The Pain Behind Posterior tibial tendon dysfunction
By Orthopaedic and Neurology Clinic
What is define by Posterior tibial tendon dysfunction (PTTD)?
The posterior tibial tendon is an important tendon in the leg. A tendon (strong cord-like tissue) attaches muscles to bones. The posterior tibial tendon attaches the calf muscle to the bones in the foot. The posterior tibial tendon extends from the calf down to the inside of the ankle and the bones of the foot. It is important for walking as it supports the stability and arch of the foot.
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. It is different from foot drop. PTTD is usually progressive, which means it will keep getting worse, especially if it is not treated early.
What are some symptoms of Posterior tibial tendon dysfunction (PTTD)?
Most commonly, people with posterior tibial tendonitis:
- Swelling in the ankle
- Weakness in the foot
- Pain on the inside of the foot and ankle bone (medial malleolus)
- Spasms of the peroneal tendons on the outside of the foot
- A gradual flattening of the arch of the foot (a flat foot)
- Pain in the tarsal tunnel (similar to carpal tunnel in the hand)
- Difficulty walking or running
Many people with this condition report having had a recent ankle sprain. However, some will have had no recent injury. The tendon can also be damaged from overuse.
“Posterior tibial tendonitis is a common cause of foot pain and dysfunction. When caught early, posterior tibial tendonitis is fairly easy to treat. But, without proper diagnosis and treatment, it gradually progresses through four different stages, which can result in permanent foot deformity.”
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What types of diagnosis?
We highly recommend seeking professional help instead of self diagnosis in order to identify the source of the issue and to receive faster recovery.
During a physical, our Specialist who specializes in foot and ankle problems, can diagnose posterior tibial tendonitis by physical examination. People with the condition have:
- Tenderness and swelling along the posterior tibial tendon
- Weakness when trying to point their toes inward
- Trouble standing on their toes on the affected side
If the examination is unclear or our doctor is considering surgical repair, they may order a MRI scan. The MRI can determine whether the tendon has ruptured, and where. It can also show inflammation surrounding the tendon.
Posterior tibial tendonitis is classified according to the stage of the condition. Stage 1 through stage 4 indicate increasing deformity (abnormal shape) of the foot as the condition progresses:
- Stage 1: The earliest stage is having pain and swelling along the tendon. The foot may appear completely normal. On the other hand, some people may notice their foot has a mild flatfoot deformity. This may be something they feel they have always had.
- Stage 2: As the condition progresses, the arch of the foot begins to collapse. When they stand, the foot appears flat along its inner side. At this stage, it may be possible to correct the flattened arch.
- Stage 3: In stage 3 of the condition, called a rigid flatfoot deformity, a physician cannot easily correct the foot.
- Stage 4: In stage 4, not only is the foot involved, but the adjacent ankle joint also is affected by the condition.
Possible treatment methods?
Early treatment is advised because of the progressive nature of PTTD. If treated early enough, your symptoms may resolve without the need for surgery, and progression of your condition can be arrested.
In contrast, untreated PTTD could leave you with an extremely flat foot, painful arthritis in the foot and ankle and increasing limitations on walking, running or other activities.
In many cases of PTTD, treatment can begin with nonsurgical approaches that may include:
- Orthotic devices or bracing. To give your arch the support it needs, our foot and ankle surgeon may provide you with an ankle brace or a custom orthotic device that fits into the shoe.
- Immobilization. Sometimes a short-leg cast or boot is worn to immobilize the foot and allow the tendon to heal, or you may need to completely avoid all weightbearing for a while.
- Physical therapy. Ultrasound therapy and exercises may help rehabilitate the tendon and muscle following immobilization.
- Medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), may help to reduce the pain and inflammation.
- Shoe modifications. Our foot and ankle surgeon may advise changes to your shoes and may provide special inserts designed to improve arch support.
If non-surgical posterior tibial tendonitis treatment has failed, meaning there has been no benefit over 6 months, and you are stage 2 or higher, then you are likely to need surgery.
Surgical options vary depending on the extent of the condition and include:
- Debridement: In the early stage, some surgeons may recommend a procedure to clean up the inflammation. During debridement, the inflamed tissue and abnormal tendon are removed. This allows for the healing of the damaged tendon.
- Reconstruction: In more advanced stages, the arch of the foot collapses and your doctor may surgically reconstruct the area. This involves using a neighboring tendon, called the flexor digitorum longus, to replace the damaged posterior tibial tendon. Bones in the foot may be cut and reshaped to create a new arch, as well.
- Fusion: Finally, in the most advanced cases, when the foot’s arch has become rigid, doctors often prefer a fusion procedure, where the bones and joints in the foot are fixed in place to restore the arch.
Early intervention and conservative treatment methods are often successful in managing posterior tibial tendonitis. Consult our specialist for a proper diagnosis and treatment plan tailored to your specific condition.