When we have foot pain, it isn't always easy to pinpoint the source because we can't visualize the structure of all the bones, muscles, and tendons on the inside. The posterior tibial tendon plays an
important supportive role within the structure of the foot. It attaches to your calf muscle and then comes down along the inside of your ankle, connecting to the bones inside your foot at the other
side. This tendon's main function is to hold up your arch and support your foot during each and every movement. Every step, run, walk, or jump is made possible with the support from this crucial
tendon. While it is designed to perform such an important role, it is vulnerable to stress and injury. A tear during a traumatic injury or stress from overuse can injure the tissues within the
tendon. This kind of injury is referred to as posterior tibial tendon dysfunction (PTTD). A really hard fall during a sports game or exposure to a repetitive motion, such as the impact on feet during
soccer, tennis, football or basketball, can cause an injury. Flat foot and flat feet in adults can exacerbate this condition. The tendon can experience small tears and become inflamed. If the
inflammation is allowed to continue and worsen over time, it will weaken further and could rupture completely.
Posterior tibial tendon dysfunction is the most common cause of acquired adult flatfoot. Sometimes this can be a result of specific trauma, but usually the tendon becomes injured from wear and tear
over time. This is more prevalent in individuals with an inherited flat foot but excessive weight, age, and level of activity are also contributing factors.
Depending on the cause of the flatfoot, a patient may experience one or more of the different symptoms here. Pain along the course of the posterior tibial tendon which lies on the inside of the foot
and ankle. This can be associated with swelling on the inside of the ankle. Pain that is worse with activity. High intensity or impact activities, such as running, can be very difficult. Some
patients can have difficulty walking or even standing for long periods of time. When the foot collapses, the heel bone may shift position and put pressure on the outside ankle bone (fibula). This can
cause pain on the outside of the ankle. Arthritis in the heel also causes this same type of pain. Patients with an old injury or arthritis in the middle of the foot can have painful, bony bumps on
the top and inside of the foot. These make shoewear very difficult. Occasionally, the bony spurs are so large that they pinch the nerves which can result in numbness and tingling on the top of the
foot and into the toes. Diabetics may only notice swelling or a large bump on the bottom of the foot. Because their sensation is affected, people with diabetes may not have any pain. The large bump
can cause skin problems and an ulcer (a sore that does not heal) may develop if proper diabetic shoewear is not used.
The adult acquired flatfoot, secondary to posterior tibial tendon dysfunction, is diagnosed in a number of ways with no single test proven to be totally reliable. The most accurate diagnosis is made
by a skilled clinician utilizing observation and hands on evaluation of the foot and ankle. Observation of the foot in a walking examination is most reliable. The affected foot appears more pronated
and deformed compared to the unaffected foot. Muscle testing will show a strength deficit. An easy test to perform in the office is the single foot raise. A patient is asked to step with full body
weight on the symptomatic foot, keeping the unaffected foot off the ground. The patient is then instructed to "raise up on the tip toes" of the affected foot. If the posterior tibial tendon has been
attenuated or ruptured, the patient will be unable to lift the heel off the floor and rise onto the toes. In less severe cases, the patient will be able to rise on the toes, but the heel will not be
noted to invert as it normally does when we rise onto the toes. X-rays can be helpful but are not diagnostic of the adult acquired flatfoot. Both feet - the symptomatic and asymptomatic - will
demonstrate a flatfoot deformity on x-ray. Careful observation may show a greater severity of deformity on the affected side.
Non surgical Treatment
Non-surgical treatment includes rest and reducing your activity until the pain improves. Orthotics or bracing help support the tendon to reduce its pull along the arch, thus reducing pain. In
moderate to severe cases, a below knee cast or walking boot may be needed to allow the tendon to rest completely and heal. Physical therapy is an integral part of the non-surgical treatment regimen
to reduce inflammation and pain. Anti-inflammatory medication is often used as well. Many times evaluation of your current shoes is necessary to ensure you are wearing appropriate shoe gear to
Although non-surgical treatments can successfully manage the symptoms, they do not correct the underlying problem. It can require a life-long commitment to wearing the brace during periods of
increased pain or activity demands. This will lead a majority of patients to choose surgical correction of the deformity, through Reconstructive Surgery. All of the considerations that were extremely
important during the evaluation stage become even more important when creating a surgical plan. Generally, a combination of procedures are utilized in the same setting, to allow full correction of
the deformity. Many times, this can be performed as a same-day surgery, without need for an overnight hospital stay. However, one or two day hospital admissions can be utilized to help manage the
post-operative pain. Although the recovery process can require a significant investment of time, the subsequent decades of improved function and activity level, as well as decreased pain, leads to a
substantial return on your investment.