...less medical jargon in a 'Quick Glance' format!
Posterior Tibial Tendonitisis a common problem in the foot as we continuously walk and use our feet on a daily basis. The posterior tibial tendon is especially prone to tendonitis as it helps to maintain the arch of the foot and prevent excessive flattening of the foot while walking, standing or running. This form of tendonitis can be a precursor to posterior tibial tendon dysfunction where there is progressive loss of strength in the tendon and a progressive flattening of the arch.
Although the tibialis-posterior tendon can rupture as a result of sudden impact forces on the foot and ankle, the most common cause of posterior tibial tendinitis is overuse, which is another way of saying that the tendon was simply not strong enough to stand up to an athlete’s chosen frequency, intensity, and volume of training. Symptoms of posterior tibial tendonitis include soreness, pain, and swelling along the inside of the ankle, as well as aching and discomfort along the bottom of the foot. The foot troubled by posterior tibial tendonitis is often ‘flatter’ than the other, problem-free foot (ie, the arch is less concave), and an athlete with this condition may have a fair amount of difficulty carrying out single-leg heel raises on the affected leg.
How does posterior tibial tendonitis of the foot develop?
Problems with the posterior tibial tendon seem to occur in stages. Initially, irritation of the outer covering of the tendon, called the paratenon, causes paratendonitis. This means the tendon is inflamed where it runs through the tunnel behind the medial malleolus.
As we age, our tendons can degenerate, or wear down and weaken over time. Degeneration in a tendon usually shows up as a loss of the normal arrangement of the fibers of the tendon.
Tendons are made up of strands of a material called collagen. Think of a tendon as similar to a nylon rope and the strands of collagen as the nylon strands. Some of the individual strands of the tendon become jumbled because of degeneration, other fibers break, and the tendon loses strength.
As the tendon heals itself from wear and tear, scar tissue forms, thickening the tendon. This process can continue to the extent that a nodule, or knot, forms within the tendon. This condition is called tendonosis. The area of tendonosis in the tendon is weaker than normal tendon. The weakened tendon sets the stage for the possibility of rupture of the tendon. Tendonosis may develop into tendonitis if the weakened area becomes inflamed.
What can be done for posterior tibial tendinitis?
. . . Nonsurgical Treatment
Treatment of posterior tibial tendonitis begins with the use of a firm arch support inserted into you shoe. The arch support is useful because it supports the arch and takes some of the stress off the tendon. To rest the tendon, you may need to decrease the time you spend up on your feet. Additionally, your doctor may prescribe anti-inflammatory medications, such as ibuprofen or aspirin.
A cortisone injection, sometimes used to ease inflammation in other types of injuries, is usually not appropriate for posterior tibial tendinitis, since the tendon is more likely to rupture following injection. Some physicians recommend a slightly different cortisone treatment called iontophoresis. Iontophoresis is a treatment that uses electric current to deliver cortisone medicine through the skin to the inflamed tendon. The risk of tendon rupture is much less when this method is used.
. . . Surgery
If all else fails to resolve your condition, surgery may be required.
If the problem appears to be primarily posterior tibial tendonitis with thickening of the tissue around the tendon, a tendon debridement operation can be performed to remove the thickened tissue around the tendon. This is done to try to decrease the symptoms of pain and to prevent rupture of the tendon.
This procedure is usually done through a small incision in the instep of the foot just over the posterior tibial tendon. The surgeon simply identifies the tendon and removes the thickened tissue.
A degenerated tendon that has not ruptured may only need to be repaired. The surgeon divides the sheath around the tendon. Areas where the tendon is degenerated are carefully removed. Tears within the tendon are sutured along the length of the tendon. If the surgeon is concerned that the repaired tendon is at risk for rupturing, a graft procedure to add strength to the tendon may be needed. The tendon sheath is repaired, and the skin is closed with sutures.
A badly degenerated or a ruptured tendon may require a tendon graft. Usually, another tendon in the foot, such as the tendon that flexes the four smaller toes, is used as a tendon graft to work in place of the posterior tibial tendon.
Finally, in cases which have been neglected and a fixed flatfoot deformity is present, a fusion of the foot may be required. A fusion is an operation where a joint between two bones is removed and the two bones on either side of the joint are allowed to grow together, or fuse. This type of operation is used to stop pain from joints that are worn out. It can be used to realign the bones when the mechanisms for maintaining normal alignment are lost, such as when the tendons and ligaments no longer work properly. Usually, several joints must be fused to control a flatfoot deformity that develops after a posterior tibial tendon rupture.