Download Progressive Flatfoot-Posterior Tibial

Produced: March 2015
Author: Clinical Support
Ref: 247/01
Review: March 2017
Royal Orthopaedic Hospital NHS Foundation Trust Patient Information
Progressive Flatfoot -Posterior Tibial
Tendon Dysfunction
Welcome to the Royal Orthopaedic Hospital (ROH).
For further information please visit www.roh.nhs.uk
What is Progressive Flatfoot or Posterior Tibial Tendon Dysfunction (PTTD) ?
Tendons connect muscles to bones and stretch across joints, enabling you to bend those
joints. One of the most important tendons in the lower leg is the posterior tibial tendon.
This tendon runs down the inside of the lower leg and round the inside of the ankle joint,
where it attaches to the inside of your foot. The posterior tibial tendon holds up your arch and
provides support as you step off on your toes when walking.
This tendon can become strained, inflamed, overstretched or torn resulting in pain and
gradually lose of the inner arch on the bottom of your foot, leading to flatfoot. This condition is
called posterior tibial tendon dysfunction (PTTD) and can get worse if not treated.
What are the symptoms of PTTD?
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Pain and swelling along the course of the tendon, (inside lower leg and foot) can be
acute – warm red and swollen, or chronic.
Increasing rolling in of the foot and ankle and flattening of the arch.
Pain on the inside of the foot and ankle. At this point, the foot and toes begin to turn
outward (‘Too many toes’ sign) and the ankle rolls inward.
As the condition progresses there can be pain on the outside of the foot and ankle
below the ankle. In these cases the tendon will have deteriorated considerably and
arthritis often develops in the foot. In more severe cases, arthritis may also develop in
the ankle.
Causes
PTTD is more common in women and in people older than 40 years of age and may be due
to an inherited abnormality of the tendon.
There are several other possible causes:
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Overuse of the tendon, poor mechanical foot function – flat feet, increased STJ
pronation.
Obesity — increased weight places additional strain on the tendon causing it to
over-works, trying to maintain the arch height. It can then becomes inflamed, swollen,
and painful.
The end results are tears within the tendon, a completely collapsed arch, an unstable
foot and pain along the course of the tendon.
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Royal Orthopaedic Hospital, Bristol Road South, Northfield, Birmingham, B31 2AP Tel: 0121 685 4000
Progressive Flatfoot-Posterior Tibial Tendon Dysfunction
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Some people are born with a small loose bone in the foot. This is called an
accessory navicular bone. When present, it lies in front of the area where the
posterior tibial tendon and would normally attach to the navicular bone, on the top
of the foot. Instead of attaching to the navicular bone, the tendon attaches to the
accessory navicular bone. This prevents the tendon from pulling on the navicular
bone so that the arch height and normal foot position cannot be maintained. Pain,
swelling, and tendon tears occur due to the tendon over -working and trying to
accomplish its functions.
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Age related changes in the tendon—With age, the tendons lose their elasticity and
ability to glide as smoothly as they used to. Thus, older individuals are more prone
to developing symptoms of tendonitis, due to the impaired gliding motion of the
tendon. When the tendon no longer functions properly, it becomes swollen,
inflamed, and painful.
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An acute injury, such as from a fall, can tear the posterior tibial tendon or cause it
to become inflamed. For example, people who do high-impact sports, such as
basketball, tennis, or soccer, may have tears of the tendon from repetitive use.
Once the tendon becomes inflamed or torn, the arch will slowly fall (collapse) over
time.
Additional risk factors include diabetes, and hypertension
Treatment
Because of the progressive nature of PTTD, early treatment is advised. If treated early
enough, symptoms may resolve without the need for surgery and progression of the
condition can be prevented.
Untreated PTTD could leave you with an extremely flat foot, painful arthritis in the foot
and ankle, and increasing limitations on walking, running, or other activities.
In many cases of PTTD, treatment can begin with non-surgical approaches that may
include:
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Orthotic devices or bracing to improve mechanical function and rest the tendon.
Podiatrist may provide you with an ankle brace or a custom orthotic device that fits
into the shoe.
Immobilization—Sometimes a short-leg cast or boot is worn to immobilize the foot
and allow the tendon to heal, or you may need to completely avoid all
weight-bearing for a while, particularly if the tendon is a acutely inflamed.
Physical therapy—Ultrasound therapy and exercises may help rehabilitate the
tendon and muscle following immobilization.
Medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as Ibuprofen,
help reduce the pain and inflammation.
Shoe modifications. Your foot and ankle surgeon /podiatrist may advise changes
to make with your shoes and may provide special inserts designed to improve arch
support.
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Royal Orthopaedic Hospital, Bristol Road South, Northfield, Birmingham, B31 2AP Tel: 0121 685 4000
Progressive Flatfoot-Posterior Tibial Tendon Dysfunction
Surgery.
In cases of PTTD which have failed to improve with non-surgical treatment, surgery may
be required. For some advanced cases, surgery may be the only option. Your foot and
ankle surgeon will determine the best approach for you.
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Royal Orthopaedic Hospital, Bristol Road South, Northfield, Birmingham, B31 2AP Tel: 0121 685 4000