This condition is characterized by a progressive flattening or falling of the arch. It is often referred to as posterior tibial tendon dysfunction (PTTD) and is becoming a more commonly recognized
foot problem. Since the condition develops over time, it is typically diagnosed in adulthood. It usually only develops in one foot although it can affect both. Since it is progressive, it is common
for symptoms to worsen, especially when it is not treated early. The posterior tibial tendon attaches to the bones on the inside of your foot and is vital to the support structure within the foot.
With PTTD, changes in the tendon impair its ability to function normally. The result is less support for the arch, which in turn causes it to fall or flatten. A flattening arch can cause the heel to
shift out of alignment, the forefoot to rotate outward, the heel cord to tighten, and possible deformity of the foot. Common symptoms include pain along the inside of the ankle, swelling, an inward
rolling of the ankle, pain that is worse with activity, and joint pain
as arthritis sets in.
The cause of posterior tibial tendon insufficiency is not completely understood. The condition commonly does not start from one acute trauma but is a process of gradual degeneration of the soft
tissues supporting the medial (inner) side of the foot. It is most often associated with a foot that started out somewhat flat or pronated (rolled inward). This type of foot places more stress on the
medial soft tissue structures, which include the posterior tibial tendon and ligaments on the inner side of the foot. Children nearly fully grown can end up with flat feet, the majority of which are
no problem. However, if the deformity is severe enough it can cause significant functional limitations at that age and later on if soft tissue failure occurs. Also, young adults with normally aligned
feet can acutely injure their posterior tibial tendon from a trauma and not develop deformity. The degenerative condition in patients beyond their twenties is different from the acute injuries in
young patients or adolescent deformities, where progression of deformity is likely to occur.
Depending on the cause of the flatfoot, a patient may experience one or more of the different symptoms here. Pain along the course of the posterior tibial tendon which lies on the inside of the foot
and ankle. This can be associated with swelling on the inside of the ankle. Pain that is worse with activity. High intensity or impact activities, such as running, can be very difficult. Some
patients can have difficulty walking or even standing for long periods of time. When the foot collapses, the heel bone may shift position and put pressure on the outside ankle bone (fibula). This can
cause pain on the outside of the ankle. Arthritis in the heel also causes this same type of pain. Patients with an old injury or arthritis in the middle of the foot can have painful, bony bumps on
the top and inside of the foot. These make shoewear very difficult. Occasionally, the bony spurs are so large that they pinch the nerves which can result in numbness and tingling on the top of the
foot and into the toes. Diabetics may only notice swelling or a large bump on the bottom of the foot. Because their sensation is affected, people with diabetes may not have any pain. The large bump
can cause skin problems and an ulcer (a sore that does not heal) may develop if proper diabetic shoewear is not used.
The diagnosis of posterior tibial tendon dysfunction and AAFD is usually made from a combination of symptoms, physical exam and x-ray imaging. The location of pain, shape of the foot, flexibility of
the hindfoot joints and gait all may help your physician make the diagnosis and also assess how advanced the problem is.
Non surgical Treatment
Because of the progressive nature of PTTD, early treatment is critical. If treated soon enough, symptoms may resolve without the need for surgery and progression of the condition can be stopped. If
left untreated, PTTD may create an extremely flat foot, painful arthritis in the foot and ankle, and will limit your ability to walk, run, and other activities. Your podiatrist may recommend one or
more of these non-surgical treatments to manage your PTTD. Orthotic devices or bracing. To give your arch the support it needs, your foot and ankle surgeon may recommend an ankle brace or a custom
orthotic device that fits into your shoe to support the arch. Immobilization. A short-leg cast or boot may be worn to immobilize the foot and allow the tendon to heal. Physical therapy. Ultrasound
therapy and stretching exercises may help rehabilitate the tendon and muscle following immobilization. Medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, help reduce the
pain and inflammation. Shoe modifications. Your foot and ankle surgeon may recommend changes in your footwear.
Surgical treatment should be considered when all other conservative treatment has failed. Surgery options for flatfoot reconstruction depend on the severity of the flatfoot. Surgery for a flexible
flatfoot deformity (flatfoot without arthritis to the foot joints) involves advancing the posterior tibial tendon under the arch to provide more support and decrease elongation of the tendon as well
as addressing the hindfoot eversion with a osteotomy to the calcaneus (surgical cut in the heel bone). Additionally, the Achilles tendon may need to be lengthened because of the compensatory
contracture of the Achilles tendon with flatfoot deformity. Flatfoot deformity with arthritic changes to the foot is considered a rigid flatfoot. Correction of a rigid flatfoot deformity usually
involves surgical fusion of the hindfoot joints. This is a reconstructive procedure which allows the surgeon to re-position the foot into a normal position. Although the procedure should be
considered for advanced PTTD, it has many complications and should be discussed at length with your doctor.