Posterior Tibial Tendon Dysfunction
What Are Flat Feet?
“Flat feet” is a loose term that defines the lack of height of the inner arch as compared to the normal arch. There are varying degrees of how flat an arch can become. Not all flat feet are created equal. Some low arches are flexible, meaning that the arch can be manipulated and flexed, while others are rigid and static. Not all people with flat feet have pain or difficulty with activity. A child with flat feet will not necessarily develop pain or problems in the future. Not all flat feet need treatment.
What is Pronation?
Pronation is a verb that describes the action of the foot bones and the arch while walking. During normal walking, the foot bones will rotate and move about their joints, going from a higher arch to a lower arch. This motion is called pronation. Patients that have too much motion at these joints during walking have over pronation. Over pronation can be painful and lead to foot fatigue and ankle, knee, and hip problems.
The major players acting on the arch of the foot that determine its height and function are:
- Subtalar Joint: the joint between the ankle bone and the heel bone
- Talo-Navicular Joint: the joint between the ankle bone and the inside foot bone
- Calcaneocuboid Joint: the joint between the heel bone and the outside foot bone
- Posterior Tibial Tendon: the tendon on the inside of the arch
What is Posterior Tibial Tendon Dysfunction?
The posterior tibial tendon serves as one of the major supporting structures of the foot, helping it to function while walking. Posterior tibial tendon dysfunction (PTTD) is a condition caused by changes in the tendon, impairing its ability to support the arch. This results in flattening of the foot.
PTTD is often called “adult acquired flatfoot” because it is the most common type of flatfoot developed during adulthood. Although this condition typically occurs in only one foot, some people may develop it in both feet. PTTD is usually progressive, which means it will keep getting worse, especially if it isn’t treated early.
What Causes Posterior Tibial Tendon Dysfunction?
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. A foot that already has a low or flattened arch is susceptible to damage of the tendon. Some patients that are born with an extra bone on the inside of their arch called an Accessory Navicular bone or Os Tibiale Externum, are more susceptible to tendon damage and pain.
The cause of PTTD is often a case of “chicken or the egg.” If the arch is relatively normal and the tendon becomes damaged, it can stretch out over time leading to a flatter arch. If the foot is flat already, and the tendon can become damaged as it becomes overstretched due to the malposition of the foot bones.
What are the Symptoms of Posterior Tibial Tendon Dysfunction?
The symptoms of PTTD may include pain, swelling, a flattening of the arch, and an inward rolling of the ankle over time. As the condition progresses, the symptoms will change and worsen.
For example, when PTTD initially develops, there is pain on the inside of the foot and arch and ankle (along the course of the tendon). In addition, the area may be red, warm, and swollen.
Later, as the arch begins to flatten, there may still be pain on the inside of the foot and ankle. But at this point, the foot and toes begin to turn outward and the ankle rolls inward.
As PTTD becomes more advanced, the arch flattens even more and the pain often shifts to the outside of the foot, below the ankle. The tendon has deteriorated considerably and begin to tear and weaken. As the tendon lengthens, it cannot function to raise the arch and help the foot propel forward in gait. Over time arthritis foot arthritis develops and in more severe cases, ankle arthritis may develop.
How is Posterior Tibial Tendon Dysfunction Diagnosed?
Diagnosis is achieved by a thorough clinical examination of the patient. Dr. Soomekh will listen to the patient’s complaints, symptoms, and goals. The examination involves a hands-on analysis of the patient’s foot and evaluating their gait. Digital radiographs (x-rays) of the feet will be obtained in the office and reviewed with the patient. A specialized in office CT scan of the foot may be obtained to evaluate the bones and their orientation in 3D for proper treatment. The positions of the bones and joints are evaluated on the x-rays and CT scan help to determine the severity of the deformity and any associated deformities. An MRI may be needed in order to examine the damage of the Posterior Tibial Tendon.
How is Posterior Tibial Tendon Dysfunction Treated?
Dr. Soomekh educates that early diagnosis and treatment of Posterior Tibial Tendonitis are the keys to successful treatment, faster recovery and painless lifestyle, due to the progressive nature of PTTD. Untreated PTTD could lead to extremely flat feet, painful arthritis in the foot and ankle, and increasing limitations on walking, running, or other activities.
Conservative Treatment for Posterior Tibial Tendon Dysfunction:
Conservative treatments rely on their ability decrease pain, reduce inflammation, stop the micro tearing of the tendon, and stretch the tendon, and support the arch of the foot. Dr. Soomekh will recommend a strict 2 to 4 week initial therapy protocol. Reduction of the inflammation and pain can be achieved by treating the area with a daily regimen of ice therapy and the use of anti-inflammatory medications (NSAID’s). A period of rest will be needed in order to reduce the constant strain on the tendon while it is trying to heal. In most cases a walking boot to restrict the use of the tendon will be recommended. Dr. Soomekh may recommend a course of visits to a Physical Therapist.
Custom Molded Orthotics
Custom molded orthotics (insoles) are an integral part of healing and maintaining the integrity of the posterior tibial tendon and pronation. The stress and strain on the tendon can be reduced with the support of a custom molded orthotic to reduce the forces placed on the tendon while walking and increased activity. The orthotics control the amount of motion through the arch and the heel during gait, and take off some of the strain the tendon would normally incur.
These treatments have a high chance of failure if the injury is left untreated or has become chronic.
Cortisone (steroid) Injections:
Dr. Soomekh does NOT recommend cortisone injections for posterior tibial tendonitis. Steroid injections have many positive applications for treatment of foot and ankle problems. However, the tendon can weaken when injected with cortisone.
Chronic Posterior Tibial Tendinosis:
Left untreated, the tendon can become more damaged and become a chronic condition. This leads to a term called Tendinosis. In chronic conditions the body’s healing factors are not trying to heal the area of concern and are busy taking care of the rest of the body. Presumably, there are less inflammatory cells around the tendon to aid in healing. In these cases, Dr. Soomekh offers more advanced treatment methods.
The following treatments aim to convert the chronic Achilles Tendinosis condition into an acute condition. By doing so, the body will recognize the injury as a new injury and respond accordingly with the appropriate inflammatory response. Under this controlled setting the new injury can be treated in order to heal it in a timely manner. These techniques will stimulate the tendon, break up scar tissue, and attempt revascularization of the tendon by converting the chronic injury into an acute inflammatory one leading to an influx of inflammatory healing cells to the tendon.
Minimmaly Invasive Procedures to Treat Chronic PTTD:
Platelet Rich Plasma (PRP) Therapy for PTTD:
Platelet-rich-plasma (PRP) can be used as a treatment option for PTTD. The introduction of a high concentration of platelets can “jump-start” the tendon to begin healing by increasing blood flow, converting the chronic injury into an acute inflammatory one leading to an influx of inflammatory healing cells to the tendon. It is a relatively non-invasive method using the patient’s own healing potential. Dr. Soomekh offers PRP therapy in the office setting. Click here for our details on PRP therapy.
Topaz Coblation Therapy for PTTD:
Topaz Coblation therapy is a minimally invasive option for the treatment of PTTD. It is performed in an operating room setting. An incision is made to expose the damaged part of the tendon. A grid of tiny holes is made through into the damaged portion of the posterior tibial tendon using a special probe. The probe then “burns” small holes into the tendon, stimulating the tendon. The patient will return home with special instructions for a post treatment protocol. A walking boot is used to control the stress on the tendon during the healing period.
Tenex™ Percutaneous Tenotomy for Achilles Tendinosis for PTTD:
Tenex™ tenotomy is a minimally invasive option for the treatment of Achilles Tendinosis. It is performed in an operating room, often with simple local anesthesia. A very small incision is made over the area of damaged and or thickened tendon. Under ultrasound guidance, a special probe is placed under the skin and into the damaged tendon. When activated, the probe removes the damaged tissue, while not interrupting the healthy tendon. The patient will return home with special instructions for a post treatment protocol. A walking boot is used to control the stress on the tendon during the healing period.
Surgical Treatment for Posterior Tibial Tendon Dysfunction:
In cases of PTTD that have progressed substantially into a chronic state or have failed to improve with non-surgical treatment, surgery may be required. For some advanced cases, surgery may be the only option, this is especially true when the bones and joints are in improper positions leading to a flat foot. In some cases, flatfoot reconstruction will also be warranted.
Dr. Soomekh has perfected and reinvented these surgical procedures and techniques and is recognized by his peers as one of the top Posterior Tibial Tendon specialists and surgeons in the Los Angeles area.