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Saturday, May 19, 2012

Posterior Tibial Tendon Dysfunction: Email Correspondance

 Blogging on Saturday is Email Correspondance

Hey Doc!!

I found your blog and I am so grateful! I have already learned a great deal. I really need your advice and help.

 Last fall I started to play tennis again. I played daily and began to have foot pain.
Dr Blake's comment: When have taken time off from exercise, it is important to start every other day so that you can access the toll on your body correctly, and give yourself the 48 hours to regain your strength in your muscles. 

 The inside of my ankle and the bottom of my foot were sore. In November I saw the ortho and he said I had PTTD.

Impression Casts taken of a left sided PTTD showing the collapse inward of the heel and arch more than the right.

Dr Blake's comment: Posterior Tibial Tendon Dysfunction diagnosis can be like shin splints, you really do not know what is wrong by the name. The Posterior Tibial Tendon is the most important tendon to support your arch. The Dysfunction part implies that the tendon is not doing it's job, and patients have seen complete collapses of the arch in severe cases requiring surgery. Since I do not know the severity, but Melanie is implying that it seems difficult to treat, to protect her immobilization must be recommended until more info is obtained. 

Removable Boot with EvenUp

 He put me in a walking boot and that did not help.
Dr Blake's comment: This requires further information Melanie. The boot, like the photo above, should have calmed the tendon down. Did  it hurt just as much, 50% as much, hard to tell? There are so many factors that come into play with your injury. Normally, the below the knee boots are better than the mid calf or ankle high ones. They distribute the force of stability over a larger area. Also, with PTTD, normally wearing an arch support in the boot is crucial. If you do not have a comfortable custom one, get the heat moldable Sole supports soft athletic version ( 

 He also told me I had an accessory navicular bone.
My most favorite OTC orthotic because I can adjust and you can heat mold if the uncomfortable out of the package.
This X-ray captured an Accessory Navicular Bone, also called Os Tibial Externum, or 2nd Ankle Bone. It forms around 9 or 10 years old, and can be painful by 16 years (my earliest patient at least). 
CT Scan showing the Accessory Navicular bone of the X-ray above. This extra bone occurs in a small percentage of people and normally weakens the attachment of the posterior tibial tendon into the arch making it less effective in supporting the arch and stabilizing the inside of the ankle. 

 It seemed to get worse. ( no arch or foot support in the boot).

 So  off I went to the podiatrist. He gave me an a shoe insert. It didn't help.
Dr Blake's comment: One of the very crucial points I need to make to all orthotic wearers is why are you wearing them, and are they successfully fulfilling the purpose they were prescribed? Why did you get the orthotics? Pain Relief or better function??? Orthotics if done well should make the posterior tibial tendon work better, but maybe, just maybe, you are in the Immobilization Phase of Rehabilitation, not the Restrengthening Phase. So, a great orthotic device for PTTD can make you hurt a lot more just because it is being used to stabilize and restrengthen at a time you should be immobilizing and anti-inflammatoring. Not really sure if that is a real word!!! You are definitely in the removable boot with some sort of orthotic and arch taping period. 

Kinesiotape used as an arch stabilization tool.

About a month ago, I slipped in the kitchen and twisted the ankle on the same foot with the PTTD. Since the initial fall I have rolled it two more times!
Dr Blake's comment: Once you hurt a major tendon, you body naturally protects itself. You can roll your foot to the outside which makes you more prone to sprains, or if a step will produce pain, you can just let the foot collapse/shut off and you fall to the ground. These scenarios are quite common. And, if they are happening to you, I can see why you emailed. It is very very frustrating. 

 I look like someone beat meup!
I keep spending money on shoes,  inserts and I need some advice.

I started the tennis to lose weight, and I was.

Do I need a PTTD brace? I purchased some Orthaheel shoes but my foot for some reason gets to a weird angle in them.

I am doing the exercise you recommend for strengthening my ankles. I know losing weight will help me, but I need to know what to do so I can get back to tennis!

Thanks you so much!!

Melanie (name changed due to witness protection)

Dr Blake's response:

Dear Melanie, 

     Thank you very much for writing. I hope some of my initial comments were helpful. Please feel free to comment on this post and I will try to respond reasonably in a timely fashion. To summarize:

#1     You are probably in Phase 1 of Rehabilation: Immobization and Anti-Inflammatory where you try to create a Pain Free Environment to let the tissue heal.  We need to get you to that 0-2 pain level range for 2 weeks straight. 

#2     You can try combining the boot and orthotic, but may have to get another boot or a different orthotic. You do not want to spend a lot of time creating this pain free environment. 

#3     You should consider crutches, and even a RollAbout, for a short time, if that is what it takes. 

#4     For the Anti-Inflammatory part, definitely start ice packing for 10 minutes three times daily. The ice pack can be placed in the boot and you walk around (multi-task). Consider anti-inflammatory meds, flector patches, and physical therapy for anti-inflammatory only (although you can send me a video of you bouncing on the trampoline). LOL

#5     Normally, if the accessory navicular is the source of pain, the pain will localize there as the symptoms die down. 

#6     You should get (if possible) a baseline MRI of the ankle. It will show the rear foot also, and may give clues to what is broken. Hopefully, you strained but not tore the tendon. 

#7    Since tennis is out of the question right now, consider elliptical or stationary bike, even some pool workouts will not irritate, as long as whatever you do does not irritate the tendon. 

#8     One important bit of information I need to further advise regards pain. What produces it? How is it in the morning? See if you can write up and email the pain questionnaire from a previous post. Also, go through the various foot and ankle exercises described in my blog, at least the ones not requiring equipment, and tell me which ones are painful and which ones are symptom free. 

Good luck. Rich
The mnemonic goes like this---

Family History of similar problem? Frequency of pain (how often)?

What is your Assessment of the problem (what do you think it is)? 
What part of your Anatomy is involved? 

I How Intense (use Pain Scale) is the pain? What Irritates (makes it 


L With one finger, point to the exact Location of the worse pain?

What Eases the Pain? Does the pain have an Electric sensation with it

What has been it’s Duration (how long has it been going on)?

O What were all the events surrounding the Onset of Pain? Are there 

any Observable skin changes?

P Pain Scale (0-10) Sleeping? Getting out of Bed? During Activity? End

of the day?

Q What is the Quality of Pain (burning, tingling, dull ache, sharp, 

numbness, throbbing, pulsating, etc)?

R Is there Redness? Does the pain Radiate and where to?

S How does Shoe gear or barefoot affect it (or high heels, or various

types of shoes)?

What have you done to Treat the problem? What Treatment has 

helped? What Treatment has made it worse?

Are there Underlying Health Issues (diabetes, osteoporosis, 

arthritis, poor circulation, etc.)?

V Does the pain Vary (better at different times, worse at other times)?

Can you Work? Were you injured at Work? Does this affect your Work



  1. Thank you so much for all of the information! The pain is definitely near the accessory navicular bone. At least that is what it feels like.
    I do not have an arch collapse, but I can see the overpronation clearly. My fear is my instability and the constant falling and rolling of the ankle. It does not take much at all, a rock or a large seam in the concrete, if I hit it just a certain way, I am down. I already have a pin in my left ankle from an injury years ago. I know there are structural issues because when I walk now, sometimes I can feel a "popping" feeling at the very top of my thigh where it joins the pelvic area. I don't know if I am doing more harm by all of the different inserts and shoes I keep trying. I read in a prior blog of yours that people with this issue need motion control shoes. Do you have an recommendations?
    The exercises do not hurt, but I clearly need to strengthen my ankles. The single leg balance I can really feel in my muscles. I greatly appreciate all of your help!

  2. If you do not have arch collapse, surgery is less imminent. Try the Brooks Ariel or Addiction for Motion Control running shoe. Spend the next year strengthening your ankle, weekly making the exercises longer, more difficult, and adding a new one. You should be able to make the ankle 3-4 times stronger if you can do the exercises I described pain free. Having an ankle that strong should make the falls much less frequent. Rich

  3. Good morning Doctor,

    This is one of the more comprehensive explanations I've seen.
    I am dealing with a 2nd round of PTT.
    I tried quickly jumping into the re-hab exercises, but noticed pain when going on balls of foot, so I stopped.
    The podiatrist put me in a ankle brace.
    I found this great self-massage that I thought I'd share with others:

    The podiatrist recommends me wear the boot for 2 weeks.
    I went for a consult in Active Release Therapy, where the guy pulled my leg and hip, and rotated ankle.
    Should I wait the 2 weeks, then go to the ART Chiropractor for treatment?

    1. Thanks for your question. You basically need to create a pain free environment and if that means wearing the boot for 2 to 6 weeks, so be it. The program of treatment for PTTD is immobilize when necessary, restrengthen the moment you get symptoms, and anti-inflammatory (normally a car load of ice). Active Release is for the scar tissue accummulation in a chronic injury, and the ART specialist will let you know if you are a candidate. Rich

  4. Dear Dr Blake,
    Thank you for all your helpful advice. I sustained a severe sprain 3 months ago. There was bruising around PTT but the main injury site was on the other side of my ankle. It was healing fairly well overall, but 6 weeks ago I started experiencing pain in my PTT; my arch was also collapsing inwards. I think I may have been over stretching my achilles, which aggravated the PTT. However, the pain has increased to the point where I am not able to put any weight on it at all at this point.One1 month ago I could walk around pretty easily, at least short distances.

    I am able to do a calf raise, so my podiatrist thinks this is just inflammation and needs to calm down. But it seems to be worsening, and I don't know what to do. I am immobilizing, icing, not walking on it. My ankle overall is weak and stiff, due to the main injury.

    Do you have any suggestions? I am quite desperate. Thanks so much!


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.