Posterior tibial tendon dysfunction or Adult Acquired Flatfoot is NOT the same as posterior tibial tendonitis which is an inflammation of the tendon.

Anatomy Posterior Tibial Tendon
Dysfuntion of Posterior Tibial Tendon

PTTD is a condition of degeneration and dysfunction in the tendon complex that helps control the medial arch of your foot. Essentially what happens is the complex is unable to do its job of supporting the arch and supinating the foot, so a progressive flat foot develops (usually called adult acquired flat foot). Initially pain and often swelling develops on the inside of the ankle and it will continue to get progressively worse. There are a number of stages of PTTD (3 Stages) and it needs to be aggressively treated early on otherwise a surgical reconstruction of the arch will invariably be required. PTTD can develop into a very disabling condition if it is not dealt with properly and promptly. As PTTD becomes more advanced, the arch flattens even more and the pain often shifts to the outside of the foot, below the ankle. Arthritis often develops in the foot and In more severe cases, arthritis may also develop in the ankle.

Collapse of the medial arch

Swelling/pain & loss of arch on the right

The tibialis posterior tendon is the primary dynamic stabiliser of the medial longitudinal arch and its contraction results in inversion and plantar flexion of the foot and serves to elevate the medial longitudinal arch, which locks the mid-tarsal bones, making the hindfoot and midfoot rigid. Without the tibialis posterior, the other ligaments and joint capsules gradually become weak, and thus a flatfoot develops.

Pain along the inside of the foot and ankle, where the tendon lies. This may or may not be associated with swelling in the area.

Pain that is worse with activity. High-intensity or high-impact activities, such as running, can be very difficult. Some patients can have trouble walking or standing for a long time.

Pain on the outside of the ankle. When the foot collapses, the heel bone may shift to a new position outwards. This can put pressure on the outside ankle bone. The same type of pain is found in arthritis in the back of the foot.

Asymmetrical collapsing of the medial arch on the affected side.

Examination – Dr. Fahoury will take a complete medical history and ask about symptoms/signs such as:

Swelling along the posterior tibial tendon. This swelling is from the lower leg to the inside of the foot and ankle.

A change in the shape of the foot. The heel may be tilted outward and the arch will have collapsed.

“Too many toes” sign. When looking at the heel from the back of the patient, usually only the fifth toe and half of the fourth toe are seen. In a flatfoot deformity, more of the little toe can be seen.

“Single limb heel rise” test. Being able to stand on one leg and come up on “tiptoes” requires a healthy posterior tibial tendon. When a patient cannot stand on one leg and raise the heel, it suggests a problem with the posterior tibial tendon.

Limited flexibility. The doctor may try to move the foot from side to side. The treatment plan for posterior tibial tendon tears varies depending on the flexibility of the foot. If there is no motion or if it is limited, there will need to be a different treatment than with a flexible foot.

The range of motion of the ankle is affected. Upward motion of the ankle (dorsiflexion) can be limited in flatfoot. The limited motion is tied to tightness of the calf muscles.

X-rays. These imaging tests provide detailed pictures of dense structures, like bone. They are useful to detect arthritis.

Magnetic resonance imaging (MRI). These studies can create images of soft tissues like the tendons and muscles. An MRI may be ordered to fully evaluate the integrity of the Posterior Tibial Tendon.
Computerized tomography scan (CT Scan). These scans are more detailed than x-rays. They create cross-section images of the foot and ankle. Because arthritis of the back of the foot has similar symptoms to posterior tibial tendon dysfunction, a CT scan may be ordered to look for arthritis.
Ultrasound. An ultrasound uses high-frequency sound waves that echo off the body to create a picture of the bone and tissues. Sometimes more information is needed to make a diagnosis.

Non-surgical Treatment
Because of the progressive nature of PTTD, early treatment is advised. If treated early enough, your symptoms may resolve without the need for surgery and progression of your condition can be arrested.

In contrast, untreated PTTD could leave you with an extremely flat foot, painful arthritis in the foot and ankle, and increasing limitations on walking, running, or other activities.

In many cases of PTTD, treatment can begin with non-surgical approaches that may include:

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

Immobilization. Sometimes a short-leg cast or boot is worn to immobilize 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 and exercises may help rehabilitate the tendon and muscle following immobilization.

Medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, help reduce the pain and inflammation.

Shoe modifications. Your foot and ankle surgeon may advise changes to make with your shoes and may provide special inserts designed to improve arch support.

Surgical Treatment
If conservative treatments don’t work, your doctor may recommend surgery. Several procedures can be used to treat posterior tibial tendon dysfunction; often more than one procedure is performed at the same time. Your doctor will recommend a specific course of treatment based on your individual case. Surgical options include:

Tenosynovectomy. In this procedure, the surgeon will clean away (debride) and remove (excise) any inflamed tissue surrounding the tendon.



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: This procedure uses some fibers from another tendon (the flexor digitorum longus, which helps bend the toes) to repair the damaged posterior tibial tendon. tibialis-posterior-reconstruction-18

Lateral column lengthening: In this procedure, the surgeon places a small wedge-shaped piece of bone into the outside of the calcaneus. This helps realign the bones and recreates the arch



Arthrodesis: This procedure welds (fuses) one or more bones together, eliminating movement in the joint. This stabilizes the hindfoot and prevents the condition from progressing further.