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Friday, June 3, 2011

Posterior Tibial Tendon Dysfunction: Email Answer

Dear Dr. Blake,

I have searched your informative blog and not found much on PTTD. I really enjoyed reading your tailored approach to each patient in your blog comments, and I am hoping you can give me some useful insights. I do like and trust my podiatrist, but I am in a quandary and want to explore every avenue before summitting to surgery.
(Dr Blake's comment: PTTD stands for Posterior Tibial Tendon Dysfunction. This is the most important tendon for supporting the arch. Complete tearing of that tendon always leads to complete arch collapse. So this is a very serious problem).
I am a 40 year woman in excellent shape, trying to avoid surgery for PTTD. . I found you in reference to your use of inverted orthoses and I am wondering if I consistent use of them might help me. I have consulted with two podiatrists and both have agreed on the PTTD diagnosis, now I just need to figure out my plan.
(Dr Blake's comment: The Inverted Orthotic Technique is the most sophisicated foot orthotic for arch support and is always used for PTTD. There are only a handful of orthotic labs in the US that may them, but a relatively easy technique to learn).
HIstory and background:

I sprained both ankles in my early 20's, the left ankle was a more severe sprain.
(Dr Blake's Comment: this probably left her with some weakness in her arch).
I have had pain in the arch ankle area of my feet for the past six or seven six years, always when wearing improper footwear (heels). The pain always stopped when I went back to supportive/comfortable shoes.
(Dr Blake's Comment: this is the classic presentation of PTTD where the symptoms begin gradually in the arch and/or ankle areas).
I work-out in the gym  four times a week (weights, elliptical, stair climbing machine) and have always hiked for exercise (usually once a week).

My problem became severe when, on a two-week trip in SE Asia in the Nov. '09, I wore flip-flops almost exclusively. We did tons of walking, and at for the first time I noticed my feet burning and tingling in the evenings. I did not connect this sensation to my other painful flare-ups, because I had always assumed it was my high heels causing it. It did not occur to me that I could hurt my feet wearing flip-flops.
(Dr Blake's comment: Again, the symptoms of PTTD gradually begin to change affecting other activities, although one day of aggressive walking in flip-flops if you have a predisposition can cause symptoms).
Over the next six months I experienced increasing pain in both feet upon getting out of bed and standing up first thing in the morning. My left ankle and arch started to look slightly swollen, but I did not see a doctor.
(Dr Blake's comment: This is probably the first mistake, if you see swelling, the body is actively trying to heal something, and may need some help and guidance).
I finally sought treatment when, after a run last summer (August '10) , I was in so much pain in both feet that I had trouble walking. I experienced shooting pains up the calves up both legs at night and my left ankle and arch was red and painfully swollen.
(Dr Blake's comment: Here she is in the Immobilization/Anti-inflammatory Phase of Rehabilitation. You must create a painfree environment and allow the tendon time to heal. You normally need a removable boot, followed by brace, followed by orthotic device. You normally need to combine immobilization with ice and contrast bathing to reduce swelling in the tendon. You normally begin strengthening the tendon painfree from the first visit. Emphasis on the painfree).
First podiatrist diagnosed stage 1 PTTD and prescribed orthotics. Second podiatrist concurred and added ice/anti-inflammatory therapy and in addition put me in a walking boot until my inflammation subsided. After six weeks in boot I went to just wearing the orthotics and sometimes Dansko shoes. My right foot felt 98% better, and my left foot was improved to the point where I could often walk with no pain (always wearing orthotics).
(Dr Blake's comment: Stage 1 the tendon is inflammed, but fully functional. Stage 2 the tendon has some tearing, and begins to not support the arch well. Stage 3 the tendon tears enough to not be functional, and the arch begins to collapse. Stage 4 the tendon completely tears and the arch completely collapses).

Which brings me to my present situation; I am in pain a lot of the time once again, as sometimes want to be barefoot (live at the beach, have a six-year old daughter), wear an attractive (flat) sandal with support, but find that I cannot do so without incurring a lot of pain in my left foot. As I write this I am back in my walking boot as left inside ankle/heel area is throbbing with a dull pain. I wore shoes without orthotic devices yesterday and I'm now paying the price!
(Dr Blake's comment: Golden Rule of Foot: Create a Painfree Environment or else the problem will not heal. This is especially true with PTTD. You need to create a painfree environment. You must stay in that boot until the pain goes away).

Upon hearing all of this from me, my podiatrist has finally recommended surgery. He is of the opinion that that is the only solution for my particular situation. I tend to agree, but I feel overwhelmed when I hear the reality of the recovery. Is there any chance he is wrong? Could I religiously wear the inverted orthoses and "heal" my left foot the way my right foot was improved? Or should I just "suck it up" and do the surgery so I can have a chance for a real recovery and a lifestyle that will resemble "normal" again?
(Dr Blake's Comment: yes, yes, maybe)

Dear Joann,
     Thanks for the email. When patients present to my office with this scenario, I just try to start over. Pretend the injury just happened. Try to put a healing environment together for them to hopefully end with a successful rehabilitation. Sometimes the decisions are hard to make, but we make them and stand by them.
     So, what must you do now? What will allow you to heal? First of all, surgery is only needed 100% for Stage 3 and 4. Does not sound like you are there. Your focus must be immobilization, anti-inflammatory, and restrengthening. Nothing from this point should hurt. The activities should not hurt, the strengthening exercises should not hurt, and the physical therapy should not hurt. Definitely read my post on Good vs Bad Pain and live by it.
     Since the posterior tibial is the strongest arch support tendon, help it out as much as you can to do it's job. This is accomplished with taping techniques, the Inverted Orthotic, stable shoes, wedging of shoes, power lacing, and bracing. Your podiatrist/therapist and you need to create a stable environment, whether it is pre or post surgery. So if a surgeon does not know how to create a stable environment for your tendon, if he/she does surgery, they most likely will not know how to rehab it after.

     Here are so many strengthening exercises for the posterior tibial tendon that is normally easy to gradually build up the strength. Remember, if you try to strengthen a muscle/tendon, and you produce a pain response, the tendon is the end gets weaker.
     What helps control inflammation? Icing (if they is no swelling or after activity), contrast bathing if there is swelling, physical therapy, accupuncture, many topical creams (some by Rx and some OTC), and oral medications. I like to stay away from months and months of oral medications, but short courses when the inflammation is flared is fine. 

So Joann, I will try to dedicate alot of my blogging over the next month to this issue. My recommendations for you right now:
  1. Stay in the Removable boot for the left side until you can walk without pain for 2 weeks.
  2. Purchase an Evenup for the right side to protect your back.
  3. Begin icing 3 times daily for 10 minutes both sides. The left should have evening contrast bathes starting at one and one due to the throbbing. 
  4. Get an Inverted Orthotic Device for both sides, or some type of orthotic that does not allow your foot to pronate at all. You will need this to gradually wean off the cast.
  5. Begin some posterior tibial tendon strengthening each evening followed by 10 minute ice bath.
  6. Get bilatteral ankle MRIs to document June 2011 status of both your tendons.
  7. Find out the stage of your posterior tibial tendon disease and comment on this blog. I will reply.
I sure hope this helps. Rich


  1. Dear Dr. Blake,

    Please post the link to the specific exercises that isolate and gradually strengthen the posterior tibial tendon. Any exercises (resisted adduction, e.g.) that I've tried hurt.


  2. Hi Dr. Blake -

    As a college athlete suffering through PTTD, you're posts (and videos especially) have been an invaluable resource. I just wanted to say thank you so much!

  3. I know you have lots of posts on inverted orthotic technique but I still don't understand exactly what it is. Which of your posts best explains the technique in terms a layman/patient can understand?



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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.