Posterior tibial tendon disease/insufficiency/dysfunction

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Posterior tibial tendon disease/insufficiency/dysfunction or Adult Acquired Flatfoot

There is a condition when the inner arch area of the foot, usually in a person over 50 years of age, becomes very painful. The arch is much lower than “normal.” Many forms of treatment will be given but they only slow the inevitable, aggressive foot reconstructive surgery.

Typical x-ray of someone with an "adult acquired" flatfoot

What is an adult acquired flatfoot?

One day a person wakes up and walks to the bathroom. They experience pain in their inner arch. There was no history of trauma and no pain before. It seems to be a real mystery. They go to their foot and ankle specialist who finds the tendon to the inner arch has become diseased. It is no longer healthy and pretty much is stretched out. X-rays are taken that show the main inner arch bone, called the navicular, has fallen, and “it can’t get up.”

Why does it happen?

There have been many theories but the leading cause is relatively simple. It has to do with the partial dislocation of the ankle bone on the heel bone. This condition is present at birth, never gets better, and only gets worse. There is a path of destruction that occurs with ankle bone instability. First the ligament between arch bone and the heel bone is over-stretched and weakens. The next structure to be over-stretched is the plantar fascia. The very strong and thick posterior tibial tendon is the last one to become diseased. That tendon is responsible for supporting the inner arch. Imagine what happens to any strong cable after it has been excessively stretched tens of millions of times.

The underlying cause of an adult flatfoot has been present since childhood. For some people that faulty foot structure does not become symptomatic until several decades of life have passed and after taking tens of millions of steps.

It is never the case when someone had a perfect foot alignment one day and their foot collapsed the next. It is a slow, repetitive process over many decades of walking on a faulty foot structure. This was the situation when a child was told not to worry about that flexible, misaligned foot – it will never cause you any trouble. That is until it does cause you trouble.

What is the best form of treatment?

The best form of treatment is a solution that eliminates or at least reduces the underlying cause. There are many forms of non-surgical options to choose from but they are not the ideal solution. There is no proof that a non-surgical option can achieve the goal of reducing the strain to the inner arch because this is an internal deformity. The ankle bone, located above the heel bone, cannot be stabilized by any brace or foot orthotic. Even if a cast was placed on the ankle/leg, the ankle bone would still internally dislocate.

The best form of treatment is an option that stabilizes the ankle bone on the heel bone while still allowing a natural range of motion. An option that “does no harm”, unlike traditional bone reconstructive surgery, with a minimal potential of risk or complication. The most important point to consider is, does that option make sense? For instance, placing an arch support in your shoe may reduce a very small strain on the foot but it is subtherapeutic because it cannot realign and stabilize the ankle bone. What about just fusing the ankle and heel bones? That’s not good because the normal motion that should occur is completely eliminated. Ankle-to-heel bone fusion leads to increased motion to the ankle joint and the bones of the mid-foot. Eventually, arthritis will set into the adjacent joints.

The insertion of HyProCure into the sinus tarsi space makes perfect sense if it’s still an option. A point is reached where the ankle bone cannot be relocated where it is supposed to be on the heel bone. If the space where HyProCure is placed cannot be “re-opened”, then HyProCure cannot be inserted. For that reason, it is better to treat this ankle bone dislocation while it is still flexible. It is also possible that other parts of the foot will need surgical repair because they could be damaged as a result of walking on a partially dislocating ankle bone.

Your surgeon will know if you can benefit from just the HyProCure space or if you need a combination of procedures. That is the great advantage of HyProCure because it works with external non-surgical options as well as the fact that it can be used in conjunction with other corrective surgical procedures.

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