PTTD is a common condition treated by foot and ankle specialists. Although there is a role for surgical treatment of PTTD, conservative care often can prevent or delay surgical intervention.
Decreasing inflammation and stabilizing the affected joints associated with the posterior tibial tendon
can decrease pain and increase functional levels. With many
different modalities available, aggressive nonoperative methods should be considered in the treatment of PTTD, including early immobilization, the use of long-term bracing, physical therapy, and
anti-inflammatory medications. If these methods fail, proper evaluation and work-up for surgical intervention should be employed.
The most common cause of acquired adult flatfoot is posterior tibial tendon dysfunction. What causes adult acquired flat foot? Fracture or dislocation. Tendon laceration. Tarsal Coalition. Arthritis.
Neuroarthropathy. Neurological weakness.
Patients often experience pain and/or deformity at the ankle or hindfoot. When the posterior tibial tendon does not work properly, a number of changes can occur to the foot and ankle. In the earlier
stages, symptoms often include pain and tenderness along the posterior tibial tendon behind the inside of the ankle. As the tendon progressively fails, deformity of the foot and ankle may occur. This
deformity can include progressive flattening of the arch, shifting of the heel so that it no longer is aligned underneath the rest of the leg, rotation and deformity of the forefoot, tightening of
the heel cord, development of arthritis, and deformity of the ankle joint. At certain stages of this disorder, pain may shift from the inside to the outside aspect of the ankle as the heel shifts
outward and structures are pinched laterally.
The history and physical examination are probably the most important tools the physician uses to diagnose this problem. The wear pattern on your shoes can offer some helpful clues. Muscle testing
helps identify any areas of weakness or muscle impairment. This should be done in both the weight bearing and nonweight bearing positions. A very effective test is the single heel raise. You will be
asked to stand on one foot and rise up on your toes. You should be able to lift your heel off the ground easily while keeping the calcaneus (heel bone) in the middle with slight inversion (turned
inward). X-rays are often used to study the position, shape, and alignment of the bones in the feet and ankles. Magnetic resonance (MR) imaging is the imaging modality of choice for evaluating the
posterior tibial tendon and spring ligament complex.
Non surgical Treatment
Footwear has an important role, and patients should be encouraged to wear flat lace-up shoes, or even lace-up boots, which accommodate orthoses. Stage I patients may be able to manage with an off the
shelf orthosis (such as an Orthaheel or Formthotics). They can try a laced canvas ankle brace before moving to a casted orthosis. The various casted, semirigid orthoses support the medial
longitudinal arch of the foot and either hold the heel in a neutral alignment (stage I) or correct the outward bent heel to a neutral alignment (stage II). This approach is meant to serve several
functions: to alleviate stress on the tibialis posterior; to make gait more efficient by holding the hindfoot fixed; and thirdly, to prevent progression of deformity. Devices available to do this are
the orthosis of the University of California Biomechanics Laboratory, an ankle foot orthosis, or a removable boot. When this approach has been used, two thirds of patients have good to excellent
If surgery is necessary, a number of different procedures may be considered. The specifics of the planned surgery depend upon the stage of the disorder and the patient?s specific goals. Procedures
may include ligament and muscle lengthening, removal of the inflamed tendon lining, tendon transfers, cutting and realigning bones, placement of implants to realign the foot and joint fusions. In
general, early stage disease may be treated with tendon and ligament (soft-tissue) procedures with the addition of osteotomies to realign the foot. Later stage disease with either a rigidly fixed
deformity or with arthritis is often treated with fusion procedures. If you are considering surgery, your doctor will speak with about the specifics of the planned procedure.