Posterior tibial tendon dysfunction

Posterior tibial tendon dysfunction is a family of conditions that begin with the tendon on the inside or medial portion of the ankle. Mild cases may be notable only for pain and swelling along the tendon, but more severe cases lead to collapse of the arch of the foot and difficulty rising to a tiptoe position.

The posterior tibial tendon is the major inverter of the foot, which assists with side-to-side motion of the foot. Therefore, when it is weak or injured, balance can become difficult, especially when walking on banked or uneven surfaces.

Risk factors for this condition include overuse, cutting sports such as basketball, tennis, or soccer, obesity, diabetes, hypertension, prior trauma or surgery, inflammatory arthritis, and pre-existing flatfeet.

DIAGNOSIS

The first step in diagnosis is appropriate imaging (weight-bearing x-rays of the foot and ankle) and a thorough physical examination. If there is suspicion for a tear of the posterior tibial tendon, an MRI will be ordered.

TREATMENT

Immobilization

If the pain is so severe that walking is difficult, a short use of a camboot or walking cast to fully immobilize the foot and anklewill be necessary.

Orthotics

Offloading the medial ankle by use of arch support can be helpful over time.

Anti-inflammatories

NSAIDs should be taken around the clock for two to three weeks for anti – inflammatory dosing. Speak to your physician if you have concerns about whether anti-inflammatories are safe for you.

Ice

Only use ice if you have no numbness in your feet. If you have any neuropathy, ice application may not be safe. Set the ice pack on the floor and place a dry washcloth on top. Then, set your foot on the ice pack. Ice for up to twenty minutes at a time, and be sure to wait an hour if you are going to repeat the ice application.

Physical therapy

Physical therapy is not expected to change the shape of the foot or to repair tears. It works to improve strength and balance, and stretch the muscles that tighten over time due to the injury. It can also address the inflammation. Many people improve significantly with physical therapy and never go on to need surgery

Surgery

The surgery required for severe posterior tibial tendinitis requires both addressing the inflammation and damage to the tendon by removal of the tendon and borrowing the tendon to the toes in its place, as well as addressing the flat foot, which requires bony cuts to reshape and reconstruct the arch. Sometimes the soft tissues are insufficient and fusion of three joints of the hindfoot is required to prevent any motion.

Summary of treatment

  • Rest/immobilization
  • Ice
  • Oral anti-inflammatories
  • Orthotics
  • Physical therapy
  • Surgery

Treatments to avoid

Do not immediately get injections or surgery for posterior tibial tendinitis. Injections should be avoided altogether to prevent rupture of the posterior tibial tendon, which cannot be repaired once ruptured. Oral steroids are not recommended as first-line treatment of plantar fasciitis because of the systemic risks; there are more specific treatment options in most cases.

Seek attention from a specialist if you are concerned that the pain is worsening, or if is not responsive to these treatments. Other sources of ankle pain should be ruled out.

References

“Progressive Flatfoot (Posterior Tibial Tendon Dysfunction.” http://legacy.aofas.org/footcaremd/conditions/ailments-of-the-midfoot/Pages/Progressive-Flatfoot.aspx

“Posterior tibial tendon dysfunction.” https://orthoinfo.aaos.org/en/diseases–conditions/posterior-tibial-tendon-dysfunction/

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