Ankle Reconstruction followed by Posterior Tibial Tendon Dysfunction: Email Advice

Dr. Blake,

I had Bromstrom procedure October 2012, and in March 2013 was diagnosed with PTTD.

Dr Blake's comment: Bromstrom is a lateral ankle reconstruction for torn ankle ligaments.

 The posterior tibialis tendon is thickened consistent with tendinosis.  There is a longitudinal tear of the posterior tibialis beginning at the level of the distal tibia and extending to the mid aspect of the talus.  The longitudinal split tear measures 2.5 cm in length.  There is moderate fluid within the posterior tibialis tendon sheath.  There is no tendon rupture identified. 

The orthopedic surgeons are saying it will not get better, when I resume my activity it will come back, until; I have surgery.  They are saying I need FDL transfer, posterior tib debridement, spring ligament repair, and medical displacement calcaneal osteotomy. 

 I have done physical therapy, and ice, medication, now use pain cream.  It seems to feel better after stretching, and strengthening, I am wearing a brace, and prescribed orthotics.  I am a flight attendant and am on my feet for long periods of time.  I know surgery will put me down for 4 to 6 months, and would rather not go through another long painful surgery and recovery.  

DO you have any suggestions as to what I can do that I am not doing currently?

Dr Blake's comment: 

     Thank you so very much for the email. Most of my patients considering such a surgery take years to make such a big decision, so you can always do that. MRI findings such as yours are common, and I am happy that no tendon rupture occurred. I am assuming that the lateral ankle surgery placed too much stress on the medial structures causing them to start barking at you. 

     Without a rupture, you have the possibility of completely healing this without surgery. It is really based on prolonged protection of the posterior tibial tendon while you go through pain free strengthening. The strengthening of the posterior tibial tendon should include all of the other foot and ankle muscles/tendons, and the rest of the leg and core. 

     The next 3 months will tell a lot about your course. Each month the tendon should gradually get stronger as you advance from active range of motion, to isometric, to progressive resistance, to functional restorative exercises. It takes a good physical therapist out there to lead you through this. You will have ups and downs. And the downs, as you attempt to push the course too fast, is psychologically demoralizing. 

     Please keep me in the loop, and I will help as I can. I will place further correspondence on this same blog post. Hope this gets the process going. You already have achieved pain free function by the sounds of things, and that is a huge step forward!!! Rich