Overview
Many patients suffer from a collapsing arch or flat foot which can cause pain, instability and difficulty while walking. This condition is more commonly known as Posterior Tibial Tendon Dysfunction (PTTD). PTTD is a progressive flattening of the arch due to loss of function of the Posterior Tibial tendon. As the foot flattens, the tendon will stretch, become insufficient and lose its ability to function. This can have a direct effect on walking and posture, ultimately affecting the ankle, knee and hip. As the condition progresses, the joints in the hind foot may become arthritic and painful.
Causes
Damage to the posterior tendon from overuse is the most common cause for adult acquired flatfoot. Running, walking, hiking, and climbing stairs are activities that add stress to this tendon, and this overuse can lead to damage. Obesity, previous ankle surgery or trauma, diabetes (Charcot foot), and rheumatoid arthritis are other common risk factors.
Symptoms
Patients often experience pain and/or deformity at the ankle or hindfoot. When the posterior tibial tendon does not work properly, a number of changes can occur to the foot and ankle. In the earlier stages, symptoms often include pain and tenderness along the posterior tibial tendon behind the inside of the ankle. As the tendon progressively fails, deformity of the foot and ankle may occur. This deformity can include progressive flattening of the arch, shifting of the heel so that it no longer is aligned underneath the rest of the leg, rotation and deformity of the forefoot, tightening of the heel cord, development of arthritis, and deformity of the ankle joint. At certain stages of this disorder, pain may shift from the inside to the outside aspect of the ankle as the heel shifts outward and structures are pinched laterally.
Diagnosis
Your podiatrist is very familiar with tendons that have just about had enough, and will likely be able to diagnose this condition by performing a physical exam of your foot. He or she will probably examine the area visually and by feel, will inquire about your medical history (including past pain or injuries), and may also observe your feet as you walk. You may also be asked to attempt standing on your toes. This may be done by having you lift your ?good? foot (the one without the complaining tendon) off the ground, standing only on your problem foot. (You may be instructed to place your hands against the wall to help with balance.) Then, your podiatrist will ask you to try to go up on your toes on the bad foot. If you have difficulty doing so, it may indicate a problem with your posterior tibial tendon. Some imaging technology may be used to diagnose this condition, although it?s more likely the doctor will rely primarily on a physical exam. However, he or she may order scans such as an MRI or CT scan to look at your foot?s interior, and X-rays might also be helpful in a diagnosis.
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
For those patients with PTTD that have severe deformity or have not improved with conservative treatments, surgery may be necessary to return them to daily activity. Surgery for PTTD may include repair of the diseased tendon and possible tendon transfer to a nearby healthy tendon, surgery on the surrounding bones or joints to prevent biomechanical abnormalities that may be a contributing factor or both.
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