PTTD is a common condition treated by foot and ankle specialists. Although there is a role for surgical treatment of PTTD, conservative care often can prevent or delay surgical intervention.
Decreasing inflammation and stabilizing the affected joints associated with the posterior tibial tendon
decrease pain and increase functional levels. With many different modalities available, aggressive nonoperative methods should be considered in the treatment of PTTD, including early immobilization,
the use of long-term bracing, physical therapy, and anti-inflammatory medications. If these methods fail, proper evaluation and work-up for surgical intervention should be employed.
A person with flat feet has greater load placed on the posterior tibial tendon which is the main tendon unit supporting up the arch of the foot. Throughout life, aging leads to decreased strength of
muscles, tendons and ligaments. The blood supply diminishes to tendons with aging as arteries narrow. Heavier, obese patients have more weight on the arch and have greater narrowing of arteries due
to atherosclerosis. In some people, the posterior tibial tendon finally gives out or tears. This is not a sudden event in most cases. Rather, it is a slow, gradual stretching followed by inflammation
and degeneration of the tendon. Once the posterior tibial tendon stretches, the ligaments of the arch stretch and tear. The bones of the arch then move out of position with body weight pressing down
from above. The foot rotates inward at the ankle in a movement called pronation. The arch appears collapsed, and the heel bone is tilted to the inside. The deformity can progress until the foot
literally dislocates outward from under the ankle joint.
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.
Perform a structural assessment of the foot and ankle. Check the ankle for alignment and position. When it comes to patients with severe PTTD, the deltoid has failed, causing an instability of the
ankle and possible valgus of the ankle. This is a rare and difficult problem to address. However, if one misses it, it can lead to dire consequences and potential surgical failure. Check the heel
alignment and position of the heel both loaded and during varus/valgus stress. Compare range of motion of the heel to the normal contralateral limb. Check alignment of the midtarsal joint for
collapse and lateral deviation. Noting the level of lateral deviation in comparison to the contralateral limb is critical for surgical planning. Check midfoot alignment of the naviculocuneiform
joints and metatarsocuneiform joints both for sag and hypermobility.
Non surgical Treatment
Flatfoot can be treated with a variety of methods, including modified shoes, orthotic devices, a brace or cast, anti-inflammatory medications or limited steroid injections, rest, ice, and physical
therapy. In severe cases, surgery may be necessary.
Surgical treatment should be considered when all other conservative treatment has failed. Surgery options for flatfoot reconstruction depend on the severity of the flatfoot. Surgery for a flexible
flatfoot deformity (flatfoot without arthritis to the foot joints) involves advancing the posterior tibial tendon under the arch to provide more support and decrease elongation of the tendon as well
as addressing the hindfoot eversion with a osteotomy to the calcaneus (surgical cut in the heel bone). Additionally, the Achilles tendon may need to be lengthened because of the compensatory
contracture of the Achilles tendon with flatfoot deformity. Flatfoot deformity with arthritic changes to the foot is considered a rigid flatfoot. Correction of a rigid flatfoot deformity usually
involves surgical fusion of the hindfoot joints. This is a reconstructive procedure which allows the surgeon to re-position the foot into a normal position. Although the procedure should be
considered for advanced PTTD, it has many complications and should be discussed at length with your doctor.