Posterior Tibial Tendinitis: Email Advice

Dr. Blake
Thanks for the opportunity to seek your opinion.

My 18 yr old daughter has an ongoing foot problem.  She is depressed, sad, has given up hope, ... every day she struggles with the physical pain and is emotionally crushed.
She has changed from a happy kid to a sad, depressed teenager with a foot injury that never ends!
The current diagnosis is Posterior Tibial tendonitis.  She had surgery 16 months ago to remove an accessory navicular ... which they thought was causing the dysfunction in the foot??

She originally twisted her foot in a basketball game when she was 13. The foot seemed to heel ... but she re-injuried it,  and the foot (left) started to collapse if she were to start running again.

It was 2 years before we started to learn about the Posterior Tibial tendon - and made efforts to strengthen and re-train this tendon.  Seemed that the accessory navicular was creating an unstable attachment for the tendon to do its job supporting the foot.  Finally, surgery was suggested - and performed on May 31, 2011. 

 Casted for 6 weeks, rehab for several ... when she tried to run, the pain and problem returned - and has been problematic for the last year!  Recent MRI shows some tendonitis in the Posterior Tibial Tendon. 

 She struggles every day with pain (and dysfunction) ... and the mental toll of missing sports for 4 years has been heart breaking - she was an absolute star runner, basketball player, tennis - a real all-around star ... and LOVED to play!  Four years on the sidelines - our family life has been transformed ... daily sadness, despair.

We are lost with what to do.  Doctors seem stumped, PRP 8 weeks ago - no response. Physiotherapist don't know what to do.
Try again with different orthodics?
Immobilize to settle tendon - (she swims, strength trains, bikes, walks to classes at U)
I can send more details?
I have copies of the MRIs.
Thanks for your time and consideration.
Dan 

Dr Blake's Response:

     Dan, I am honored to share some of your burden. Thank you so very much for contacting me. 

     First of all, posterior tibial tendinitis does not cause this, but posterior tibial tendon dysfunction can. The MRIs should give us a clue to her pain, but she may need some diagnostic injections into the various joints in the area to see where her pain originates from. The two Golden Rules of Foot that initially apply are: Find the Source of Pain and Create A Painfree Environment. Please fed ex any tests to Dr Rich Blake 900 Hyde Street San Francisco, Ca, 94109, USA for my review. The tests available for this syndrome are MRIs (so I should look at what you have), X-rays with obliques to pick up that side of the foot, bone scans, ultrasonography, CT scans, diagnostic injections, nerve conduction tests, thermography, and exploratory surgery. The last I would save until the other tests have been done. Your daughter has all the right to be very depressed, but you guys must be her strength and fight to get these tests done, etc. Make this a project for the next few months to begin to get a handle on this.

     Secondlly, immediately Create A Painfree Environment. If this requires a removable cast, a more inverted orthotic, a Ritchie Brace or another AFO, a Roll A Bout, crutches, whatever, and in what ever combination it is crucial. It is crucial to know right now what it takes to make her pain free all day long. That is vital information for the treating physician. 

     Thirdly, the past is the past, and right now we do not need to focus on the last 4 years, but I do need to know what the docs or the PTs are finding (i.e.. collapsed arch only on that side, positive tinell's sign at the tarsal tunnel, limited subtalar joint motion, inability to contract the posterior tibial tendon, etc). Basically, what are the clues she is giving us that we can use to help her. 

     So Dan, I will put any new correspondence, etc on this same post. Let us see if we can begin the process logically. This is so highly unusual that I know something is being missed. Hopefully we can find out. Please send me a photo of her standing of the back of her heels from about 3 feet behind her centering the camera in the middle of both legs.

      Finally, I am attaching a medical history form for her to fill out and email back. I only need to know what is happening now that is not enabling her to walk without pain. Thank you Rich

http://www.drblakeshealingsole.com/2010/06/giving-good-medical-history-for-pain.html

Dr. Blake

Thank you for the quick reply.

I am very appreciative of your caring attitude and willingness to help my daughter.

I have the MRIs and reports ready to send.  My daughter will work on the history later today.  I'll also get a few photos taken to send as well.

Next ... will be getting some of the testing done.  I will try with the doctor who has been working with her this summer; he tried the PRP injections in July - can likely get the testing ordered.

Also, we'll explore some of the solutions to get the current pain under control.

As things move forward, if you need to see her we can arrange to do that.  We are in Ontario.  Flights typically out of Detroit.

THANKS AGAIN.

Dan

This video sent shows the common area involved by the posterior tibial tendon.

This photo shows a slightly more pronated left foot, but only slightly. That gives us great hope that the injured left foot can be supported by standard orthotic devices with some inversion in the RX well.