What is the Posterior Tibial Tendon?
The posterior tibial tendon is one of the most important supporting structures of the foot. It helps to stabilize the ankle and hold up the arch. If the posterior tibial tendon fails, the arch can collapse, leading to foot pain, ankle pain and difficulty walking. Posterior tibial tendonitis is a frequent cause of pain at the inside of the ankle.
A tendon is a structure that is the body’s equivalent of a living cable. But instead of steel wire, thin collagen strands bundle together and connect muscle to bone. The posterior tibial tendon runs down the back of the leg, turns behind the inside ankle bone (tibia) and then attaches to foot at the inside of the arch.
If the tendon becomes inflamed, it may become painful. If the inflammation is ignored, the tendon can become weaker and lead to flatfoot deformity. Doctors call this “adult acquired flatfoot” or “posterior tibial tendon dysfuction” (PTTD). It usually develops in only one foot, but it is possible to develop this sort of flatfoot deformity in both feet. PTTD will get progressively worse if not treated early.
You Might Have Posterior Tibial Tendonitis/Dysfunction if you have any of the following symptoms:
Posterior Tibial Tenderness: if you press anywhere along the posterior tibial tendon and you feel pain or tenderness, it could be tendonitis. In its early stages, you may only notice this pain when you walk or climb stairs. You might only notice some soreness in the foot and/or ankle when you get out of bed, first thing in the morning. As the tendon gets stretched or torn, it may be more painful walking uphill or climbing stairs. Standing up on the toes becomes painful in the arch and ankle. The tender area may also be red, hot and swollen.
Posterior Tibial Deformity: an abnormal appearance of the ankle or tendon could be a problem. The posterior tibial tendon is normally firm, thin and perfectly smooth. If you feel any swelling, lump, bump, knot or nodule anywhere along the tendons, this is not normal. Posterior tibial tendonosis is the most common reason for these types of changes in the tendon. However, there are other problems that can cause these deformities such as a ganglion cyst or other tendon tumors.
Posterior Tibial Tendon Weakness: as the tendon begins to stretch or tear, it becomes weaker. It may be difficult to walk uphill or climb stairs. Standing up on the toes becomes more difficult. In the advanced stages, it becomes nearly impossible to stand up the toes while standing on only one foot.
Ankle Instability: because the posterior tibial tendon helps pull the arch up and supinate the foot, you can develop medial ankle instability if the tendon becomes weak. When this happens, the ankle “rolls inward” as you walk. This can be a sign of tendon weakness.
Foot Deformity: many patients will say that they notice the arch is collapsing and the toes are getting pushed to the outside. I have had several patients say they are “walking like a duck.” Podiatrists call this the “too many toes sign.” What that means is that as the patient walks away, you can see more toes sticking out the side than the other foot. This is a sign that the arch is collapsing.
Ankle Arthritis: as the tendon fails, the arch flattens out and the ankle continues to roll in. This creates abnormal stress and wear in the ankle joint. If not treated, severe arthritis in the ankle can develop.
What Causes PTTD?
Posterior tibial tendon dysfunction is basically caused by overuse. Although certain people have a foot type that makes them more prone to developing PTTD, activity is the root cause. Flat feet, obesity, and diabetes are just a few of the conditions that can put you more at risk for PTTD. But once the tendon gets overused, a cycle of inflammation sets in. The chronic inflammation leads to weakness and micro-tears in the tendon that make it weaker, and susceptible to continued injury. Activities that strain the posterior tibial tendon and can lead to PTTD are hiking, walking on uneven surfaced (like a roof top), ladder climbing, hiking, stair climbing, mountain climbing, step aerobics, working out on a stair-climbing machine or elliptical trainer at the gym, and running.
Diagnosis of Posterior Tibial Tendonitis
If it seems your ankle pain might be caused by posterior tibial tendonitis, your foot doctor will begin by taking a complete history to get an idea of how this might have started. A physical exam will be performed to evaluate the foot, ankle and supporting tendons. X-rays are taken to determine the foot joints and ankle joint alignment. The exam, history and x-rays might be sufficient for your podiatric surgeon to determine the best treatment. In some cases, you may also need an ultrasound or MRI to look closer at posterior tibial tendon. While fractures and joint deformities show up well on xray, torn tendons, inflammation and tendon degeneration show up much better on ultrasound and MRI. These test results can usually be explained on the first visit. You then will have a full understanding of how the problem started, what you can do to treat it, and what you can do to prevent it from getting any worse. You will also know how to make your posterior tibial pain go away.
How is Posterior Tibial Tendonitis Treated?
Treatment of Posterior Tibial Tendonitis:
It is critical to start treatment as soon as possible. Although some doctors disagree on which surgery is best for PTTD, most surgeons agree that it is easy to treat early on, and difficult to treat as it gets worse. In many cases, the progression of the tendon damage can be halted without surgery if treated when you first notice problems.
Surgery for posterior tibial tendonitis should always be the last resort. We believe that biologic treatments that preserve normal tendon anatomy are very helpful, particularly for runners, athletes, and all active people. Non-surgical approaches attempt to support the arch and foot structure, stop inflammation and prevent degeneration of the tendon. Some non-surgical treatments include:
• Oral Anti-inflammatory Medications. NSAID’s (non-steroidal anti-inflammatory medications) such as Motrin, Aleve, and Steroids (like prednisone) may help control the pain and stop the inflammation in the tendons.
• Topical Anti-inflammatory Medications. NSAID’s in cream or lotion form may be applied directly to the painful area. With these, there is no concern for stomach upset or other problems often associated with oral medication.
• Ice. Ice can applied be applied right to the inflamed ankle area and help calm it down. Try applying ice to the affected area for 20 minutes per hour. Just make sure you don’t put ice directly against the skin.
• Shoe modification. Your podiatrist can recommend shoes that provide the best arch support. This is often complicated because some arch supports or shoes inserts can cause pain when you have PTTD.
• Physical therapy. Physical therapy, such as ultrasound, massage and stretching can all reduce inflammation and may help you avoid surgery.
• Orthotics and braces. Custom arch supports known as foot orthotics control abnormal motion in the foot and stabilize the ankle to relieve stress on the posterior tibial tendon. Orthotics can decrease symptoms in mild cases and help prevent it from happening again. Custom braces can provide more support than orthotics and are often a great solution that helps people avoid surgery.
• Immobilization. In some cases, a walking cast boot or plaster/fiberglass cast is necessary to take pressure off the injured tendon, while allowing it to heal. Sometimes crutches are needed as well.
• ESWT. Extra-corporeal Shock Wave Therapy uses high energy sound waves to break up diseased tissue in the posterior tibial tendon and stimulate your own body’s own natural healing processes to repair the diseased area. It is usually done in an outpatient surgery center. There is no incision and no stitches with ESWT.
• PRP. Platelet Rich Plasma (PRP) is a therapeutic injection which uses your body’s own natural healing cells to repair the tendon. A small sample of blood is drawn from the patient and the healing factors found in the platelets are concentrated in a centrifuge. By injecting the concentrated solution right into the damaged posterior tibial tendon, a powerful healing can be stimulated. This can be done in the office. No hospital or surgery required.
Because of the progressive nature of PTTD, it’s best to see your foot and ankle surgeon as soon as possible. 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.
When Is Surgery Needed?
If and (only if) non-surgical treatments fail, will it make sense to consider surgery. Having said that, we know that some advanced cases with severe deformities and tendon ruptures are unlikely to get better without surgery.
Surgery for PTTD In cases of PTTD that have progressed to advanced stages (or haven’t improved with non-surgical care) surgery may be required. An operation to treat PTTD can include many different surgical procedures. Some of these include removal of the diseased or degenerated portion of the tendon, tendon reconstruction, reinforcing a weak tendon with a tendon graft, fusion of foot joints to add stability, flatfoot reconstruction, and arthroeresis (placing a small implant in the foot to stabilize the foot and arch).
Regardless of which exact surgery is planned, the goal is always to decrease pain and correct the problem. The idea is to get you back to your favorite activities. You will work with your foot and ankle surgeon to determine the exact surgical procedure that is most likely to correct the problem in your case. The two of you work as a team to develop a plan that will help assure success.
When to See a Foot Specialist for Posterior Tibial Tendonitis
Any time you notice that your arch is collapsing, or you have pain, tenderness or swelling along the inside of the foot or ankle, you should see an ankle expert. Get help immediately. Keep in mind that PTTD is progressive. It is very important that you seek treatment to avoid permanent tendon damage. Without help, it will usually get continually worse. It is best to treat the problem early, so you can move on, and get back to enjoying your activities.