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Monday, August 29, 2011

Posterior Tibial Tendon Dysfunction/Tarsal Tunnel Syndrome: Email Advice

Dear Dr Blake,
                           I was wondering if you could give me some advice.   Three months ago I did some heel raises and foot stretches after a very long bushwalk. Two hours later I could not walk and had very mild swelling on my left foot. I could not weight bare for 6 weeks and  within a day I saw a physio and podiatrist who diagnosed PTTD. I faithfully did stretches to strenthen the post tib tendon, and wore the orthotics.
    I am slowly getting better, though not as quickly as I would like. I can walk short distances but walking up and down steps can give me a mild ache.
  I saw a sports doc who said that I would need surgery as my arches are getting flatter and an ultrasound confirmed accessory navicular, and the tendons were in tact with no tears and no nerve compression or inflammation. I have seen slow improvements but wish to avoid surgery and the sports doc said that I may if i wear aggressive orthotics , my current ones are rigid but dont have a huge arch in them.
    In your experience is it possible to avoid surgery? I have always worn supportive shoes and have not had problems with my feet. I would appreciate any advice that you have.   By the way I love your site!
                                                                                                                                        sincerely   myf

Dear MYF,

      Thank you so very much for your email. If you have seen slow improvements, wait it out. Do everything you can to create a painfree environment. If that requires you to wear orthotics and supportive shoes to the Opera, so be it. Respect your tendon. It has a long way to go to supporting you through life. Be kind to it for a few more months while you work on the swelling and strength of the tendon daily.

     Only a very small percentage of patients with accessory naviculars need surgery, so it only raises the odds slightly of going under the knife

    .It is also an extremely unusual presentation of PTTD (posterior tibial tendon dysfunction), but more consistant with some tarsal tunnel syndrome (sharp totally incapacitating pain without swelling that was not there yesterday). Tarsal Tunnel is a nerve problem with different treatments and a possible low back cause. Hopefully the physio and podiatrist have ruled these out.

     Before you have too much physical therapy, consider an MRI to look at what tissues are irritated. Could be revealing. If negative, consider a nerve conduction test with a neurologist or physiatrist.

     So what should you be doing now? Create that painfree environment. Gradually strengthen your ankle, especially the posterior tibial tendon. Ice or contrasts or both three times daily to the sore area. Wear a removable cast part of the day to reduce the motion across the area. Wear orthotics and supportive shoes if they help with your pain. If not, seek advice regarding better shoes and better orthotic devices (may seem to be crucial if the pain is difficult to manage.

    If you plateau, where progress is at a stand still, perfect all the variables--better information gathering, better orthotics, better anti-inflammatory regimen, better painfree environment (?casting), and better strengthening program.

       September (today is August 30th in at least some parts of our small world) should be a better month than August, and October better than September. If not, please let me know. If you email me again with further info, I will attach it all to this original. I sure hope this helps. Rich Blake

MYF sent this response to my email.


Dear Dr Blake,
                           Thanks so much for your opinion. I raised the possibility of tarsal tunnel to docs as I had burning and tingling pain for the first 8 weeks and now only after standing for long periods of time. I will get onto looking at that , I also have a dreadful lower back with nerve pain/muscular tightness.   Who would have though tthat our wonderful bodies can be so complicated!   thanks again    myf

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.