Posterior Tibial Tendon Dysfunction

Overview
Adult Acquired Flatfoot occurs when the arch of your foot collapses after your skeleton has stopped growing, usually resulting in the foot ?falling? inward with the toes pointing out. This allows your entire sole to touch the ground when you stand, instead of just the outside area. Arches fall for many reasons, including arthritis, injury to the supporting tendons or bones, nerve problems, diabetic collapse, pregnancy, aging, and obesity. A fallen arch doesn?t have to be painful-though as it develops and worsens, it can lead to strain and weakness in the feet that could allow for more uncomfortable foot problems later. Diabetics can develop serious complications from their fallen arches, and need to have their condition evaluated and treated.

Causes
Flat feet causes greater pressure on the posterior tibial tendon than normal. As the person with flat feet ages, the muscles, tendons and ligaments weaken. Blood supplies diminish as arteries narrow. These conditions are magnified for obese patients because of their increased weight and atherosclerosis. Finally, the tendon gives out or tears. Most of the time, this is a slow process. Once the posterior tibial tendon and ligaments stretch, body weight causes the bones of the arch to move out of position. The foot rotates inward (pronation), the heel bone is tilted to the inside, and the arch appears collapsed. In some cases, the deformity progresses until the foot dislocates outward from the ankle joint.

Symptoms
Pain and swelling behind the inside of your ankle and along your instep. You may be tender behind the inner ankle where the posterior tibial tendon courses and occasionally get burning, shooting, tingling or stabbing pain as a result of inflammation of the nerve inside the tarsal tunnel. Difficulty walking, the inability to walk long distances and a generalised ache while walking even short distances. This may probably become more pronounced at the end of each day. Change in foot shape, sometimes your tendon stretches out, this is due to weakening of the tendon and ligaments. When this occurs, the arch in your foot flattens and a flatfoot deformity occurs, presenting a change in foot shape. Inability to tip-toe, a way of diagnosing Posterior Tibial Tendon Dysfunction is difficulty or inability to ?heel rise? (stand on your toes on one foot). Your tibialis posterior tendon enables you to perform this manoeuvre effectively. You may also experience pain upon attempting to perform a heel rise.

Diagnosis
Starting from the knee down, check for any bowing of the tibia. A tibial varum will cause increased medial stress on the foot and ankle. This is essential to consider in surgical planning. Check the gastrocnemius muscle and Achilles complex via a straight and bent knee check for equinus. If the range of motion improves to at least neutral with bent knee testing of the Achilles complex, one may consider a gastrocnemius recession. If the Achilles complex is still tight with bent knee testing, an Achilles lengthening may be necessary. Check the posterior tibial muscle along its entire course. Palpate the muscle and observe the tendon for strength with a plantarflexion and inversion stress test. Check the flexor muscles for strength in order to see if an adequate transfer tendon is available. Check the anterior tibial tendon for size and strength.

Non surgical Treatment
Treating PTTD is almost always easier the earlier you catch it. So, the first step in treatment is to see your doctor as soon as you begin experiencing painful symptoms. However, once your condition has been diagnosed, your podiatrist will likely try to give the upset tendon a bit of a break so it?ll calm down and stop being so painful. This can often be accomplished by immobilizing the foot using tape and padding, braces, or casts, depending on what your podiatrist believes will work best for you, and depending on the severity of your condition. You may also be instructed to reduce inflammation by applying ice to the area (usually 40 minutes on and 20 minutes off, with a thin towel between you and the ice). Or, you might take anti-inflammatory medications like ibuprofen (steroidal anti-inflammatory meds are actually likely to make this problem worse, and are not usually recommended in treating PTTD), or use ultrasound therapy. Once the inflammation has gone down a bit, your podiatrist may recommend using orthotics (prescription shoe inserts) to support your damaged arch. Ankle braces can also be helpful.

Surgical Treatment
For those patients with PTTD that have severe deformity or have not improved with conservative treatments, surgery may be necessary to return them to daily activity. Surgery for PTTD may include repair of the diseased tendon and possible tendon transfer to a nearby healthy tendon, surgery on the surrounding bones or joints to prevent biomechanical abnormalities that may be a contributing factor or both.