PTTD is a condition of degeneration and dysfunction in the tendon complex that helps control the medial arch of your foot. Essentially what happens is the complex is unable to do its job of
supporting the arch and supinating the foot, so a progressive flat foot develops (usually called adult
acquired flat foot
). Initially pain and often swelling develops on the inside of the ankle and it will continue to get progressively worse. There are a number of stages of PTTD (3 Stages) and it
needs to be aggressively treated early on otherwise a surgical reconstruction of the arch will invariably be required. PTTD can develop into a very disabling condition if it is not dealt with
properly and promptly. As PTTD becomes more advanced, the arch flattens even more and the pain often shifts to the outside of the foot, below the ankle. Arthritis often develops in the foot and In
more severe cases, arthritis may also develop in the ankle.
The cause of posterior tibial tendon insufficiency is not completely understood. The condition commonly does not start from one acute trauma but is a process of gradual degeneration of the soft
tissues supporting the medial (inner) side of the foot. It is most often associated with a foot that started out somewhat flat or pronated (rolled inward). This type of foot places more stress on the
medial soft tissue structures, which include the posterior tibial tendon and ligaments on the inner side of the foot. Children nearly fully grown can end up with flat feet, the majority of which are
no problem. However, if the deformity is severe enough it can cause significant functional limitations at that age and later on if soft tissue failure occurs. Also, young adults with normally aligned
feet can acutely injure their posterior tibial tendon from a trauma and not develop deformity. The degenerative condition in patients beyond their twenties is different from the acute injuries in
young patients or adolescent deformities, where progression of deformity is likely to occur.
Initially, flatfoot deformity may not present with any symptoms. However, overtime as the tendon continues to function in an abnormal position, people with fallen arches will begin to have throbbing
or sharp pain along the inside of the arch. Once the tendon and soft tissue around it elongates, there is no strengthening exercises or mechanism to shorten the tendon back to a normal position.
Flatfoot can also occur in one or both feet. If the arch starts to slowly collapse in one foot and not the other, posterior tibial dysfunction (PTTD) is the most likely cause. People with flatfoot
may only have pain with certain activities such as running or exercise in the early phase of PTTD. Pain may start from the arch and continue towards the inside part of the foot and ankle where the
tendon courses from the leg. Redness, swelling and increased warmth may also occur. Later signs of PTTD include pain on the outside of the foot from the arch collapsing and impinging other joints.
Arthritic symptoms such as painful, swollen joints in the foot and ankle may occur later as well due to the increased stress on the joints from working in an abnormal position for a long period of
Observe forefoot to hindfoot alignment. Do this with the patient sitting and the heel in neutral, and also with the patient standing. I like to put blocks under the forefoot with the heel in neutral
to see how much forefoot correction is necessary to help hold the hindfoot position. One last note is to check all joints for stiffness. In cases of prolonged PTTD or coalition, rigid deformity is
present and one must carefully check the joints of the midfoot and hindfoot for stiffness and arthritis in the surgical pre-planning.
Non surgical Treatment
Treatment depends very much upon a patient?s symptoms, functional goals, degree and specifics of deformity, and the presence of arthritis. Some patients get better without surgery. Rest and
immobilization, orthotics, braces and physical therapy all may be appropriate. With early-stage disease that involves pain along the tendon, immobilization with a boot for a period of time can
relieve stress on the tendon and reduce the inflammation and pain. Once these symptoms have resolved, patients are often transitioned into an orthotic that supports the inside aspect of the hindfoot.
For patients with more significant deformity, a larger ankle brace may be necessary.
A new type of surgery has been developed in which surgeons can re-construct the flat foot deformity and also the deltoid ligament using a tendon called the peroneus longus. A person is able to
function fully without use of the peroneus longus but they can also be taken from deceased donors if needed. The new surgery was performed on four men and one woman. An improved alignment of the
ankle was still evident nine years later, and all had good mobility 8 to 10 years after the surgery. None had developed arthritis.