Posterior Tibial Tendon Dysfunction (PTTD)
The Tibialis Posterior tendon helps to hold up the arch of the foot, to plantarflex and invert the ankle. The muscle starts along the shin and runs down along the medial ankle and inserts into the arch of the foot.
Posterior Tibial Tendon Dysfunction (PTTD) is the most common cause of adult acquired flat foot deformity. PTTD usually only occurs in one foot, but can occur bilaterally as well. Acute injury can be the cause, which tears the tendon. However, the more likely cause is overuse of Tibialis posterior where the tendon can no longer cope with the load and begins to weaken and degenerate. The area surrounding the tendon tends to have poor vascularity, and as the tendon breaks down it is replaced by ineffective fibrotic tissue. In the later stages of the dysfunction, the tendon is unable to provide support and stability to the arch of the foot resulting in a flat foot and deformation. Also, as the deformity progresses the distal fibula meets the lateral calcaneus thereby causing pain to shift to the lateral ankle.
In elderly woman the prevalence of PTTD may be as high as 10%. Risk factors include obesity, previous ankle/foot trauma and surgery, diabetes, hypertension, and local steroid injections. Other causes that can contribute to PTTD are excessive pronation, non-supportive footwear, and/or a sudden increase in activity that strains Tibialis posterior (i.e., walking, running, hiking, climbing stairs).
There are four stages of PTTD: 1. inflamed and intact tendon without deformity, 2. ruptures or non-functional tendon with planovalgus deformity, 3. advanced foot deformity with subtalar joint arthritis, and 4. ankle joint involvement with tibio-talar degeneration.
PTTD is progressive and if not treated early it will often worsen over time. The first signs and symptoms are generally pain in the medial ankle/arch, weakness and sometimes swelling around the medial ankle. Often the pain is worse during and after activity. Early detection and intervention are important because as the PTTD progresses to the later stages with more ridged deformity (Stages 3 and 4), surgical reconstruction of the ankle often becomes necessary. Also, during the later stages of PTTD varying levels of ligmametous ruptures can accompany this disorder.
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