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Thanks for the positive comments about part one.This is part two of a three part post on Posterior Tibial Tendon issues. It's a bit more detail than most need but it may serve as a reference for you one day.
Posterior Tibial Tendon Dysfunction
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Posterior tibial tendon dysfunction is one of the most common problems of the foot and ankle. It occurs when the posterior tibial tendon becomes inflamed or torn. As a result, the tendon may not be able to provide stability and support for the arch of the foot, resulting in flatfoot.
Most patients can be treated without surgery, using orthotics and braces. If orthotics and braces do not provide relief, surgery can be an effective way to help with the pain. Surgery might be as simple as removing the inflamed tissue or repairing a simple tear. However, more often than not, surgery is very involved, and many patients will notice some limitation in activity after surgery.
The posterior tibial tendon is one of the most important tendons of the leg. A tendon attaches muscles to bones, and the posterior tibial tendon attaches the calf muscle to the bones on the inside of the foot. The main function of the tendon is to hold up the arch and support the foot when walking.
The posterior tibial tendon attaches the calf muscle to the bones on the inside of the foot.
An acute injury, such as from a fall, can tear the posterior tibial tendon or cause it to become inflamed. The tendon can also tear due to overuse. For example, people who do high-impact sports, such as basketball, tennis, or soccer, may have tears of the tendon from repetitive use. Once the tendon becomes inflamed or torn, the arch will slowly fall (collapse) over time.
Posterior tibial tendon dysfunction is more common in women and in people older than 40 years of age. Additional risk factors include obesity, diabetes, and hypertension.
- Pain along the inside of the foot and ankle, where the tendon lies. This may or may not be associated with swelling in the area.
- Pain that is worse with activity. High-intensity or high-impact activities, such as running, can be very difficult. Some patients can have trouble walking or standing for a long time.
- Pain on the outside of the ankle. When the foot collapses, the heel bone may shift to a new position outwards. This can put pressure on the outside ankle bone. The same type of pain is found in arthritis in the back of the foot.
The most common location of pain is along the course of the posterior tibial tendon (yellow line), which travels along the back and inside of the foot and ankle.
Medical History and Physical Examination
This patient has posterior tibial tendon dysfunction with a flatfoot deformity.(Left) The front of her foot points outward. (Right) The "too many toes" sign. Even the big toe can be seen from the back of this patient's foot.
Your doctor will take a complete medical history and ask about your symptoms. During the foot and ankle examination, your doctor will check whether these signs are present.
- Swelling along the posterior tibial tendon. This swelling is from the lower leg to the inside of the foot and ankle.
- A change in the shape of the foot. The heel may be tilted outward and the arch will have collapsed.
- "Too many toes" sign. When looking at the heel from the back of the patient, usually only the fifth toe and half of the fourth toe are seen. In a flatfoot deformity, more of the little toe can be seen.
This patient is able to perform a single limb heel rise on the right leg.
- "Single limb heel rise" test. Being able to stand on one leg and come up on "tiptoes" requires a healthy posterior tibial tendon. When a patient cannot stand on one leg and raise the heel, it suggests a problem with the posterior tibial tendon.
- Limited flexibility. The doctor may try to move the foot from side to side. The treatment plan for posterior tibial tendon tears varies depending on the flexibility of the foot. If there is no motion or if it is limited, there will need to be a different treatment than with a flexible foot.
- The range of motion of the ankle is affected. Upward motion of the ankle (dorsiflexion) can be limited in flatfoot. The limited motion is tied to tightness of the calf muscles.
Imaging Tests
Other tests which may help your doctor confirm your diagnosis include:
X-rays. These imaging tests provide detailed pictures of dense structures, like bone. They are useful to detect arthritis. If surgery is needed, they help the doctor make measurements to determine what surgery would most helpful.
(Top) An x-ray of a normal foot. Note that the lines are parallel, indicating a normal arch.(Bottom) In this x-ray the lines diverge, which is consistent with flatfoot deformity.
Computerized tomography scan (CT Scan). These scans are more detailed than x-rays. They create cross-section images of the foot and ankle. Because arthritis of the back of the foot has similar symptoms to posterior tibial tendon dysfunction, a CT scan may be ordered to look for arthritis.
Ultrasound. An ultrasound uses high-frequency sound waves that echo off the body. This creates a picture of the bone and tissue. Sometimes more information is needed to make a diagnosis. An ultrasound can be ordered to show the posterior tibial tendon.
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