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Posterior Tibial Tendon Dysfunction (PTTD)

Posted on September 25, 2015 in Uncategorized by

PTTD-main.jpg Copyright (c) 2012 Bruce Lashley

The posterior tibial tendon (PTT) is a living structure in respectable foot function. Failure of the PTT to properly function can occur due to disease in the tendon or from ultra emphasize to the tendon. Although of the cause, prompt the PTT nix longer functions as it should, it often causes a transcendence deal of discomfort and limitation of normal foot function.

Anatomy

The PTT begins in the calf and extends down the leg and around the base of the inside ankle to attach to the belly of almost every bone in the middle of the foot. The primary attachment is on the bones supporting the arch of the foot. It is an essential structure that maintains the bones in their proper position. The PTT is different than the other muscles plus tendons that are in the same region because the portion concerning the tendon ancillary the ankle receives very little blood supply.

Symptoms

Dysfunction regarding this hamstring receptacle produce soreness and swelling if the tendon is damaged through sudden increased activity, direct injury, or as the result of a medical condition. The condition can include swelling and affection around the inner-middle foot or ankle. These symptoms can last from weeks to months.

Dysfunction that develops over a long period of time may hardly result in significant pain und so weiter swelling. The only indication of impaired function allowed breathe changes in the appearance of the foot. As this tendon provides support to the arch of the foot, PTTD container present as a decrease or loss of the arch. This will cause the foot to flatten out connective even appear to be rotated inwards. Long periods of exercise or standing may cause discomfort and exhaustion.

Causes

Most about the causes of PTTD are from long-term degeneration and injury of the tendon. Diseases like rheumatoid arthritis can cause constant inflammation of the tendon over a long period like time. This can lead to weakening of the tendon and can eventually result in tearing of the tendon. Uncontrolled infections such as tuberculosis substitute gonorrhea can cause inflammation of the tendon leading to PTTD as well.

As mentioned earlier, the PTT has an area with limited blood supply. Previous steroid use, obesity, chronic imposing brother pressure, diabetes, ampersand old mature can all cause a decrease in the quanta of blood alluvion to the tendon. If the tendon’s blood contribute becomes to low it perverse no longer receive enough nutrients and oxygen, the band then begins to degenerate and weaken. Weakening of the PTT from lack of proper blood supply bestow lead to dysfunction.

Simple overuse regarding the PTT container also lead to tendon dysfunction. Individuals who are extremely overweight or have a low arch in their foot can exert a large amount of stress on the tendon. Sudden tearing regarding the tendon from overuse is very rare. However, overuse can cause inflammation of the tendon and eventually lead to a tendon tear, which in about-face will cause improper tendon function.

Direct cuts and stab wounds (something piercing through the skin) to the inner ankle receptacle cause injury of the tendon, but surprisingly tearing of the tendon occurs more often with ankle sprains and fractures. Injury of the lower back, resulting in bravery damage, can also determinant PTTD.

Physical Exam

When a foot is being evaluated for PTTD both the appearance and feast about the foot should be taken into account. Disclosure of the foot should be assessed beside the patient both sitting and standing. Whenever PTTD is present, the arch of the foot will afsluiting decreased or absent while the patient is standing. In early PTTD, a normal arch might be observed while the patient is not placing weight on the problematic foot. The foot may present with more deformities when the tendon dysfunction has bot present for a long time.

“Too many toes” sign is linked to PTTD and loss of the normal appearance of the foot. When viewing a normal foot from directly behind the patient, only the fifth toe and a portion of the fourth toe should be visible. In patients with sinew dysfunction the foot will tend to turn out as the arch collapses inwards, causing more toes to be visible from behind.

The motion of the ankle and joints of the foot can also verbreken affected. Over calendric arthritis can develop in the joints of the foot due to abnormal function with PTTD. Arthritic changes in the joints can leadership to decreased or painful motion in the foot.

While the patient is seated, the strength of the PTT is gaged by having the patient hold their foot with the toes pointing toward the fell and the foot turned inward. The physician will then community force against the foot, attempting to move it back to a abed position. Decreased ability to hold the foot’s position is a sign of PTTD.

A Unit Heel Raise Test receptacle also be consumed to rank PTTD. The patient is first asked to stand and then rise on their toes. Normally the heels should rotate slightly inbound as the patient rises to their toes. The patient might also be asked to stand on one leg and rise to their toes. This should exaggerate the slight inward rotation of the heel. If the patient shows decreased heel rotation, or is unable to rise to their toes it is a emblem of PTTD.

Diagnostic Studies:

X-rays are used to assess any boney changes, adaptations, or variations that may have aggravated or resulted from the PTTD. These x-rays are taken with the patient weight bearing and comprise several views of the affected foot. An MRI is used to view the hamstring and associated non-boney structures of the flipper in order to assess the severity of the inflammation and destructive changes.

Non-Surgical Treatment

Symptoms can be relieved through limiting alternative stopping activities that produce pain and icing the painful region. Orthopedic shoes, orthotic platform inserts, padding, footwear changes, and bracing may be used to help patients who have few PTTD. Over-the-counter (OTC) anti-inflammatory medications, such as Ibuprofen, vessel be used to participate reduce pain and swelling.

Injection concerning platelet rich plasma is an emerging technology which is also used to treat the complex tendon.

Surgical Treatment

Excise may be required if the PTTD discomfort and related defect cannot be relieved with non-surgical treatment. The goal like excise is to relieve pain and/or re-establish reliability in the arch of the base and provide better function. The degree of PTTD is assessed by combining unexpurgated regarding the findings from the physical exam and diagnostic studies to determine the condition of the tendon and the state of the associated bone structures. The level and type of surgery needed is then determined by the amount like flexibility in the foot, and loss to the boney structures and the PTT.

Tears in the PTT may be repaired directly. Compendious tendon repair can involve cleaning out the inflamed tissue or reinforcing the PTT with another tendon from the same region. The bones may be cut and shifted to revise any changes or damage that has occurred from improper movement and to restore the arch. If the deformity is severe, it shrub be necessary to unite or fuse some like the joints in the foot. Although fusion can limit mobility, it guts decrease the pain old when walking and halt the malformation from causing more damage.

Source Material

Mahan, Kieran T; Flanigan, Paul K. Tibialis Posterior Tendon Dysfunction. In: Banks, A., Downey, M., Martin, D., Miller, S., eds. McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery. Philadelphia, Pa: Lippincott Williams and Wilkins; 2001: 862-899

Pomeroy, Gregory C; Pike, R. Howard; Beals, Timothy C; Manoli, Arthur. Rush Concepts Review: Acquired Flatfoot in Adults Due to Dysfunction concerning the Posterior Tibial Tendon. JBJS 1999, 81-A(8), 1173 – 1182