Flat Feet

Posterior Tibial Tendon Dysfunction (PTTD)

 

What Is PTTD?   Posterior tibial tendon dysfunction (PTTD)

The posterior tibial tendon serves as one of the major supporting structures of the foot, helping it to function while walking. Posterior tibial tendon dysfunction (PTTD) is a condition caused by changes in the tendon, impairing its ability to support the arch. This results in flattening of the foot.

PTTD is often called adult acquired flatfoot because it is the most common type of flatfoot developed during adulthood. Although this condition typically occurs in only one foot, some people may develop it in both feet. PTTD is usually progressive, which means it will keep getting worse, especially if it is not treated early.

Causes

Overuse of the posterior tibial tendon is often the cause of PTTD. In fact, the symptoms usually occur after activities that involve the tendon, such as running, walking, hiking or climbing stairs.

SymptomsInward rolling of the ankle

The symptoms of PTTD may include pain, swelling, a flattening of the arch and an inward rolling of the ankle. As the condition progresses, the symptoms will change.

For example, when PTTD initially develops, there is pain on the inside of the foot and ankle (along the course of the tendon). In addition, the area may be red, warm and swollen.

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.

Nonsurgical Treatment

Because of the progressive nature of PTTD, early treatment is advised. If treated early enough, your symptoms may resolve without the need for surgery, and progression of your condition can be arrested.

In contrast, untreated PTTD could leave you with an extremely flat foot, painful arthritis in the foot and ankle and increasing limitations on walking, running or other activities.

In many cases of PTTD, treatment can begin with nonsurgical approaches that may include:

  • Orthotic devices or bracing. To give your arch the support it needs, your foot and ankle surgeon may provide you with an ankle brace or a custom orthotic device that fits into the shoe.
  • Immobilization. Sometimes a short-leg cast or boot is worn to immobilize the foot and allow the tendon to heal, or you may need to completely avoid all weightbearing for a while.
  • Physical therapy. Ultrasound therapy and exercises may help rehabilitate the tendon and muscle following immobilization.
  • Medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, help reduce the pain and inflammation.
  • Shoe modifications. Your foot and ankle surgeon may advise changes to your shoes and may provide special inserts designed to improve arch support.

When Is Surgery Needed?

In cases of PTTD that have progressed substantially or have failed to improve with nonsurgical treatment, surgery may be required. For some advanced cases, surgery may be the only option. Your foot and ankle surgeon will determine the best approach for you.

 

Pediatric Flatfoot: Cause for Alarm?

Parents keep a close eye on their growing children, watching for proper development and being alert for any sign of a problem because small problems can have big implications. Pediatric flatfoot is a childhood condition that, if left untreated, can result in permanent deformity in adulthood. Flatfoot deformity makes mobility and exercise painful, increasing the risk of reduced cardiovascular health and obesity.

“Parents never want their child to undergo a surgical procedure,” says Mary Crawford, DPM, FACFAS, an Everett, Washington foot and ankle surgeon. “But uncorrected symptomatic flatfoot can lead to chronic pain and instability as the child ages into adulthood. Children will be on their feet for a long time to come. It’s vital to keep those feet healthy. A foot and ankle surgeon can help parents understand the options—surgical and nonsurgical—for treating pediatric flatfoot.”

Not all children have symptoms, but others will complain of pain, tenderness or cramping in the foot, leg and knee. Parents may notice an outward tilting of the heel, awkwardness or clumsiness in walking and difficulty with shoes. Pediatric flatfoot makes participating in activities more difficult, so parents should take note if their child is unable to keep up with playmates, tires easily or voluntarily withdraws from physical activities.

To diagnose a pediatric flatfoot, a foot and ankle surgeon examines the child’s foot in weightbearing and nonweightbearing positions, both in and out of shoes. The physician also notes how the child walks and evaluates the foot’s range of motion. In some cases, flat feet are associated with issues of the hip and knee, so the physician may examine those as well.

For further detailed analysis, the physician may order imaging tests, such as an x-ray, CT scan, MRI or bone scan. Family history will be evaluated as well since the presence of flatfoot disorder in the family increases the possibility of flatfoot in the child.

“There are different types of flatfoot deformities,” notes Crawford. “Thorough testing helps us pinpoint the causes of the flatfoot disorder and develop an appropriate treatment plan.”

Pediatric flatfoot can be divided into two categories, flexible and rigid. Flexible flatfoot is characterized by a normal arch when nonweightbearing, or sitting, and disappearance of the arch when standing.  There may or may not be symptoms. In the case of rigid flatfoot, however, the arch is stiff and flat when both sitting and standing. In most cases, children with rigid flatfoot display symptoms associated with the condition. In either case, flexible or rigid flatfoot, there are a variety of underlying reasons requiring different treatments.

Babies often appear to have flat feet due to cramped positioning inside the womb, and the symptoms will abate with time. In other cases, the surgeon recommends stretching exercises or a soft brace for a short period. Children who do not exhibit symptoms typically do not require treatment but will be monitored and reevaluated periodically by the foot and ankle surgeon.

For children who exhibit symptoms, the physician may recommend physical therapy, shoe modifications, anti-inflammatory medications, such as ibuprofen to reduce pain and inflammation, or an orthotic device. This device fits inside the shoe and supports the structure of the foot. In some cases, surgery is the best alternative.

 

Fallen Arches

Fallen arches is a term commonly used to describe a flatfoot condition that develops during adulthood. This should not be confused with other causes of flatfoot that may develop during childhood or adolescence.

Most cases of fallen arches develop when the main arch-supporting tendon (the posterior tibial tendon) becomes weakened or injured, causing the arch to gradually become lower. With time, the shape of the foot changes and secondary symptoms start to appear.

Common problems associated with fallen arches include plantar fasciitis, tendonitis, increased fatigue and arthritis of the foot and ankle.

For more information, see Posterior Tibial Tendon Dysfunction (PTTD)Flexible Flatfoot.