Posterior tibial tendon insufficiency
(also called posterior tibial
tendon dysfunction or adult acquired flatfoot) has been named literally after failure of the posterior tibial tendon. However, the condition is caused not only by the progressive failure of the
posterior tibial tendon; it is also failure of associated ligaments and joints on the inner side of the ankle and foot. This results in collapse of the arch of the foot, along with the deformity
which most often becomes the debilitating problem in its later stages. While at the beginning the common symptom is pain over the tendon in the inner part of the hindfoot and midfoot, later on it is
the deformity that can threaten a person's ability to walk. Just as the tendon degenerates and loses its function, other soft tissue on the same inner side of the foot - namely the ligaments -
degenerate and fail. Ligaments are responsible for holding bones in place, and when they fail, bones shift to places where they shouldn?t; deformity is the result. The deformity causes malalignment,
leading to more stress and failure of the ligaments.
A person with flat feet has greater load placed on the posterior tibial tendon which is the main tendon unit supporting up the arch of the foot. Throughout life, aging leads to decreased strength of
muscles, tendons and ligaments. The blood supply diminishes to tendons with aging as arteries narrow. Heavier, obese patients have more weight on the arch and have greater narrowing of arteries due
to atherosclerosis. In some people, the posterior tibial tendon finally gives out or tears. This is not a sudden event in most cases. Rather, it is a slow, gradual stretching followed by inflammation
and degeneration of the tendon. Once the posterior tibial tendon stretches, the ligaments of the arch stretch and tear. The bones of the arch then move out of position with body weight pressing down
from above. The foot rotates inward at the ankle in a movement called pronation. The arch appears collapsed, and the heel bone is tilted to the inside. The deformity can progress until the foot
literally dislocates outward from under the ankle joint.
In many cases, adult flatfoot causes no pain or problems. In others, pain may be severe. Many people experience aching pain in the heel and arch and swelling along the inner side of the foot.
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
Flatfoot can be treated with a variety of methods, including modified shoes, orthotic devices, a brace or cast, anti-inflammatory medications or limited steroid injections, rest, ice, and physical
therapy. In severe cases, surgery may be necessary.
In cases of PTTD that have progressed substantially or have failed to improve with non-surgical treatment, surgery may be required. For some advanced cases, surgery may be the only option. Surgical
treatment may include repairing the tendon, tendon transfers, realigning the bones of the foot, joint fusions, or both. Dr. Piccarelli will determine the best approach for your specific case. A
variety of surgical techniques is available to correct flexible flatfoot. Your case may require one procedure or a combination of procedures. All of these surgical techniques are aimed at relieving
the symptoms and improving foot function. Among these procedures are tendon transfers or tendon lengthening procedures, realignment of one or more bones, or insertion of implant devices. Whether you
have flexible flatfoot or PTTD, to select the procedure or combination of procedures for your particular case, Dr. Piccarelli will take into consideration the extent of your deformity based on the
x-ray findings, your age, your activity level, and other factors. The length of the recovery period will vary, depending on the procedure or procedures performed.