• Anatomy

The posterior tibial tendon connects muscle on the inside of the leg to the Navicular Tuberosity on the inside of the long arch of the foot. This tendon runs behind the inside ankle bone.

  • Function

The posterior tibial tendon is very important in maintaining the structural stability of the foot. It is important in aligning the rearfoot so the foot can propel the body forward during walking. Injury or rupture to this structure can make walking difficult, can make the forefoot unstable and allow all the metatarsal bones to elevate and malfunction. This can ultimately limit mobility or your ability to walk or exercise.

  • Causes of Injury

The number one cause is long standing genetically inherited flatfoot condition. This condition will put excessive strain on the tendon during walking eventually causing it to become inflamed, and possibly tear.
Having diabetes causes glycosylation of all tendon structures and can add to the chances of rupture. Rupture of this tendon in a diabetic person can cause further weakening of the foot and potentially further collapse of the foot.
There are numerous other predisposing conditions including obesity, trauma, and overuse syndrome that could result in injury to the posterior tibial tendon.

  • Treatments
    1. Immobilization and Protection
      This is the single most important treatment. You must protect the injury to give it a chance to heal and to lessen the chance of total rupture. A cam walker boot is used in more severe cases for the short term protection and functional foot orthotic devices are used for less severe injury and for long term treatment, to prevent harmful pronation of the foot during walking.

    2. Steroid Injections and Non-Steroidal Medications
      Cortisone shots reduce pain temporarily. They do not heal the injury, and can cause rupture of the tendon. Cortisone shots are harmful and contra-indicated for this condition. Non-Steroidal Anti-Inflammatory Medications do not relieve inflammation in tendons and give a false sense of security which may prevent you from properly protecting the injury.

    3. Physical Therapy
      Can be mildly helpful to relieve symptoms temporarily but is not capable of stimulating healing of an injured tendon lying deep in the foot. Stretching of this structure by the therapist may be counterproductive and prolong the injury healing time.

    4. Heat vs Cold
      Ice is used only to stop bleeding. Although everyone recommends Ice for almost anything that hurts. This is wrong thinking. Use heat to increase the circulation. Increasing circulation washes out toxins and promotes healing. Use wet heat daily and consistently to promote healing.

    5. Shock Wave Therapy
      Pneumatic shock wave therapy will injure the tissue with pressure and start the healing process. Following the procedure that will take place in the office, Patient receives 4-5 weekly treatments until healing is achieved. Estimated time is 6 weeks.

    6. Cutting Edge Laser MLS Therapy
      MLS Laser Therapy is a focused therapeutic treatment given 3 times per week for 4 weeks. The laser beam shows right through the skin and soft tissue and increases the circulation directly around the tendon and bone.

    7. Topaz Surgical Repair of the Tendon
      This procedure is performed in the operating room. No incision is needed for this procedure. Through multiple puncture holes in the bottom of the heel, burn holes are created in the plantar fascia with the Topaz wand. The burn holes allow ingrowth of blood vessels into the tendon. Using a needle inserted into your heel bone, bone marrow containing stem cells is extracted and injected directly into the burn holes. It is believed the stem cells further encourage tendon healing and improve the outcome of the operation. The procedure temporarily weakens the tendon but eventually stimulates it to heal. Post operatively a cam walker boot must be worn for six weeks to give the plantar fascia time to heal. All surgery carries risks and possible complications that will be discussed during surgical planning.

Recommendations
Combination therapy always works better. Each part contributes to healing in different ways.

  1. Immobilize and protect with orthotics in some cases cam walker boot.
  2. Stimulate healing with shockwave therapy.
  3. Increase circulation to the tendon with Cutting Edge Laser Therapy 3 times per week.

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