This condition is characterized by a progressive flattening or falling of the arch. It is often referred to as posterior tibial tendon dysfunction (PTTD) and is becoming a more commonly recognized foot problem. Since the condition develops over time, it is typically diagnosed in adulthood. It usually only develops in one foot although it can affect both. Since it is progressive, it is common for symptoms to worsen, especially when it is not treated early. The posterior tibial tendon attaches to the bones on the inside of your foot and is vital to the support structure within the foot. With PTTD, changes in the tendon impair its ability to function normally. The result is less support for the arch, which in turn causes it to fall or flatten. A flattening arch can cause the heel to shift out of alignment, the forefoot to rotate outward, the heel cord to tighten, and possible deformity of the foot. Common symptoms include pain along the inside of the ankle, swelling, an inward rolling of the ankle, pain that is worse with activity, and joint pain as arthritis sets in.Causes
Damage to the posterior tendon from overuse is the most common cause for adult acquired flatfoot. Running, walking, hiking, and climbing stairs are activities that add stress to this tendon, and this overuse can lead to damage. Obesity, previous ankle surgery or trauma, diabetes (Charcot foot), and rheumatoid arthritis are other common risk factors.Symptoms
Posterior tibial tendon insufficiency is divided into stages by most foot and ankle specialists. In stage I, there is pain along the posterior tibial tendon without deformity or collapse of the arch. The patient has the somewhat flat or normal-appearing foot they have always had. In stage II, deformity from the condition has started to occur, resulting in some collapse of the arch, which may or may not be noticeable. The patient may feel it as a weakness in the arch. Many patients initially present in stage II, as the ligament failure can occur at the same time as the tendon failure and therefore deformity can already be occurring as the tendon is becoming symptomatic. In stage III, the deformity has progressed to the extent where the foot becomes fixed (rigid) in its deformed position. Finally, in stage IV, deformity occurs at the ankle in addition to the deformity in the foot.Diagnosis
The history and physical examination are probably the most important tools the physician uses to diagnose this problem. The wear pattern on your shoes can offer some helpful clues. Muscle testing helps identify any areas of weakness or muscle impairment. This should be done in both the weight bearing and nonweight bearing positions. A very effective test is the single heel raise. You will be asked to stand on one foot and rise up on your toes. You should be able to lift your heel off the ground easily while keeping the calcaneus (heel bone) in the middle with slight inversion (turned inward). X-rays are often used to study the position, shape, and alignment of the bones in the feet and ankles. Magnetic resonance (MR) imaging is the imaging modality of choice for evaluating the posterior tibial tendon and spring ligament complex.Non surgical Treatment
Treatment depends very much upon a patient?s symptoms, functional goals, degree and specifics of deformity, and the presence of arthritis. Some patients get better without surgery. Rest and immobilization, orthotics, braces and physical therapy all may be appropriate. With early-stage disease that involves pain along the tendon, immobilization with a boot for a period of time can relieve stress on the tendon and reduce the inflammation and pain. Once these symptoms have resolved, patients are often transitioned into an orthotic that supports the inside aspect of the hindfoot. For patients with more significant deformity, a larger ankle brace may be necessary.Surgical Treatment
Good to excellent results for more than 80% of patients have been reported at five years' follow up for the surgical interventions recommended below. However, the postoperative recovery is a lengthy process, and most surgical procedures require patients to wear a plaster cast for two to three months. Although many patients report that their function is well improved by six months, in our experience a year is required to recover truly and gain full functional improvement after the surgery. Clearly, some patients are not candidates for such major reconstructive surgery.