Posterior Tibial Tendon Dysfunction

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Dr Poh Seng Yew

MBBS

MRCSEd

MMED (Ortho)

FRCSEd

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What is Posterior Tibial Tendon Dysfunction?

Posterior tibial tendon dysfunction (PTTD) is a condition where the posterior tibial tendon becomes inflamed or damaged. This tendon connects the calf muscle to the bones on the inside of the foot and plays a role in supporting the foot’s arch. In PTTD, the compromised tendon may lead to a progressive flattening of the foot, commonly referred to as adult flatfoot.

This condition is characterised by the posterior tibial tendon’s inability to provide adequate support and stability for the foot’s arch, leading to a gradual collapse of the arch. The progression of PTTD can lead to changes in foot alignment, impacting mobility and overall foot function.

Causes of Posterior Tibial Tendon Dysfunction

PTTD can arise from a variety of causes, often involving a combination of intrinsic and extrinsic factors.

  • Acute Injuries and Overuse
    Sudden injuries, such as falls, can directly damage the posterior tibial tendon. Repetitive stress from high-impact sports like basketball, tennis, or soccer can also lead to injury, causing the tendon to tear or become inflamed.
  • Age-Related Degeneration
    The posterior tibial tendon naturally experiences age-related wear and tear. This process weakens the tendon, making it more susceptible to injury.
  • Underlying Medical Conditions
    Women are more likely to develop PTTD, and conditions like obesity, diabetes, and hypertension can increase the risk. These issues can potentially accelerate tendon degeneration or exacerbate the condition.
  • Abnormal Foot Alignment or Function
    An individual’s foot structure and biomechanics can also contribute to the development of PTTD. Abnormal foot alignment or biomechanical function may increase strain on the posterior tibial tendon.

Symptoms and Signs

PTTD presents a range of symptoms and signs, which usually progress as the condition worsens.


  • Pain and Swelling: The inside of the foot and ankle often experience pain and swelling. This discomfort is particularly noticeable during activities that strain the foot, such as walking or standing for extended periods.
  • Gradual Change in Foot Shape: As PTTD progresses, the foot may gradually change shape. This includes the collapse of the foot’s arch, which can lead to a flatfoot deformity.
  • Difficulty in Foot Movements: Individuals with PTTD may experience challenges when standing on tiptoes or walking on uneven surfaces. There might also be difficulty in performing movements that require foot flexibility and strength.
  • Altered Gait: The condition can cause a change in walking patterns, including an outward shift in the heel and an inward rolling of the ankle. This can lead to uneven wear on shoes and potentially affect balance and mobility.

Diagnosis

Diagnosing PTTD involves a combination of medical history review, physical examination, and diagnostic imaging.

  • Medical History: The initial step in diagnosing PTTD involves a thorough review of the patient’s medical history, focusing on any previous foot injuries or underlying health conditions.
  • Physical Examination: During the physical examination, the foot and ankle specialist will assess for swelling and changes in the shape of the foot, and then evaluate the range of motion of the foot joints.
  • Diagnostic Imaging Tests: X-rays, MRIs, CT scans, and ultrasounds can provide detailed images of bones and soft tissues, aiding in determining the integrity of the posterior tibial tendon. They can also help confirm diagnosis and confirm the presence of other related conditions such as arthritis.

Non-Surgical Treatment Options

Non-surgical treatment methods are often the first line of approach for PTTD, especially in the early stages of the condition. These strategies aim to alleviate symptoms and prevent further deterioration of the tendon.

Rest and Activity Modification

For less serious cases, the foot and ankle specialist may initially suggest reducing or ceasing activities that aggravate the symptoms. Patients should avoid high-impact activities and instead engage in low-impact exercises like swimming or cycling.

Nonsteroidal Anti-inflammatory Medications (NSAIDs)

Over-the-counter medications such as ibuprofen or naproxen can help manage pain and inflammation.

Use of Orthotic Devices

Custom shoe inserts or braces may be used to provide support for the arch and alleviate stress on the posterior tibial tendon.

Physical Therapy

Physical therapy can help maintain joint flexibility and muscle strength. This may include exercises to strengthen the posterior tibial tendon and improve foot and ankle mobility.

Surgical Treatment Options

When non-surgical treatments for PTTD do not yield sufficient improvement, or if the condition is in a more advanced stage, surgical intervention may be necessary. The choice of surgery depends on the severity and specific characteristics of the patient’s condition.

Gastrocnemius Recession

This procedure involves lengthening the calf muscles (specifically the gastrocnemius muscle). It aims to improve ankle movement and reduce the stress on the posterior tibial tendon. Gastrocnemius recession is often considered when tight calf muscles contribute to the patient’s condition.

Tenosynovectomy

In this procedure, the foot and ankle specialist removes the inflamed tissue surrounding the posterior tibial tendon (tenosynovium). Tenosynovectomy is beneficial in reducing pain and swelling and is often performed in conjunction with other procedures to address tendon damage.

Tendon Transfer

This involves rerouting another tendon from the foot to replace or assist the function of the damaged posterior tibial tendon. A tendon transfer is used to restore the strength and stability of the foot, particularly in cases where the posterior tibial tendon is severely damaged or torn.

Osteotomy

In cases of severe deformity, an osteotomy, which involves cutting and shifting the bones of the hindfoot, may be performed to recreate the arch of the foot.

Fusion (Arthrodesis)

For patients with severe arthritis, fusion of the affected foot joints may be necessary. This involves removing damaged cartilage and bone and fixing the bones together to reduce pain and improve stability.

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Prevention Strategies

While PTTD cannot always be completely prevented, several strategies can reduce the risk of developing the condition.

  • Using Supportive Footwear to Minimise Strain - Wear shoes that provide adequate arch support and cushioning. Supportive footwear can help distribute pressure evenly across the foot, reducing strain on the posterior tibial tendon.
  • Maintaining a Healthy Weight - Excess body weight can place additional stress on the feet and tendons. Keeping a healthy weight reduces this strain and lowers the risk of developing PTTD.
  • Regular Stretching and Strengthening Exercises - Exercises that stretch and strengthen the foot and calf muscles can improve foot mechanics. This includes resistance band exercises, calf stretches, and toe curls.
  • Avoiding High-Impact Activities - Avoid repetitive activities that put excessive stress on the tendon. Incorporating low-impact exercises like swimming or cycling can help maintain fitness without overstressing the foot and ankle.
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Dr Poh Seng Yew

MBBS

MRCSEd

MMED (Ortho)

FRCSEd

With over 18 years of experience, Dr Poh Seng Yew is an orthopaedic surgeon specialising in hip, knee, shoulder and elbow surgery, sports medicine, and trauma surgery.

  • Bachelor of Medicine, Bachelor of Surgery (MBBS), National University of Singapore
  • Member, Royal College of Surgeons of Edinburgh (MRCSEd)
  • Master of Medicine (Orthopaedic Surgery), National University of Singapore
  • Fellow, Royal College of Surgeons of Edinburgh, FRCSEd (Orthopaedic Surgery)
  • Clinical Hip and Sports Medicine Fellow, Orthopädische Chirurgie München (OCM), Germany

 

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38 Irrawaddy Road, #08-62/63
Singapore 329563
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    Mount Elizabeth Novena Specialist Centre
    38 Irrawaddy Road, #08-62/63
    Singapore 329563

    Frequently Asked Questions (FAQ)

    What Are the Stages of Posterior Tibial Tendon Dysfunction?

    PTTD progresses through four stages, ranging from mild to severe. Stage I involves injury to the tendon without tearing, Stage II involves a torn or dysfunctional tendon with foot deformity, Stage III is marked by severe foot deformity and degenerative changes in connective tissue, and Stage IV includes degenerative changes in the ankle joint.

    How Long Does Posterior Tibial Tendon Dysfunction Take to Heal?

    The healing time for PTTD varies based on the severity and treatment approach. Early-stage PTTD may respond well to non-surgical treatments within weeks to months, whereas more advanced stages requiring surgery might necessitate a longer recovery period.

    Can I Walk with Posterior Tibial Tendon Dysfunction?

    Walking with PTTD is possible, but it may be challenging, especially in advanced stages. Using supportive footwear and orthotic devices can help alleviate discomfort. If walking causes severe pain, seek guidance from a foot and ankle specialist for appropriate management strategies.

    What Happens if Posterior Tibial Tendon Dysfunction Goes Untreated?

    Untreated PTTD can lead to worsening symptoms, increased pain, and further foot deformity. Progressive stages of PTTD can impact mobility and quality of life. Timely consultation with a foot and ankle specialist can help manage the condition and reduce the risk of long-term complications.