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 typically 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 rarely 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 in order 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 feet sign'. The way too many toes sign' is a test used to determine abduction deviation away from the midline of the body) with the forefoot. With damage to the rear tibial tendon, the forefoot will abduct or transfer in relationship to the rest of the foot. In the event of PTTD, once the foot is viewed from at the rear of, 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 sinus tarsi refers to a small tube 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 declined, the arch will collapse overloading the subtalar combined. As a result, there is increased pressure applied to the joint areas of the lateral aspect of the subtalar joint, resulting in discomfort.
There have been many proposed explanations for PTTD over the years given that this condition was first described by Kulkowski inThe most contemporary explanation refers to an area of hypovascularity (limited blood flow) in the tendon just below the ankle. Tendon gets nearly all of its' nutritional support from synovial fluid produced by the particular outer lining of the tendon. Very small blood vessels also permeate the muscle sheath to achieve tendon. This makes all tendon notoriously slow in order to heal. In the case of the posterior tibial tendons, 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 most vunerable to fatigue and failure at an area in which the tendon 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 interior 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 alterations course, the tibia acts as a wedge and may use enough force to actually damage or rupture 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 feet at the ankle (move the toes toward you).Equinus is usually because of tightness in the leg muscle mass, 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 causes the posterior tibial tendons to accept additional insert during gait.
Additional contributing factor to the onset of PTTD may include hypertension, diabetes, peripheral neuropathy, smoking or arthritis.
- The progression of PTTD may bring about tendonitis, partial tears of the tendon or perhaps complete muscle shatter.
- Many classifications have been developed to describe PTTD.
- The group as described by Johnson and Strom is most commonly used today.
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- Stage I Tendon status Attenuated (lengthened) with tendonitis but simply no rupture Clinical findings Palpable pain in the medial arch.
- Foot is supple, adaptable with a lot of foot sign X-ray/MRIMild to moderate tenosynovitis on MRI, no X-ray changes
- Stage II Tendon status Attenuated with possible partial or complete rupture Clinical findings Pain in arch.
- Unable to raise on toes.
- Too many toes indication present X-ray/MRI MRI notes tear in tendons.
- X-ray noting abduction of forefoot, collapse of talo-navicular joint
Stage III Tendon status Severe degeneration with likely ruptureClinical findings Rigid flatfoot together with inability to raise up on toes X-ray/MRI MRI shows tear in tendon. X-ray noting abduction of forefoot, collapse of talo-navicular joint.
Treatment of posterior tibial tendons dysfunction and posterior tibial tendonitis
- Treatment for PTTD is dependant after the clinical stage and the health status of the patient.
- It is important to recognize thatPTTD is a mechanical problem that will require a mechanical solution.
- This means that treating PTTD with treatment on your own is fraught with failure.
- Timely introduction of some form of mechanical support is imperative.
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Surgical procedures that focus on primary repair of the posterior tibial tendon are very unsuccessful. This is due to the fact that muscle heals slowly following damage and cannot be relied upon as a sole solution for PTTD cases. Surgical success is usually achieved simply by stabilization of the rearfoot subtalar joint) which significantly reduces the work performed by the posterior tibial tendons.
Stage I May Respond to Rest, 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 as well as heel elevation, for the rest of their lives, will be crucial. Arch support, whether included in the shoe or added as an orthotic, helps support the posterior tibial muscle and decrease its' perform. Elevation of the heel, reduces equinus, one of the most significant contributing factors to PTTD. If Stage I patients return to low heels with out arch support, PTTD will recur.
Stage II patients, or Stage I patients that do not respond to rest and assistance, require surgical correction in order to strengthen the subtalar joint prior to further damage to the posterior tibial tendon. Subtalar arthroeresis is a procedure used to support 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 be able to moderate deformation of the arch has occurred and MRI findings show the muscle to be only partially ruptured. Subtalar arthroeresis is typically performed in conjunction with anAchilles tendon lengthening procedure to fix equinus. These procedures require casting for a period of weeks following the method.
Stage III patients require stabilization of the rearfoot with procedures that fuse the primary joints of the arch and base. These kinds of procedures are salvage procedures and also 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 and 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 bad surgical candidates 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 tendons is the extension of the posterior tibial muscle that lies deep to the calf. The origin of the posterior tibial muscle is the posterior aspect of both the tibia and fibula and the interosseus membrane. The insertion of the posterior tibial muscle is the medial navicular the location where the tendon divides into nine different insertion site on the bottom of the foot.
The function of the posterior tibial tendon is always to plantarflex the feet in the toe away from phase of the gait cycle and to strengthen the medial arch.
The symptoms of phase 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. Considerable activity may result in a partial rupture of the tendon, moving to stage II.
- Stage II signs and symptoms are seen with more regularity.
- Pain is present at the onset of standing and walking.
- Some restriction of a chance to raise up on the toes will be present.
- Stage III symptoms are severe with an inability to finish 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 shatter, flexor hallucis longus tendonitis, gout, osteoarthritis of the subtalar joint or a fracture of the posterior process of the actual talus.
Additional References Include;
Cantanzariti, A.R., Lee, M.S., Mendicino, R.W. PosteriorCalcaneal Displacement Osteotomy with regard to Adult Acquired Flatfoot. J.of Foot and Ankle Surgery. 39-1: 2-14, 2000
- Myerson, M.S., Corrigan, J.
- Treatment of posterior tibial muscle inability with flexor digitorum longus tendons transfer and calcaneal osteotomy.
- Orthopedics 19:383-388, 1996
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Myerson, M.S. Adult purchased 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 Author:Jeffrey a
Oster, DPM, C.Ped is a board certified foot and ankle surgeon. Dr. Oster can also be board certified in pedorthics. Dr. Oster is medical director of Myfootshop.com and is in active practice in Granville, Ohio.