Posterior Tibial Tendon Dysfunction - Overview

What is PTTD?

PTTD is a flat foot condition caused by inflammation or a tear in the posterior tibial tendon - the tendon which connects from the posterior tibialis muscle (sometimes considered a part of the calf or the posterior compartment), along the ankle medial to the Achilles tendon, and to the bottom of the inner foot bones.

The primary role of this tendon is to form the arch of the foot and to provide support when weight-bearing with activities like walking. When it becomes damaged or inflamed, it is unable to hold the arch and leading to pain and can lead to pronounced flattening of the foot.

Also known as Adult Acquired Flat Foot, this condition mainly affects those over 40 years of age, particularly women. In fact, some research suggests PTTD may affect as many as one in ten older women.

We're here to explain all you need to know about PTTD; including the signs and symptoms, causes and risk factors, methods of diagnosis, and treatment options.

PTTD Stages & Symptoms

When a doctor diagnoses PTTD, they will typically class the condition as being in one of four stages.

Stage 1 PTTD

Not many people are diagnosed with Stage 1 PTTD - simply because there are little to no noticeable symptoms in the early stages! At most, some people may experience swelling or inflammation along the tendon, or they may find their feet tire easily.

Stage 2 PTTD

Those in stage 2 PTTD will start to experience some symptoms, and may even notice a visible change in the shape of the foot. Signs and symptoms include:

• Mild to moderate foot pain, particularly of the midfoot and forefoot
• Inflammation along the tendon
• A falling of the medial longitudinal arch of the foot
• Partial dislocation of joints in the foot
• A turning outward of the toes and foot

Stage 3 PTTD

Stage 3 PTTD involves significant physical signs and symptoms such as:

• Moderate to severe pain of the foot or ankle joint
• Weakness in the foot
• Foot deformity (flat foot and changes in bone positioning)
• Arthritis in the foot

Stage 4 PTTD

The final stage of the condition is that of a severe flat foot. At this stage, the recovery progress to address the damage will be a tough one - highlighting the importance of seeking medical treatment as early as possible.

In stage 4 PTTD, patients experience:

• Severe foot or ankle pain
• Tenderness along the posterior tibia (back of the shin bone)
• Extreme damage to the joints, soft tissue, and ligaments of the foot
• Arthritis in the foot or ankle due to joint degeneration
• Posterior tibial tendon insufficiency (complete failure of the local tendon, bones, and plantar ligaments)
• Increased risk of full tendon rupture 

Causes and Risk Factors of PTTD

Arches can fall over time as the tendon along the inside of your ankle (which supports the arch) starts to weaken ( Image Reference).

The posterior tibial tendon may become torn or inflamed from an injury like a fall, or a sports-related impact.

Overuse of the foot can also cause damage to the tendon. If you take part in high-impact activities such as tennis or running, you may be at greater risk of experiencing PTTD as a result of damage to the tendon over time.

In addition, there are other risk factors for the development of PTTD. It is most common in:

• Women
• Older adults
• Anyone that is primarily sedentary (resulting in foot weakness with standing)
• Diabetics
• People with high blood pressure (hypertension)
• The overweight or obese
• People with one leg slightly shorter than the other (this can happen over time or can be caused by knee replacements, hip fractures, poor pelvic alignment etc.)

PTTD Diagnosis

The posterior tibial tendon attaches the posterior tibialis muscle to the bones inside the foot. It works to hold up the arch and support the foot as you walk ( Image Reference).

Posterior tibial tendon dysfunction should always be diagnosed by a qualified medical health professional to get you on the right track for a full recovery. As mentioned earlier, if you suspect you may have PTTD it is important to seek medical advice as soon as possible to avoid the condition progressing through the stages, leading to a reduction in quality of life and disability.

Doctor Diagnosis: Medical History and Physical Examination

Your doctor will make a diagnosis of PTTD based on a comprehensive medical history, current symptoms, and physical examination.

They will look for:

• Swelling

  Particularly any swelling along the posterior tibial tendon (from the calf to the medial malleolus- inside ankle bone- to the inside of the foot).

• Abnormalities in the Shape of the Foot

  In PTTD, the heel can turn outward and the arch becomes less pronounced.

• The Appearance of "Too Many Toes"
  

  the doctor may stand behind you and view your foot and ankle (the hindfoot) from that position. In those with PTTD, more than two toes can be seen outside the calcaneus (heal).

The orthopedic doctor may also request you complete some small exercises to help confirm a diagnosis or inform a treatment plan. For example, the doctor may ask you to:

• Perform a one-legged heel rise. Here, you should stand on one leg and raise the other heel (i.e. stand on your “tiptoes”). If you are unable to do this, or the heel turns outward or is unstable during the exercise, it can help to indicate PTTD - patients in stage 2 or subsequent stages are often unable to balance on one foot.

• Attempt to “lift” the bottom of the foot off the ground to create an arch shape- this assesses the coordination and strength of the lower leg muscles, particularly the posterior tibialis muscle.

• Move your foot from side to side and up and down. Your level of flexibility will help the doctor to determine the stage of PTTD, and which treatments may be best suited to your needs.

In addition, imaging tests can help with diagnosis:

• A radiographic X-ray or CT scan may be performed to rule out arthritis in the foot or ankle, which can have similar symptoms to PTTD.

• An MRI scan or ultrasound can be carried out to confirm PTTD if the doctor is unsure based on the physical examination alone.

Self-Examination

Although there is no substitute for a qualified medical examination for PTTD, this simple home test may help you decide if you have a flat foot condition:

1. Submerge your bare feet in a basin of water, or thoroughly wet them with a shower or hose.

2. Stand on a flat surface where the imprint will be visible - such as on a bathroom tile or concrete sidewalk.

3. Check your footprint. Healthy feet will show a ‘missing’ piece of the print, indicating a complete arch. Those with flat feet will see a complete imprint showing the entire foot, indicating a fallen arch and flatfoot deformity.

Preventing PTTD

This condition may be prevented by taking proper care of your feet and ankles. This includes avoiding repetitive activities that put excessive strain on the feet and posterior tibial tendon, such as running or other high-impact sports. Plus, regular foot and ankle strength exercises with a focus on proper biomechanical form can also help immensely. Wearing supportive shoes most, if not all of the time, is also recommended.

How to Make Your Shoes More Supportive.

Additionally, limiting the risk factors associated with PTTD may help prevent it. This means reducing your risk for diabetes, high blood pressure, and obesity. If you already have one or more of these conditions, ensure you keep up with your treatment regimen to keep symptoms under control.

Finally, maintaining proper alignment of the body with activity will reduce strain on the tendons in the feet and ankles.

Be Proactive with These Treatment Options

Take Care of Your Feet!

Because PTTD is a painful and progressive condition - which can ultimately lead to permanent foot damage and reduced mobility. Rarely, steroid injections or even foot surgery are required, such as a calcaneal osteotomy (bone reformation), fusion (arthrodesis), tenosynovectomy, or tendon transfer. Thus, it’s important to take the necessary steps to prevent or treat PTTD as soon as possible to have success with non-surgical treatment.

Temporary immobilization with a walking boot, wearing footwear with arch support, taking nonsteroidal anti-inflammatory medication, custom orthotics (shoe inserts), physical therapy, choosing your activities wisely, and giving your feet plenty of R&R are some of the basic things you can do to ensure happy and healthy feet through all stages of life. These conservative treatment options are always better than the alternative.

If you think you are experiencing some of the signs and symptoms of PTTD, discuss your concerns with an orthopaedic doctor or physical therapist. Those who have already been diagnosed with the condition should take care to closely follow their prescribed treatment plan.