Posterior Tibial Tendon Dysfunction

Posterior Tibial Tendon Dysfunction

The posterior tibial tendon connects the calf muscle to bones on the inner side of the foot. The main purpose of the tendon is to support the arch on the inside of the foot. So, when the posterior tibial tendon becomes inflamed or torn it results in Posterior Tibial Tendon Dysfunction. As a result, the tendon may not be able to provide stability and support for the arch of the foot, resulting in flatfoot. It can be a painful injury that negatively affects foot and ankle movements, including walking and running. PTTD is the most common cause of adult-acquired flatfoot.

What are the stages of posterior tibial tendon dysfunction?

Talocrural Joint

Stage I: The tendon is injured but otherwise intact.

Stage II: The tendon is torn (ruptured) or not working properly. The foot is deformed.

Stage III: The foot is significantly deformed. There are degenerative changes to the connective tissue (cartilage) in the back of the foot.

Stage IV: There are degenerative changes to the ankle joint.

Who does posterior tibial tendon dysfunction affect?

PTTD most frequently affects people over the age of 40. The tendon often degenerates, or breaks down, as you get older. However, it can also affect those with conditions including:

• Obesity.
• High Blood Pressure (Hypertension).
• Diabetes.
• Foot or ankle tissue injuries.
• Joint disorders.
• Prior surgery.
• Steroid use.

The tendon can also experience damage from a fall or overuse. People who participate in high-impact sports or activities, including football, basketball, soccer, track and long-distance running, may tear the tendon from repeated use.

Causes:

Posterior tibial tendon dysfunction may develop due to:

• Injury: Ankle sprain, fracture or direct blow to the inner ankle which damages the posterior tibial tendon
• Overuse: high-impact sports e.g. football or basketball, or running or hiking may damage the tibialis posterior tendon due to repetitive use and over-loading
• Demographics: Typically affects people over the age of 40, and is more prevalent in women than men
• Altered Foot Biomechanics: People who already have flat feet are more prone to developing posterior tibial tendonitis as it places more force through the tendon
• Footwear: Whilst not a specific cause, wearing shoes that do not provide adequate foot arch support can be a contributing factor
• Obesity: Being overweight places extra strain on the posterior tibial tendon making it prone to injury
• Inflammatory Arthritis: Certain medical conditions such as rheumatoid arthritis and gout increase the risk of developing tendonitis

Symptoms:

The symptoms of posterior Tibial Tendon Dysfunction are:

• Pain initially along the course of the posterior tibial tendon dysfunction
• Painful Limp
• Difficulty in walking or weight bearing
• Swelling along the posterior tibial tendon region
• Loss of the arch of the foot

Diagnosis

Your doctor will begin by examining your foot. They may look for swelling along the posterior tibial tendon. Your doctor will also test your range of motion by moving your foot side to side and up and down. PTTD can cause problems with a side-to-side range of motion, as well as issues with moving the toes toward the shinbone.

Your doctor will also look at the shape of your foot. They’ll look for a collapsed arch and a heel that has shifted outward. Your doctor may also check how many toes they can see from behind your heel when you’re standing.

Normally, only the fifth toe and half of the fourth toe are visible from this angle. In PTTD, they can see more than the fourth and fifth toes. Sometimes even all the toes are visible.

You may also need to stand on the leg that’s bothering you and try to stand up on your tiptoes. Usually, an individual with PTTD won’t be able to do this.

Most doctors can diagnose problems with the posterior tibial tendon by examining the foot, but your doctor may also order some imaging tests to confirm the diagnosis and rule out other conditions.

Your doctor may order X-rays or CT scans if they think you have arthritis in the foot or ankle. MRI and ultrasound scans can confirm PTTD.

Treatments

Non-Operative Treatment:

Treatment for stage 1 posterior tibial tendonitis usually involves a combination of:

• Rest: Avoid activities that bring on your symptoms as much as possible. Try and stick to activities that don’t place much force through the foot such as swimming and cycling
• Ice: Regularly applying ice packs 3-4 times a day for around 10 minutes to the inner ankle helps to reduce pain and inflammation.
• Compression: Wearing a tubigrip compression bandage helps to reduce swelling and provides support to the ankle. It should be worn double thickness from the mid-foot to just below the knee, during the day only.
• Elevation: Whenever you are resting, try and keep your leg elevated, preferably so your ankle is higher than your chest, to reduce any swelling. Make sure the knee is supported
• Medication: Taking pain-relieving medication and anti-inflammatories (NSAIDs) regularly helps to reduce the pain and inflammation – always check with your doctor before starting on medication
• Orthotics: There are a whole range of orthotics that can be helpful with posterior tibial tendonitis.
• Footwear: It is important to wear supportive shoes. Ideally you want flat, sturdy lace-up shoes that have enough space to incorporate your orthotics. Try and wear your shoes and orthotics whenever you are walking, even around the house – avoid going bare-foot as much as possible
• Physiotherapy: You will be given a rehab plan involving ankle strengthening exercises and calf stretches to improve the strength and mobility of the posterior tibial tendon and the surrounding muscles. These will again help to improve the support and flexibility around the ankle, reducing the tension through the tibialis posterior tendon
• Ankle Immobilisation: Your doctor may advise wearing a cast or removable boot for 1-2 months with posterior tibial tendonitis. These hold the ankle and foot in a fixed position and reduce the tension on the tendon to allow it time to heal
• Steroid Injection: Corticosteroid injections are sometimes used to reduce pain and inflammation in tendons, but they are rarely advisable with posterior tibialis tendinopathy as there is a high risk of the tendon rupturing.

All of these treatments are most effective during the first stage of posterior tibial tendonitis.

Surgical Treatment

If non-surgical posterior tibial tendonitis treatment has failed, meaning there has been no benefit over 6 months, and you are stage 2 or higher, then you are likely to need surgery. In some cases, ankle immobilisation may be sufficient during stage 2, but this is rare.

Surgery for posterior tibial tendonitis aims to reduce pain, improve function and reduce the progression of posterior tibial tendon dysfunction.

The type of surgery carried out will depend on how much tendon damage there is and which part of the tendon is affected. Surgery for tibialis posterior dysfunction may involve one of more of the following:

• Debridement: Any inflamed parts of the posterior tibial tendon tissue are removed. This is only effective in the early stages of posterior tibial tendonitis before the foot has changed shape
• Achilles Lengthening: If the Achilles tendon is particularly tight, it is released to allow greater ankle movement and reduce the tension on tibialis posterior
• Tendon Transfer: This is where the damaged portion of the tibialis posterior tendon is removed and replaced with one of the other foot or ankle tendons.
• Flexor Digitorum Longus: which helps bend the outer four toes down
• Flexor Hallucis Longus: which bends the big toe downwards
• Tibialis Anterior: which pulls the foot upwards. This is known as a Cobb Procedure

People can typically walk normally after the tendon transfer procedure, but they may have difficulty running and may not be able to resume certain sports.

• Osteotomy: This is where one or more of the foot bones are cut and their position shifted and fixed, most typically the heel bone, to recreate a “normal” foot position. The bones are fixed into place using plates or screws and are sometimes removed once the bones have healed
• Fusion: Sometimes an osteotomy is sufficient to correct the foot position, in which case the bones in the back of foot are fused. The cartilage between the foot bones is removed and the bones are held together with plates and/or screws. Over time, the individual bones gradually fuse together to become one bone. The foot will still be able to move up and down but sideways movement is lost.

Patients who require surgery for their posterior tibial tendonitis, particularly osteotomies or fusions generally have very limited ankle and foot movement, moderate to severe pain, and are very limited in how far they can walk prior to surgery. While surgery may seem extreme for posterior tibial tendonitis, people typically find they have much less pain and can actually walk better after surgery.