Overview
Posterior Tibial Tendon Dysfunction (PTTD) is a painful flatfoot condition that affects adults, primarily over the age of 50. Also known as Adult Acquired Flatfoot, this issue affects women more than men and is linked to obesity, hypertension and diabetes. Most people with PTTD have had flat feet all of their lives. Then, for reasons not fully understood, one foot starts to become painful and more deformed.
Causes
Many health conditions can create a painful flatfoot, an injury to the ligaments in the foot can cause the joints to fall out of alignment. The ligaments support the bones and prevent them from moving. If the ligaments are torn, the foot will become flat and painful. This more commonly occurs in the middle of the foot (Lisfranc injury), but can also occur in the back of the foot. In addition to ligament injuries, fractures and dislocations of the bones in the midfoot can also lead to a flatfoot deformity.
Symptoms
Depending on the cause of the flatfoot, a patient may experience one or more of the different symptoms here. Pain along the course of the posterior tibial tendon which lies on the inside of the foot and ankle. This can be associated with swelling on the inside of the ankle. Pain that is worse with activity. High intensity or impact activities, such as running, can be very difficult. Some patients can have difficulty walking or even standing for long periods of time. When the foot collapses, the heel bone may shift position and put pressure on the outside ankle bone (fibula). This can cause pain on the outside of the ankle. Arthritis in the heel also causes this same type of pain. Patients with an old injury or arthritis in the middle of the foot can have painful, bony bumps on the top and inside of the foot. These make shoewear very difficult. Occasionally, the bony spurs are so large that they pinch the nerves which can result in numbness and tingling on the top of the foot and into the toes. Diabetics may only notice swelling or a large bump on the bottom of the foot. Because their sensation is affected, people with diabetes may not have any pain. The large bump can cause skin problems and an ulcer (a sore that does not heal) may develop if proper diabetic shoewear is not used.
Diagnosis
Observe forefoot to hindfoot alignment. Do this with the patient sitting and the heel in neutral, and also with the patient standing. I like to put blocks under the forefoot with the heel in neutral to see how much forefoot correction is necessary to help hold the hindfoot position. One last note is to check all joints for stiffness. In cases of prolonged PTTD or coalition, rigid deformity is present and one must carefully check the joints of the midfoot and hindfoot for stiffness and arthritis in the surgical pre-planning.
Non surgical Treatment
It is imperative that you seek treatment should you notice any symptoms of a falling arch or PTTD. Due to the progressive nature of this condition, your foot will have a much higher chance of staying strong and healthy with early treatment. When pain first appears, your doctor will evaluate your foot to confirm a flatfoot diagnosis and begin an appropriate treatment plan. This may involve rest, anti-inflammatory medications, shoe modifications, physical therapy, orthotics and a possible boot or brace. When treatment can be applied at the beginning, symptoms can most often be resolved without the need for surgery.
Surgical Treatment
In cases where cast immobilization, orthoses and shoe therapy have failed, surgery is the next alternative. The goal of surgery and non-surgical treatment is to eliminate pain, stop progression of the deformity and improve mobility of the patient. Opinions vary as to the best surgical treatment for adult acquired flatfoot. Procedures commonly used to correct the condition include tendon debridement, tendon transfers, osteotomies (cutting and repositioning of bone) and joint fusions. (See surgical correction of adult acquired flatfoot). Patients with adult acquired flatfoot are advised to discuss thoroughly the benefits vs. risks of all surgical options. Most procedures have long-term recovery mandating that the correct procedure be utilized to give the best long-term benefit. Most flatfoot surgical procedures require six to twelve weeks of cast immobilization. Joint fusion procedures require eight weeks of non-weightbearing on the operated foot - meaning you will be on crutches for two months. The bottom line is, Make sure all of your non-surgical options have been covered before considering surgery. Your primary goals with any treatment are to eliminate pain and improve mobility. In many cases, with the properly designed foot orthosis or ankle brace, these goals can be achieved without surgical intervention.
Posterior Tibial Tendon Dysfunction (PTTD) is a painful flatfoot condition that affects adults, primarily over the age of 50. Also known as Adult Acquired Flatfoot, this issue affects women more than men and is linked to obesity, hypertension and diabetes. Most people with PTTD have had flat feet all of their lives. Then, for reasons not fully understood, one foot starts to become painful and more deformed.
Causes
Many health conditions can create a painful flatfoot, an injury to the ligaments in the foot can cause the joints to fall out of alignment. The ligaments support the bones and prevent them from moving. If the ligaments are torn, the foot will become flat and painful. This more commonly occurs in the middle of the foot (Lisfranc injury), but can also occur in the back of the foot. In addition to ligament injuries, fractures and dislocations of the bones in the midfoot can also lead to a flatfoot deformity.
Symptoms
Depending on the cause of the flatfoot, a patient may experience one or more of the different symptoms here. Pain along the course of the posterior tibial tendon which lies on the inside of the foot and ankle. This can be associated with swelling on the inside of the ankle. Pain that is worse with activity. High intensity or impact activities, such as running, can be very difficult. Some patients can have difficulty walking or even standing for long periods of time. When the foot collapses, the heel bone may shift position and put pressure on the outside ankle bone (fibula). This can cause pain on the outside of the ankle. Arthritis in the heel also causes this same type of pain. Patients with an old injury or arthritis in the middle of the foot can have painful, bony bumps on the top and inside of the foot. These make shoewear very difficult. Occasionally, the bony spurs are so large that they pinch the nerves which can result in numbness and tingling on the top of the foot and into the toes. Diabetics may only notice swelling or a large bump on the bottom of the foot. Because their sensation is affected, people with diabetes may not have any pain. The large bump can cause skin problems and an ulcer (a sore that does not heal) may develop if proper diabetic shoewear is not used.
Diagnosis
Observe forefoot to hindfoot alignment. Do this with the patient sitting and the heel in neutral, and also with the patient standing. I like to put blocks under the forefoot with the heel in neutral to see how much forefoot correction is necessary to help hold the hindfoot position. One last note is to check all joints for stiffness. In cases of prolonged PTTD or coalition, rigid deformity is present and one must carefully check the joints of the midfoot and hindfoot for stiffness and arthritis in the surgical pre-planning.
Non surgical Treatment
It is imperative that you seek treatment should you notice any symptoms of a falling arch or PTTD. Due to the progressive nature of this condition, your foot will have a much higher chance of staying strong and healthy with early treatment. When pain first appears, your doctor will evaluate your foot to confirm a flatfoot diagnosis and begin an appropriate treatment plan. This may involve rest, anti-inflammatory medications, shoe modifications, physical therapy, orthotics and a possible boot or brace. When treatment can be applied at the beginning, symptoms can most often be resolved without the need for surgery.
Surgical Treatment
In cases where cast immobilization, orthoses and shoe therapy have failed, surgery is the next alternative. The goal of surgery and non-surgical treatment is to eliminate pain, stop progression of the deformity and improve mobility of the patient. Opinions vary as to the best surgical treatment for adult acquired flatfoot. Procedures commonly used to correct the condition include tendon debridement, tendon transfers, osteotomies (cutting and repositioning of bone) and joint fusions. (See surgical correction of adult acquired flatfoot). Patients with adult acquired flatfoot are advised to discuss thoroughly the benefits vs. risks of all surgical options. Most procedures have long-term recovery mandating that the correct procedure be utilized to give the best long-term benefit. Most flatfoot surgical procedures require six to twelve weeks of cast immobilization. Joint fusion procedures require eight weeks of non-weightbearing on the operated foot - meaning you will be on crutches for two months. The bottom line is, Make sure all of your non-surgical options have been covered before considering surgery. Your primary goals with any treatment are to eliminate pain and improve mobility. In many cases, with the properly designed foot orthosis or ankle brace, these goals can be achieved without surgical intervention.