Posterior Tibial Tendon Dysfunction (PTTD)
Posterior tibial tendon dysfunction (PTTD), also referred to 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 normally 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 seldom 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 boost up on the feet without pain.
Too Many Toes Sign
Lateral subtalar joint (outside of the ankle) pain.
Common Test to Evaluate PTTD May be the 'Too Many Foot Sign'
The too many toes sign' is a test used to calculate 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 cases of PTTD, when the foot is viewed from at the rear of, the toes show up 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 nose tarsi refers to a small tunnel 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 rear tibial tendon to support the arch becomes declined, the arch will collapse overloading the subtalar joint. As a result, there is increased pressure put on the joint surfaces of the lateral aspect of the subtalar joint, resulting in pain.
There have been many proposed explanations for PTTD over time since this condition was first described by Kulkowski inThe most modern 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 outer lining of the tendon. Extremely small blood vessels also permeate the muscle sheath to arrive at muscle. This makes all tendon notoriously slow in order to recover. In the case of the posterior tibial muscle, this problem is exacerbated by a distinct area of bad 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 many prone to fatigue and failure at an area the location where the tendons 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 inside of the ankle). The tendon then takes a dramatic turn towards the arch of the foot. If the tendons is put in a situation where significant load is applied to the foot, the tendon responds by pulling up as the load of the body (in addition in order to gravity) pushes down. At the location where the tendon changes course, the tibia acts as a wedge and could apply enough force to actually damage or shatter 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 as a result 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 forces the rear tibial tendons to accept additional load during gait.
Additional contributing factor to the onset of PTTD may include hypertension, diabetes, peripheral neuropathy, smoking or arthritis.
- The progression of PTTD might bring about tendonitis, partial tears of the tendon or perhaps complete tendon break.
- Many categories have been developed to describe PTTD.
- The group as described by Johnson and Strom is most commonly used today.
- 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 way too many foot sign X-ray/MRIMild to moderate tenosynovitis on MRI, no X-ray changes
- Stage II Tendon status Attenuated with possible partial or complete break Clinical findings Pain in arch.
- Not able to raise on foot.
- Too many toes indication present X-ray/MRI MRI notes tear in muscle.
- 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 observing abduction of forefoot, collapse of talo-navicular joint.
- Treatment for PTTD is dependant upon 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 alone is fraught with failure.
- Timely introduction of some form of physical support is imperative.
Surgical procedures that focus on primary repair of the posterior tibial tendon are very unsuccessful. This is due to the fact that tendon heals slowly following damage and cannot be relied upon as a sole solution for PTTD cases. Medical success is usually attained through stabilization with the rearfoot subtalar joint) which significantly reduces the work performed by the rear tibial tendon.
Stage I might respond to sleep, for instance 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 and also heel elevation, for the rest of their lives, is actually imperative. Arch support, whether constructed into the shoe or added as an orthotic, helps support the posterior tibial tendons and decrease its' work. Elevation of the heel, reduces equinus, one of the most significant contributing factors to PTTD. In the event that Stage I patients return to low heels without arch support, PTTD can recur.
Stage II patients, or Stage I patients that do not respond to rest and support, require surgical correction in order to stabilize the subtalar joint prior to further damage to the posterior tibial tendon. Subtalar arthroeresis is a procedure used to strengthen 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 tendons 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 procedure.
Stage III patients require stabilization of the rearfoot with procedures that fuse the primary joints of the arch and feet. 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 weak 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 rear tibial muscle is the medial navicular the location where the tendon divides into nine different insertion website on the bottom of the foot.
The function of the posterior tibial tendon is to plantarflex the base on the toe away from phase of the gait cycle and to support the medial arch.
The symptoms of period 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 are seen with more regularity.
- Pain is present at the onset of weight bearing.
- Some restriction of the ability to raise up on the foot will be present.
- Stage III signs are severe with an inability to accomplish most normal daily activities such as laundry 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 break, flexor hallucis longus tendonitis, gout, joint disease of the subtalar joint or a fracture of the posterior process of the 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 tendons inability with flexor digitorum longus tendon transfer and calcaneal osteotomy.
- Orthopedics 19:383-388, 1996
Myerson, M.S. Adult acquired flatfoot deformity. J. Bone andJoint Surgery. 78-A;780, 1996
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Johnson, K.A., Tibialis posterior tendon rupture. Clin. Orthop. 177:140-147, 1983
About the Particular Author:Jeffrey a
Oster, DPM, C.Ped is a board certified foot and ankle surgeon. Dr. Oster can be board certified in pedorthics. Doctor. Oster is medical director of Myfootshop.com and is in active practice in Granville, Ohio.