Posterior Tibial Tendon Dysfunction (PTTD)
Posterior tibial tendon dysfunction (PTTD), also known as posterior tibial tendonitis, is one of the leading causes of acquired flatfoot in adults. The onset of PTTD may be slow and progressive or sudden. An abrupt starting point is usually linked to some form of trauma, whether it be simple (stepping down off a curb or ladder) or severe (falling from a height or car accident). PTTD is hardly ever seen in children and increases in frequency with age.
The Characteristic Finding of PTTD Include;
Loss of medial arch height.
Edema (Swelling) of the Medial Ankle
Loss of the ability to resist force to be able to abduct or push the foot out from the midline of the body.
Pain on the Medial Ankle With Weight Bearing
Inability to raise up on the foot without pain.
Too Many Toes Sign
Lateral subtalar joint (outside of the ankle) pain.
Common test to evaluate PTTD could be the 'too many foot sign'. The too many toes sign' is a test used to calculate abduction deviation away from the midline of the body) of the forefoot. With damage to the rear tibial tendon, the forefoot will abduct or move out in relationship to the rest of the foot. In cases of PTTD, if the foot is viewed from guiding, the toes seem as 'too many' on the outside of the foot due to abduction of the forefoot.
Advanced cases of PTTD, in addition to the pain of the tendon itself, pain will also be noted at the sinus tarsi. The nose tarsi refers to a small tunnel or divot on the outside of the ankle that can actually be felt. This tunnel is the entry to the subtalar joint. The subtalar joint is the joint that controls the side to side motion of the foot, motion that would occur with uneven surfaces or sloped hills. As PTTD progresses and the ability of the posterior tibial tendon to support the arch becomes diminished, the arch will collapse overloading the subtalar shared. As a result, there is increased pressure placed on the joint areas of the lateral aspect of the subtalar joint, resulting in soreness.
There have been many proposed explanations for PTTD over time because this condition was first described by Kulkowski inThe most modern day explanation refers to an area of hypovascularity (limited blood flow) in the tendon just below the ankle. Tendon gets most of its' nutritional support from synovial fluid produced by the particular outer lining of the tendon. Very small blood vessels also permeate the tendons sheath to reach tendon. This makes all tendon notoriously slow to heal. In the case of the posterior tibial tendon, this problem is exacerbated by a distinct area of poor blood flow hypovascularity). This area is located in the posterior tibial tendon just below or distal to the inside ankle bone (medial malleolus).
Tendon is also the majority of vunerable to fatigue and failure at an area in which the tendons changes direction. As the posterior tibial tendon descends the leg and comes to the inside of the ankle, the tendon follows a well defined groove in the back of the tibia (bone of the lining of the ankle). The tendon then takes a dramatic turn towards the arch of the foot. If the tendons is placed into a situation where significant load is applied to the foot, the tendon responds by pulling up as the load of the body (in addition to gravity) pushes down. At the location where the tendon changes course, the tibia acts as a wedge and may even apply enough force to actually damage or break the tendon.
Equinus is Also a Contributing Factor to PTTD
Equinus is the term used to describe the ability or lack of ability to dorsiflex the base on the ankle (move the toes toward you).Equinus is usually because of tightness in the leg muscle, also known as the gastroc-soleal complex (a combination of the gastrocnemius and soleus muscles). Equinus may also be due to a bony block in the front of the ankle. The presence of equinus makes the rear tibial tendons to accept additional fill during gait.
Additional contributing factor to the onset of PTTD may include hypertension, diabetes, peripheral neuropathy, smoking or arthritis.
- The progression of PTTD may well lead to tendonitis, partial tears of the tendon or complete muscle break.
- A number of categories have been developed to describe PTTD.
- The classification as described by Johnson and Strom is most commonly used today.
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- Stage I Tendon status Attenuated (lengthened) with tendonitis but no rupture Clinical findings Palpable pain in the medial arch.
- Foot is supple, flexible with too many foot indication X-ray/MRIMild to moderate tenosynovitis on MRI, no X-ray changes
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- Stage II Tendon status Attenuated with possible partial or complete rupture Clinical findings Pain in arch.
- Can not raise on foot.
- A lot of toes indication present X-ray/MRI MRI notes tear in tendon.
- X-ray noting abduction of forefoot, collapse of talo-navicular joint
Stage III Tendon status Severe degeneration with likely ruptureClinical findings Rigid flatfoot with inability to raise up on toes X-ray/MRI MRI shows tear in tendon. X-ray observing abduction of forefoot, collapse of talo-navicular joint.
- Treatment for PTTD is dependant upon the clinical stage and the health status of the patient.
- It is important to recognize thatPTTD is a mechanical problem that requires a mechanical solution.
- This means that treating PTTD with medicine on your own is fraught with failure.
- Timely introduction of some form of mechanised support is imperative.
Surgical procedures which focus on primary repair of the posterior tibial tendon have been very unsuccessful. This is due to the fact that tendon heals slowly following injuries and cannot be relied upon as a sole solution for PTTD cases. Operative success is usually attained simply by stabilization of the rearfoot subtalar joint) which significantly reduces the work performed by the posterior tibial tendon.
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Stage I Might Respond to Relaxation, Such as a Walking Forged
Pain and inflammation might be controlled with anti-inflammatory medications. It is important to make sure that Stage I patients realize that the use of shoes with additional arch support and also heel elevation, for the rest of their lives, is actually imperative. Arch support, whether included in the shoe or added as an orthotic, helps support the posterior tibial tendon and decrease its' perform. Elevation of the heel, reduces equinus, one of the most significant contributing factors to PTTD. When Stage I patients return to low heels without having arch support, PTTD can recur.
Stage II patients, or Stage I patients that do not respond to rest and support, require surgical correction to stabilize the subtalar joint prior to further damage to the posterior tibial tendon. Subtalar arthroeresis is a procedure used to strengthen the subtalar joint. Arthroeresis is a term that means the motion of the joint is blocked without fusion. Subtalar arthroeresis can only be used in cases of Stage I or II exactly where mild to moderate deformation of the arch has occurred and MRI findings show the tendons to be only partially ruptured. Subtalar arthroeresis is typically performed in conjunction with anAchilles tendon lengthening procedure to correct equinus. These procedures require casting for a period of weeks following the procedure.
Stage III patients require stabilization of the rearfoot with procedures that fuse the primary joints of the arch and feet. These types of procedures are salvage procedures and require prolonged casting and disability following surgery. A common procedure forStage III is called triple arthrodesis which is a technique used to fuse the subtalar combined, the talo-navicular joint as well as the calcaneal cuboid joint.
PTTD is a condition that increases in frequency with age and the prevalence of poor health indicators such as diabetes and obesity. As a result, many patients with PTTD are poor surgical individuals for correction of PTTD. Prosthetics such as an ankle foot orthotic (AFO), Arizona Brace or other bracing may be very helpful to control the symptoms of PTTD. Anatomy:
The posterior tibial tendon is the extension of the posterior tibial muscle that lies deep to the calf. The origin of the rear tibial muscle is the posterior aspect of both the tibia and fibula and the interosseus membrane. The insertion of the rear tibial muscle is the medial navicular the location where the tendon divides into nine different insertion web site on the bottom of the foot.
The function of the posterior tibial tendon is to plantarflex the foot in the toe off phase of the gait cycle and to stabilize the medial arch.
The symptoms of stage I PTTD include a dull ache of the medial arch. The pain become worse with activity, better on days with limited time on the feet. Substantial activity may result in a partial rupture of the tendon, relocating to stage II.
- Stage II signs and symptoms are seen with more regularity.
- Pain is present at the onset of weight bearing.
- Some constraint of a chance to raise up on the foot will be present.
- Stage III symptoms are severe with an inability to accomplish most normal daily activities such as laundry washing or going to the store.
- Collapse of the medial arch will be obvious.
- Abduction of the forefoot will show 'too many toes sign'.
Conditions that may resemble PTTD include tarsal tunnel syndrome, tibial stress fractures, posterior tibial tendons break, flexor hallucis longus tendonitis, gout, arthritis of the subtalar joint or a fracture of the posterior process of the particular talus.
Additional References Include;
Cantanzariti, A.R., Lee, M.S., Mendicino, R.W. PosteriorCalcaneal Displacement Osteotomy regarding Adult Acquired Flatfoot. J.of Foot and Ankle Surgery. 39-1: 2-14, 2000
- Myerson, M.S., Corrigan, J.
- Treatment of posterior tibial tendons disorder with flexor digitorum longus tendons transfer and calcaneal osteotomy.
- Orthopedics 19:383-388, 1996
Myerson, M.S. Adult acquired flatfoot deformity. J. Bone andJoint Surgery. 78-A;780, 1996
Johnson, K.A., Tibialis posterior tendon rupture. Clin. Orthop. 177:140-147, 1983
About the Actual Author:Jeffrey a
Oster, DPM, C.Ped is a board certified foot and ankle surgeon. Dr. Oster can be board certified in pedorthics. Medical professional. Oster is medical director of Myfootshop.com and is in active practice in Granville, Ohio.