Posterior Tibial Tendon Dysfunction and Adult-Acquired Flatfoot

The posterior tibial tendon is one of the major supporting structures of the foot.  It functions to help add stability to the arch, and assists in normal gait fuction.  Posterior tibial tendon dysfunction is a condition caused by changes in the tendon, leading to a loss of this stability and a flattening of the arch of the foot. 

Posterior tibial tendon dysfunction, or PTTD, is often referred to as “adult-acquired flatfoot”.  This is because PTTD is the most common cause of flatfootedness in adults.  The condition can occur in one or both of the feet.  PTTD is usually a progressive condition, meaning that the arch will continue to flatten and the symptoms will worsen over time if not addressed. 

PTTD is most often attributed to overuse of the tendon, although there may be other contributing factors.  Inflammatory arthropathies such as rheumatoid arthritis can contribute to it’s development, as well as injuries to the foot and ankle, or other bony abnormalities of the foot. 

Symptoms of PTTD may include pain, swelling, or redness around the posterior tibial tendon.  This is located on the medial side of the foot and ankle.  As the condition progresses, pain may also develop in the arch of the foot or the ankle.  Arthritis of the joints of the foot and ankle may develop overtime, leading to worsening symptoms. 

The diagnosis of PTTD or adult-acquired flatfoot is largely a clinical diagnosis.  On physical examination, the pain may be localized to one or more of the effected areas.  The arch of the foot will usually appear flattened, and the forefoot may be abducted, or shifted laterally, in relation to the rearfoot.  This is known as the “too many toes” sign, as the examiner will be able to see more of the toes from behind the patient on the affected side than on the non-affected side.  Patients with PTTD may also have a difficult time rising to their toes on the affected side, especially when asked to rise to their toes using only one leg. 

X-rays are typically taken to rule out other potential causes of pain, such as arthritis, fractures, or dislocations.  They also serve as a baseline study to monitor the progression of the foot and ankle, should the symptoms worsen over time.  If a tear of the tendon is suspected, an MRI may be useful in determining the extent of the tendon tear. 

Treatment for PTTD will typically begin with conservative treatment.  This will involve things such as orthotics and other types of braces, anti-inflammatroy medications, and periods of rest and ice.  For patients with a painful flare-up of symptoms, a period of immobilization may be beneficial.  This would involve the use of a cast or immobilizing cast boot to protect the foot and ankle.  If some of the symptoms are related to arthritis of the nearby joints, such as the subtalar joint or ankle, a cortisone injection may be beneficial to relieve some of the pain. 

Surgical intervention may be warranted if conservative treatment fails, or is deemed to not be helping enough in managing pain and function.  Surgical treatment will vary depending on the symptoms, and the extent of foot and ankle deformity.  For patients with symptoms isolated to the tendon and not involving the surrounding joints, the foot and ankle surgeon may recommend “cleaning up the tendon” and restoring as much normal anatomy as possible to the tendon.  This is a procedure that is as minimally invasive as possible for these types of complaints.

For patients with more advanced pathology, a variety of approaches may be used.  Surgical techniques may involve repositioning the calcaneus (heel bone), shifting tendons in the foot, and repositioning the bones and joints of the midfoot to recreate a more functional foot.  Of course, these methods can vary greatly between patients, and depend on a number of factors.  Factors such as the patient’s lower extremity anatomy, age, weight, and overall health status should be considered in the pre-operative work-up. 

Surgical reconstruction of the foot and ankle is not without risk, and a thorough conversation should be had between the patient and doctor before surgery can be considered.  Time off of work, time to heal, and post-operative expectations of all parties should be discussed.  

Central Florida Foot & Ankle Center, LLC 
101 6th Street N.W. 
Winter Haven, FL 33881 
Phone: 863-299-4551 
www.FLFootandAnkle.com