Dysfunction of the tibialis posterior tendon is a common condition and a common cause of acquired flatfoot deformity in adults. Women older than 40 are most at risk. Patients present with pain and
swelling of the medial hindfoot
. Patients may also report a change in the shape of the foot or flattening of the foot. The foot develops a valgus
heel (the heel rotates laterally when observed from behind), a flattened longitudinal arch, and an abducted forefoot. Conservative treatment includes non-steroidal anti-inflammatory drugs, rest, and
immobilisation for acute inflammation; and orthoses to control the more chronic symptoms. Surgical treatment in the early stages is hindfoot osteotomy combined with tendon transfer. Arthrodesis of
the hindfoot, and occasionally the ankle, is required in the surgical treatment of the later stages of tibialis posterior dysfunction.
There are a number of theories as to why the tendon becomes inflamed and stops working. It may be related to the poor blood supply within the tendon. Increasing age, inflammatory arthritis, diabetes
and obesity have been found to be causes.
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.
Posterior Tibial Tendon Dysfunction is diagnosed with careful clinical observation of the patient?s gait (walking), range of motion testing for the foot and ankle joints, and diagnostic imaging.
People with flatfoot deformity walk with the heel angled outward, also called over-pronation. Although it is normal for the arch to impact the ground for shock absorption, people with PTTD have an
arch that fully collapses to the ground and does not reform an arch during the entire gait period. After evaluating the ambulation pattern, the foot and ankle range of motion should be tested.
Usually the affected foot will have decreased motion to the ankle joint and the hindfoot. Muscle strength may also be weaker as well. An easy test to perform for PTTD is the single heel raise where
the patient is asked to raise up on the ball of his or her effected foot. A normal foot type can lift up on the toes without pain and the heel will invert slightly once the person has fully raised
the heel up during the test. In early phases of PTTD the patient may be able to lift up the heel but the heel will not invert. An elongated or torn posterior tibial tendon, which is a mid to late
finding of PTTD, will prohibit the patient from fully rising up on the heel and will cause intense pain to the arch. Finally diagnostic imaging, although used alone cannot diagnose PTTD, can provide
additional information for an accurate diagnosis of flatfoot deformity. Xrays of the foot can show the practitioner important angular relationships of the hindfoot and forefoot which help diagnose
flatfoot deformity. Most of the time, an MRI is not needed to diagnose PTTD but is a tool that should be considered in advanced cases of flatfoot deformity. If a partial tear of the posterior tibial
tendon is of concern, then an MRI can show the anatomic location of the tear and the extensiveness of the injury.
Non surgical Treatment
Treatment will vary depending on the degree of your symptoms. Generally, we would use a combination of rest, immobilization, orthotics, braces, and physical therapy to start. The goal is to keep
swelling and inflammation under control and limit the stress on the tendon while it heals. Avoidance of activities that stress the tendon will be necessary. Once the tendon heals and you resume
activity, physical therapy will further strengthen the injured tendon and help restore flexibility. Surgery may be necessary if the tendon is torn or does not respond to these conservative treatment
methods. Your posterior tibial tendon is vital for normal walking. When it is injured in any way, you risk losing independence and mobility. Keep your foot health a top priority and address any pain
or problems quickly. Even minor symptoms could progress into chronic problems, so don?t ignore your foot pain.
Surgery is usually performed when non-surgical measures have failed. The goal of surgery is to eliminate pain, stop progression of the deformity and improve a patient?s mobility. More than one
technique may be used, and surgery tends to include one or more of the following. The tendon is reconstructed or replaced using another tendon in the foot or ankle The name of the technique depends
on the tendon used. Flexor digitorum longus (FDL) transfer. Flexor hallucis longus (FHL) transfer. Tibialis anterior transfer (Cobb procedure). Calcaneal osteotomy - the heel bone may be shifted to
bring your heel back under your leg and the position fixed with a screw. Lengthening of the Achilles tendon if it is particularly tight. Repair one of the ligaments under your foot. If you smoke,
your surgeon may refuse to operate unless you can refrain from smoking before and during the healing phase of your procedure. Research has proven that smoking delays bone healing significantly.