Sunday, January 21, 2018

Progressive flatfoot

Treating with posterior tibial tendon dysfunction...


Mark Fraser

An important tendon in the lower leg is the posterior tibial tendon. It serves as one of the major support structures of the foot, and helps as you step off on your toes when walking. Posterior tibial tendon dysfunction (PTTD), is a condition caused by changes in the tendon, impairing its ability to support the arch, which results in flattening of the foot.

Adult acquired flatfoot, as it is sometimes called, is the most common type of flatfoot developed during adulthood. Typically it occurs in only one foot; however, some people may develop it in both feet. It is usually progressive, which means it will keep getting worse, especially if it isn’t treated early.

Signs and symptoms

• Pain and swelling on the inside of the ankle

• Loss of the arch and the development of a flatfoot

• Gradually developing pain on the outer side of the ankle or foot

• Weakness and an inability to stand on the toes

• Tenderness over the mid foot, especially when under stress during activity


Overuse of the posterior tibial tendon is often the cause of PTTD.

In fact, the symptoms usually occur after activities that involve it, such as running, walking, hiking, or climbing stairs, which can cause it to become inflamed, over-stretched or torn.

Risk factors

The condition often occurs in women over 50 years of age, and may be due to an inherent abnormality of the tendon. But there are several other risk factors, including:

• Obesity

• Diabetes

• Hypertension

• Previous surgery or trauma, such as an ankle fracture on the inner side of the foot

• Steroid injections

• Inflammatory diseases such as Reiter’s syndrome, rheumatoid arthritis, spondy losing arthropathy and psoriasis.

Athletes who are involved in sports such as basketball, tennis, football or hockey may tear the posterior tibial tendon. The tendon may also become inflamed if excessive force is placed on the foot, such as when running on a banked track or road.


The diagnosis is based on both a history and a physical examination. Your physician may ask you to stand barefooted, facing the opposite direction, to view how your foot functions. As the condition progresses, the front of the affected foot will start to slide to the outside. From behind, it will look as though you have “too many toes” showing.

You may also be asked to stand on your toes or to do a single heel rise: stand with your hands on the wall, lift the unaffected foot off the ground, and raise up on the toes of the other foot.

Normally, the heel will rotate inward; the absence of this sign indicates posterior tibial tendon dysfunction. Your doctor may request X-rays, an ultrasound or a magnetic resonance image (MRI) of the foot.


Without treatment, the flatfoot that develops from the dysfunction eventually becomes rigid. Arthritis could develop in the hind foot, while pain increases and spreads to the outer side of the ankle. The way you walk may be affected and wearing shoes may be difficult.

The treatment your doctor/podiatrist recommends will depend on how far the condition has progressed.

In the early stages, the dysfunction may be treated with rest and these other non-surgical approaches:

• Orthotic devices or bracing — To give your arch the support it needs, your specialist or podiatrist may provide you with an ankle brace or a custom orthotic device that fits into the shoe.

• Immobilisation — Sometimes a short-leg cast or boot is worn to immobilise the foot and allow the tendon to heal, or you may need to completely avoid all weight-bearing for a while.

• Physical therapy — Ultrasound therapy, therapy with a physiotherapist may help rehabilitate the tendon and muscle following immobilisation.

• Medications — Non-steroidal anti-inflammatory drugs help reduce the pain and inflammation.

• Shoe modification — Your specialist may advise on changes for your shoes, and may provide special inserts to improve arch support.

If conservative treatments don’t work, your doctor/podiatrist may recommend you visit a specialist to explore the option of surgery.

Several procedures can be used to treat progressive flatfoot; often more than one procedure is performed simultaneously. Your doctor will recommend a specific course of treatment based on your individual case. Surgical options include:

• Osteotomy — This procedure changes the alignment of the heel bone (calcaneus). The surgeon may sometimes have to remove a portion of the bone.

• Tendon transfer — Fibres from another tendon are used to

repair the damaged posterior tibial tendon.

• Lateral column lengthening — The surgeon removes a small wedge-shaped piece of bone from either your hip or that of a cadaver, and places it into the outside of the calcaneus.

This helps re-align the bones and recreates the arch.

• Arthrodesis: One or more bones are fused together, eliminating movement in the joint. This stabilises the hind foot and prevents further deterioration. ?

Patients with adult acquired flatfoot are advised to thoroughly discuss the benefits vs risks of all surgical options.

Most procedures have long-term recovery mandating that the correct procedure be utilised for the best long-term benefit.

Most flatfoot surgical procedures require six to twelve weeks of cast immobilisation.

Joint fusion procedures require eight weeks of non-weight bearing on the operated foot — meaning you will be on crutches for two months.

The bottom line is, to make sure all of your non-surgical options have been covered before considering surgery.

Your primary goals with any treatment are to eliminate pain and improve mobility.

In many cases, with properly designed foot orthoses or ankle brace, these goals can be achieved without surgical intervention.

Your feet mirror your general health . . . cherish them!

Leana Huntley is an English trained foot health


attached to ALMAWI Limited The Holistic Clinic. Contact the clinic at, or visit the website at