Posterior tibialis tendon dysfunction.

When I notice patients’ flat feet during consultations, my patient will usually tell me they’ve have had them their whole life. When patients instead tell me they’ve noticed their feet, or especially just one foot getting flatter, and they’re experiencing pain, that’s a different story.

Posterior tibialis tendon dysfunction (PTTD) is a disabling condition arising from the loss of function of one of the most important structures in the leg, the posterior tibial tendon. This muscle and tendon structure holds the arch up and absorbs shocks, stabilising and supporting the foot when walking.

When this tendon begins to give out, or stops working over time, what you see is a change of shape and a loss of function as the foot gets flatter. And it stays that way if it goes untreated.

What patients report to me (their symptoms):

Patients suffering from PTTD will most commonly tell me they have pain and tenderness behind the inside ankle bone, extending down towards the arch. This discomfort is exacerbated by activity (eg. going up or down stairs), walking, or extended periods of standing. Some patients also report feeling “crackling” in movement, known as crepitus. Most patients will also report that the arch of their foot has collapsed, or family members may have also mentioned the fact that their ankle or heel has begun “rolling-in.”

People who I see with PTTD often have one or more of the following risk factors:

  • Obesity or an elevated body mass index (BMI)
  • Excessively rolled-in feet
  • Inflammatory diseases and conditions such as rheumatoid arthritis
  • Direct trauma/injury sustained to the inner part of the ankle
  • The patient is female, especially from middle age onwards

How is PTTD diagnosed?

In addition to thoroughly assessing my patients with PTTD, I will often refer patients for either ultrasound (US) or magnetic resonance imaging (MRI). Getting appropriate scans is important because it will show the severity of any tendon damage, plus the condition of other structures around the tendon. It also helps me figure out how best to treat the affected foot.

What does an assessment from a podiatrist involve?

The first thing I will check is the precise location of the pain which, in the case of PTTD, exists primarily along the course of the tendon. I will also want to know which movements/activities cause irritation and pain within the tendon. Flexibility in the rear- and mid-foot is measured to determine how bad it is; in the late stages of the condition, the foot may become “stuck” or fixed in a rolled-in position. The strength of the foot is tested against resistance to see whether the muscle is still working efficiently. I also check for a change in shape of the foot in while standing. This includes looking at the heel from behind to see if it’s rolled-in, whether the arch has collapsed, and the “too many toes” sign, where it appears the toes are spilling out to the outside of the foot. Finally, I assess whether the foot has suffered a decrease in function; i.e. does the strength of the painful foot still match the other foot? This is tested using a single-leg heel raise, where I ask the patient to stand on just the sore foot, and try to go up onto tiptoes.

“Too many toes” sign

Single leg heel raise

What’s to be done once PTTD is diagnosed?

Treatment must be swift and aggressive to achieve good pain relief and maintain foot function, and potentially includes some of the following interventions:

  • Non-steroidal anti-inflammatory drugs (NSAIDs)
  • Ultrasound therapy
  • Strapping and taping the foot into a better position
  • Soft over-the-counter insoles or customised rigid orthotics in more severe cases
  • Better shoes
  • Plaster to moon boot immobilisation
  • Surgery

If tibialis posterior dysfunction is not treated early and correctly, the rear foot becomes stuck in a rolled-in position, and significant arthritis develops.

Wanting more information on this? Please call 1300 122 884 and schedule an initial consultation with one of our Senior Podiatrists.

 

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