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Foot Conditions

Posterior Tibial Dysfunction or Adult Flatfoot (PTTD):

The posterior tibial tendon is one of the major supporting structures of the foot. A tendon attaches muscles to bones, and 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. Posterior tibial tendon dysfunction (PTTD) is a condition caused by changes in the tendon. It occurs when the posterior tibial tendon becomes inflamed or torn, impairing its ability to support the arch, resulting in flattening of one foot, and some occasions both feet. PTTD is progressive, which means it will get worse overtime, especially if it isn’t treated early.

Overuse of the posterior tibial tendon is often the cause of PTTD. Other Several risk factors include:  

Age - Progressive flatfoot often occurs in women over 40-50 years of age

Injuries - injury from a fall can tear the posterior tibial tendon or cause it to become inflamed, previous surgery or trauma, such as an ankle fracture on the inner side of the foot.

Sports - Athletes who are involved in high-impact sports, such as basketball, tennis, or soccer, may have tears of the tendon from repetitive use.

Inflammatory diseases - diseases like Such as Reiter's syndrome, rheumatoid arthritis, spondylosing arthropathy or psoriasis.

The symptoms of PTTD include pain, a flattening of the arch, swelling, and an inward rolling of the ankle. When PTTD initially develops, there is pain on the inside of the foot and ankle (along the course of the tendon). In addition, the area may be red, warm, and swollen. As the arch begins to flatten, there may still be pain on the inside of the foot and ankle. But at this point, the foot and toes begins to turn outward and the ankle rolls inward. As it becomes more advanced, the arch flattens more and the pain moves to the outside of the foot, below the ankle. The tendon has deteriorated significantly and arthritis develops in the foot and ankle.

Non-surgical Treatment
Because PTTD is progressive, early treatment is always recommended. When treated early, your symptoms may resolve without the need for surgery. If left untreated PTTD could leave you with an extremely flat foot, arthritis in the foot and ankle, and limitations on walking, running, or other activities. Treatment can begin with non-surgical approaches that include:

Orthotic devices or bracing - It is the most common non-surgical treatment for a flatfoot. Your foot and ankle surgeon may provide you with an ankle brace or a custom orthotic device that fits into the shoe to give your arch the support it needs. A lace-up ankle brace may help mild to moderate flatfoot. The brace would support the joints of the back of the foot and take tension off of the tendon.

Physical therapy - Physical therapy that strengthens the tendon can help patients with mild to moderate disease of the posterior tibial tendon, and it may help rehabilitate the tendon and muscle following immobilization.

Medications - Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, help reduce the pain and inflammation. Taking such medications about a half of an hour before an exercise activity helps to limit inflammation around the tendon.

Immobilization - Sometimes a short-leg cast or boot is worn to immobilize the foot for 6 to 8 weeks allowing the tendon to heal, or you may need to completely avoid all weight-bearing for a while.

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.

Steroid Injection - is an anti-inflammatory medication that your doctor may inject around the tendon and does carry a risk of tendon rupture. Discuss this risk with your doctor before getting an injection.

PRP injection - Platelet Rich Plasma and Stem Cell Therapy can be useful for PTTD cases that did not respond well to conservative therapy. PRP can fool the body into responding to chronic injury site by causing a large inflammatory response. This could lead to a healing response from patient’s own body.

Surgical Treatment
Surgery should only be done if the pain does not get better after few months of appropriate treatment. Several procedures can be used to treat progressive flatfoot. The following is a list of the more commonly used operations. Additional procedures may also be required. Your doctor will recommend a specific course of treatment based on your individual case. Surgical options include: 

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

Osteotomy (Cutting and Shifting Bones) - This procedure is often used when the calcaneus (heel bone) has shifted out from underneath the leg. This procedure changes the alignment of the heel bone, changing the shape of a flexible flatfoot to recreate a more "normal" arch shape. The surgeon may sometimes have to remove a portion of the bone.

Tendon transfer - This procedure uses some fibers from another tendon. Tendon transfer can be done in flexible flatfoot to recreate the function of the damaged posterior tibial tendon.

Arthrodesis (Fusion) - Fusion of a joint or joints in the back of the foot is used to realign the foot and make it more "normal" and remove any arthritis. Fusion involves removing any remaining cartilage in the joint, fusing one or more bones together eliminating movement in the joint. Over time, this lets the body "glue" the joints together so that they become one large bone without a joint, which eliminates joint pain.

Surgical Outcome
Most patients have good results from surgery allowing patients to go home the day of surgery. The leg will be placed in a splint or cast and should be kept elevated for the first two weeks. After two weeks, sutures are removed and a new cast or a removable boot is then placed. It is important that patients do not put any weight on the corrected foot for first few weeks following the operation. After the initial healing period, patients commonly can transition to wearing a shoe. Inserts and ankle braces are often used. Physical therapy may be recommended.