Posterior Tibial Tendon Dysfunction (PTTD) Cause And Treatment


Overview
Collapsed arches occur in five percent of adults 40 years and older, especially those who are overweight or maintain sedentary lifestyles. At the onset of the condition, adult acquired flatfoot can be controlled with anti-inflammatory medications, physical therapy, taping, bracing, and orthotics. While most cases of adult-onset flatfoot require surgery, congenital flatfoot is an entirely different condition that is best treated with orthotics in children. Ninety percent of children born with flat feet will be fine with conservative treatment.
Flat Feet

Causes
Overuse of the posterior tibial tendon is often the cause of PTTD. In fact, the symptoms usually occur after activities that involve the tendon, such as running, walking, hiking, or climbing stairs.

Symptoms
Symptoms are minor and may go unnoticed, Pain dominates, rather than deformity. Minor swelling may be visible along the course of the tendon. Pain and swelling along the course of the tendon. Visible decrease in arch height. Aduction of the forefoot on rearfoot. Subluxed tali and navicular joints. Deformation at this point is still flexible. Considerable deformity and weakness. Significant pain. Arthritic changes in the tarsal joints. Deformation at this point is rigid.

Diagnosis
The adult acquired flatfoot, secondary to posterior tibial tendon dysfunction, is diagnosed in a number of ways with no single test proven to be totally reliable. The most accurate diagnosis is made by a skilled clinician utilizing observation and hands on evaluation of the foot and ankle. Observation of the foot in a walking examination is most reliable. The affected foot appears more pronated and deformed compared to the unaffected foot. Muscle testing will show a strength deficit. An easy test to perform in the office is the single foot raise. A patient is asked to step with full body weight on the symptomatic foot, keeping the unaffected foot off the ground. The patient is then instructed to "raise up on the tip toes" of the affected foot. If the posterior tibial tendon has been attenuated or ruptured, the patient will be unable to lift the heel off the floor and rise onto the toes. In less severe cases, the patient will be able to rise on the toes, but the heel will not be noted to invert as it normally does when we rise onto the toes. X-rays can be helpful but are not diagnostic of the adult acquired flatfoot. Both feet - the symptomatic and asymptomatic - will demonstrate a flatfoot deformity on x-ray. Careful observation may show a greater severity of deformity on the affected side.

Non surgical Treatment
Orthotic or anklebrace, Over-the-counter or custom shoe inserts to position the foot and relieve pain are the most common non-surgical treatment option. Custom orthotics are often suggested if the shape change of the foot is more severe. An ankle brace (either over-the-counter or custom made) is another option that will help to ease tendon tension and pain. Boot immobilization. A walking boot supports the tendon and allows it to heal. Activity modifications. Depending on what we find, we may recommend limiting high-impact activities, such as running, jumping or court sports, or switching out high-impact activities for low-impact options for a period of time. Ice and anti-inflammatory medications. These may be given as needed to decrease your symptoms.
Adult Acquired Flat Feet

Surgical Treatment
When conservative care fails to control symptoms and/or deformity, then surgery may be needed. The goal of surgical treatment is to obtain good alignment while keeping the foot and ankle as flexible as possible. The most common procedures used with this condition include arthrodesis (fusion), osteotomy (cutting out a wedge-shaped piece of bone), and lateral column lengthening. Lateral column lengthening involves the use of a bone graft at the calcaneocuboid joint. This procedure helps restore the medial longitudinal arch (arch along the inside of the foot). A torn tendon or spring ligament will be repaired or reconstructed. Other surgical options include tendon shortening or lengthening. Or the surgeon may move one or more tendons. This procedure is called a tendon transfer. Tendon transfer uses another tendon to help the posterior tibial tendon function more effectively. A tendon transfer is designed to change the force and angle of pull on the bones of the arch. It's not clear yet from research evidence which surgical procedure works best for this condition. A combination of surgical treatments may be needed. It may depend on your age, type and severity of deformity and symptoms, and your desired level of daily activity.
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