Just as an old bridge would become unsafe as the structure was compromised, your feet can experience the same. If you have PTTD
and the tendon continues to weaken, it simply won't be able hold up your arch. In this situation,
the arch can fall or collapse, which is referred to as adult-acquired flat foot. You may experience pain and tenderness behind the inside of the ankle. Over time, in addition to the flattening of the
foot, you may also notice a misalignment of the heel so that it no longer aligns underneath the rest of the leg. A tightening of the heel cord, arthritis, and possible deformity of the ankle joint
may also occur. You may feel the discomfort move from the inside to the outside of the ankle as well. Flat foot can also contribute to problems with the plantar fascia, which is the tendon that runs
along the length of your arch.
Flat feet causes greater pressure on the posterior tibial tendon than normal. As the person with flat feet ages, the muscles, tendons and ligaments weaken. Blood supplies diminish as arteries narrow.
These conditions are magnified for obese patients because of their increased weight and atherosclerosis. Finally, the tendon gives out or tears. Most of the time, this is a slow process. Once the
posterior tibial tendon and ligaments stretch, body weight causes the bones of the arch to move out of position. The foot rotates inward (pronation), the heel bone is tilted to the inside, and the
arch appears collapsed. In some cases, the deformity progresses until the foot dislocates outward from the ankle joint.
Patients often experience pain and/or deformity at the ankle or hindfoot. When the posterior tibial tendon does not work properly, a number of changes can occur to the foot and ankle. In the earlier
stages, symptoms often include pain and tenderness along the posterior tibial tendon behind the inside of the ankle. As the tendon progressively fails, deformity of the foot and ankle may occur. This
deformity can include progressive flattening of the arch, shifting of the heel so that it no longer is aligned underneath the rest of the leg, rotation and deformity of the forefoot, tightening of
the heel cord, development of arthritis, and deformity of the ankle joint. At certain stages of this disorder, pain may shift from the inside to the outside aspect of the ankle as the heel shifts
outward and structures are pinched laterally.
Diagnostic testing is often used to diagnose the condition and help determine the stage of the disease. The most common test done in the office setting are weightbearing X-rays of the foot and ankle.
These assess joint alignment and osteoarthritis. If tendon tearing or rupture is suspected, the gold standard test would be MRI. The MRI is used to check the tendon, surrounding ligament structures
and the midfoot and hindfoot joints. An MRI is essential if surgery is being considered.
Non surgical Treatment
Nonoperative treatment of posterior tibial tendon dysfunction can be successful with the Arizona AFO brace, particularly when treatment is initiated in the early stages of the disease. This mandates
that the orthopedist has a high index of suspicion when evaluating patients to make an accurate diagnosis. Although there is a role for surgical management of acquired flat feet, a well-fitted,
custom-molded leather and polypropylene orthosis can be effective at relieving symptoms and either obviating or delaying any surgical intervention. In today's climate of patient satisfaction directed
health care, a less invasive treatment modality that relieves pain may prove to be more valuable than similar pain relief that is obtained after surgery. Questions regarding the long-term results of
bracing remain unanswered. Future studies are needed to determine if disease progression and arthrosis occur despite symptomatic relief with a brace. Furthermore, age- and disease stage-matched
control groups who are randomized to undergo surgery or bracing are necessary to compare these different treatment modalities.
Although non-surgical treatments can successfully manage the symptoms, they do not correct the underlying problem. It can require a life-long commitment to wearing the brace during periods of
increased pain or activity demands. This will lead a majority of patients to choose surgical correction of the deformity, through Reconstructive Surgery. All of the considerations that were extremely
important during the evaluation stage become even more important when creating a surgical plan. Generally, a combination of procedures are utilized in the same setting, to allow full correction of
the deformity. Many times, this can be performed as a same-day surgery, without need for an overnight hospital stay. However, one or two day hospital admissions can be utilized to help manage the
post-operative pain. Although the recovery process can require a significant investment of time, the subsequent decades of improved function and activity level, as well as decreased pain, leads to a
substantial return on your investment.