Posterior tibial tendon dysfunction is one of the most common problems of the foot and ankle. It occurs when the posterior tibial tendon becomes inflamed or torn. As a result, the tendon may not be able to provide stability and support for the arch of the foot, resulting in flatfoot.
Most patients can be treated without surgery, using orthotics and braces. If orthotics and braces do not provide relief, surgery can be an effective way to help with the pain. Surgery may be as simple as removing the inflamed tissue or repairing a simple tear. However, more often than not, surgery is very involved, and many patients will notice some limitation in activity after surgery.
The posterior tibial tendon is one of the most important tendons of the leg. A tendon attaches muscles to bones, and the posterior tibial tendon attaches the calf muscle to the bones on the inside of the foot. The main function of the tendon is to hold up the arch and support the foot when walking.
Cause
An acute injury, such as from a fall, can tear the posterior tibial tendon or cause it to become inflamed. The tendon can also tear due to overuse. 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.
Posterior tibial tendon dysfunction is more common in women and in people 40 years and older. Additional risk factors include obesity, diabetes, and hypertension.
Symptoms
• Pain along the inside of the foot and ankle, where the tendon lies. This may or may not be associated with swelling in the area.
• Pain that is worse with activity. High-intensity or high-impact activities, such as running, can be very difficult. Some patients can have trouble walking or standing for a long time.
• Pain on the outside of the ankle. When the foot collapses, the heel bone may shift to a new position outward. This can put pressure on the outside ankle bone. The same type of pain is found in arthritis in the back of the foot.
The most common location of pain is along the course of the posterior tibial tendon (yellow line), which travels along the back and inside of the foot and ankle.
Your doctor will take a complete medical history and ask about your symptoms. During the foot and ankle exam, they will check for:
• Swelling along the posterior tibial tendon. This swelling is from the lower leg to the inside of the foot and ankle.
• A change in the shape of the foot. The heel may be tilted outward and the arch will have collapsed.
• “Too many toes” sign: When looking at the heel from the back of the patient, usually only the fifth toe and half of the fourth toe are seen. In a flatfoot deformity, more of the little toe can be seen.
“Single limb heel rise” test. Being able to stand on one leg and come up on “tiptoes” requires a healthy posterior tibial tendon. When a patient cannot stand on one leg and raise the heel, it suggests a problem with the posterior tibial tendon. This patient is able to perform a single limb heel rise on the right leg only.• The doctor will check for limited flexibility and range of motion of the ankle joint. Upward motion of the ankle (dorsiflexion) can be limited in flatfoot. The limited motion is tied to tightness of the calf muscles.
Imaging tests
X-rays look at the bones. They are useful to detect arthritis and can show changes in the shape of the foot. Magnetic resonance imaging (MRI) may be ordered to look at the soft tissues.
Non-surgical treatment
Symptoms can be relieved in most patients with appropriate non-surgical treatment. Pain may last longer than three months even with early treatment.
Rest: Decreasing or even stopping activities that worsen the pain is the first step. Switching to low-impact exercise is helpful. Biking, elliptical machines, or swimming do not put a large impact load on the foot, and are generally tolerated by most patients.
Ice: Apply cold packs on the most painful area of the posterior tibial tendon for 20 minutes at a time, three or four times a day, to keep down swelling. Do not apply ice directly to the skin. Placing ice over the tendon immediately after completing an exercise helps to decrease the inflammation around the tendon.
Non-steroidal anti-inflammatory medication: Drugs, such as ibuprofen or naproxen, reduce pain and inflammation. Taking such medications about a half an hour before an exercise activity helps to limit inflammation around the tendon. The thickening of the tendon that is present is degenerated tendon. It will not go away with medication. Talk with your primary care doctor if the medication is used for more than one month.
Immobilization: A short leg cast or walking boot may be used for six to eight weeks. This allows the tendon to rest and the swelling to go down. However, a cast causes the other muscles of the leg to atrophy (decrease in strength) and thus is only used if no other conservative treatment works.
Orthotics: Most people can be helped with orthotics and braces. An orthotic is a shoe insert. It is the most common non-surgical treatment for a flatfoot. An over-the-counter orthotic may be enough for patients with a mild change in the shape of the foot. A custom orthotic is required in patients who have moderate to severe changes in the shape of the foot. The custom orthotic is more costly, but it allows the doctor to better control the position the foot.
Braces: A lace-up ankle brace may help mild to moderate flatfoot. The brace would support the joints of the back of the foot and take tension off of the tendon. A custom-molded leather brace is needed in severe flatfoot that is stiff or arthritic. The brace can help some patients avoid surgery.
Physical therapy: Physical therapy that strengthens the tendon can help patients with mild to moderate disease of the posterior tibial tendon.
Steroid injection: Cortisone is a very powerful anti-inflammatory medicine that your doctor may consider injecting around the tendon. A cortisone injection into the posterior tibial tendon is not normally done. It carries a risk of tendon rupture.
Surgical treatment
Surgery should only be done if the pain does not get better after six months of treatment. The type of surgery depends on where tendonitis is located and how much the tendon is damaged. Surgical reconstruction can be extremely complex. It may involve a tendon lengthening, replacing the tendon, cutting the bone or an osteotomy.
One of two possible tendons are commonly used to replace the posterior tibial tendon. One tendon helps the big toe point down and the other one helps the little toes move down. After the transfer, the toes will still be able to move and most patients will not notice a change in how they walk. Some people may not be able to run or return to competitive sports after surgery.
Osteotomy (cutting and shifting bones): An osteotomy can change the shape of a flexible flatfoot to recreate a more “normal” arch shape. One or two bone cuts may be required, typically of the heel bone (calcaneus).
Fusion: Sometimes flatfoot is stiff or there is also arthritis in the back of the foot. In these cases, the foot will not be flexible enough to be treated successfully with bone cuts and tendon transfers. Fusion (arthrodesis) of a joint or joints in the back of the foot is used to realign the foot and make it more “normal” shaped and remove any arthritis. Screws or plates hold the bones in places while they heal.
Surgical outcome: Most patients have good results from surgery. The main factors that determine surgical outcome are the amount of motion possible before surgery and the severity of the flatfoot. The more severe the problem, the longer the recovery time and the less likely a patient will be able to return to sports. In many patients, it may be 12 months before there is any great improvement in pain.
• For more information on foot conditions, visit www.apma.org, healthcentral.com, or email us at foothealth242@gmail.com. To see a podiatrist, visit Bahamas Foot Centre, Rosetta Street, or telephone 325-2996 for an appointment at Bahamas Surgical Associates Centre, Hilltop Medical, or call 394-5820 for an appointment. You can also visit Lucayan Medical Centre in Freeport, Grand Bahama, or telephone 373-7400 for an appointment.
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