There are four stages of posterior tibial tendon dysfunction
. In the first stage the posterior tibial
tendon is inflamed but has normal strength. There is little to no change in the arch of the foot. In stage two the tendon is partially torn or shows degenerative changes and as a result loses
strength. There is considerable flattening of the arch without arthritic changes in the foot. Stage three results when the posterior tibial tendon is torn and not functioning. As a result the arch is
completely collapsed with arthritic changes in the foot. Stage four is identical to stage three except that the ankle joint also becomes arthritic.
Damage to the posterior tendon from overuse is the most common cause for adult acquired flatfoot. Running, walking, hiking, and climbing stairs are activities that add stress to this tendon, and this
overuse can lead to damage. Obesity, previous ankle surgery or trauma, diabetes (Charcot foot), and rheumatoid arthritis are other common risk factors.
Pain and swelling around the inside aspect of the ankle initially. Later, the arch of the foot may fall (foot becomes flat), this change leads to walking to become difficult and painful, as well as
standing for long periods. As the flat foot becomes established, pain may progress to the outer part of the ankle. Eventually, arthritis may develop.
Observe forefoot to hindfoot alignment. Do this with the patient sitting and the heel in neutral, and also with the patient standing. I like to put blocks under the forefoot with the heel in neutral
to see how much forefoot correction is necessary to help hold the hindfoot position. One last note is to check all joints for stiffness. In cases of prolonged PTTD or coalition, rigid deformity is
present and one must carefully check the joints of the midfoot and hindfoot for stiffness and arthritis in the surgical pre-planning.
Non surgical Treatment
Initial treatment for most patients consists of rest and anti-inflammatory medications. This will help reduce the swelling and pain associated with the condition. The long term treatment for the
problem usually involves custom made orthotics and supportive shoe gear to prevent further breakdown of the foot. ESWT(extracorporeal shock wave therapy) is a novel treatment which uses sound wave
technology to stimulate blood flow to the tendon to accelerate the healing process. This can help lead to a more rapid return to normal activities for most patients. If treatment is initiated early
in the process, most patients can experience a return to normal activities without the need for surgery.
If cast immobilization fails, surgery is the next alternative. Treatment goals include eliminating pain, halting deformity progression and improving mobility. Subtalar Arthroereisis, 15 minute
outpatient procedure, may correct flexible flatfoot deformity (hyperpronation). The procedure involves placing an implant under the ankle joint (sinus tarsi) to prevent abnormal motion. Very little
recovery time is required and it is completely reversible if necessary. Ask your Dallas foot doctor for more information about this exciting treatment possibility.