What Is Posterior Tibial Tendon Dysfunction

Overview
The posterior tibialis muscle originates on the bones of the leg (tibia and fibula). This muscle then passes behind the medial (inside) aspect of the ankle and attaches to the medial midfoot as the posterior tibial tendon. The posterior tibial tendon serves to invert (roll inward) the foot and maintain the arch of the foot. This tendon plays a central role in maintaining the normal alignment of the foot and also in enabling normal gait (walking). In addition to tendons running across the ankle and foot joints, a number of ligaments span and stabilize these joints. The ligaments at the medial ankle can become stretched and contribute to the progressive flattening of the arch. Several muscles and tendons around the ankle and foot act to counter-balance the action of the posterior tibial tendon. Under normal circumstances, the result is a balanced ankle and foot with normal motion. When the posterior tibial tendon fails, the other muscles and tendons become relatively over-powering. These muscles then contribute to the progressive deformity seen with this disorder.

Causes
Rheumatoid arthritis This type of arthritis attacks the cartilage in the foot, leading to pain and flat feet. It is caused by auto-immune disease, where the body?s immune system attacks its own tissues. Diabetes. Having diabetes can cause nerve damage and affect the feeling in your feet and cause arch collapse. Bones can also fracture but some patients may not feel any pain due to the nerve damage. Obesity and/or hypertension (high blood pressure) This increases your risk of tendon damage and resulting flat foot.

Symptoms
Symptoms shift around a bit, depending on what stage of PTTD you?re in. For instance, you?re likely to start off with tendonitis, or inflammation of the posterior tibial tendon. This will make the area around the inside of your ankle and possibly into your arch swollen, reddened, warm to the touch, and painful. Inflammation may actually last throughout the stages of PTTD. The ankle will also begin to roll towards the inside of the foot (pronate), your heel may tilt, and you may experience some pain in your leg (e.g. shin splints). As the condition progresses, the toes and foot begin to turn outward, so that when you look at your foot from the back (or have a friend look for you, because-hey-that can be kind of a difficult maneuver to pull off) more toes than usual will be visible on the outside (i.e. the side with the pinky toe). At this stage, the foot?s still going to be flexible, although it will likely have flattened somewhat due to the lack of support from the posterior tibial tendon. You may also find it difficult to stand on your toes. Finally, you may reach a stage in which your feet are inflexibly flat. At this point, you may experience pain below your ankle on the outside of your foot, and you might even develop arthritis in the ankle.

Diagnosis
Posterior Tibial Tendon Dysfunction is diagnosed with careful clinical observation of the patient?s gait (walking), range of motion testing for the foot and ankle joints, and diagnostic imaging. People with flatfoot deformity walk with the heel angled outward, also called over-pronation. Although it is normal for the arch to impact the ground for shock absorption, people with PTTD have an arch that fully collapses to the ground and does not reform an arch during the entire gait period. After evaluating the ambulation pattern, the foot and ankle range of motion should be tested. Usually the affected foot will have decreased motion to the ankle joint and the hindfoot. Muscle strength may also be weaker as well. An easy test to perform for PTTD is the single heel raise where the patient is asked to raise up on the ball of his or her effected foot. A normal foot type can lift up on the toes without pain and the heel will invert slightly once the person has fully raised the heel up during the test. In early phases of PTTD the patient may be able to lift up the heel but the heel will not invert. An elongated or torn posterior tibial tendon, which is a mid to late finding of PTTD, will prohibit the patient from fully rising up on the heel and will cause intense pain to the arch. Finally diagnostic imaging, although used alone cannot diagnose PTTD, can provide additional information for an accurate diagnosis of flatfoot deformity. Xrays of the foot can show the practitioner important angular relationships of the hindfoot and forefoot which help diagnose flatfoot deformity. Most of the time, an MRI is not needed to diagnose PTTD but is a tool that should be considered in advanced cases of flatfoot deformity. If a partial tear of the posterior tibial tendon is of concern, then an MRI can show the anatomic location of the tear and the extensiveness of the injury.

Non surgical Treatment
Orthoses (insoles, functional orthoses, ankle supports, braces, ankle foot orthoses (AFOs)) - are usually custom-made to increase the functional stability of the foot and improve the mechanical properties of the tendon as well as reducing the actual degree of strain on the tendon. This reduces pain and inflammation. Physiotherapy - exercises and physiotherapy are often used to increase mobility, strengthen the tendon itself, stretch your Achilles tendon as well as reduce pain. Once the tendon has been stretched (stage one), the heel starts rolling outwards. Total immobilisation in a cast may help the symptoms to subside and prevent progression of the deformity in a smaller percentage of patients. Long-term use of orthoses may help stop progression of the deformity and reduce pain without surgery. Non-surgical treatment is unlikely to prevent progression to stage three and four but may be chosen by some patients who either are unsuitable for surgery or prefer not to have surgery.

Surgical Treatment
If conservative treatment fails to provide relief of pain and disability then surgery is considered. Numerous factors determine whether a patient is a surgical candidate. They include age, obesity, diabetes, vascular status, and the ability to be compliant with post-operative care. Surgery usually requires a prolonged period of nonweightbearing immobilization. Total recovery ranges from 3 months to one year. Clinical, x-ray, and MRI examination are all used to select the appropriate surgical procedure.