative approaches include:

Rest: stop participating in activities that cause or worsen the pain. Low-impact exercises can help maintain overall health without affecting the tendon. These include bicycling, yoga, elliptical training, and swimming.
Ice: apply an ice pack covered in a light towel to the most painful areas of your foot or ankle for up to 20 minutes three or four times a day.
Medications: over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen, and naproxen, will reduce pain and inflammation.
Physical therapy: physical therapy exercises can strengthen the tendon.
One may be prescribed a walking boot, cast, or custom orthotic brace specifically molded to the foot.
Orthotic devices or bracing. To give the arch the support it needs, the patient may be provided an ankle brace or a custom orthotic device that fits into the shoe.
Immobilization. Sometimes, a short-leg cast or boot is worn to immobilize the foot and allow the tendon to heal, or one may need to completely avoid all weight-bearing for a while.

WHEN IS SURGERY INDICATED?

If post-tibial tendon dysfunction is left untreated, treated too late, or in cases of PTTD that have progressed substantially, surgery may be the only option. Key indicators for surgery include:

Persistent pain and disability: despite non-surgical treatments, the patient experiences significant pain, swelling, and functional limitations in the foot and ankle.
Surgery may be an option with a recently broken, fractured, or dislocated ankle.
Surgery may also be done for long-term (chronic) inflammation from overuse.
Progressive deformity: when the condition advances to a later stage (Stage II or beyond), and the patient develops flatfoot deformity, tendon degeneration, or arthritis, surgery may be needed to restore foot alignment.
Tendon rupture or severe damage: in cases where there is a partial or complete tear of the posterior tibial tendon, surgery is often indicated to repair or reconstruct the tendon.

There are different surgical options for PTTD, which can be discussed with your surgeon.

GETTING THE RIGHT DIAGNOSIS. GETTING THE RIGHT DOCTOR.

Post-tibial tendon dysfunction isn’t simply about getting a diagnosis but an accurate diagnosis from a skilled and seasoned orthopedic specialist. One who can be counted on to avoid the pitfalls of ineffective treatment strategies and unsuccessful surgeries. At the Colorado Center of Orthopaedic Excellence in Colorado Springs, Colorado, you’ll find renowned surgeons who are foremost in their field. To the attentive and caring surgeons at Advanced Orthopedics, the right diagnosis isn’t just what it is but what it isn’t. For example, because the tibialis posterior tendon runs close to the Achilles tendon, this condition can sometimes be confused with Achilles tendinopathy. While X-rays, CT scans, MRIs, and ultrasounds may be ordered to give important information to the surgeon, special addition tests may be ordered. At CCOE, their knowledgeable and highly proficient surgeons offer the most advanced treatment options for post-tibial tendon dysfunction. At CCOE, they make the future outcomes of their patients a priority, giving them the highest level of individualized care, with the goal of helping them get back to full activity and life as usual.