WHAT IS POSTERIOR TIBIAL TENDON DYSFUNCTION:
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 flat foot 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.

WHAT CAUSES POSTERIOR TIBIAL TENDON DYSFUNCTION?
Overuse of the posterior tibial tendon is often the cause of PTTD. In fact, the symptoms usually occur after activities that involve the tendon, such as running, walking, hiking, or climbing stairs. A foot that already has a low or flattened arch is susceptible to damage of the tendon. Some patients that are born with an extra bone on the side of their arch called an accessory navicular bone or Os tibiale externum, are more susceptible to tendon damage and pain.

This cause of PTTD is often a case of “chicken or the egg”. If the arch is relatively normal and the tendon becomes damaged. It can stretch out over time leading to a flatter arch. If the foot is already flat, then the tendon can become damaged as it becomes over stretched due to the mal position of the foot bones.

WHAT ARE THE SYMPTOMS OF POSTERIOR TIBIAL TENDON DYSFUNCTION?
The symptoms of PTTD may include pain, swelling, a flattening of the arch, and an inward rolling of the ankle over time. As the condition progresses, the symptoms will change and worsen. For example, when PTTD initially develops, there is pain on the inside of the foot and arch and ankle (along the course of the tendon). In addition, the area may be red, warm and swollen.

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 begins to tear and weaken. As the
tendon lengthens, it cannot function to raise the arch and help the foot propel forward in gait. Overtime foot arthritis develops and in more severe cases ankle arthritis may develop.

HOW IS POSTERIOR TIBIAL TENDON DYSFUNCTION DIAGNOSED?
Diagnosis is achieved by a thorough clinical examination of the patient. Dr. Heath will listen to your complaints, symptoms, and goals. The examination involves a hands on analysis of the patients foot and evaluating their gait. Radio-graphs (x-rays) of the feet will be obtained in the office and reviewed with the patient. The positions of the bones and joints are evaluated on the x-ray and help to determine the severity of the deformity and any associated deformities. And MRI may be needed in order to examine the damage of the posterior tibial tendon.

HOW IS POSTERIOR TIBIAL TENDON DYSFUNCTION TREATED?
Dr. Heath educates that early diagnosis and treatment of posterior tibial tendonitis are the keys to successful treatment, faster recovery and painless lifestyle, due to the progressive nature of PTTD. Untreated PTTD could lead to extremely flat feet, painful arthritis in the foot and ankle and increasing limitation on walking, running or other activities.

CONSERVATIVE TREATMENT FOR POSTERIOR TIBIAL TENDON DYSFUNCTION
Conservative treatments rely on their ability to decrease the pain, reduce inflammation, stop the micro tearing of the tendon, and stretch the tendon, and support the arch of the foot. Dr. Heath will recommend a strict 2 to 4 week initial therapy protocol. Reduction of the inflammation and pain can be achieved by treating the area with a daily regimen of ice therapy and the use of anti-inflammatory medications (NSAIDs) a period of rest will be needed in order to reduce the constant strain on the tendon while it is trying to heal in most cases a walking boot to restrict the use of the tendon will be recommended Dr. Heath may recommend a course of visits to a physical therapist.

POSTERIOR TIBIAL TENDON DYSFUNCTION
Custom molded orthotics (insoles) are an integral part of healing and maintaining the integrity of the posterior tibial tendon and pronation. The stress and strain on the tendon can be reduced with the support of a custom molded orthotics to reduce the forces placed on the tendon while walking and increased activity. The orthotics control the amount of motion through the arch and the heel during gait, and take off some of the strain the tendon would normally incur.

These treatments have a high chance of failure if the injury is left untreated or has become chronic.

CORTISONE (STEROID) INJECTIONS :
Dr. Heath does NOT recommend cortisone injection for posterior tibial tendinitis. Steroid injections have many positive applications for treatment of foot and ankle problems. However, the tendon can weaken when injected with cortisone.

CHRONIC POSTERIOR TIBIAIL TENDINOSIS :
Left untreated, the tendon can become more damaged and become a chronic condition. This leads to a term called tendinosis. In chronic conditions the body’s healing factors are not trying to heal the area of concern and are busy taking care of the rest of the body. Presumably, there are less inflammatory cells around the tendon to aid in healing. In these cases Dr. Heath offers more advanced treatment methods.

TOPAZ COBLATION THERAPY FOR PTTD:
Topaz coblation therapy is a minimally invasive option for the treatment of PTTD. lt is performed in an operating room setting. An incision is made to expose the damaged part of the tendon. A grid of tiny holes is made through into the damaged portion of the posterior tibial tendon using a special probe. The probe then “burns” small holes into the tendon, stimulating the tendon. The patient will return home with special instructions for a post treatment protocol. A walking boot is used to control the stress on the tendon during the healing period.

TENEX PERCUTANEOUS TENOTOMY FOR ACHILLES TENDINOSIS FOR PTTD:
Tenex tenotomy is a minimally invasive option for the treatment of Achilles tendinosis. It is performed in an operating room, often with simple local anesthesia. A very small incision is made over the area of damaged and or thickened tendon. Under ultrasound guidance, a special probe is placed under the skin and into the damaged tendon.

When activated, the probe removes the damaged tissue, while not interrupting the healthy tendon. The patient will return home with special instructions for a post treatment protocol. A waking boot is used to control the stress on the tendon during the healing period.

SURGICAL TREATMENT FOR POSTERIOR TIBIAL TENDON DYSFUNCTION:
In cases of PTTD that have progressed substantially into a chronic state or have failed to improve with nonsurgical treatment, surgery may be required. For some advanced cases, surgery may be the only option, this
is especially true when the bones and joints are improper positions leading to flat foot. The tendon is cleaned up from the frayed damaged part of the tendon, then the bone is shaved down where it attaches and anchored with dis-solvable anchors. This done in a state of the art surgical facility under general and is about a 30-minute surgery. The patient with a sit-down job, is off work for about 3 -4 days then walks in a cast boot 4-6 weeks. The patient with a sit and stand job needs 2-3 weeks off work. The patient with a stand all day job needs 6 weeks off work or light duty., upon return and then may go back sooner. All will be in a cast boot 4-6 weeks.