Posterior Tibial Tendon Dysfunction

The posterior tibial tendon plays a crucial role in supporting the arch and providing stability to the foot. Dysfunction of this important combination of muscle and tendon may result in a severe flatfoot deformity. There is a broad spectrum in the symptoms of a patient with posterior tibial tendon dysfunction, ranging from a painful, well-aligned foot to a severe flatfoot. Most typical is the patient who presents early in onset and complains of painful swelling behind the inner ankle that may radiate to the arch.

X-rays may be taken of your foot during an examination. Even though x-rays will not image the tendon itself, they are of great value in assessing positional bony relationships and arthritic or adaptive changes. MRI studies provide much more information about the extent of damage to the tendon.

Classification is necessary and essential for the treatment of the dysfunction:

• Stage I- asymptomatic phase, results from an underlying biomechanical fault that predisposes one to develop PTTD

• Stage II- symptomatic phase with the development of tendonitis, mild symptoms, and progressive flatfoot deformity

• Stage III- characterized by tendon rupture, either complete or partial, severe symptoms, and a disabling flatfoot condition. The tendon and deformity may be reconstructable during this stage

• Stage IV- demonstrates rapid progression of the severely disabling arthritic flatfoot deformity

Conservative treatments are recommended in stages I and II. In the acute or early stages, treatment is directed at reducing inflammation and removing stress to the tendon in the hope that the damaged tendon will heal. Nonsteroidal anti-inflammatory drugs (NSAIDS) may be beneficial in providing pain relief and in reducing inflammation. Oral steroids may be indicated for short-term treatment of the acute inflammation in some patients. Physical therapy may be utilized to resolve inflammation and to strengthen the tendon. Often immobilization may be required with a cast, cam- walker, or braces.

Surgery is usually recommended for stages III and IV. Soft tissue procedures for the treatment of tibialis posterior tendon dysfunction revolve around two primary components: repair of the tibialis posterior tendon, and restoring stability to the foot.

Recent medical advances have developed new techniques in flexible flatfoot caused by PTTD. The Subtalar MBA implant is a small threaded titanium implant which is inserted into the subtalar joint. It is designed to block excessive pronation of the subtalar joint to realign the foot, thus allowing normal joint motion and lessening stress on the tendon. Bone procedures may also be necessary to correct the deformity. These procedures provide greater structural correction and stability to the foot.