Posterior Tibial Tendon Dysfunction
The posterior tibial tendon is one of the most important tendons of the leg which attaches the calf muscle to the bones on the inside of the foot. The main function of the posterior tibial tendon is to hold up the arch and provide support to the foot while walking.
Posterior tibial tendon dysfunction, commonly referred to as acquired adult flatfoot deformity is a chronic foot condition where the soft issues on the inside of the foot and ankle are subject to repetitive pressure during standing and walking. Posterior tibial tendon dysfunction occurs when the posterior tibial tendon becomes inflamed or torn and as a result the tendon is no longer able to provide stability and support for the arch of the foot, resulting in flatfoot. Flatfeet can sometimes cause problems in ankles and knees since the condition can alter optimal alignment of the legs.
Some of the most common symptoms of posterior tibial tendon dysfunction are as follows:
- Pain in the affected foot triggered or worsened by any physical activity
- Trouble walking or standing for extended periods of time
- Pain along the inside of the foot and ankle with possible swelling
- Pain along the outside of the ankle due to excessive pressure
Not all flatfoot deformities result from problems with the posterior tibial tendon. A flat foot can be a normal variant and does not necessarily need treatment if it is not painful and does not limit function. However, if there is pain associated with the physical appearance of a flatfoot, a visit to the physician to rule out posterior tibial tendon dysfunction is highly recommended.
Diagnosis of posterior tibial tendon dysfunction is generally made on physical examination. The physician will examine the foot for the symptoms mentioned above in addition to tenderness over the tendon and the inside of the ankle. They physician may ask the individual to stand on his/her toes in order to view the mechanics of the feet. Additionally, looking at the wear pattern of the shoes might help diagnosis. The physician may order an X-ray of the foot to help identify the severity of the collapse.
Posterior tibial tendon dysfunction is classified into four stages:
First Stage - This stage is characterized by inflammation caused by an irritated posterior tibial tendon which is still functional, but may be painful and swollen.
Second Stage - This stage is characterized by a torn posterior tibial tendon where there is a change in the alignment of the foot and performing single-heel raises is difficult at best. However, it's possible to restore proper, "normal" position.
Third Stage - This stage is characterized by a stiff, flat foot due to arthritis and restoring "normal" position is not possible.
Fourth Stage - This stage is characterized by severe arthritis where the foot has been flat for a long time and has started to affect the ankle joint.
The treatment approach for posterior tibial tendon dysfunction depends on the stage and severity of the condition. No treatment is necessary if there is no associated pain; however, if the flatfoot is causing pain and uneasiness, there are non-operative and operative treatment options. Appropriate non-operative treatments will relieve most symptoms and is always the first method of treatment. Operative treatments should only be considered after trying more-conservative approaches.
Rest - It is advised to decrease or completely stop the activity that makes the pain worse. A great way to stay active while allowing the symptoms to subside is to switch to low-impact, cross-training activities such as biking, elliptical machines, or swimming.
Ice - Placing ice (with a barrier such as a towel) on the most painful areas of the posterior tibial tendon for up to 30 minutes (less if the skin becomes numb) three to four times a day can greatly soothe the pain and keep the swelling down.
Medication - Over-the-counter medication such as ibuprofen and naproxen usually help reduce pain and swelling. If these are deemed insufficient by your physician, they might prescribe stronger medication to relive pain and reduce inflammation. These medications will reduce pain, but will not reduce the degeneration of the posterior tibial tendon.
Physical Therapy - Physical Therapists will often prescribe specific strengthening and stretching exercises that promote healing and strengthening of the posterior tibial tendon. They might even recommend orthotic devices such as a shoe insert to relieve pressure and strain on the posterior tibial tendon and distribute the pressure more evenly. If your pain is severe, your physician or physical therapist may recommend an ankle brace for some time to take the pressure off the posterior tibial tendon.
Surgery - Surgery should only be considered if the pain does not improve after six months of nonsurgical treatments. The specific type of surgery depends on the severity of the posterior tibial tendon dysfunction and should be discussed with the physician extensively when the need is identified. Some common operative treatments are:
- Tenosynovectomy - This procedure involves a cleaning-out process of the posterior tibial tendon. This procedure helps reduce the inflammation and pain, but the posterior tibial tendon may continue to degenerate and the pain might return.
- Osteotomy - This procedure involves cutting and moving of bones within the foot in an attempt to recreate a "normal" arch. If the posterior tibial tendon dysfunction is severe, a bone graft may be required to lengthen the outside of the foot; screws or plates may be used to reinforce the bone graft.
- Gastrocnemius Recession - This is a surgical lengthening of the calf muscles and is beneficial for patients who have limited range of motion of the ankle joint. This procedure prevents the posterior tibial tendon dysfunction or flatfoot from recurring, but has the potential to create some weakness with climbing stairs or pushing off.
- Tendon Transfer - In this procedure, another tendon from the foot is attached to the diseased posterior tibial tendon. If the disease is severe, the posterior tibial tendon is removed and replaced with the transfer tendon.
- Arthrodesis - This procedure is essentially a fusion of the joints in the back of the foot as a means to realign the foot and make it more "normal." This often requires the removal of any remaining cartilage in the joint. Since this procedure glues the joints together into a larger bone, side-to-side motion is completely lost after this operation.
Recovery varies based on the treatment approach most non-operative treatments require upwards of six months for symptoms to subside. Recovery from operative treatments varies based on the procedure and the individual's condition. Each patient is unique and their recover will depend on the treatment method prescribed by the physician, but it may be 12 months before there is any great improvement in pain.
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