Posterior Tibial Tendon Dysfunction (Adult-Acquired Flat Foot)

Noticed that your foot is getting flatter and more painful? Do you have difficulty walking or performing exercise activity without leg and arch pain? Have you heard the term “fallen arches”? All of these things refer to a condition known as posterior tibial tendon dysfunction. This is an inflammation and overuse syndrome of one of the long tendons that pass from the leg around the inside of the ankle and attaches to the inside arch of the foot. The posterior tibial tendon’s job is to help support the arch and allow for more efficient gait.

PTTD is most commonly seen in adults and referred to as “adult acquired flatfoot”. Symptoms include pain and swelling along the inside arch and ankle, loss of the arch height and an outward sway of the foot. If not treated early, the condition progresses to increased flattening of the arch, increased inward roll of the ankle and deterioration of the posterior tibial tendon. Often, with end stage complications, severe arthritis may develop.

How does all this happen? In the majority of cases, it is overuse of the posterior tibial tendon that causes PTTD. And it is your inherited foot type that may cause a higher possibility that you will develop this condition.

Non-surgical treatment includes rest and reducing your activity until the pain improves. Orthotics or bracing help support the tendon to reduce its pull along the arch, thus reducing pain. In moderate to severe cases, a below knee cast or walking boot may be needed to allow the tendon to rest completely and heal. Physical therapy is an integral part of the non-surgical treatment regimen to reduce inflammation and pain. Anti-inflammatory medication is often used as well. Many times evaluation of your current shoes is necessary to ensure you are wearing appropriate shoe gear to prevent re-injury.

For those patients with PTTD that have severe deformity or have not improved with conservative treatments, surgery may be necessary to return them to daily activity. Surgery for PTTD may include repair of the diseased tendon and possible tendon transfer to a nearby healthy tendon, surgery on the surrounding bones or joints to prevent biomechanical abnormalities that may be a contributing factor or both.

Posterior Tibial Tendonitis

Many people have begun a vigorous exercise program to start their New Year’s resolution of losing weight and getting in shape. But with this, comes unexpected pain that stops the workout sessions and ultimately prevents them from fulfilling their goal. Most often this is due to “too much, too soon, too fast” syndrome.

Pain along the inside of the ankle that extends to the inside arch is often due to strain of the posterior tibial tendon. The main job of this tendon is to prevent overpronation of the foot and stabilize the arch and ankle. Overuse of this tendon, particularly in people with flat feet, causes the tendon to swell and become painful so that exercise activity is not possible. Ultimately, this type of injury can lead to tear of the tendon and possible surgery. The pain is often sharp, stabbing and radiates along the course of the tendon. Often the entire ankle will be swollen.

Treatment for this begins with rest. This doesn’t mean you have to stop exercising, but no weight bearing exercise until the pain subsides. Ice daily and apply compression to reduce swelling. When pain is gone, then gradual return to an exercise program with appropriate shoes and brace as needed.

A complete lower extremity exam will help determine what types of shoes are best for your workouts and what type of inserts can prevent recurrence of the pain. Often with flat feet, custom orthotics are the best devices that support the ankle and arch and prevent overpronation, thus reducing the likelihood that the pain will return.

If left untreated, posterior tibial tendonitis leads to tear of the tendon (a.k.a. Adult-onset flat foot) and often extensive foot and ankle surgery. It is best to treat this pain as early as possible.

Plantar Fasciitis

Plantar fasciitis is the most common cause of heel pain. It is a condition seen in the old the young, the active and inactive. It can be incapacitating if early efforts in treatment are not made. The good news is that 80-85% of the time, it is successfully treated conservatively. The odds are in your favor if you act quickly to heal it.

Plantar fasciitis is an inflammatory condition where pressure in and around the arch of your foot causes a strain and sometimes even a tear in the main ligament (the plantar fascia) that helps to hold up the arch. This ligament spans the bottom of the foot from heel to the ball of the foot. Think of the plantar fascia ligament as a rope made of many fibers. The fibers can tear and shred causing pain and inflammation. The most common area for pain occurs at the heel, which is the weakest attachment of this ligament. Yet, there are many cases where pain is felt along the course of this ligament especially right underneath the arch itself.

Once the strain and pain occurs, you may notice a pattern in the way it feels. Commonly, you may feel mild to intense pain with the first few steps out of bed in the morning or after sitting, or even after a long drive. When you think about it, our feet tend to point slightly down ward in these instances. This temporarily relaxes the arch and the ligament tightens. When you stand up, you place all of your weight on the foot and the arch once again strains downward. This puts tension on an already injured plantar fascia, essentially re-injuring it every time this occurs. You may then find early on in the injury, that once your ligament has stretched somewhat, after the first few steps, that the pain resolves. Over time however, you may discover that the pain lingers longer than before. This is when plantar fasciitis becomes a real problem and when most people seek help.

The challenge for a podiatrist is to get the injured ligament to heal even though you are constantly using it. This requires a lot of patient involvement in the healing process.

Healing the plantar fascia requires patience and persistence. Stretching plays a big role in helping this condition. The more you stretch, the better. Your doctor will give you information on the proper stretches that target the plantar fascia. By keeping the ligament limber, it will strain less under your weight.

You may be dispensed something called a “night splint”. This comes in the form of what looks like half of a boot-type splint. This splint rests against your leg and foot to hold your foot up, keeping it from pointing down while you sleep. This keeps a constant stretch on the ligament and surrounding tendons as well. This stretch lessens the strain and can help in healing and improving your pain.

Supporting the arch is essential in preventing further strain and inflammation of the plantar fascia. Too many shoes have poor excuses for an arch support. Even what you may buy as an over-the –counter arch support may not be adequate for your foot type. Your doctor will make the proper recommendations for what your foot needs.

Icing the heel and arch can help as this is an inflammatory process. Taking an anti-inflammatory as needed for the pain may help as well. If your inflammation is beyond what an oral anti-inflammatory can manage, you may be offered a cortisone injection in the heel. Nobody likes them, but they sure can help!

Your doctor may also recommend physical therapy to help with deeper stretches and manipulations, as well as also working on areas that may be constricted or tight in other area of your body. They may also choose to use other modalities such as ultra sound and even cold laser therapy.

Extracorporeal Pulse Activation Treatment (EPAT) is a wonderful modality used to deliver pulses of acoustic waves to treat chronic plantar fasciitis and can be performed at FAANT’s office

This fancy stuff is worth every visit if it means getting you better quicker.

In the very worst of cases, surgical intervention may become necessary. Your doctor will discuss this thoroughly with you if conservative treatment has been exhausted.

Finally, you may now understand what can potentially aggravate this condition. The types of exercises you perform may play a role. For the time being, any exercise that causes excessive impact on the arch and plantar fascia such as running or jumping should be replaced with exercises that are more lenient on the injury. Biking, swimming, ellipse cycle and arc trainer are effective aerobic options and much gentler on your healing fascia.

Weight gain plays a role in aggravating plantar fasciitis. Increased weight means increased strain. The non-impact exercises just mentioned are great options to get some of the weight off the ligament and off your body.

Supportive shoes are just as important as the arches inside them. Flip flops and barefoot walking needs to be placed to the side for now since you will get the most strain in the ligament if nothing is keeping the tension off of it. If you want to wear a slipper instead of a shoe around the house, then look for options with good arch support.

Lastly, just be good to your feet. They are the only set of tires you’ve got. Get them to my office at the first signs of fatigue or the first signs of pain. Don’t wait till you have a blow out!