The posterior tibial tendon serves as one of the major supporting structures of the foot, helping it to function while walking. 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. PTTD is often called adult acquired flatfoot
because it is the most common type of flatfoot developed during
adulthood. Although this condition typically occurs in only one foot, some people may develop it in both feet. PTTD is usually progressive, which means it will keep getting worse, especially if it
isn?t treated early.
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.
The symptoms of PTTD may include pain, swelling, a flattening of the arch, and inward rolling of the ankle. As the condition progresses, the symptoms will change. For example, later, as the arch
begins to flatten, there may still be pain on the inside of the foot and ankle. But at this point, the foot and toes begin to turn outward and the ankle rolls inward. As PTTD becomes more advanced,
the arch flattens even more and the pain often shifts to the outside of the foot, below the ankle. The tendon has deteriorated considerably and arthritis often develops in the foot. In more severe
cases, arthritis may also develop in the ankle. Symptoms, which may occur in some persons with flexible flatfoot, include. Pain in the heel, arch, ankle, or along the outside of the foot. ?Turned-in?
ankle. Pain associated with a shin splint. General weakness / fatigue in the foot or leg.
In diagnosing flatfoot, the foot & Ankle surgeon examines the foot and observes how it looks when you stand and sit. Weight bearing x-rays are used to determine the severity of the disorder.
Advanced imaging, such as magnetic resonance imaging (MRI) and computed tomography (CAT or CT) scans may be used to assess different ligaments, tendons and joint/cartilage damage. The foot &
Ankle Institute has three extremity MRI?s on site at our Des Plaines, Highland Park, and Lincoln Park locations. These extremity MRI?s only take about 30 minutes for the study and only requires the
patient put their foot into a painless machine avoiding the uncomfortable Claustrophobia that some MRI devices create.
Non surgical Treatment
A patient who has acute tenosynovitis has pain and swelling along the medial aspect of the ankle. The patient is able to perform a single-limb heel-rise test but has pain when doing so. Inversion of
the foot against resistance is painful but still strong. The patient should be managed with rest, the administration of appropriate anti-inflammatory medication, and immobilization. The injection of
corticosteroids is not recommended. Immobilization with either a rigid below-the-knee cast or a removable cast or boot may be used to prevent overuse and subsequent rupture of the tendon. A removable
stirrup-brace is not initially sufficient as it does not limit motion in the sagittal plane, a component of the pathological process. The patient should be permitted to walk while wearing the cast or
boot during the six to eight-week period of immobilization. At the end of that time, a decision must be made regarding the need for additional treatment. If there has been marked improvement, the
patient may begin wearing a stiff-soled shoe with a medial heel-and-sole wedge to invert the hindfoot. If there has been only mild or moderate improvement, a longer period in the cast or boot may be
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.