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Saturday, October 15, 2011

Posterior Tibial Tendon Dysfunction: Correspondence from a Sufferer scheduling Surgery

Joann has been kind enough to share more information about her struggles with the terrible problem of posterior tibial tendon dysfunction which leads to severe breakdown of the arch of the foot. The link below is our initial correspondance.

Hello Dr. Blake!

Feel free to edit this as needed....I got a little long-winded. Thanks for listening!

It's JoAnn from June 2011; PTTD stage 1. Thank you so much for your reply to me, and your devotion on your blog to this issue. I'm happy to say that I am pretty much pain free now in my left arch. It has been a long haul-over one year since I started treatment-but when I think about the fact that I have more than like been (unknowingly) hurting my tendon through overuse/under support for over a decade, I guess that's not so crazy.

It's been tough giving up most of my intense physical activities, and I'm sick of the stationary bike, I will tell you that! I am definitely not in the same great physical shape I was before this began, but I feel I can regain the lost ground in a few month's time. The important thing is, I feel amazed that I can work a normal day (I'm a teacher) and not be limping by day's end. This is where I was when I wrote in June. I am sure you have heard this a million times, but I will never take my health for granted again.

So, it's been six months since I wrote to you in desperation; and haven't done everything you recommended, either, which has no doubt hindered my progress. I have just been wearing my orthotics, and icing as needed. I am ready now, however, to see if I can make even more progress, and start doing my exercises to strengthen my tendon. I am watching the videos on your blog to learn how to properly execute them.

My question for you today one that is haunting me daily, and something I didn't address in my first email. My podiatrist has told me in blunt terms that due to the structure of my foot (in layman's terms, he called it "overly flexible"), a problem like mine will only get worse over time: NEVER BETTER. Because of this, I have scheduled surgery for December; the surgery involves five different procedures, which according to my doc will basically "rebuild" the structure of my foot. In your opinion, are there cases like mine where a foot's bone structure is such that simply makes worsening PTTD inevitable? I really don't want to have surgery (who does?), but nor do I want to live in some fantasy world, do all of this work/PT, only to have my PTTD reoccur once I resume my active lifestyle (MY DREAM). In other words, sure I feel better now because I am babying my foot, wearing only the proper footwear, and being "perfect". But I want to get my active life back; are my odds for having that reality better with surgery? Or can I really achieve it with physical therapy? Without knowing my case, I am sure you can't really answer definitively.

Again, thanks a million.


Dr Blake's Comment: Wow, JoAnn, what a thing to tell you!! Amazing how docs and PTs think they are helping you when they say something like that. Giving you the preverbial "dose of reality" you need. And yes, I have never seen your feet, so I can only really speak in generalizations. From his/her prespective, unless they are unethical, they believe they are right. And sure may be!!

I just had a patient with Stage I PTTD problems run a marathon with no problems, although was reinforced with orthotic devices, shoe wedging, motion control shoes, ankle brace, and power lacing. Can not remember if she was also kinesiotaping her arch, but probably was. Never seen a PTTD patient post surgery do that, but they probably can. If I only used the little sampling of patients I have, I would have to conclude surgical repaired patients are less active, but I am not sure. Most of my surgical patients, whether it is knee, hip, ankle or feet, have some limitation post surgery. Sometimes, it is only psychological, since once you go through the surgery, you want to protect the area forever. So, my gut level, what you will have to do post surgery is the same things you should do pre-surgery to avoid the surgery in the first place.

The type of surgery you are talking about in December is preventative surgery. I do not think this really exists since surgery can have complications, and surgery always weakens the area. The big toe joint is forever physiologically weaker after bunion surgery, the ankle joint is forever weaker, the knee joint is forever weaker, and it takes alot of work to get most of the stability back post surgery. I always tell my patients that surgery brings with it even with the best surgeon on the face of the earth, and even mars or jupiter, a 10% chance of complications, and 10% of these can leave permanent problems. These are small odds for most, but not if it is you that got the complication in what would be deemed elective, preventative, surgery.

And every procedure within 1 surgery, you mentioned they are considering 5 for you, has its own chance of complications. So  you have really a 50% chance of some complication slowing you down, and a 5% chance that complication will have some permanence (suggestive some form of disability).

JoAnn, if you are still reading this, and not just turned me off and looking at YouTube, let's place where you are now. You have a significant injury, and you are in the rest/immobilization phase of rehabilitation. You have a long way to go over the next 2 years to get very very strong and powerful in your foot and ankle. The stronger you become in avoiding surgery, even if you need surgery, your strength will speed up the post-op rehabilitation. As you try to rehab this ankle of yours, you need to find a smart PT who can guide you carefully through the strengthening process. It may take a few PTs to find one whom is locked in. But he/she will be the one if you need surgery to rehabilitate you. How very frustrating would it be to have to search for a great PT after surgery, when the tissue is more fragile, and poor PT can make the difference between great results and okay/fair results. I think you would deserve great results.

So, if you have been reading the blog, you know my bias. You hopefully can tell that every small aspect of the surgery, and the rehabilitation, can make big differences. The team you should compile if you are serious about this is a great surgeon who gets his patients running after this surgery (you should be allowed to talk to several of these patients pre-operatively. They will also give you insights into other aspects of what you are going to go through), a great doctor to run your rehabilitation, and a great physical therapist to see that every aspect of the rehab goes well.

Personally, as I end now, I think you should cancel your surgery for one year, and get strong. Get that foot and ankle strong. Make sure every part of the puzzle is in place. Then, if you need surgery, it will be no longer preventative, but because the tendon is not doing well as you gradually increase its stress. Go slow over the next year. Keep any pain within 0-2 levels. Add 10% to your workouts weekly, initially that is painfully slow. If you are walking 30 minutes now painfree, start a walk/run program with 5 workouts per level, and workouts every other day. If all goes well you are running 30 minutes in 100 days, and then more serious running can occur. Own the blog post on good vs bad pain. Believe me, there is no lesson you will now, that won't help you if you eventually need surgery.

Finally, I see patients all the time with loose ligaments who need some orthotics to function, but never advance in 20 plus years with their Stage I PTTD. A few do, but it is not inevitable. Do not believe that. Tomorrow your arch could collapse, and you could move up the surgery. But, it may never collapse. Perhaps other patients stories can come out between now and December to influence you one way or the other. Good luck JoAnn. Rich

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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.