Posterior tibial tendon dysfunction is one of several terms to describe a painful, progressive flatfoot deformity in adults. Other terms include posterior tibial tendon insufficiency and adult acquired flatfoot
. The term adult acquired flatfoot is more appropriate because it allows a broader recognition of causative factors, not
only limited to the posterior tibial tendon, an event where the posterior tibial tendon looses strength and function. The adult acquired flatfoot is a progressive, symptomatic (painful) deformity
resulting from gradual stretch (attenuation) of the tibialis posterior tendon as well as the ligaments that support the arch of the foot.
Obesity - Overtime if your body is carrying those extra pounds, you can potentially injure your feet. The extra weight puts pressure on the ligaments that support your feet. Also being over weight
can lead to type two diabetes which also can attribute to AAFD. Diabetes - Diabetes can also play a role in Adult Acquired Flatfoot Deformity. Diabetes can cause damage to ligaments, which support
your feet and other bones in your body. In addition to damaged ligaments, uncontrolled diabetes can lead to ulcers on your feet. When the arches fall in the feet, the front of the foot is wider, and
outer aspects of the foot can start to rub in your shoe wear. Patients with uncontrolled diabetes may not notice or have symptoms of pain due to nerve damage. Diabetic patient don?t see they have a
problem, and other complications occur in the feet such as ulcers and wounds. Hypertension - High blood pressure cause arteries narrow overtime, which could decrease blood flow to ligaments. The
blood flow to the ligaments is what keeps the foot arches healthy, and supportive. Arthritis - Arthritis can form in an old injury overtime this can lead to flatfeet as well. Arthritis is painful as
well which contributes to the increased pain of AAFD. Injury - Injuries are a common reason as well for AAFD. Stress from impact sports. Ligament damage from injury can cause the bones of the foot to
fallout of ailment. Overtime the ligaments will tear and result in complete flattening of feet.
As different types of flatfoot have different causes, the associated symptoms can be different for different people. Some generalized symptoms are listed. 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 and jumping, can be very difficult. Some patients can have difficulty walking or even standing for long periods of time and may experience pain at the inside of the ankle and in the
arch of the foot. Feeling like one is ?dragging their foot.? When the foot collapses, the heel bone may shift position and put pressure on the outside ankle bone (fibula). This can cause pain in the
bones and tendons in the outside of the ankle joint. 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 shoe
wear very difficult. Sometimes, 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. Diabetic patients may not
experience pain if they have damage to their nerves. They may only notice swelling or a large bump on the bottom of the foot. The large bump can cause skin problems and an ulcer (a sore that does not
heal) may develop if proper diabetic shoe wear is not used.
There are four stages of adult-acquired flatfoot deformity (AAFD). The severity of the deformity determines your stage. For example, Stage I means there is a flatfoot position but without deformity.
Pain and swelling from tendinitis is common in this stage. Stage II there is a change in the foot alignment. This means a deformity is starting to develop. The physician can still move the bones back
into place manually (passively). Stage III adult-acquired flatfoot deformity (AAFD) tells us there is a fixed deformity. This means the ankle is stiff or rigid and doesn???t move beyond a neutral
(midline) position. Stage IV is characterized by deformity in the foot and the ankle. The deformity may be flexible or fixed. The joints often show signs of degenerative joint disease
Non surgical Treatment
PTTD is a progressive condition. Early treatment is needed to prevent relentless progression to a more advanced disease which can lead to more problems for that affected foot. In general, the
treatments include rest. Reducing or even stopping activities that worsen the pain is the initial step. Switching to low-impact exercise such as cycling, elliptical trainers, or swimming is helpful.
These activities do not put a large impact load on the foot. Ice. Apply cold packs on the most painful area of the posterior tibial tendon frequently to keep down the swelling. Placing ice over the
tendon immediately after completing an exercise helps to decrease the inflammation around the tendon.
Nonsteroidal Anti-inflammatory Medication (NSAIDS). Drugs, such as arcoxia, voltaren and celebrex help to reduce pain and inflammation. Taking such medications prior to an exercise activity helps to
limit inflammation around the tendon. However, long term use of these drugs can be harmful to you with side effects including peptic ulcer disease and renal impairment or failure. Casting. A short
leg cast or walking boot may be used for 6 to 8 weeks in the acutely painful foot. This allows the tendon to rest and the swelling to go down. However, a cast causes the other muscles of the leg to
atrophy (decrease in strength) and thus is only used if no other conservative treatment works. Most people can be helped with orthotics and braces. An orthotic is a shoe insert. It is the most common
non-surgical treatment for a flatfoot and it is very safe to use. A custom orthotic is required in patients who have moderate to severe changes in the shape of the foot. Physiotherapy helps to
strengthen the injured tendon and it can help patients with mild to moderate disease of the posterior tibial tendon.
Surgery is usually performed when non-surgical measures have failed. The goal of surgery is to eliminate pain, stop progression of the deformity and improve a patient?s mobility. More than one
technique may be used, and surgery tends to include one or more of the following. The tendon is reconstructed or replaced using another tendon in the foot or ankle The name of the technique depends
on the tendon used. Flexor digitorum longus (FDL) transfer. Flexor hallucis longus (FHL) transfer. Tibialis anterior transfer (Cobb procedure). Calcaneal osteotomy - the heel bone may be shifted to
bring your heel back under your leg and the position fixed with a screw. Lengthening of the Achilles tendon if it is particularly tight. Repair one of the ligaments under your foot. If you smoke,
your surgeon may refuse to operate unless you can refrain from smoking before and during the healing phase of your procedure. Research has proven that smoking delays bone healing significantly.