Wednesday, July 25, 2012

PTTD Conservative Treatments

Once diagnosed with Posterior Tibial Tendon Dysfunction as evidenced by the “too many toes” sign and the heel rise test, there are some conservative treatments available to help support or slow the progression of the condition.  The best treatment for you will depend on how far advanced you are with the disorder.

If caught far enough in advance, minor modifications can be made to shoe gear to help reduce the amount of pronation.  Custom orthotics made from plaster molds can be fashioned to give support to the arch.  Modifications can be made to the orthotics with time.   If pain persists, a steroid shot can be given to help decrease inflammation.   The decision to go ahead with a shot must be carefully considered as steroids can weaken ligaments and cause the condition to progress faster.  Oral steroids or anti-inflammatory medication may provide some relief, but will not reverse or halt the progression.

In most cases, orthotics will not provide enough relief.  In many instances, orthotics are skipped as a treatment and the doctor will recommend a custom ankle brace as the primary treatment.  Similar to orthotics, you will be casted for the brace, which will then be sent off to a lab for fabrication.  There are many variations to this brace, and they will be fabricated slightly different.  This brace laces up the front, extends up around the ankle, and fits into most shoes.  It helps to give support to the arch and foot.  Movement of the joints in the foot is minimized, thus reducing pain and swelling.  If worn consistently, this brace can be a definitive treatment for some individuals.  However, the brace can be bulky and difficult to wear during the warm summer months.

Despite our best efforts, some patients will eventually exhaust conservative treatments.  At this point, surgical options are explored.  Your doctor will probably order an MRI to get an idea of how degenerated the posterior tibial tendon is.  This will help the doctor to recommend the best surgical option.  We’ll discuss these options next post.

Tuesday, July 17, 2012

Signs of Flatfoot (PTTD)

We discussed last week the development of flatfoot in adulthood.  There are some diagnostic signs and tests that your podiatrist uses to determine if you have the condition, as well as how far the condition has advanced.

Pain along the course of the posterior tibial tendon is the most important sign when diagnosing PTTD.  The posterior tibialis tendon wraps around the inside of the ankle and inserts on the arch.  This allows the muscle to support the arch.  If there is pain at the tendon’s insertion or pain when the doctor palpates the tendon as it goes up the leg, you may be experiencing PTTD.  If there is no pain, PTTD is unlikely.
Assuming there is pain along the tendon, there are other tests that can be done to help confirm the diagnosis.  The doctor will have the patient stand facing the wall.  The doctor will stand directly behind the patient.  Normally, the doctor can only see the 4th and 5th toes, with the leg covering the rest of the toes.  In PTTD, when positioned behind the patient, the doctor will be able to see almost all of toes.  This is known as the “too many toes” sign.

Another test your doctor will use to grade the amount of dysfunction is called the heel rise test.  The doctor will have you stand next to the wall or counter for balance.  You will then be asked to stand on your toes, first each foot individually, then both feet together.  In someone with PTTD, this will illicit large amounts of pain in the arch and up the leg.  In more advanced situations, the patient will not be capable of lifting their heels off the ground at all.  Patients often are surprised that they didn’t notice their inability to lift up on their heels before their appointment.

Lastly, the doctor will watch you walk in the office.  This is called gait analysis.  The “too many toes sign” will be seen as they walk.  The heel bone will not have normal movement, and the person will practically be walking on the inside of the foot, the arch being completely absent.  The doctor will then correlate these findings to the x-rays taken in order to suggest the best treatment options.  We’ll discuss some of those treatment options next week.

Thursday, July 12, 2012

How Did My Foot Become So Flat?

It is a normal phenomenon for the foot to get larger over a lifetime of use.  Ligaments lose their tensile strength and tendons can lengthen over time making the shape and size of the foot change.  However, these changes happen over a long period of time, making them unnoticeable from month to month.  The only situation is which noticeable changes happen normally would be in pregnancy, since women have hormones in their body which are meant to make ligaments more flexible to allow for child birth.  But have you noticed that your arch has slowly but noticeably flattened over a period of months?  If so, you may have a condition termed Posterior Tibial Tendon Dysfunction or PTTD.

The posterior tibial muscle is the main muscle that supports the arch of the foot.  The tendon runs on the inside of the leg right behind the inside of the ankle.  It is the main muscle that allows you to turn the sole of one foot in so that it is facing the other foot.  In certain foot types, this muscle can be subject to a significant amount of force, causing over lengthening and breakdown of the tendon.  If the tendon degenerates or loses its strength, the muscle loses its ability to hold the arch up.  With time, the arch slowly loses its height, causing pain and difficulty fitting in shoes.  This process may not produce enough discomfort to push you to see a podiatrist until some irreversible damage has already been done.  There are different stages of PTTD, thus the treatment depends on how degenerated the tendon is.  In most cases, an MRI is needed to assess the current status of the tendon.

There are a couple tests that we can do in the office to assess if PTTD is present, and if so present, how far advanced the condition is.   This helps to determine which conservative or surgical options may help.  We’ll discuss these clinical tests in the next post.

Thursday, July 5, 2012

Ankle Sprain Surgery

As mentioned before, the overwhelming majority of ankle sprains will get better with conservative care in 2-3 months.  Once x-rays have confirmed there isn’t any fracture, most sprains get better with R.I.C.E., as well as bracing and protection.  However, there are some people who will continue to have pain and discomfort despite our best efforts.  The decision to go ahead with surgery is one that is complicated. Both the patient and doctor will have to discuss and agree upon a plan as a team.  Let’s discuss some options.

One attractive option is to do ankle arthroscopy.  Similar to what is done in the knee, a small fiber-optic camera is inserted into the ankle joint along with a tool to remove any loose particles inside the ankle joint.  With multiple ankle sprains, pieces of bone, cartilage, or inflamed ligaments can impinge on the ankle joint.  Once loose particles are removed, pain is lessened and improvement is seen.  The main advantage to ankle arthroscopy is that there are only 2 small incisions made where the instruments are inserted.   The incisions heal quickly and downtime is usually 10 days to 2 weeks.

Another procedure that can be done is called a Brostrom procedure.  As we discussed, ankle sprains can cause ligaments to tear.  The Brostrom procedure attempts to sew back together a ligament that is often torn in ankle sprains.  It is sewn together with a very strong suture material, so that stability is gained and pain is minimized.  This procedure requires a longer healing period as the ligament fiber ends need to reconnect.'

In some cases, torn ligaments are so bad that it is impossible to sow them back together.  In these cases, grafts can be used.  There are many variations to what can be done to recreate the ligaments.  The doctor can use a graft made from bovine or porcine sources, or harvest tendon from another source in the body.  Depending on which ligaments are torn, the doctor can adjust what he uses to restore stability.

There are additional procedures that exist to help a persistent ankle sprain.  Work with your doctor to decide which procedure best fits your situation.