Rotator Cuff Tear

Rotator Cuff
The rotator cuff is the name for the tendons that surround the shoulder joint. The rotator cuff is important in allowing the shoulder to function through a wide range of motions. In part due to the rotator cuff, the shoulder joint can move and turn through a wider range than any other joint in the body. This motion of the shoulder joint allows us to perform an amazing variety of tasks with our arms.

Unfortunately, a rotator cuff tear is not an uncommon problem, and these injuries make many routine activities difficult and painful. The rotator cuff is part of this mechanism that, when healthy functions very well, but when injured can be a difficult and frustrating problem.

What is the rotator cuff?
The rotator cuff is a group of four muscles and their tendons that wraps around the front, back, and top of the shoulder joint. Together the rotator cuff muscles help guide the shoulder through many motions, and also lend stability to the joint. The ends of the rotator cuff muscles form tendons that attach to the arm bone (humerus). It is the tendinous portion of the rotator cuff that is usually involved in a rotator cuff tear.

What is a rotator cuff tear?
A rotator cuff tear occurs when there is an injury to one of the rotator cuff tendons. Rotator cuff tears occur in many shapes and sizes, but can be thought of as a hole in one of the tendons around the shoulder joint. Like most orthopedic conditions, the most common mechanisms of a rotator cuff tear are separated into 'repetitive use' and 'traumatic injuries.'

* Repetitive Use Injury
In repetitive use injuries to the rotator cuff, repeated activities cause damage to the rotator cuff tendons. Over time, the tendons wear thin and a rotator cuff tear can develop within the tendons. Patients with repetitive use injuries to the rotator cuff often have complaints of shoulder bursitis prior to developing a rotator cuff tear through the tendons.

* Traumatic Injuries
Traumatic injuries to the rotator cuff are seen after events such as falling on to an outstretched hand. The traumatic event can cause a rotator cuff tear by injuring the rotator cuff tendons. This mechanism is much less common than repetitive use injuries, but when a rotator cuff tear occurs in a patient younger than 60 years old it is usually a traumatic injury.

Who is most susceptible to a rotator cuff tear?
A rotator cuff tear is seen both in the young and old, but they are much more common in the older population. Usually in younger patients, there is either a traumatic injury, or the patient is demanding unusual use of their shoulder, as seen in professional athletes.

As people age, the muscle and tendon tissue of the rotator cuff loses some elasticity, becomes more susceptible to injuries, and is often damaged while performing everyday activities. This is the reason that rotator cuff tears are more commonly seen in older patients.

How common are rotator cuff tears?
Not every rotator cuff tear causes significant pain or disability. In fact, autopsy studies have shown rotator cuff tears in up to 70 of people over the age of 80 and 30 of the population under the age of 70. Clearly, all of the people with rotator cuff tears are not complaining of painful symptoms. However, in many individuals, a rotator cuff tear can cause significant disability, and prompt diagnosis and treatment can have a profound improvement in symptoms.
Provides immobilization for rotator cuff repairs, capusular shifts, Bankhart repairs, glenohumeral dislocations / subluxation and soft tissue repairs and strains. For use after initial anterior shoulder dislocation or post operatively when external rotation is desired.
Surgery is also considered in patients who have tried conservative treatment, and still have difficulty with their shoulder.

For more information on what factors are used to decide when rotator cuff surgery is necessary:

o When is rotator cuff surgery needed?

There are several surgical procedures that are possible for rotator cuff treatment. The three most common procedures are:

* Open Repair
Prior to the use of the arthroscope, all rotator cuffs were repaired by looking directly at the torn tendon, through an incision about 6-10 centimeters in length. The advantage is the rotator cuff tendons are easily seen by this method, but the incision is large, and the recovery can be longer and more painful.

* Mini-Open Repair
The mini-open method of repairing a rotator cuff involves both the use of an arthroscope, and a short incision to get access to torn tendon. By using the arthroscope, the surgeon can also look into the shoulder joint to clean out any damaged tissue or bone spurs. The incision is about 3-4 cm, and the recovery is somewhat less involved than the open cuff repair.

* Arthroscopic Repair
An arthroscopic repair is done with small incisions, and the repair is done by the surgeon looking through a small camera to watch his or her repair on a television monitor. This is a more recent development in treatment of rotator cuff tears, and not all types of tears can be treated by this method. Some advantages and disadvantages of this procedure are discussed in the article comparing arthroscopic rotator cuff repairs to open methods.

The surgery to perform the rotator cuff repair generally lasts about two hours.

How long is the recovery from rotator cuff repair surgery?
This will depend on several factors, including your level of strength before the operation and the severity of the rotator cuff tear. Some period of immobilization of the shoulder joint is needed to protect the newly placed sutures from being disrupted. After one to two weeks, physical therapy begins. Initially, the therapy is gentle so as not to affect the rotator cuff repair. After four to six weeks, more active lifting with the arm begins. Several months after the rotator cuff repair, physical therapy will become more intense in an effort to strengthen the rotator cuff muscles. Complete recovery usually requires at least four to six months.

Ultra-Sling for Unstressed Wound Healing

Shoulder Pain, Fever, and Chills in a Fifty-Three-Year-Old Man (continued)

Answer: Abscess between the subscapularis and posterior portion of the chest wall.

Multiplanar magnetic resonance images of the area about the right shoulder girdle, including T1-weighted images, STIR (short-tau-inversion-recovery) images, and T1-weighted images with fat saturation following intravenous injection of gadolinium, demonstrated a multiloculated fluid collection between the subscapularis muscle and the posterior portion of the chest wall (Figs. 1 and 2). The rotator cuff muscles, including the subscapularis muscle, demonstrated no abnormalities. The walls of the lesion were thickened and irregular, with multiple septations that were enhanced with the gadolinium. There was moderate surrounding edema. The abscess extended inferiorly from the area anterior to the scapula, along the midaxillary and posterior axillary lines, to the level of the diaphragm. The pleura, hilum, and mediastinum of the lung appeared to be normal. Aspiration of fluid from the lesion was not performed before the operation.
The patient was taken to the operating room for urgent open drainage of the abscess on the evening of admission. After induction of general anesthesia, the patient was placed in the lateral decubitus position on a beanbag. Routine preparation and draping were performed. A curvilinear incision was made over the medial border of the scapula and was extended inferiorly. The inferior border of the trapezius muscle was retracted superiorly to expose the lower half of the medial scapular border. Electrocautery was used to release the rhomboid musculature from the medial scapular edge and to expose the underlying space. Upon entrance into the scapulothoracic space, a massive amount of purulent fluid was immediately encountered. Approximately 500 mL of purulent material was evacuated. Intraoperative gram-staining of the specimen yielded gram-positive cocci in clusters.

Multiple areas of loculation were released by gently sweeping an index finger through the area. A moderate degree of necrotic tissue was found to be forming the septations and lining the edges of the abscess and was removed with a rongeur. The space was then irrigated with pulsatile lavage with use of 9 L of saline solution with cefazolin antibiotic (2 g of cefazolin per 3-L bag). Two large Hemovac drains were placed to evacuate fluid from the scapulothoracic space. The rhomboid musculature was reapproximated to the medial scapular border with absorbable PDS (polydioxanone) monofilament suture. Prolene monofilament suture (Ethicon, Somerville, New Jersey) was used for skin closure. A shoulder sling (DonJoy UltraSling; dj Orthopedics, Vista, California) was used postoperatively, with the arm positioned at the side to allow unstressed wound-healing.

Ultra-Sling ER Video Application

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DonJoy Velocity for PTTD

Velocity™ Ankle Brace
Introduction

The Velocity™ represents an evolution in DonJoy ankle brace technology, utilising several new, proprietary design features, resulting in a new level of ankle brace performance and providing the foundation for successful ankle injury prevention and treatment. The Velocity can also be used for mild PTTD dysfunction.

Indications

• Anterior talofibular ligamant sprains grade 1-3
• Calcaneofibular ligamant sprains grade 1-3
• Posterior talofibular ligamant sprains grade 1-3
• Combined lateral ligamant sprains grade 1-3
PTTD Dysfuntion
• Rehabilitation after lateral collateral ligamant reconstruction


Information on Ordering

At OrthopaedicsAndTrauma.com we only supply the ES version and you can have "any colour as long as it is black". This is because the ES can be cut down to the MS or LS versions and most athletes need the ES version at first.
Choose left or right
Choose calf circumference standard fitting (STD)<25.5cm or wide fitting (WD)>25.5cm by measuring the calf circumference 20cm above the ground in bare feet.

Size / UK Men / UK Women
x=2=small / <7 / <7.5
x=3=medium / 7-11 / 7.5-11.5
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• This Velocity ES (extra support) version can be cut down as the inate stability of your patient's ankle improves to the LS (light support) version affording patients and athletes two ankle support levels at the same price.
• Available only in black
• ES offers extra support and rigidity.
• Left and Right versions.
• Standard and wide calf cuff.

Posterior Tibial Tendon Anatomy

Anatomy:

The posterior tibial tendon is the extension of the posterior tibial muscle that lies deep to the calf. The origin of the posterior tibial muscle is the posterior aspect of both the tibia and fibula and the interosseus membrane. The insertion of the posterior tibial muscle is the medial navicular where the tendon divides into nine different insertion site on the bottom of the foot.

Anatomy_tibialis_posterior_muscle Anatomy_Posterior_leg_muscles Anatomy_posterior_leg_exploded_view Anatomy_medial_ankle

Biomechanics:

The function of the posterior tibial tendon is to plantarflex the foot at the toe off phase of the gait cycle and to stabilize the medial arch and subtalar joint as the body passes over the foot.

Symptoms:

The symptoms of stage I PTTD include a dull ache of the medial arch. The pain become worse with activity, better on days with limited time on the feet. Continued weight bearing activity may result in a partial rupture of the tendon, moving to stage II. Stage I typically show no swelling but presents with pain along the course of the PT tendon from the medial ankle to the insertion of the PT tendon on the medial arch.

Stage II symptoms are persistent and only partially relieved by rest. Pain is present at the onset of weight bearing and continues throughout the day. Some limitation of the ability to raise up on the toes will be present and limited by pain. Mild swelling may be present in the medial arch.

Stage III symptoms are severe with an inability to complete most normal daily activities. Collapse of the medial arch will be obvious. Abduction of the forefoot will show 'too many toes sign'. Patients are unable raise up on their toes.

Posterior Tibial Tendon Dysfunction: A Review of Pain and Activity Levels of Twenty-one Patients

Christopher Lake, CPO
Gary S. Trexler, CO
William J. Barringer, CO.
ABSTRACT

Posterior tibial tendon dysfunction (PTTD), which results in painful pes planus, is a common clinical problem that requires careful orthotic management. The purpose of this study was to conduct a chart review and telephone survey to determine the effectiveness of orthotic treatment. In this preliminary study the authors define effective orthotic treatment as treatment that reduces pain and assists the patient in returning to pre-PTTD activity levels. When comparing orthotic management among foot orthoses fabricated from cork and pelite, UCB-type foot orthoses, and various types of AFOs, strong trends were noted. UCBs and AFOs reduced pain in five and seven subjects respectively, but only AFO management successfully increased activity levels of the subjects.

Key Words: Posterior tibial tendon dysfunction, pes planus, orthoses, ankle-foot.

First described in the orthopedic literature in 1969, posterior tibial tendon dysfunction (PTTD) can be caused by a partial or complete tear of the distal muscle tendon.1 Since the initial report, several authors have commented on the presentation and progressive nature of this pathology in regard to orthotic and/or surgical management.2-5

This pathology is more common in middle-aged and older individuals. The progression is insidious and often unnoticed until significant deformity is present. Though rare, PTTD has been described in young athletes.6 The mechanism of injury involves an excessive amount of stress placed on the tendon during rapid changes in direction, as in playing basketball or hockey.

The posterior tibial muscle originates at the proximal third of the tibia and interroseus membrane. The distal tendon takes a course that passes posterior to the medial malleolus. The muscle's tendonous insertions include the navicular, all three cunieforms, talonavicular capsule, cuboid, and corresponding metatarsals.5 This muscle has a significant role in supporting the medial longitudinal arch; however, it is more the unopposed eversion action of the peroneal brevis that initiates the deformity than it is the absent inversion of the posterior tibialis.2 Furthermore, the medial longitudinal arch does not necessitate muscle force to maintain it.7 The bony anatomy and ligaments alone are sufficient for maintaining arch integrity until the presentation of muscle imbalance, as found in PTTD, slowly introduces a painful deformity.

In addition to its influence on the medial longitudinal arch, the posterior tibial muscle plantarflexes and inverts the foot. PTTD will cause collapsing of the medial longitudinal arch, subtalar eversion, valgus at the ankle, and forefoot abduction. There will be stretching of the spring and deltoid ligaments as well as the talonavicular capsule. Increasing equinus with progression and the possible development of contractures are also suspected.5 The posterior tibialis initiates inversion and stabilizes the subtalar joint, allowing the gastrocnemius to plantarflex and invert the heel as the patient rises onto his/her toes. When the posterior tibialis is compromised, patients with PTTD will be unable to single-limb heel rise as the pathology progresses.

Several variables contribute to the etiology of this pathology. The PTTD patient often exhibits: obesity, hypertension, diabetes, previous trauma to the foot and ankle, and steroid treatment in the area of the posterior tibial tendon. Holmes and Mann found that obesity, diabetes, and hypertension were common clinical diagnoses in this patient population, noting higher incidences than found in the general population.8

Frey concluded that there is an area of hypovascularity in the tendon just distal to the area of the tendon that courses around the medial malleolus.9 He attributes this finding to the sharp angle the tendon takes as it courses around the medial malleolus. This hypovascularity is not seen in the flexor digitorum longus, which takes a common path around the medial malleolus.
Clinical Presentation

During orthotic evaluation, the patient might verbalize that he or she has been experiencing pain on the medial aspect of the ankle, secondary to the stretching of the medial ligaments and soft tissues. Severity of valgus angulation should be measured and the orthotist should note if medial edema is present from repetitive stretching and traumatizing of the area (Figure 1a , Figure 1b , and Figure 1c ). If the patient is progressing, pain will develop laterally as the fibula impinges on the calcaneus. Muscle testing inversion strength and single-limb heel rise are helpful in determining severity of the problem as well as in developing the orthotic plan.

The orthotist should be aware of the classification specifics of Myerson.11 This classification is an adaptation of Johnson and Strom's staged classification.10 Stage I involves patient complaints of medial pain and edema. The patient can still perform a single-limb heel rise and has a flexible hindfoot. Orthotic treatment options include medial heel and sole wedges, arch support, and articulated AFOs. In stage II, individuals present with heel valgus and cannot perform single-limb heel rise. Pain is now present on the lateral aspect of the ankle. Orthotic treatment is the same as that in stage I, with the addition of more rigid arch supports. With progression to stage III, the hindfoot is now rigid, and solid ankle AFOs are suggested. Finally, stage IV is distinguished by a valgus angulation of the talus with rigid AFO management as the orthotic treatment.

The only other finding in the literature pertaining to orthotic treatment was an abstract and paper presented by Chao, et al., to the American Academy of Orthopaedic Surgeons.11 The authors found that PTTD "can be effectively treated with aggressive conservative management using molded ankle foot orthoses and UCB inserts." In addition ,"67% of the subjects had results that were considered good to excellent based on pain, function, use of an assistive device, distance of ambulation and patient satisfaction." While all the papers reviewed were informative, there was a lack of solid orthotic observations in regard to what to expect and how to treat these patients. Questions of pain and activity levels with orthotic management encouraged the authors to review cases seen in their clinic and to observe similarities and differences within this patient population.
Methodology

A chart review and telephone survey was conducted of all patients under the direct care of the authors for a period of 11 months. No statistical tests were performed during this case review due to the variety of treatments. Comparisons among foot orthoses fabricated from cork and pelite, UCB-type foot orthoses, and AFO users were made. Variables reviewed were patients' age, side affected, sex, duration of orthotic treatment, weight, incidence of diabetes, and hypertension. The authors were particularly interested in activity level and pain level with orthotic treatment. Though subjective, activity level and pain level prove to be good measurements of the effectiveness of orthotic treatment from the patient's perspective. In regard to activity level, some patients, as noted in the results, expressed that they were able to walk further and for longer duration with orthotic treatment.
Results

Of the 25 patients seen, 21 were available for follow-up. The sample consisted of 17 females and 4 males with a mean age of 57 years. After calculating a body mass index for each patient, 86% were found to be overweight for their height and age,12 24% were diabetic, and 62% were hypertensive. Three individuals presented with deformity bilaterally.

Orthotic treatment was determined by the prescribing orthopedic surgeon, usually as an effort to avoid surgery. All patients described varying levels of both medial and lateral pain before treatment, indicating that orthotic management was initiated late, often after bed rest, short leg cast, or pain-management injection treatments failed.
Foot Orthoses Fabricated with Cork and Pelite

Orthoses in this group were fabricated with an arch support and 5º medial wedge. This group consisted of six subjects with a mean duration of treatment of 7.2 months (4- to 10-month range). Three individuals in this group perceived their condition as good since the initiation of orthotic treatment. One subject was within the average weight range and another would not discuss weight characteristics. The other four individuals averaged 36.8 pounds over the upper limit of the average weight range. Activity level increased in only one subject and pain decreased in three subjects.
UCB-Type Orthoses

Orthoses in this group were posted medially, and relief for the prominent plantar aspect was made accordingly. This group consisted of six subjects with a mean duration of treatment of 6.2 months (1- to 9-month range). Five individuals in this group stated that they were doing well and not progressing. Only one subject was within the average weight limits. The other five subjects were an average of 48.2 pounds overweight. Activity level increased in one subject and pain decreased in five subjects.
AFOs

Three different types of AFOs were used, as deemed appropriate after evaluation of the patient's needs. All AFOs incorporated a valgus-controlling trimline (Figure 2 ).

Articulated AFOs were used in cases where the valgus present could be controlled with a minimal amount of surface area contact medially with a well-molded medial longitudinal arch support and where the hindfoot exhibited no pathological related rigidity. The ankle was free motion unless the physician anticipated the development of an equinus contracture. If this was the case, a 90º plantarflexion stop was included.

A dorsiflexion-assist AFO with valgus-controlling trimlines, as described by Smith,13 was used when ankle motion needed no restriction and a UCB, or articulated AFO insert would not provide sufficient ankle control due to lack of medial surface area contact (Figure 3 ). The flexibility of this type of AFO seems to affect the function of the patient minimally and exhibits ground reaction forces to a lesser degree than solid ankle orthoses.

Solid ankle AFOs with valgus-controlling trimlines and neutral ankle alignment were used for patients who presented a rigid hindfoot, obesity, and extensive valgus angulation that required maximum control. No correction of deformity could be obtained in these patients. Seven subjects were studied in this group. (Originally there were eleven subjects; three had shoe conflicts and refused to acquire proper footwear, and one was attending an orthotic clinic closer to her home.) Mean duration of treatment was 5.6 months, with a range of 1 to 11 months. All seven subjects wearing their AFOs felt that they were doing well. One subject was within the average weight range; the others averaged 51 pounds over the superior limits of the weight range. Activity levels increased in six and pain decreased in all seven. Pertinent was the finding that four of the AFO subjects were previously managed in cork and pelite foot orthoses. These orthoses did not provide adequate control of the ankle valgus and allowed the deformity to progress.
Discussion

While pain reduction was evident in UCB type orthoses and AFO treatment, activity level was most influenced by AFO treatment. AFOs provided a greater degree of control over the ankle. As patient weight increased, so did the degree of orthotic control, indicating the careful consideration of this variable in orthotic design as well as in material selection.

The orthotist must be aware that, in many cases, the deformity that presents around the ankle should be accommodated more than corrected. The orthotist should specifically be aware that with progression of this pathology, the navicular becomes very prominent on the plantar aspect of the foot. Adequate relief is essential for patient comfort and success of treatment.

The authors find it particularly helpful to take a plaster impression with partial weight bearing to provide a more accurate impression of the plantar surface. It is necessary during the impression process to provide a low-durameter foam block on which the patient can bear weight. We have also found that the use of impression foam is not advantageous in the effective treatment of this pathology. It is difficult to determine bony alignment and adequately distinguish bony prominences using impression foam.

Padding the medial aspect of the orthosis will not only increase comfort but also allow for a soft and flexible correction, provided the positive model was modified accordingly. Insufficient modification will cause discomfort as the ankle is wedged medially/laterally within the orthosis.

The dorsiflexion-assist AFO with valgus-controlling trimlines provides more control by design than does the UCB-type orthoses. It has a lower profile than articulated AFOs, allowing it to fit more easily in shoes. Smith outlined a plastic thickness guide based on the patient's weight.13 He suggests 1/8 inch for less than 100 pounds, 3/16 inch for 100 to 200 pounds, and 1/4 inch polypropylene for 200 to 300 pounds. Our experience has shown that simply varying the distal aspect of the medial trimline can increase the rigidity. As the trimline courses distally, there is a point where the trimline makes a 180º turn proximally to form the medial valgus control extension. If this point is located more superior and rigidity is increased, a wider range of weights can be accommodated with the same plastic thickness.
Conclusion

Orthotic management of posterior tibial tendon dysfunction requires careful consideration of progression of deformity and tolerable corrective forces. Orthoses must be fabricated with adequate relief of all medial bony prominences. Given the progressive and biomechanical nature of this pathology, a radiographical study comparing effectiveness of the above orthoses and any other orthoses deemed appropriate is necessary to develop definitive orthotic plans.

As orthotists, we try to provide adequate control without limiting the function or causing severe biomechanical consequences at other joints. This is noted if one should induce a rigid neutral ankle alignment while ignoring a knee flexion contracture, compromising the patient's balance. In the case of posterior tibial tendon dysfunction, insufficient control could lead to progression of the deformity. Orthotic management should be, as Chao11 stated, "aggressive."

References:

1. Kettelkamp DB. Spontaneous rupture of the posterior tibial tendon. JBJS. 1969;51-A:4:759-764.
2. Mann RA, Coughlin, MJ. Surgery of the foot and ankle. 6th ed., Vol 1. Chicago: Mosby. 1993:757-784.
3. Teitz CC, et al. Tendon problem in athletic individuals. JBJS 1997;79-A:1:138-152.
4. Mann RA., et al. Rupture of the posterior tibial tendon causing flat foot. JBJS. 1985;67-A:4:556-561.
5. Myerson MS. Adult acquired flatfoot deformity. JBJS. 1996;78-A:5:780-792.
6. Conti SF. Posterior tibial tendon problems in athletes. Ortho Clinics of North America 1994;25:1:109-21.
7. Basmajian VJ, Stecko G. The role of muscles in arch support of the foot: an electromyographic study. JBJS. 1963;45-A:1184.
8. Holmes GB, Jr., Mann RA. Possible epidemiological factors associated with rupture of the posterior tibial tendon. Foot and Ankle. 1992;13:2:70-79.
9. Frey C., et al. Vascularity of the posterior tibial tendon. JBJS. 1990; 72-A:6:884-888.
10. Johnson KA, Strom DE. Tibialis posterior tendon dysfunction. Clinical Orthopedics. 1989;239:196-206.
11. Chao W, et al. Conservative management of posterior tibial tendon rupture. Orthopedic Transcriptions. 1994-95;18:1030.
12. Bray GA, MD. Obesity in America. U.S. Department of Health. NIH Publication # 79 - 359. Nov 1979:4-7.
13. Smith R. The AFO and ankle control-technical note. Orthotics & Prosthetics. 1979;33:1:46-8.

What is PTTD?

What is PTTD?pttd
Posterior tibial tendon dysfunction (PTTD) is an inflammation and/or overstretching of the posterior tibial tendon in the foot. An important function of the posterior tibial tendon is to help support the arch. But in PTTD, the tendon’s ability to perform that job is impaired, often resulting in a flattening of the foot.

The posterior tibial tendon is a fibrous cord that extends from a muscle in the leg. It descends the leg and runs along the inside of the ankle, down the side of the foot,
and into the arch. This tendon serves as one of the major supporting structures of the foot and helps the foot to function while walking.

PTTD is often called “adult-acquired flatfoot” because it is the most common type of flatfoot developed during adulthood. Although this condition typically occurs in only one foot, some people may develop it in both feet. PTTD is usually progressive, which means it will keep getting worse—especially if it isn’t treated early.


Symptoms of PTTD
The symptoms of PTTD may include pain, swelling, a flattening of the arch, and an inward rolling of the ankle. As the condition progresses, the symptoms will change.

For example:posterior tibial tendon

* When PTTD initially develops, typically there is pain on the inside of the foot and ankle (along the course of the tendon). In addition, the area may be red, warm, and swollen.
* Later, as the arch begins to flatten, there may still be pain on the inside of the foot and ankle. But at this point, the foot and toes begin to turn outward and the ankle rolls inward.
* As PTTD becomes more advanced, the arch flattens even more and the pain often shifts to the outside of the foot, below the ankle. The tendon has deteriorated considerably and arthritis often develops in the foot. In more severe cases, arthritis may also develop in the ankle.

What Causes PTTD?
Overuse of the posterior tibial tendon is frequently the cause of PTTD. In fact, the symptoms usually occur after activities that involve the tendon, such as running, walking, hiking, or climbing stairs.


Treatment:
Non-surgical Approaches
Because of the progressive nature of PTTD, it’s best to see your foot and ankle surgeon as soon as possible. If treated early enough, your symptoms may resolve without the need for surgery and progression of your condition can be arrested. In contrast, untreated PTTD could leave you with an extremely flat foot, painful arthritis in the foot and ankle, and increasing limitations on walking, running, or other activities.

In many cases of PTTD, treatment can begin with non-surgical approaches that may include:

* Orthotic devices or bracing. To give your arch the support it needs, your foot and ankle surgeon may provide you with an ankle stirrup brace or a custom orthotic device that fits into the shoe.
* Immobilization. Sometimes a short-leg cast or boot is worn to immobilize the foot and allow the tendon to heal, or you may need to completely avoid all weightbearing for a while.
* Physical therapy. Ultrasound therapy and exercises may help rehabilitate the tendon and muscle following immobilization.
* Medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, help reduce the pain and inflammation.
* Shoe modifications. Your foot and ankle surgeon may advise you on changes to make with your shoes and may provide special inserts designed to improve arch support.

When is Surgery Needed?
In cases of PTTD that have progressed substantially or have failed to improve with non-surgical treatment, surgery may be required. For some advanced cases, surgery may be the only option. Surgical treatment may include repairing the tendon, realigning the bones of the foot, or both. Your foot and ankle surgeon will determine the best approach for your specific case.