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What Can Cause Posterior Tibial Tendon Dysfunction (PTTD) ?

Overview
Flatfoot may sound like a characteristic of a certain water animal rather than a human problem. Flatfoot is a condition in which the arch of the foot is fallen and the foot is pointed outward. In contrast to a flatfoot condition that has always been present, this type develops after the skeleton has reached maturity. There are several situations that can result in fallen arches, including fracture, dislocation, tendon laceration, tarsal coalition, and arthritis. One of the most common conditions that can lead to this foot problem is posterior tibial tendon dysfunction. The posterior tibial tendon attaches the calf muscle to the bones on the inside of the foot and is crucial in holding up and supporting the arch. An acute injury or overuse can cause this tendon to become inflamed or even torn, and the arch of the foot will slowly fall over time. Adult Acquired Flat Feet

Causes
As discussed above, many health conditions can create a painful flatfoot. Damage to the posterior tibial tendon is the most common cause of AAFD. The posterior tibial tendon is one of the most important tendons of the leg. It starts at a muscle in the calf, travels down the inside of the lower leg and attaches to the bones on the inside of the foot. The main function of this tendon is to hold up the arch and support your foot when you walk. If the tendon becomes inflamed or torn, the arch will slowly collapse. Women and people over 40 are more likely to develop problems with the posterior tibial tendon. Other risk factors include obesity, diabetes, and hypertension. Having flat feet since childhood increases the risk of developing a tear in the posterior tibial tendon. In addition, people who are involved in high impact sports, such as basketball, tennis, or soccer, may have tears of the tendon from repetitive use. Inflammatory arthritis, such as rheumatoid arthritis, can cause a painful flatfoot. This type of arthritis attacks not only the cartilage in the joints, but also the ligaments that support the foot. Inflammatory arthritis not only causes pain, but also causes the foot to change shape and become flat. The arthritis can affect the back of the foot or the middle of foot, both of which can result in a fallen arch.

Symptoms
The symptoms of PTTD may include pain, swelling, a flattening of the arch, and inward rolling of the ankle. As the condition progresses, the symptoms will change. For example, later, as the arch begins to flatten, there may still be pain on the inside of the foot and ankle. But at this point, the foot and toes begin to turn outward and the ankle rolls inward. As PTTD becomes more advanced, the arch flattens even more and the pain often shifts to the outside of the foot, below the ankle. The tendon has deteriorated considerably and arthritis often develops in the foot. In more severe cases, arthritis may also develop in the ankle. Symptoms, which may occur in some persons with flexible flatfoot, include. Pain in the heel, arch, ankle, or along the outside of the foot. ?Turned-in? ankle. Pain associated with a shin splint. General weakness / fatigue in the foot or leg.

Diagnosis
Clinicians need to recognize the early stage of this syndrome which includes pain, swelling, tendonitis and disability. The musculoskeletal portion of the clinical exam can help determine the stage of the disease. It is important to palpate the posterior tibial tendon and test its muscle strength. This is tested by asking patient to plantarflex and invert the foot. Joint range of motion is should be assessed as well. Stiffness of the joints may indicate longstanding disease causing a rigid deformity. A weightbearing examination should be performed as well. A complete absence of the medial longitudinal arch is often seen. In later stages the head of the talus bone projects outward to the point of a large "lump" in the arch. Observing the patient's feet from behind shows a significant valgus rotation of the heel. From behind, the "too many toes" sign may be seen as well. This is when there is abducution of the forefoot in the transverse plane allowing the toes to be seen from behind. Dysfunction of the posterior tibial tendon can be assessed by asking the patient to stand on his/her toes on the affected foot. If they are unable to, this indicates the disease is in a more advanced stage with the tendon possibly completely ruptured.

Non surgical Treatment
Conservative (nonoperative) care is advised at first. A simple modification to your shoe may be all that???s needed. Sometimes purchasing shoes with a good arch support is sufficient. For other patients, an off-the-shelf (prefabricated) shoe insert works well. The orthotic is designed specifically to position your foot in good alignment. Like the shoe insert, the orthotic fits inside the shoe. These work well for mild deformity or symptoms. Over-the-counter pain relievers or antiinflammatory drugs such as ibuprofen may be helpful. If symptoms are very severe, a removable boot or cast may be used to rest, support, and stabilize the foot and ankle while still allowing function. Patients with longer duration of symptoms or greater deformity may need a customized brace. The brace provides support and limits ankle motion. After several months, the brace is replaced with a foot orthotic. A physical therapy program of exercise to stretch and strengthen the foot and leg muscles is important. The therapist will also show you how to improve motor control and proprioception (joint sense of position). These added features help prevent and reduce injuries. Acquired Flat Feet

Surgical Treatment
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. Symptomatic flexible flatfoot conditions are common entities in both the adolescent and adult populations. Ligamentous laxity and equinus play a significant role in most adolescent deformities. Posterior tibial tendon dysfunction (PTTD) is the most common cause of adult acquired flatfoot. One should consider surgical treatment for patients who have failed nonoperative therapy and have advancing symptoms and deformities that significantly interfere with the functional demands of daily life. Isolated Joint Fusion. This technique is used for well reducible flat foot by limiting motion at one or two joints that are usually arthritic. The Evans Anterior Calcaneal Osteotomy. This is indicated for late stage II adult acquired flatfoot and the flexible adolescent flatfoot. This procedure will address midtarsal instability, restore the medial longitudinal arch and reduce mild hind foot valgus. The Posterior Calcaneal Displacement Osteotomy (PCDO). This technique is indicated for late stage I and early stage II PTTD with reducible Calcaneal valgus. This is often combined with a tendon transfer. A PCDO is also indicated as an adjunctive procedure in the surgical reconstruction of the severe flexible adolescent flatfoot. Soft tissue procedure. On their own these are not very effective but in conjunction with an osseous procedure, soft tissue procedures can produce good outcome. Common ones are tendon and capsular repair, tendon lengthening and transfer procedures. Flat foot correction requires lengthy post operative period and a lot of patience. Your foot may need surgery but you might simply not have the time or endurance to go through the rehab phase of this type of surgery. We will discuss these and type of procedures necessary for your surgery in length before we go further with any type of intervention.