Sports Medicine

Posterior Tibial Tendon Dysfunction

Anatomy

The ankle joint connects the leg and the foot. It is formed by three separate bones, the tibia, fibula and talus. The shinbone (tibia) supports most of a person's weight when standing. The outer bone (fibula) is the smaller bone of the lower leg. A small, irregular-shaped foot bone (talus) connects the tibia and fibula. Acting as a hinge, these bones form the ankle.

The foot is a complex, flexible structure that contains bones, joints, and more than 100 muscles, tendons and ligaments, all working together to enable movement and balance. The foot is divided into three sections, the forefoot, the midfoot and the hindfoot. The midfoot contains a pyramid-like group of bones, strengthened by tendons, muscles and ligaments to form three curves, or arches (medial, lateral and fundamental longitudinal), at the bottom of the foot.

Tendons are bands of tissue that attach muscle to bone. The posterior tibial tendon attaches the calf muscle to the bones on the inside of the foot. The main function of this tendon is to hold up the arch and support the foot when walking. The posterior tibial tendon is one of the most important tendons of the leg.

Description

Posterior tibial tendon dysfunction is one of the most common problems of the foot and ankle. It occurs when the tendon becomes inflamed or torn, which impairs the tendon's ability to provide stability and support for the arch of the foot, resulting in flatfoot.

Causes

An acute injury, such as from a fall or overuse, can result in a tear or inflammation in the posterior tibial tendon. Repetitive use that occurs from participation in high-impact activities and sports, such as basketball, tennis, or soccer may also cause tears in the tendon. Once the tibial tendon becomes inflamed or torn, the arch slowly falls, or collapses, over time. Posterior tibial tendon dysfunction is more common in women, and in both men and women older than 40 years of age. Additional risk factors include obesity, diabetes and hypertension.

Symptoms

Common symptoms of posterior tibial tendon dysfunction include:

• Pain along the inside of the foot and ankle—May be associated with swelling in the area, but not necessarily so.
• Pain worsens with activity—High-intensity or high-impact activities such as running may be difficult, and for some patients, even walking or standing for long periods of time can be a problem.
• Pain on the outside of the ankle—When the foot collapses, the heel bone may shift outwards, putting painful pressure on the outside ankle bone. This type of pain is found in arthritis, in the back of the foot.
• Pain along the back and inside of the foot and ankle—This is the most common location of pain, along the course of the posterior tibial tendon.

Diagnosis

An examination of the foot and ankle may include X-rays or other imaging tests. Your physician will be checking for a variety of signs, including the following:

• Swelling along the posterior tibial tendon—From the lower leg to the inside of the foot and ankle.
• Changes in the shape of the foot—The heel may be tilted outward and the arch will have collapsed.
• The appearance of having "too many toes"—When observing the patient's heel from behind, usually only the fifth toe and half of the fourth toe can be seen. In a flatfoot deformity, more of the little toe is visible.
• "Single limb heel rise"—Being able to stand on one leg and rise up on tiptoes requires a healthy posterior tibial tendon. If a patient cannot do so, it suggests a problem with this tendon.
• Limited flexibility—The appropriate treatment plan varies, depending on the flexibility of the foot. Your physician may move your foot from side to side during the examination to determine the level of flexibility.
• Range of motion in the ankle—Upward motion of the ankle (dorsiflexion) can be limited in flatfoot and is tied to tightness of the calf muscles.

Nonsurgical Treatment

For most patients, symptoms will be relieved by appropriate nonsurgical treatment. If surgery is necessary, it may be as simple as removing the inflamed tissue or repairing a simple tear. Even with early treatment, pain may last 3 months or longer. For patients who have been experiencing pain for many months before seeking treatment, the discomfort may continue for another 6 months after treatment begins. If appropriate, a foot and ankle conditioning program may be prescribed. Nonsurgical treatment may include:

• Rest—Discontinue participation in athletic activities and avoid walking on the injury.
• Ice—Apply ice several times a day to help reduce swelling and pain.
• Nonsteroidal anti-inflammatory medication (NSAIDs)Drugs such as ibuprofen or naproxen may help relieve pain, inflammation and swelling. Most people are familiar with nonprescription NSAIDs such as aspirin and ibuprofin, however, whether using over-the-counter or prescription strength, they must be used carefully. Using these medications for more than one month should be reviewed with your primary care physician. If you develop acid reflux or stomach pains while taking an anti-inflammatory, be sure to talk to your doctor.
• Steroid injection—An injection of corticosteroid medication can reduce the swelling and inflammation, bringing some relief from pain.
• Immobilization—A cast or splint may be used to immobilize the foot and ankle to allow the injury to heal.
• Orthotics, braces

Surgery

Surgical treatment should only be considered if pain has not improved after 6 months of appropriate treatment.

• Gastrocnemius recession—Surgical lengthening of the Achilles tendon or calf muscles is useful in patients with limited upward motion of the ankle (dorsiflexion).
• Tenosynovectomy (cleaning the tendon)—Used when there is very mild disease, the shape of the foot has not changed, and there is pain and swelling over the tendon.
• Tendon transfer—Performed in flexible flatfoot to recreate the function of the damaged posterior tibial tendon.
• Osteotomy—An osteotomy (cutting and shifting bones) can change the shape of a flexible flatfoot to recreate a more normal arch. One or two bone cuts may be required, typically of the heel bone (calcaneus).
• Fusion—The goal of this procedure is to reduce pain by eliminating motion. It may be used if the flatfoot is stiff or there is also arthritis in the back of the foot. In these cases, the foot will not be flexible enough to be treated successfully with bone cuts and tendon transfers.

Most patients have good results from surgery, however, the amount of motion possible before surgery and the severity of the flatfoot are the main factors in determining the outcome. The more severe the problem, the longer the recovery time and the less likely a patient will be able to return to sports. For many patients, it may be a year before there is great improvement in pain.

With any surgery there are some risks, and these vary from person to person. Complications are typically minor, treatable and unlikely to affect your final outcome. Your orthopaedic surgeon will speak to you prior to surgery to explain any potential risks and complications that may be associated with your procedure.