Dr. Davis - Posterior Tibial Tendon Dysfunction & Flat Foot Deformity

The posterior tibial tendon (PTT) carries a large mechanical load. It fails because it has an area of poor blood supply that weakens it. Minor trauma such as an “ankle sprain” or awkwardly stepping down forcefully on the foot adds injury to the already “sick” tendon. After the incident, the tendon stretches out and a cascade of changes in the foot occur leading to a painful flat foot deformity.

Non-operative treatment:

  • The tendon is rested and protected in a boot with custom shoe insert to take the load off the tendon
  • Medication to decrease inflammation of the tendon.
  • If the pain completely resolves with the initial treatment, the next step is to gradually wean out of the boot into athletic shoes and orthotics. The tendon still needs support and rest, so it is very important to always wear the athletic shoe with the custom insert (orthotics) the next several months. After several months of no discomfort, shoe wear can be liberalized. It is best to wear the orthotics during all sports participation and when standing and/or walking for more than an hour at a time.

Operative treatment

If non-operative treatment is not successful, surgery may be needed. The particular surgery performed depends on the extent of tendon damage, deformity, and other factors.

Tenosynovectomy (teeno-sin-o-vectomy):

  • Removal of the irritated tissue around the tendon is removed.
  • Non-weight bearing for 2 weeks and then weightbearing in a boot with a custom shoe insert for 4 weeks.
  • Start physical therapy and wean out of the boot into an athletic shoe and custom insert 6 weeks post-op.

Tendon reconstruction, calcaneal osteotomy, and gastrocnemius release:

  • The inflamed tissue is removed (tenosynovectomy).
  • The thickened scarred degenerated portion of the tendon is removed (debridement).
  • The tendon that flexes (bends) the big toe (Flexor Hallucis Longus) is used to reinforce the PTT.
  • The heel bone (calcaneus) is cut (osteotomy) and shifted to decrease the mechanical load on the tendon.
  • The gastrocnemius (calf muscle) is released (lengthened) to take stress off the posterior tibialis tendon.
  • Non-weightbearing for six weeks post op.
  • At six weeks post op, weightbearing in the cast boot is allowed and physical therapy is started.
  • At about 10 weeks post op, wean out of the boot into athletic shoes and orthotics.
  • Rehabilitation continued until the calf muscles are strong enough to do 10 single stance toe raises without stopping to rest. At that point running and jumping sports can be started.

Triple arthrodesis and gastrocnemius release:

  • Three joints of the foot are fused (arthrodesis) correcting the flat foot permanently by putting the bones in the right position and then causing them to grow together (fuse). After surgery, the foot does not move side to side, but the ankle still moves up and down.
  • The gastrocnemius (calf muscle) is released (lengthened) so that stress on the ankle is decreased.
  • Non-weightbearing for 8 weeks.
  • At 8 weeks post op, weightbearing in the cast boot is allowed and physical therapy is started.
  • At 3 months post op, wean out of the boot into athletic shoes and orthotics.
  • Rehabilitation continues until the calf muscles are strong enough to do 10 single stance toe raises without stopping to rest.
  • Total recovery time is 6-12 months. Full recovery is achieved when the bone is healed and the leg muscles regain normal strength. The postoperative rehabilitation and total recovery is very similar to the tendon reconstruction surgery.

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American Orthopaedic. Foot & Ankle Society American Academy Of Orthopaedic Surgeons. American Association Of Orthopaedic Surgeons. The American Board of Orthopaedic Surgery. A member board of the American Board of Medical Specialities.