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Posterior Tibial Tendon Dysfunction

What is Posterior Tibial Tendon Dysfunction?

FOOT AND ANKLE CONDITION

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.

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 might 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 limitations inactivity after surgery.

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Symptoms Of Posterior Tibial Tendonitis

Symptoms of posterior tibial tendonitis include pain and swelling along the inside of the ankle and arch along the course of the tendon. Pain is present with exercise, extended periods of walking or standing. This discomfort will usually increase as the disease progresses and is localized along the course of the tendon around the inside of the ankle or along the inside of the arch. 

This pain initially is absent when at rest but may progress to the point where the pain is present even when not active. Pain and swelling are signs of injury to the tendon. The sheath or sleeve that surrounds the tendon will produce excessive amounts of lubricating fluid in an attempt to allow the tendon to glide easier during the healing process. This excessive fluid production results in the swelling the patient sees and feels on the inside of the ankle and arch. In advanced cases, the injury to the tendon that started as tendonitis may progress to a full or partial tear of the tendon.

Diagnosis 

The diagnosis can often be made from your doctor by the history and physical exam. In many instances, an MRI or ultrasound will be performed to determine the extent of damage to the posterior tibial tendon. A simple assessment of tendon strength can be performed by standing on the “tip of the toes” on each foot. The affected foot may feel weak and painful in cases of tendonitis. In advanced cases, the patient may not be able to lift the heel from the ground as much or not at all in comparison to the unaffected foot.

Posterior Tibial Tendon Treatment

Symptoms will be relieved in most patients with appropriate nonsurgical treatment. Pain may last longer than 3 months even with early treatment. For patients who have had pain for many months, it is not uncommon for the pain to last another 6 months after treatment starts.

  • 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, 3 or 4 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.

  • Nonsteroidal Anti-inflammatory Medication

Drugs, such as ibuprofen or naproxen, reduce pain and inflammation. Taking such medications about a half of an hour before an exercise activity helps to limit inflammation around the tendon. The thickening of the tendon that is present has degenerated tendon. It will not go away with medication. Talk with your primary care doctor if the medication is used for more than 1 month.

  • Immobilization

A short leg cast or walking boot may be used for 6 to 8 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 nonsurgical 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 of 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. Discuss this risk with your doctor before getting an injection.

  • Surgical Treatment

Surgery should only be done if the pain does not get better after 6 months of appropriate treatment. The type of surgery depends on where tendonitis is located and how much the tendon is damaged. Surgical reconstruction can be extremely complex. The following is a list of the more commonly used operations. Additional procedures may also be required.

  1. Gastrocnemius Recession or Lengthening of the Achilles Tendon

This is a surgical lengthening of the calf muscles. It is useful in patients who have limited ability to move the ankle up. This surgery can help prevent flatfoot from returning but does create some weakness with pushing off and climbing stairs. Complication rates are low but can include nerve damage and weakness. This surgery is typically performed together with other techniques for treating flatfoot.

  1. Tenosynovectomy (Cleaning the Tendon)

This surgery is used when there is very mild disease, the shape of the foot has not changed, and there is pain and swelling over the tendon. The surgeon will clean away and remove the inflamed tissue (synovium) surrounding the tendon. This can be performed alone or in addition to other procedures. The main risk of this surgery is that the tendon may continue to degenerate and the pain may return.

  1. Tendon Transfer

Tendon transfer can be done in flexible flatfoot to recreate the function of the damaged posterior tibial tendon. In this procedure, the diseased posterior tibial tendon is removed and replaced with another tendon from the foot, or, if the disease is not too significant in the posterior tibial tendon, the transferred tendon is attached to the preserved (not removed) posterior tibial tendon.

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.

Although the transferred tendon can substitute for the posterior tibial tendon, the foot still is not normal. Some people may not be able to run or return to competitive sports after surgery. Patients who need tendon transfer surgery are typically not able to participate in many sports activities before surgery because of pain and tendon disease.

  1. 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).

If flatfoot is severe, a bone graft may be needed. The bone graft will lengthen the outside of the foot. Other bones in the middle of the foot also may be involved. They may be cut or fused to help support the arch and prevent the flatfoot from returning. Screws or plates hold the bones in places while they heal.

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