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Friday, May 20, 2016

Posterior Tibial Tendon Injury and Long Term Concerns

Hi Dr Blake,

I've been reading your blog archives since I first started having
problems with my foot.  It's kind of a long story, so I apologize in
advance for the length.

I am/was a runner.  I ran anything from 5K through ultras.  I had been
running in the same pair of orthotics for 4 years at that point and
never had a problem.

Then last May (2015) I developed PF in my right foot.  I rested, iced, rolled
and it wouldn't go away.  I saw a Sports Med Doc who eventually gave
me a US guided steroid shot into the PF.  He had me run on it within
three days.  I was fine until two weeks later when the shot wore off
and then I was worse than before.
Dr Blake's comment: Patients get cortisone shots for plantar fasciitis all the time when a plantar heel bursae forms. So, the shot is into the bursae, not the plantar fascia. It is always risky to inject right into the plantar fascia with cortisone, for fear of causing a rupture. The odds of a rupture are small, but it can happen. If the pain intensifies following a cortisone shot in the bottom of the heel, assume that the plantar fascia tore, and start plantar fascia tear protocol of 3 months in a removable cast. 

The pain was still bearable, I could walk but not run.  In September,
one month after the shot, I was hiking and felt a pop in my arch just
in front of the heel but more towards the outside of the foot.  The PF
got a lot worse after that.
Dr Blake's comment: This is when it completely tore.

I saw a podiatrist right after that.  The area was red and puffy and
he noted that my ankle rolled in a little more on that side.  I have
very high arches and roll in a little on both sides so I didn't make
note of that.

He had me fit for corrective orthotics.  When they came back, they
inflamed my heel really badly.  I started aggressively rolling and
stretching my arch (I think this is part of where I went wrong and
tore or worsened the tears).  I kept having the orthotics adjusted
because they really hurt my right foot.  They adjusted the left to
match, even though I was fine on that side.
Dr Blake's comment: So you are in the Immobilization Phase. This is the time you should be in a removable boot with heel cushion, or modified arch support to transfer weight into your arch and cushion and protect your heel. 

About this time, this is late November now, I was at the gym and
couldn't do a heel rise.  My foot was in almost constant pain, my
podiatrist was very dismissive and told me I was fine.  He didn't
really seem concerned with my pain or inability to do a heel rise.  He
told me that I shouldn't be doing them anyway with the PF (??) but
sent me for an ultrasound "for my peace of mind".
Dr Blake's comment: The inability to do a heel raise indicates the arch has been compromised. As you begin to lift your heel, all the weight goes from the heel to the supporting structures of the arch, and eventually to the ball of the foot. But when you can not lift your heel off the ground, some structure(s) has been injured that helps lift up the arch (Plantar Fascia, spring ligament, posterior or anterior tibial tendons, etc). 

It showed that I had a full thickness partial tear of the PF and split
tear of the PTT.  He put me in a boot and wanted to see me the
following week.  Immediately the boot hurt, it had no arch support so
he put in lifts.
Dr Blake's comment: It is good to have an arch support inside the boot in situations like this. 

By the next day, my foot started to swell and the
pain was excruciating. 
Dr Blake's comment: There are 3 sources of pain: mechanical (due to the injury), the inflammatory reaction to the injury, and the gradual onset of nerve hypersensitivity for your body's protection (the worse of all the pain sources). You were now really triggering nerve pain affecting the sympathetic nervous system with some swelling and possible skin discoloration. Ideally, this gets everyone's attention by now. 

I started using crutches the following day.
By the time I saw him the next week, my foot was painfully swollen and
it was discovered that I developed a blood clot in my calf.  He took
me out of the boot and had me NWB.  This was mid December.  After that
he took one phone call from me telling me to stay NWB and that he
wouldn't see me until I was cleared by a vascular surgeon.  I was
cleared, but that podiatrist didn't take or return my calls after
Dr Blake's comment: I apologize for my profession. It was clearly over his head, but you had a bad reaction, and doctors are human and can behave badly. 

In the beginning of January, I started seeing a new podiatrist.  She
ordered an MRI that confirmed the PF tear and showed a small
insertional tear of the PTT.  She thought I needed surgery but her
colleague came in and said that it was small and he thought most of my
problem was from atrophy.  He wanted me to go from the crutches to my
sneaker.  In a matter of five minutes I had gone from needing surgery
to needing nothing, not even a boot.

I was confused and still in pain so I decided to see an orthopedist
foot and ankle specialist.  He had me go from crutches to a boot,
which I thought was reasonable.  He said that the PTT tear was small
and most of the problem was from the large PF tear.  My arch still
hurt in the boot so he had me wear the orthotics I had gotten in
Nov/Dec in the boot.
Dr Blake's comment: Thank you, finally some reason applied to this. 

Around this time, I started getting tingling and pain in my left PTT.
We thought it was compensation. Mid February I came out of the boot.
I was doing physical therapy twice a week and things seemed to be
improving.  The PF pain was gone.  I was able to do weak but pain free
single heel rises.
Dr Blake's comment: I am so happy when the pain got out of control, with the swelling, that you do not develop a condition called "Complex Regional Pain Syndrome". The Golden Rule that applies here is to get the pain level between 0-2 as quickly as possible. That just did not happen. Pain syndromes from the Posterior Tibial Tendon tend to always be on both sides, with different starting dates, so after you identify the posterior tibial tendon as a source of pain, immediately start doing some preventative things for the opposite side (orthotics, strengthening, or simply just icing). 
I kept having medial ankle pain whenever we would do any balance
exercises.  I took a day trip walking around a city and afterwards I
had swelling all long the left PTT.  I was very concerned and went
back to the orthopedist.  He put me in an aircast PTT brace and told
me that he'd send me for an MRI if it didn't improve.  I asked him why
this was happening and he said he didn't really know.  I have very
high arches and that should protect the PTT.
Dr Blake's comment: High Arch feet have worse problems with posterior tibial tendons if the arch starts to fall. High Arch Feet are more unstable in general than pronated flat feet, which can have more alignment issues. High Arch Feet need more muscle/tendon strength around the ankles to keep upright. High Arch Feet never get good arch support from shoes, OTC arch supports, and even most custom foot orthotic devices, so relie on tendon and ligament strength. When these are compromised, even by simply favoring one foot for awhile, pain begins.  

Sorry, I know this is long, I'm almost at present day.

The symptoms calmed down and I stopped using the brace after about a
week.  I kept trying to figure out why the left was hurting me.  I
decided to try my old orthotics again, the ones from now five years
ago, and my left PTT calmed down immediately.  The right one
aggravated the heal and irritated my ankle.
Dr Blake's comment: Good detective work!! Something is off. 

I thought the problem was that they were old and needed some tweaking.
I dug around and found the name of the podiatrist who had made the old
orthotics.  He took x-rays and discovered that I have an accessory
navicular, which, he says, is very uncommon in high arched feet.  He
has scheduled me for shockwave treatment on my PTTs.  He wants to have
the old orthotics refurbished and has me wearing them with a gel heal
Dr Blake's comment: I have no experience with shockwave, but it is to break down scar tissue, and there is good scar tissue presumably helping heel the Posterior Tibial issues. 

The shockwave won't fix the right foot where the arch falls a little
but he thinks that it will help heal the damage.  The plan is to try
to stop it from falling further with my old orthotics.  I've tried
wearing just the old orthotics but on the right foot, the one that
tore, they cause my arch and ankle to ache badly, and the outside of
my foot to hurt.  Yesterday I was limping, my ankle swelled and
something by my lateral ankle sounded like a knuckle cracking when I
walked.  Today I'm wearing the orthotics that hurt the left foot
because they are better, but not perfect, on the right.
Dr Blake's comment: Definitely, you can temporarily wear 2 different generation orthotics on the right and left, or a custom and OTC, on each foot, to handle the pain aspect. Without more complex information, we have to listen to your body and let pain be your guide. 
My questions are:

Can they make me one orthotic to deal with the PTTD on the right side
but not make the same adjustment on the left?  I think that's what
caused the problem on the left side.
Dr Blake's comment: Yes they can. You have very different needs for each foot, so the orthotics made should reflect that with different support. If you were in my office now, before I made anything else, I would try to understand why one orthotic feels good, and one causes problems. It is in knowing that info that you can redesign a new pair to help. 
Can orthotics really halt the progression of my arch falling?
Dr Blake's comment: Never on there own. Orthotic devices are used to stabilize the foot, along with taping, bracing, and good shoes. Then, foot strengthening exercises like the ones in the video below, can triple the strength on the tissue. What you do not know is if there is a degenerative process that will continue in the ligaments or tendons. You have to set a one year goal to perfect your orthotics, your ability to tape as needed, and triple the strength of your ankles and feet.

Will I be able to run again if I have proper orthotics?  Will anything
get me back to running?
Dr Blake's comment: Without knowing everything, my expectation would be that you could run again. Once you can walk 30 minutes for 2 weeks without pain, you can start a Walk/Run program with stability shoes, power lacing, great orthotics, and some version of posterior tibial taping like in the video below. I love having you begin to run as soon as possible, when walking is fine, because your feedback is crucial to modifying your orthotics, changing shoes, perfecting taping, etc.

Is having the accessory navicular removed a reasonable option?  From
what I've read, they anchor the PTT down where it should have been
instead of doing a tendon transfer.  If that's true, wouldn't it be
better to have that done before the tendon stretches out even further?
Dr Blake's comment: I understand completely what you are saying, but right now it is preventative surgery, and that does not sit well with me. I would have a better feel  for that based on the ease or difficulty getting back to running, the level of pain is have to constantly deal with, a repeat MRI and even CT scan looking at the tissue. I have seen plenty of accessory navicular bones that cause no problem whatsoever. I hope this has been somewhat helpful. Rich

I'm really starting to lose hope that I'll ever be able to even go
about my day without one PTT or the other bothering me, let alone run
or hike or any of the other things I love.

Thank you so much for taking the time to read this.  I appreciate any
advice you may have to offer.


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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.