Saturday, March 14, 2009

Posterior Tibial Tendon Problems


We have to take good care of our feet to do what we do. Many have learned the hard way about Plantar Faciitis, metatarsal stress fractures, interdigital neuromas and the like through unplanned interaction with the medical community. I have always felt the more knowledgeable the athlete the better. The ones with problems who end up in my office who've already asked around or researched their concerns on the net seem to be in a better place to help me help them.

Athletes frequently complain of two types Posterior Tibial Tendon difficulties. The first is a slow, subtle deterioration process that actually tears or can even stretch the tendon leading to what's known as an acquired flat foot deformity. The tendon has slowly, over time, lengthened and can, in some cases, no longer do it's job in maintaining the longitudinal arch of the foot. In other instances, the tendon will actually rupture frequently leading to surgical repair. Those who seem to be at higher risk for this injury are the obese, diabetic, rheumatoid arthritics and those who may have had a steroid injection in the area.

I used this B&W out of one of my old Anatomy texts as it shows only the business part of the PTT (labeled Tibialis Posterior)coursing behind the tibia and inserting on the navicular.

So, if you have pain over the inside of the ankle, get it checked out. Your doctor will examine the ankle looking for tenderness over the course of the tendon, swelling, weakness...and those with a real problem...a gap in the tendon. The doctor will check your muscle strength by asking you to stand on your toes or determine if there's an asymmetry in he longitudinal arch while weight bearing. Although this is usually a clinical diagnosis, an MRI may be required. In my office, although tendons are not normally seen on x-ray, a plain x-ray always precedes an MRI.

If a PTT problem is noted in the early stages, a supportive orthotic might be recommended or even a cast. I'm partial to casts. If, over time, the problem continues to worsen, then an operative procedure may be recommended to repair the tendon, occasionally using a nearby tendon as a graft. In the worst case scenario a fusion of the foot bones is done to restore the arch of the foot. As you might expect, rehab is considerable and even with appropriate treatment, one's triathlon future might be in jeopardy.

120 comments:

  1. Hello, I have a completely torn posterior tendon. I am looking to have surgery the end of August. I have been having PT the last few months which has eliminated most of the pain-- almost to the point to make me wonder if I should have this surgery at all. My orthopod says that would be a bad idea and things would get worse if I didn't have the repair. I was just wondering about how people do long term after the surgery. Is there still pain or lack of function?

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  2. Anne - I agree with your Orthopod and that repair is in order. Some reason you haven't already had it and are waiting over two months? In my mind this is something you'd like to get behind you as, in some cases, as I'm sure your doc has told you, bone fusions are done and you'd likely be an ex-runner then. Go for it.

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  3. I have the first instance you mentioned... the slow, subtle deterioration process that has stretched the tendon so much that my ankle is killing me, my tendon is very swollen and I've acquired flat foot deformity. Right now I'm wearing a boot to see if it gets any better. If I have to do the surjery, as a diabetic, am I looking at a longer recovery process than others?

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  4. 3fates - it's obvious you are already prepared for the fact that diabetics are different, usually more complex, in the surgical arena. If you already have a flat foot, there's a fair chance that the tendon has seen better days and that a more complicated situation exists. The one thing I'd ask the Orthopedic Foot and Ankle surgeon was how many of these he'd fixed in the last year!

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  5. Hi Dr. Post,
    Terrific website. Have been diagnosed by a Dallas orthopod as having PTT (for 3-4 months); have been wearing (2 months) some orthotics--when they fit in my shoes--mostly during my 5 day a week exercise routine (bike and stairmaster). Like most athletes I'm impatient--and frustrated. You mentioned a preference for a cast versus orthotics. What are they and can I get a mold locally?

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  6. Sure, simply ask either the pedorthodist who made your orthotics or the orthopedic surgeon. Good luck.

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  7. Thank you for your post. I was diagnosed with PTT a month ago and it has subsided a little, but one thing that has not let up is the pinpoint sharp pain in my navicular bone closer to the arch of the foot. Originally I was thinking stress fracture, but I was wondering if this pain could also be associated with PTT? Thanks!
    Kristin

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  8. Kristin- tough to say, as you'd expect me to say knowing that, as a physician, I'm trained to at least try to find a singular explantion for a person's complaints. That said, you wouldn't be the first athlete with two separate problems. Were you in my office, I think I'd lean toward trying to resolve the PTT issues before I'd start working up the potential for a stress fracture. Good luck.

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  9. I am a comptetive runner with a 2:25 marathon PR and recently diagnosed with PTT by an orthopedic surgeon, after years of living with on/off pain of my ankle. At this point, the X-RAY & MRI show swelling around the tendon but no further complications (e.g. tendon OK and bone angles OK). He prescriped orthotics, but believed the ultimate solution is the tendon graft to help the PT and bone realignment surgery. In your opinion, would this surgery allow me to run 70 miles a week pain free, or would it "put my [running] future in jeopardy" as you say?

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  10. Web - I'd be really careful here. If your only MRI positive is peri-tendon swelling, one would think the tendon sound. If the prescribed orthotics do not solve the problem perhaps a couple hours in you local gait lab would yield an imbalance in your stride that could be corrected.

    Here in Charlottesville, we're lucky to have the UVA Speed Lab with pretty sophisticated imaging techniques and I'd bet there's one not far from you.

    My oldest son works at the local running shoe store, and one of his buddies ran 2:20 and change at Boston last year. If he asked me the same question at the shop tomorrow...the answer would be no. Good luck.

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  11. Dr. Post;

    Thank you for the informative website/blog. I experienced a sharp pain in my ankle/foot last fall during a hard 10K training run while training for a marathon. It felt ok after a day or two and was never more than a discomfort factor thereafter. But I went to a local orthopod several months after the marathon just to make sure that I did't have a lingering issue such as a stress fracture and was diagnosed via an MRI with a 60% torn PTT. I began PT, was fitted with orthotics and stopped running since the diagnosis. (Oddly, it hurt far worse after I stopped running than when I was running, but now feels about like it did.) The PT indicated that I likely would never (or should never) run a marathon again but the doc was much less pessimistic and indicated that I could still run limited distances now and start the marathon training program again this summer, mainly due to no indications of PTT disease/dysfunction, normal toe raise strength, normal arch/foot appearance and minimal pain. However, I don't think the doc has seen many PTT injuries and in particular, in runners. My questions are thus; how important is it to see a doc that has had recent experience with this type of injury and in particular in runners, and what is the normal prognosis for recovery in terms of how much time it typically takes to heal and whether it is conceivable to still do 1 marathon a year going forward after this type of injury? Also, fyi, I do not have any of the risk factors you mention such as diabetes, etc. Thank you in advance for the insight.

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  12. Aufvdrzn - Different people see different things different ways. 60% tear is pretty significant in my book and I think I'd be pointing you in a different direction.

    What might be helpful is seeing an Ortho doc who specializes in foot and ankle care. www.aofas.org will take you to their web site - it's a national orgnization. If that doesn't work, send me an e-mail and tell me where you live and I'll see if I can't come up with a name.

    By the way, how's your swimming?

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  13. Dr. Post,

    I was diagnosed with PTT and have been placed in a walking boot (no activity) for the next 2-3 weeks at which time I will be evaluated again. My background is collegiate runner turned triathlete. Last year I did my first ultra and had no issues during training. This past winner after the JFK 50 miler I backed my training down to swimming twice a week, strength training and running 2-3x week. I had previously qualified for this years Boston Marathon; however did not really do any significant training to prepare. I did one long run of 18 and tweaked my hamstring (same leg of my PTT) and it never really got better. Went to Boston (since no medical exemptions were granted this year) and ran very conservatively (3:20). Felt fine during race. Came home major tightness in achilles. After a couple days this settled down and the pain on the medial side of the foot and ankle (PTT) presented itself. I find it interesting though that since the 50 miler...my shoe size is up a half (flattening of foot?) Connection to the PTT I assume?

    Sorry to be so long winded. I guess my main questions are....in your opinion, what is the best way to treat PTT? What type of rehabilitation do you typically encourage (PT, Ultrasound, etc.)? When can rehab start? Do athletes with PTT return to running fast and long again? I had planned to do an ultra in November again.

    Thanks so much for any input you may provide!
    Rick

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    1. Rick -One's initial experience with PTT is usually brief. It sounds like you're headed in the right direction. You'd like to get this to resolve completely and then work with your caregiver to determine what led to this episode and fix it. Should you ever rupture this stout structure -yes, it does happen - your ultra career would be over.
      Your rehab, return to running, etc. should all be controlled by your physician who has hands on ability to follow your progress.
      Good luck.

      John

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  14. Dr. Post,
    I came down on a girls foot playing volleyball in High School. I went to podiatrist and he said I had an accessory navicular, broken navicular and most likely partial tear of PTT. I was in cast for 3 1/2 months to no avail. Surgery removed accessory bone and was supposed to fix partial tear. 20 years later in May I stepped out of my truck and felt and immediate pain and burning on the inside of my arch. Went to podiatrist and he said it was my PTT. He put me in walking boot, gave me 6 day pack of Prednisone and ordered MRI. MRI showed partial tear of PTT that he said was grade 1 and a large bone spur that would not need surgery. He gave me cortisone shot and 12 pack of Prednisone for inflammation. Went back with still pain and inflammation. He put me in a cast for 3 weeks to not avail. He said I would need surgery to clean up tendon. Had surgery on Sept 6, he said tendon was completely torn off bone at top attachment of navicual. He cleaned up the tendon and reattached it with a metal anchor, shaved down the bone spur and lengthened my achielles tendon that he said was tight. I have been in a cast for 9 weeks and am still having a lot of discomfort in the bone and tendon. I have had the cast changed twice and was still having the pain in the tendon area at each appointment, not typicall stiffness pain from non-use. My question is should I have had a tendon transfer or is the pain I am still having normal?
    Sorry for the long post, but am frustrated and at witts end,
    Heather

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    1. Heather - sorry to hear about your troubles. One would expect you to probably be a little further along by now, but whether you could have or should have done something else is really immaterial. You have a complex problem. I'm quite biased, as an orthopedic surgeon, and believe that if you don't get the healing that you anticipate, that you at least get a second opinion by a fellowship trained orthopedic foot and ankle surgeon.

      John

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    2. Dr. Post,
      Thank you for your reply. I see that you are from Charlottesville, Va. I am from the Hampton Roads area of Virginia. Is there a fellowship trained orthopedic foot an ankle doctor you could reccomend? One other question I have is do you think the accessory navicular bone created all these problems with the PTT for me? If, so do you think I may develop problems in the other foot because I have the accessory bone there as well and have had a little discomfort in that foot since I have been hoblling around on that single foot since dealing with the other one? Is there light at the end of the tunnel for no pain and some running/jugging in my future. I was a three sport athlete in high school and am so frustrated hobbling around.

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    3. Heather- that's easy. We are fortunate to have one the most noteworthy foot an ankle docs in the world nearby. In fact, he operated on my foot and I three more Ironmans in before retiring. He's Mark Myerson, MD at Mercy in Baltimore.
      http://www.mdmercy.com/footandankle/about_physicians/myerson.html

      Best of luck,

      John

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  15. Dr Post,
    I have had issues with both my feet/ankles since the end of May this year and I haven't been running since. I had my third baby in at the end of Jan and started running 3x a week and playing soccer 2x a week 5 or 6 weeks postpartum. I had a sudden pain in my left ankle toward the end of a 7 mile run, at the top of a hill and since then my other ankle has followed suit. I had anterior tibial tendonitis diagnosed by a chiro and had some ART done on it. That has mostly cleared up. However, I've been having pain in my posterior tibial tendon behind my shin on both sides now. I've seen a podiatrist who said the anterior tendon likely inflamed due to tight calves and a tight posterior tibial tendon. He gave me topical anti-inflammatory ointment to help with the anterior tendon. As I said, they feel pretty good now. I have really high arches and the podiatrist recommended orthodics--I'm leery of getting any because I've always heard mixed reviews on them weakening feet in the long run and whatnot.

    Anyway, what can I do to eliminate the pain altogether? It's not awful, just annoying and I want to start running again. I'm only 29 and would like to train for more half marathons. I've been stretching my calves a ton and doing calf raises--are there other exercises I should be doing? Stretches? I'm up for anything, I just need to know that it will get better and not always linger. Mostly it's just an ache on my ankle bones and that ache on the inner part underneath my shin bones.

    Thank you in advance!!!

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    1. SB - for any treatment to be effective, you have start with an accurate diagnosis. Typical PTT problems are focused directly over the tendon on the medial (inside) of the ankle. Although not impossible, most 29 year olds wouldn't have an anatomic abnormality with the tendon (s) at that youthful age. Many athletes have orthotics but they're not free and if you do obtain them you want a very specific reason. If you were a local athlete, I'd send you to our local running shoe store to talk with the owner (nearly 30 years in the business), examine current foot wear - both running and daily use - and even put you up on the tread mill. That way, the best 2013 shoe that's specific to your anatomic needs would be chosen, maybe questions about your training answered, and hopefully a solution being the result.

      Best of luck.

      John

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  16. Dr Post
    I'm 37 yo working mother of 2 active little boys. I'm not a runner/athlete. I have Posterior tibial tendinitis in both ankles which got severe on Oct 31st. A month before that I had started having aches and pains/ fatigue in lower legs, but did not know what was going on. It flared up on Halloween day after walking with my kids for an hour after a long work day. Pain was limiting my walk in the house so much that I had to start using a walker to take some weight off my feet. My Ortho started me on Physical therapy. Where I was suggested to wear Aircast airlift ankle brace in both ankles for walking. I have been on Meloxicam since Nov 24th and MRI was done on Dec 1st which showed nothing. After 5 weeks of therapy, I was worse if not same. As of last week I have had to start using a wheelchair just to get to the bathroom. Now unable to tolerate walking. Most importantly, I now have pain at rest in both ankles (before I had pain only when walking) location of pain is at the corner of the Malleolus where the Posterior tibial tendon turns in "L" shape, at the insertion point at the arch. Sometimes I have pain alongside the malleolus parallel to the tibia.
    So what do I do? I'm desperate! Do I need different treatment approach? Pain has just not subsided in the last 2 and a half months. Why are the tendons not healing? I'm in central NJ... Any suggestions on a specialist in the area? My ortho is talking about steroid injections. I'm wondering if MRI report can be wrong. If I have pain at rest, does that mean the tendons may have torn in time?
    Sorry for so many questions, but this has been a puzzle for me and I'm so immobilized by now that I'm desperate for help.

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    1. Vib - sorry to hear about all this pain. I've seen a number of folks over the years and can't recall a similar set of complaints. Particularly on both sides. The fact that your MRI was negative for tendon damage is certainly in your favor. Was there something else seen perhaps? I know if I get into this situation in patient care, and what I'm doing is not helping, I'm not above asking another doc in town to have a look. My favorite is a Physiatrist. Physical Medicine Specialist not to be confused with a PT, or physical therapist. Sounds like you need another opinion from here.
      Best wishes, John

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  17. Hi Dr. Post
    I have been diagnosed with posterior tibial tendinosis (not tendonitis) by my podiatrist. Ultrasound reveals degenerative tissue near the navicular, and posteriorly along the tendon. Like a nuthead, I walked along the Lake Michigan sand dunes this summer without my orthotics in my shoes. I consulted with Dr. Gregory Berlet, in Westerville Ohio (he did my STAR ankle implant which is doing great), and he agreed that I have PTT. We are trying an ASO brace for a few months to see if it improves. I really have 3 questions. One, how successful are tendon transfers in this tendon? Second, will I be able to bicycle again (I ride about 2000+ miles a year)? Third, does PT help with this condition - or does it just put off the inevitable surgery? Right now it's painful (short, sharp pains) to walk; I'm not able to bicycle. It also aches occasionally, making standing tough.
    Great comments and questions from others.
    Jeff

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    1. Jeff - sorry to hear you're having problems. After undergoing ankle replacement you probably expected to pick back up with life. I don't know if you can blame this current problem on sand dunes but at least considering the potential of why you ankle required replacement in the first place would be appropriate. I guess my biggest question is why you have two docs here? Greg Berlet is national, if not internationally known for his foot and ankle care, already is familiar with your joint, and in my mind would be able to understand any influences the replacement may have on the biomechanics of the remainder of the joint. Specifically, if tendon transfer were even in the conversation, Dr. Berlet would be too. Try the bracing which hopefully will eventually get you back on the bike. No offense intended to your other care giver but I think this is a pretty complex situation and it's important to you.

      Best of luck, John

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  18. Dr. Post,

    About a month ago, I was diagnosed with posterior tibial dysfunction (no flat foot). I have been having inner ankle pain while running since the beginning of November, and the pain sometimes occurs when I am walking. Before I saw a doctor, I took a couple weeks off from running, and the pain was worse the next time I ran. The doctor gave me orthotics and an ankle brace, and told me I can continue to run. I am supposed to run a half marathon at the beginning of May. It still hurts when I run (some days are worse than others). I was wondering if there was anything else I could be doing to help the healing process so I am still able to run the half.

    Thanks
    Kathy

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    1. Kathy - I think that if you are still in pain, which is not uncommon, that 9 weeks may not be enough time to be prepared - and pain free! - for the half. You don't want to say, "Yeah I ran it," do poorly, or worse set yourself up for a year of pain. Keep in touch with your doc, pool run, bike and use the elliptical, and see where it goes/

      Good luck! John

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  19. Dear Post,

    I am training for a half marathon this coming October and had noticed some mild pain on the medial malleolus on my left leg. I continued to run through it until the other day it was moderately painful after my run. The next day it was swollen and a little bit bruised on the path of tendon on my foot. I saw an orthopedic doctor who took x rays (everything looked normal), gave me a walking boot, and referred me to PT. He wrote my diagnosis on the PT script as "flexor tendonitis". The PT immediately diagnosed it as posterior tibial tendonitis, and told me I should wear the boot for 5-6 weeks. At the point of my PT appointment ( today) , I no longer have any pain in my foot and the swelling is considerably decreased (it was never really that bad). I'm wondering if the boot is excessive at this point? I've been reading about doing strengthening exercises and maybe ART. Also thinking that the cause could be my extremely tight calves so I am planning on working on loosening my calves to see if that helps.

    Thanks,

    Jordan

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    1. Jordan - I can certainly understand your enthusiasm. Feeling better is always a good thing. Post tib problems can be bad actors some times. If you think you can advance your status you have two options. One, call the doctor's nurse/assistant and tell her/him what you've written me. Or, in my hands, I'd rather have my hands on the patient, look them in the eye while I'm examining them, so I make the best decision for both of us.
      Getting into the doc can sometimes be difficult. In my office, Helena the receptionist is a softie. If someone stopped by and asked very nicely to be worked into the schedule. Maybe not that day, but Helena would find a spot soon. That's what I'd do. Good luck.

      John

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  20. Hi
    I started having pain which was diagnosed as tendonitis. My doc told me to get new shoes and take advil. I found some days it was more painful than others but it didn't seem to depend on whether I exercised or not so I kept going. 6 Months later with no improvement and obvious swelling I went back. The doc recommended a PT who put me in a night light boot and a day light brace.and gave me some exercises and sent me on my way. After a around a month it wasn't improving. She suggested another doc who told me to get crutches and a aircast and sit for a month and forget ever exercising again. (I do have flat feet but they have not been a problem before). I am following her recommendation but...I find keeping my foot still almost makes it hurt more than using it. She said if I didn't stay off it I would need an operation and it wouldn't go well. I want to return to exercising - treadmill walking and kick boxing to a computer program - which doesn't seem like much and go back to work where I need to stand. No one has taken an MRI I diagnosed myself based on what the PT said and what I have read. But the symptoms sound spot on. She saw my flat feet which I was born with and basically became angry with me.Does staying off it for 5 weeks and being on crutches make sense? My other question is should I seek out a specialist in tendonitis ortho rather than a podiatrist?

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    1. Bremner - sounds to me like you need a better answer than you've been given to date. You must be a very patient person. In most offices, after a careful history is obtained from the patient, a physical exam is performed and a treatment planned outlined. If, after a certain time, the problem hasn't resolved, it can be time for plain xrays. If they are unremarkable, and the problem has not gone away, some type of scan depending on the working diagnosis can be ordered to augment the treatment.
      For whatever reasons, this hasn't happened in you. In our community the next step would be an Orthopedic fellowship trained foot and ankle doc to weigh in with his/her opinion.
      You need more of an answer than you've gotten so far.

      John

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  21. Sir,
    I am a professional football player in India. I started to have Posterior tibial tendonitis in both my ankles 6 months ago. My team physiotherapists gave me some ankle exercises and enabled me to play through the season. After the season, i gave it some rest and allowed the pain to subside. After about a month, i started to play again. On the first day itself, i heard a snap sound in my inner left ankle and when i removed the socks i noticed internal bleeding in my left foot ankle. I dint take much notice of it as it din't pain after that. But very next day, i missed a step and my right foot hit the ground forcefully and pained immensely. I was unable to play after these two incidents. Both ankles painting badly. I went to an orthopaedic surgeon after that and took MRI and Ct scan. The scans showed no tendon tear. But the scans also showed that my ankle joint was mildly deformed and i have bony spurs in my ankle. My doctor says i have arthritis and says i should stop playing football professionally. I have been flat footed both feet since childhood. I have tried using arch supports but they only cause me pain.

    My doubt is, was the bony spurs and arthritis caused because i neglected my tendonitis or because of my flat feet from childhood ? Because i never had ankle pain before i developed tendonitis. And is there any long term cure for the painful spurs and preventing the arthritis from destroying my joint further while i continue to play professionally ? Thank you.

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    1. Sorry you're having problems. One would wonder, since by your report, the posterior tib tendons are unremarkable on MR and CT, if they are the source of your distress or the arthritis. One does not get bone spurs with ordinary posterior tendon problems so is the ankle arthritis the culprit?
      I wish I had something simple for you but I don't. As far as ceasing your play, only you can make that decision. We see American football players who can hardly move 6 days a week, but come Sunday, somehow they will their bodies on to the field of play. That said, they're likely headed for a good deal of pain when playing days are over. I think that you and your doc figure out what's best for your specific ankles and go from there. Best of luck.

      John

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  22. Hello. I am a runner, and about 3 months ago was dx with a post tib tear (length-wise). End of August, I had post tib tendon repair with FDL transfer (NO bone realignment, just the tendon transfer). I am 10 weeks post op, and in a custom AFO brace. Two questions: do people typically run pain free after this surgery, so long as there is no bone realignment (I believe the answer is yes, but looking for other opinions). Secondly, the most pain I have is ABOVE the incision, like up the inside of my tibia. It feels like I have a terrible shin splint there, and I did not have that pain before surgery. Is this likely due to that leg being immobilized for 6 weeks? I was in walking boot 6 weeks, then weaned into AFO over 8 weeks. Thank you!

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    1. Wendy -I believe your first question/answer may be correct. You would want to discuss the exact nature of the repair (how stout was the donor tendon?), was the original PTT repaired? sacrificed? etc.,to give you the best course for your running future. Then,ask the doc about the course of the FDL and how it was utilized in your case. I think you'll get the answer you seek.

      Good luck, John

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  23. Hi! I would appreciate it if you could give me your opinion on my long term prognosis. Seven months ago, I had a very rare and odd injury. As I was making a cut at full speed in a football game, my right ankle just gave out...in an inversion injury. I had no fractures, but was unable to bear weight for a few weeks. The MRI later revealed that I tore my deep deltoid ligament structure and also had a longitudinal split tear of my PTT. I waited until 2.5 months ago to actually get surgery and the procedures done on me were: tenosynovectomy, repair of the split tear, and deep deltoid ligament repair. For the life of me, I can't find anyone on any forum with a similar injury, so I have no idea if I can make it back to high level sports. Do you have any experience with primary repairs for PTT split tears? If so, are the outcomes generally good? Thanks a ton!

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    1. As you can tell, this isn't a common problem but you not the first questioner with a tendon split. Your repair may have included a tendon transfer. It sounds like your repair was performed fairly early in the course of this problem and that, unlike some of the above folks you didn't have collapse of the ankle, hardware put in, etc. That said, as said, it's a big deal and the best person to answer your question is the person who put it back together. I suggest you query your surgeon who knows best the quality of the repair, any weaknesses or encountered difficulties. Best of luck.
      John

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    2. Thanks for the prompt reply! I actually didn't get an FDL transfer, but upon my pedantic search through pubmed, most authors just say to "suture up the split tear", with no mention of an FDL transfer unless the tendon is degenerated, which mine was not. Is the norm in your practice to augment repaired split tears with FDL transfers? If it is, I may consult with another surgeon (know any good ones in Chicago?) I don't have an appointment with my surgeon for another 6 weeks, so I am in mental tiff in regards to my predicament. I am 23 and was at the peak of my athletic potential prior to my injury. Thank you.

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  24. I'm a 33 year old marathoner and ultra runner. I was battling plantar fasciitis for a few months and had a steroid shot to treat it. A few weeks later, I suddenly had a bad pain on my inner ankle and swelling/redness in the arch. I thought the KT tape I was using irritated the posterior tibial tendon. It's three months later, the area behind my ankle looks thick, not quite swollen, and it feels like my foot wants to roll in to the arch. I can still go up on my toes, though.
    If this is a tear or rupture, will I ever be able to run again? Can someone get back to distance running after PTTD?

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    1. Before choosing your long term, perhaps an accurate diagnosis would be helpful. Why not have an evaluation by someone in your community like an orthopedic surgeon who deals with the management of these issues on a daily basis. Once you know the specific abnormality, and it might require xrays or more, a plan specific for your needs can be developed. Good luck.

      John

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    2. Hi Dr Post,

      Since I last wrote, I had an ultrasound that showed a partially ruptured plantar fascia and a small lateral split tear of the PTT. I was 5 weeks non weight bearing.

      Then I was sent for an MRI that confirmed the partial rupture of the PF and showed, "Insertional partial-thickness tear of the posterior tibialis tendon." What does that mean? Can that or will that heal without surgery?

      I'm currently in a walking boot but I'm unclear about what all this means and what to expect going forward.

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    3. The ordering physician will go over the scan with you, tell you if partial is 5% or 50%, and help you chart a path toward healing consistent with that. It could mean an operation, yes.
      With the PF lesion, you and your buddy Peyton have something in common!
      John

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    4. Thanks much!

      He seemed much more concerned with the PF tear. Maybe that's a good sign? I have some more specific questions for him at our next appointment.

      Haha! I tried looking up what to expect with the PF tear and all I got were articles about Peyton Manning.

      Thanks again,
      L

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  25. Hi, I'm also dealing with a similar situation as the individual in the above post. I trained through plantar fasciitis last summer/fall and had a shot of cortisone in October. After taking a month off I tried running in Nov and experienced sharp, tearing pain in the heel area. I now have a gap in my PTT near the medial malleolus and I'm waiting for an MRI Jan 5. My question is-could the delay in treatment effect my surgical outcome?
    Thank you!

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    1. That's a pretty hard question to answer. If the diagnosis is presumed tendon rupture or partial rupture, ordinarily the earlier the repair the better. If it's felt that this may be more of a chronic situation, and the options of observe versus fusion are on the table then it's probably less of a rush. Your specific answer would best come from your surgeon who knows you a lot better than some internet guy like me.
      Good luck from all of us,

      John

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  26. Hi Doc: I had a so far very successful PTT tranfer with FDL tendon, calcaneal osteotomy, and gastric slide on October 15, 2015. No swelling, no pain, rehab progressing fantastically. I am a healthy very active 59 year old male. Very active prior to PTT that is. I will of course ask my surgeon at next follow up visit in 2 weeks but am not known for my patience. With someone of my profile is there any chance of a return to light running say 1-2 miles 3X per week after recovery? If yes what time frame? Thank you!

    ReplyDelete
  27. Spook - glad to hear that things are going well. If you had a gastric slide, that would be an operation on your stomach....pretty far from ones PTT! (I'm guessing you really mean gastroc.) You will ultimately be given the go ahead to run by your doc. But only he/she knows the quality of fixation of the osteotomy, the robustness of the tendon repair, technical things like that upon which YOUR future is based. Each of us is different as you'd suspect so I just couldn't speak for the operating surgeon. Best of luck though.

    John

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    Replies
    1. Hi John: Update: Got full clearance and release to return to ALL activities from surgeon. With the caveat of slowly reintroducing of course. Very happy, I have my life back and hopefully can offer hope to other PTT sufferers.

      Delete
    2. Good deal! A modicum of restraint is, of course, squarely in your sights. Plus, you asked your caregiver what you can do to ensure this never occurs again right? Perhaps you can share that with the reader base.
      Good luck! John

      Delete
  28. Yes that would be a bad "slide" ha ha. Thanks for response, Happy New Year!

    ReplyDelete
  29. Hi Doc,

    I was a weightlifter and occasional runner. I am 25 years old.

    Recently I instepped too hard on my left foot accidentally, flexing my arch muscles hard to compensate. Immediately following that day, I had a sharp pain at my navicular where the PTT inserts. I tried walking on it for a few days, but it eventually hurt too much so I put myself on cructhes. I iced and used ibueprofen to bring down the inflammation which has had success. Two weeks later I saw my podiatrist. He put me in a walking boot for 3 weeks, said my PTT was inflamed. I am a week into the boot, and there is still some sensitivity. It stings if I try stretching my big toe sideways (spreading toes). X-rays showed nothing, and standing on it hurts slightly less than before, but prolongued weight bearing hurts (I have not done this since the x-ray).

    My question is twofold, does the posterior tibial tendon go back to normal/fully heal on its' own if caught early enough? And, if so, does my case sound promising?

    Thank you so much for any insight you can offer. I just want to know if it is possible I can go back to lifting at some point this year.

    ReplyDelete
    Replies
    1. At 25, with patience, reasonable care and a little luck you'd expect complete resolution of the issue. If it doesn't resolve, think alternate diagnosis, subtle fracture, etc. Lifting should be in your future.
      Best of luck,
      John

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    2. Thank you for your opinion Dr Post.

      By a little luck, I sincerely hope you mean nearly none at all.

      I don't like leaving things to chance. Lifting is my career.

      How long do you think it'll take? 3 weeks sounds really short from what I have seen others say about their PT tendonitis. Realistically, how long should it take?

      Thank you.

      Delete
    3. John - each of us is different. With the acute onset you described, labeling this as tendinitis might be a stretch. Some might be more comfortable with insertional tear or partial tear. As such, we heal at very individual rates, some of the more stubborn taking 6 months. And, sadly, others don't heal and go on to surgical repair or augmentation. The PTT is one tendon you don't want to mess around with. If things aren't going well, you might want further study. Don't be ashamed to ask your caregiver how many PTT he/she has repaired in the last year. If you don't like the answer, take action.
      John

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    4. Thank you so much for your advice.

      It sounds like though, if it is a tear of some type, most people heal within six months, even with a "stubborn" case. I have seen it become a little less sensitive in a month's time, so that gives me hope.

      Seems like surgery should be more on the "unlikely" side (I know I am an individual case, but barring that). Just curious, what is the success rate generally of recovery? And what is the success rate of surgeries?

      I will ask for an MRI to see if we can confirm what is happening. Thank you again, I will ask him, that is an excellent question.

      You are a very nice man Mr Post. Thank you.

      Delete
  30. Hi Doc,

    I was a weightlifter and occasional runner. I am 25 years old.

    Recently I instepped too hard on my left foot accidentally, flexing my arch muscles hard to compensate. Immediately following that day, I had a sharp pain at my navicular where the PTT inserts. I tried walking on it for a few days, but it eventually hurt too much so I put myself on cructhes. I iced and used ibueprofen to bring down the inflammation which has had success. Two weeks later I saw my podiatrist. He put me in a walking boot for 3 weeks, said my PTT was inflamed. I am a week into the boot, and there is still some sensitivity. It stings if I try stretching my big toe sideways (spreading toes). X-rays showed nothing, and standing on it hurts slightly less than before, but prolongued weight bearing hurts (I have not done this since the x-ray).

    My question is twofold, does the posterior tibial tendon go back to normal/fully heal on its' own if caught early enough? And, if so, does my case sound promising?

    Thank you so much for any insight you can offer. I just want to know if it is possible I can go back to lifting at some point this year.

    ReplyDelete
  31. Hello. I am now 5+ months out from FDL transfer (just transfer, no bone shaving) for lengthwise PTT tear. My old pain is 100% gone. However, I have pain at the anchor site (navicular bone) where the absorbable suture anchor was placed. There is also a small bump there. Surgeon says he thinks it will go away and it may be a reaction to the anchor. Is it common to have pain at anchor site this far out? Thanks!

    ReplyDelete
  32. Hi Wendy - you're back! Each surgical procedure has a life of it's own. Hardware placement always carries the risk of post op pain. I was reading about Floyd Landis last night, his hip fracture, and the need to remove one of the screws. You might ask your doc if one of the PT's can work with you on an aggressive soft tissue program, maybe for 3-4 weeks, and see if it makes a difference. Hardware removal may also be offered but I would recommend against rushing into it.

    John

    ReplyDelete
    Replies
    1. Hi Dr Post,

      Do you think Graston technique would be helpful in a small tear at the navicular site or is that too aggressive?

      Also, after anchoring, does the gear ever get removed and things go back to pre op feeling and functionality?

      Insertional tendinosis is not extremely painful, but definitely very uncomfortable.

      Thanks in advance for the reply. I hope my question helps Wendy too!

      Delete
    2. You know, I'm the wrong guy to ask that. I've never understood Graston. But that's just me.

      John

      Delete
  33. Thank you! It is an absorbable suture, so not actual hardware. Are those typically removed?

    ReplyDelete
    Replies
    1. Rather than absorbable suture, more likely absorbable suture anchor. They can take a year +/- to be absorbed depending on a host of factors.

      John

      Delete
  34. Oh, I see! Didn't realize it took that long. So the pain may go away at that point? Or would you sometimes recommend actually removing it before absorption?

    ReplyDelete
    Replies
    1. I don't think so, it's something I've never done.
      John

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  35. Dr. Post - Great blog. Thank you taking the time to put it together. Here's my story - Any thoughts you have appreciated.
    41 year old runner/skier (water) who sprained ankle (eversion) in July. Tried to work through for about 4 weeks until it popped and got worse. Took August off of everything and began rehabbing.

    Took a month off and slowly rehabbed through October. Ran a 5k in late October and within 10 days had pain walking that wouldn't go away. Primary physician put in boot for a month, clean x-ray, clean MRI (with the exception of mild swelling on fat pad). No tears.

    I've seen two orthopedic surgeons specializing in ankles (last one in early January). Both have looked at the MRI and xray. Once says PTTD (I can do heal raises all day long) and the other says tight calves/tight arch/deltoid issue. I have custom orthotics at their request. I go to PT once a week. Pain is in the arch where the orthotics push it up.

    It's now February and I can't walk more than 1/2 mile w/o pain (that's an improvement) let alone run. Do I need a 3rd opinion or should I be patient. We are just over 3 months since the ankle went crazy.

    ReplyDelete
    Replies
    1. Hard to be put in the middle here. You'd wonder if there isn't a role for a top notch PT who can direct your rehab efforts. The other possibility is the "running shoe shop guy." Here in Charlottesville, we have Mark. Store owner for 34 years. Knows more than most docs, certainly more than me, about the intricacies and nuances of the injured runner. It might help you validate your path forward.

      John

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    2. Dr. Post - Appreciate the advice and you taking the time to respond. I'll follow up with a running shop. Thanks for the advice.

      Delete
    3. Welcome. Just so you know, many of these posters, many athletes actually, go through periods like this where they cannot train as they wish. Maybe they become better swimmers or bikers, maybe they find opportunity elsewhere. It's just your turn.
      John

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  36. Thank you so much for your response. I saw surgeon today and had an MRI and x-rays. He said tendon looks good (but that it's "large") and the bioabsorbable anchor appears to be absorbing, based on comparison to prior imaging. The anchor is not out of place. However, he said the large bump on the outside along with the pain indicates that I'm having a foreign body reaction to the anchor. He prescribed a double round of prednisone (I am taking two 6-day packs at the same time). That seems like reasonable treatment?

    ReplyDelete

  37. w - all sounds reasonable. You have to trust the "man on the scene" as they used to say. There just seems to be a subset of folks who react more strongly than most to the bioabsorbable pins and anchors for some reason. Patience is your friend.
    John

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    Replies
    1. And my man on the scene is pretty good (Dr. David Porter in Indianapolis)--and he told me keep running while I stay patient. Thank you again for all your responses.

      Delete
  38. Hi Dr Post,

    Is it normal to feel like something like this almost "recovered overnight?" I have had this painful injury at the insertion for months. Almost 2 months in, it seems there was no improvement, then, boom! All of a sudden within a week or so the area was about 50% less sensitive.

    Is that a normal thing to feel for some healing people?

    Thank you

    ReplyDelete
    Replies
    1. I don't think that's unheard of, no. Be glad it's not the other way!
      John

      Delete
  39. Hi Dr Post,

    I had PTTD surgery in November. I had an accessory navicular bone that was fragmented and the PTT was ruptured. My surgeon removed the bone and reattached the tendon with an anchor. He did not need to do a tendon transfer. I am now four months out and I still have pain in the tendon when I walk more than a half a mile or when I go up and downhill. Is this normal? Thanks, Megan

    ReplyDelete
    Replies
    1. Megan -you'd hope to be pain free bye now but not everyone is. Why not mention it to your doc, see if there isn't something he/she has to make you better.
      John

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  40. Me again. I am 7 months out from FDL transfer for a torn PTT. I am pain free all along the line of the tendon where my incision is (old pain 100% gone), but have had, since surgery, pain right behind the ankle bone on the medial, where the FDL and PTT come together. It feels like a shin splint. Surgeon says sometimes that can get irritated. But it's my understanding that these tendons are always next to each other, and that isn't affected by the surgery?

    ReplyDelete
    Replies
    1. WEndy - indeed the the tendinous portion of both the posterior tib and flexor digitorum longus are posterior to the medial malleolus. But as to the exact location and extent of the tear, the depth of the dissection to expose the tendon for repair are questions only the operating surgeon would know. Sorry, wish I could be more help.
      John

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  41. Okay, thank you. My tear was much more distal...near the insertional point at the navicular. That pain is 100% gone, just nagging soreness/tightness behind ankle bone, which I did not have before surgery.

    ReplyDelete
  42. So I have a slight dilemma, I have had 2 MRIs confirming a tear in my ptt 1.5cm x 2 cm, mr dr is saying that I need to be in this darn "walking" boot for another 8 weeks, its already been 12, should I get a 2nd opinion or tell him to just to the surgery and fix it and I will take the chances on the healing of the tendon

    ReplyDelete
    Replies
    1. Jason that's a hard call. While a second opinion is always useful, even if only to confirm the diagnosis, your doc has probably seen this tear type heal before. Why not ask, and if the probability of conservative success is unacceptably low, have it repaired.
      John

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    2. Thanks John for that info, I have another appointment tomorrow so we will see what he says. Would it be wrong to tell the dr to just do the surgical repair, I mean do I have that right as a patient

      Delete
  43. No, not really. If your doc has given that as one of the options, I see nothing wrong with taking the approach that's right for you. Good luck.
    John

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  44. Who would you see in the Richmond area? I saw you recommended a dr in Baltimore. Thank you. I'm currently seeing a foot and ankle specialist in the area. He wants to repair my tendon. I have faith in him but would just like s second opinion. Do you think I should see an orthopedic surgeon vs my podiatrist? Thank you!

    ReplyDelete
  45. Carrie -I'm sorry but I'm not real familiar with the foot and ankle community in Richmond other than Bob Adelaar at MCV. He enjoys an excellent reputation. As for ortho or podiatry, when you ask an ortho guy that question, 100% of the time it will be an ortho answer. If you ask a podiatrist,.......

    John

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  46. Hi Dr. Post,

    I've been struggling with PTT in my left foot for 3 months now -- started by trying the boot (it led to PF flaring up in my other foot), then physical therapy. I just had an MRI that showed no tear, but significant inflammation, and the doctor recommended that I go back into the boot.

    The problem is, the boot doesn't seem to help. I still get sharp, stabbing pains up my ankle, and my arch hates it as well (I was also diagnosed with PF in the left). I put a supporting insert (Superfeet) into the boot, but I'm also noticing pain now in my hips, knees, and along the inner ankle on the other foot.

    I've heard so much about the "standard conservative treatment" of a boot for 3 months, but how do you know if it's actually working? It feels like it's not, and instead just doing damage to other parts of my body.

    I can't stand the thought of going through three months of this and then, at the end, having no improvement. I used to be a runner/hiker, and now I don't know if I'll even be able to dance at my own wedding in October.

    Any insight or advice would be helpful -- thank you for taking the time to put this blog together as a resource!

    ReplyDelete
    Replies
    1. With PTT problems, sorry to say but the conservative, non-operative pathway works for many. Since you don't seem to be getting relief, do you have a second or different problem that has yet to be revealed. It wouldn't be the first time that a finding on MRI or CT, while present, is not the source of the patients pain. If, after further thought this is your only diagnosis, is there room for other modalities, formal physical therapy, ultrasounds, and in rare cases, an ultrasound guided injection. Give that a try.
      John

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    2. @Cobalt, I am suffering from the same thing and after 5 weeks of immobility and the boot (which I don't do well in either)--I am still in pain all the time. Unfortunately I got PTT in both ankles---so walking has been a huge trial. I actually was just referred to a nerve doctor for the shooting pain though---and they think I have trapped or damaged nerves. I am scheduled to have a blocker for this--which is supposed to help--and there are also meds that help. You may want to see if this is what is causing your pain. It could be that you have PTT and nerve issues going on all at the same time. I was also told that if you do have this and don't treat it--that it can really slow your healing process down. At any rate--maybe another avenue to explore....

      Delete
  47. I have similar symptoms to @Cobalt. I have been in a boot for 5 weeks with sharp pain and my feet--yes I have PTT in both ankles are always in pain. I have been sitting pretty much and been inactive trying to get better but not much progress yet. But I actually was just referred to a nerve doctor and they think it is nerve related---e.g. my nerves are trapped and firing which is causing the horrible pain I feel all the time. @Cobalt--you might want to look into this as it could be what is also causing you pain. I am a runner and this is driving me crazy. I am also slotted to get a nerve blocker injection to help with this.As Dr Post mentions---this is something that can help with the nerve pain--as can meds.

    ReplyDelete
  48. I have similar symptoms to @Cobalt. I have been in a boot for 5 weeks with sharp pain and my feet--yes I have PTT in both ankles are always in pain. I have been sitting pretty much and been inactive trying to get better but not much progress yet. But I actually was just referred to a nerve doctor and they think it is nerve related---e.g. my nerves are trapped and firing which is causing the horrible pain I feel all the time. @Cobalt--you might want to look into this as it could be what is also causing you pain. I am a runner and this is driving me crazy. I am also slotted to get a nerve blocker injection to help with this.As Dr Post mentions---this is something that can help with the nerve pain--as can meds.

    ReplyDelete
  49. Thanks much, John and Sarah, for the ideas -- I'm going to be starting PT hopefully next week (re-starting, actually). I've also thrown an arch support into the boot in the hopes of taking some stress off the tendon (my arch has basically collapsed). I'll try sticking this out for a couple more weeks with those, and re-assess from there. Injections make me terribly nervous re: rupture, though.

    Sarah, I'll keep that in mind about nerve pain, it's something I never considered but it makes sense. I'm sorry that you're in so much pain (both ankles! I can't imagine), and I hope the nerve blocker gets you some relief!

    I am also a runner, and I've been through the injury grieving process to the point where I'll settle for just being able to walk again. At least I enjoyed every single sunrise I got to see on the road.

    ReplyDelete
  50. Dear Dr Post, I hope to get some advice from you. I am 60 years old and have been in pain with my ankle for a year now. After several months, my insurance agreed to an MRI. Here is the finding: PTT tendinosis with low grade partial thickness tearing at the level of the medial malleolus . Tenosynovitis involving the PTT and FDL tendons . No significant ankle effusion.The other major tendons and ligaments of the tarsal region appear intact.The plantar fascia is intact without a focal tear.
    I have been between a boot and a brace for several weeks and taking some strong anti-inflammatory, but stopped the medication because of stomach issues. I was careful not to walk too much; but 2 days ago, i had no choice but to be on my feet all day, and it took a turn for the worse. My ankle is swollen again and quite painful. My first question is do you think that the surgery is inevitable? It is very difficult for me to stop working and i would rather not do surgery and maybe try again something more conservative. I have done quite a bit of research. Are you familiar with Richie brace and what do think of blood flow stimulation therapy? I had several sessions of PT but had to stop because of travels for work. Not sure where to go from here. Do you have a recommendation of a good ankle specialist/surgeon in Connecticut or NY.

    ReplyDelete
    Replies
    1. Catherine - Sorry to hear about this and sorry for the delay in responding. No, I don't think surgery is inevitable. I think the first step is getting an accurate diagnosis from a provider well versed in PTT care. As you can already tell, it's an unclear area of care. As for whom to see, my strong bias would be an Orthopedic Foot and Ankle surgeon. In NY, the Hospital for Special Surgery enjoys a good reputation for care of difficult problems like yours. Why not review their web site under foot and ankle care and see if you like what you see.
      Here's the kicker. I had my foot operated on about 12 years ago, and can go to any F&A surgeon in the country. Whom did I choose? Mark Myerson, MD in Baltimore. My operated foot is normal and I've finished the Ironman World Championship 3 times since then. I guess it's pretty obvious where I'd go if I needed more foot care!
      John

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  51. Back with another question! I am 11 months post PTT surgery with FDL transfer. Pretty much pain free in that area. However, I seem to have a strained abductor hallucis longus and accompanying tendinitis (where it attaches at big toe). Never had it before. Could this be due to altered mechanics from the surgery?

    ReplyDelete
  52. Wendy - I can't say that I have enough experience with the operation to be able to give you a valid answer. Best to ask the operating surgeon.

    John

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  53. Hi Dr. Post. I have been recently diagnosed with PTT by the ortho doctor's physician assistant, even though I've had the symptoms for years, and am currently in a walking boot. I will be getting PT soon and also see the ortho soon. My question is why I still have swelling in my ankle after coming out of the boot, icing the ankle and even after a good night's rest. Something in my itty bitty brain doesn't get it. Can you help? Thanks so much!

    ReplyDelete
  54. Hi Linda - sorry for the delay, we've been off the grid for the last week hiking in CA. Swelling is a funny thing, more generalized than specific. I think an organized work up, examination by the orthopedist, regular x-rays, and then a consideration of the various possibilities and options involved in each would suit you best. Otherwise, you're just shooting in the dark. Good luck.

    John

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  55. Hello John,

    I have been diagnosed like others with PTT. I went to the ortho and he placed me in a boot for 4 weeks. It been a week and I really don't see much of a difference except for loss of strength in my left foot. My question is when will I see an improvement and what does the doctor expect to notice after my 4 weeks in a boot? Thank you for time and message board.

    ReplyDelete
    Replies
    1. Andrew- sorry to see you've joined the list of the above. Each person is an individual. You doctor must believe that this is more inflammatory than actual tendon damage and that a period of rest is the first step. It didn't get this way in a week, it won't resolve in a week. I would expect your physician, whose hands have examined your ankle as no one on the internet has, may be in the best position to answer that. Perhaps you could give his assistant a call/e-mail tomorrow, pose the same question, and see what you get. It may help guide your thoughts and actions over the next three weeks. Good luck.
      John

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  56. John,

    Do you believe it is ok to add a shoe insert inside the boot?

    ReplyDelete
    Replies
    1. In my patients, in certain instances, yes. But I'm not the one to whom you've entrusted your care.
      John

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  57. Hi Dr John,

    I have a situation, back in 2006 I sprained my right ankle went to the ER and after having an X-ray they determined I had a high/low sprain I had a splint for 8 weeks then a brace to wear in my shoe my ankle healed well no problems, fast forward to December 2014 I sprained my ankle again the same foot while skating. This time around I went to the ER and after X-rays they diagnose just a sprain and gave me a temporary splint that I could take on and off.. not like the last time when I had to wear it for 8 weeks.. ever since the last sprain I've been dealing with sharp pains in my right ankle underneath the ankle bone going around the back of my foot to the arch. The pains occur sporadically I can go a week or two or a couple of days, without an episode of a sharp pain but this has been going on for 2 to 3 years now. I finally went to see an orthopedic dr and he took and X-ray said my bones were perfectly normal, my ankle had some swelling (which never really ever goes down) It also gets stiff at times off and on, I had a little less range of motion in the injured ankle, he also did a test had me stand on one foot and looked at my feet (also told me I had flat feet) and then after that informed me that I had posterior tibial tendon dysfunction.. he decided to have me do just physical therapy for 6 weeks.. I have 2 weeks left of physical therapy and just when I thought I was getting better and my episode of sharp pains started to decrease a little I had a full day today of pain on a scale of 1-10 I would give a 6.. stiffness, sharp pains on and off throughout the day.. I also forgot to mention above that I also hear a clicking noise when I move my foot up and down sounds like your cracking your knuckles I hear it most when I'm driving as my foot goes on and off the pedal and brake.. do you think that by me still having this type of pain or since it's been going on for so long and for the fact that I injured the same ankle twice that my tendon is no longer working properly and is stretched out .. my ortho said we would see how things went at the follow up visit to determine if we needed to do an MRI, initially when I went in he said I didn't seem like I had a bad case that my case was moderate and that I didn't even need a shoe brace or orthotics for my issue, Physical therapy has helped me gain my range of motion back but I t still hasn't help with the random episodes of sharp pain and the dull achy pain in my ankle sometimes just while lying down, as well as some sensation loss .. wheat could be going on here? Any insight or recommendations you could assist with?

    ReplyDelete
    Replies
    1. N. Elizabeth- PTT, as you've read above and may be experiencing, is neither straightforward in it's presentation nor formulaic in it's treatment. Never-the-less, for proper care one depends on an accurate diagnosis.

      If you have confidence in your orthopedic care giver, it sounds like an MRI is a strong choice for your next step. Once accomplished, ask your orthopedist how many of these he's cared for in the last year or two and how many he's successfully repaired. If the answer is too low as I suspect it will be, find a board certified, Foot and Ankle fellowship trained orthopedic surgeon and ask the same questions. The more of these you care for, the better quality care you can offer the next one.
      Good Luck, John

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  58. Do you have a recommendation for NC foot and ankle specialists. My husband like many of your other posts was sent home with Mobic and orthotics and told to rest up when seeing ortho. It's been over a month and nothing has changed, in fact, orthotics seem to exacerbate problem. After his visit today we decided on 2nd opinion. I'm frustrated that no brace, no boot, not even a heel test was performed and makes me wonder how much farther we are set back. My husband was very active and now can't be on his feet for longer than an hour without pain. Also, can I get your weigh in on the preferring casts? And they did an ultrasound and xray and both clear. They scheduled MRI, is it really worth the expense?

    ReplyDelete
    Replies
    1. Hi Mary - Happy to help. First off, whether a certain treatment, therapy or scan is needed depends a lot on the diagnosis and response to treatment to date. Where in NC do you live so I can see what I can do for a 2nd opinion doc for you.

      John

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    2. We live in Greensboro, but are relatively close driving distance to Triangle area

      Delete
    3. Mary - why not try the Duke University Orthopedic Department, Foot and Ankle Division. The two gents with whom I'm familiar are Annunziato Amendola and James Nunley. They can be reached at 855-855-6484.

      Good Luck, John

      Delete
  59. Two days ago, I twisted my ankle. I had slight pain when it happened, but it quickly eased. I did nothing for it as it did not hurt and I was in a meeting for the next 4 hours, so not walking on it. However, for the next hour I was walking on it and then, I suddenly experienced very significant pain which continued to escalate to what may have been the greatest pain I have experienced. I hobbled to my car and found that just pushing on the gas peddle was unbearable. I pulled into a BetterMed Clinic where they x-rayed it. No fracture, just calcaneal spurring. However, my outer ankle was swollen. It was wrapped and I was given a script for an anti-inflammatory, an ankle air splint and crutches. Later, it became discolored. Once home, the pain was so intense, I tried Lamaze-type breathing and I became extremely chilled and my whole body was shaking. The pain remained at a 10 (1-10) for several more hours and then gradually diminished. The next morning my whole foot was swollen and there was some discoloration just below the outside ankle bone, but pain was so slight, I felt able to walk on it without the use of crutches.

    I am baffled by the extreme pain and then total remission of pain. There is still some swelling though I have been icing it. What could it have been? I, typically, have a high pain threshold. Should I just assume a miracle occurred and forget it?

    Thank you.

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    Replies
    1. Hi Terry- I've gotten this message from you four times today, I'll answer it I promise. I had a race this morning more than two hours from home so much of my day was already scheduled.

      The exact diagnosis of your ankle injury is not easily produced given the odd time sequences you report. That said, I don't think you've heard the last of it as that degree of swelling is far from ordinary. You would keep soft tissue trauma at the top of your list but every Orthopedic Surgeon has had patients with negative xrays at time of injury prove positive at a later date. Blood clots, tendon issues, etc. while less likely, stay in the back of your mind as well. If this doesn't completely resolve, I'd make an appt to see your local Sports Doc for another opinion. Seeing your kids graduate from college is a miracle in some cases, but I doubt ankle trauma. Good luck.
      John

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  60. Hi Dr. Post,
    I was diagnosed with PTT in February. The pain appeared bilaterally inferior to the medial malleolus about 8 miles into a 20 mile run. The pain went away after the run, and became undeniably worse a week later after my back-to-back long runs. At that point my right ankle felt painful and unstable so I stopped running.
    I received Graston therapy for a few weeks. Then I saw an ortho who rec'd Aqua jogging and cold soaks. At the point the tendon was tender to touch superior to the med malleolus. I wasn't getting better but wasn't any worse until mid April after a weekend of too much walking.
    I saw a podiatrist who put me in a boot on the right (x 3 wks now). My right tendon is less tender to touch but I'm experiencing nerve pain on both sides as well as peroneal spasms. The left is worse with the boot on the right.
    I am completely inactive besides the 3 miles I walk daily as a nurse but feel like I'm getting worse. I was previously running 30-50 miles per week and gearing up to climb a mountain this summer. Neither provider thought an MRI would be worthwhile though I'm questioning whether to request bilateral MRIs anyway? What is your opinion?
    I've had an X-ray of the right side only and am getting custom orthotics this week.
    I'm not feeling very confident in the care I'm receiving- any recommendations for the western WA region?
    Thank you!

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    1. Mr/Ms Paulson - sorry to hear that things are not going the way you'd like them to. From the length of this comment section you tell you have a good bit of company. As for your care givers, you'd usually like to hope that their training and experience have taught them the right, and wrong times, to order a not inexpensive test like an MRI. That said, if you've lost confidence in them, and if the results of an MRI would make you change the direction of your treatment, then maybe it's time. I looked at the foot and ankle faculty of Wash U, didn't recognize anyone, but even though it's not in your back yard might be the place to start. If you don't mind a little traveling, Amol Saxena in Palo Alto has a pretty long history of helping runners on many levels. I know it's a hike but this might help some. http://www.amolsaxena.com/

      Wherever you choose your next step, best of luck.

      John

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  61. Thank you for taking the time to respond. I appreciate your insights and recommendations.
    -Melissa

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  62. This is probably going to sound really "out there", but...is it possible...for pressure on the post tib tendon where it inserts into the navicular (that squishy part you can feel) to cause pain and - if done repeatedly (like, up to 35 mpw during a marathon training season, lol) to ultimately cause post tibial tendonitis? As an example, I wear "no show" socks which run right across that area and one of the first "symptoms" I had was a sore navicular, very tender to the touch.

    I've been struggling with PTTD since last August, but didn't it didn't get ugly until mile 17 of the Chicago Marathon. I've gone through all of the protocols everyone else has mentioned except a boot or a brace. My PT said a boot would cause immeasurable other problems up the chain and a brace irritated my navicular just having it on so I declined.

    I was off running from Dec 1 to Apr 1 (more on that below) but was able to bike pain-free during that time as long as I loosened up my shoe...keep the navicular free. Interestingly, over the last eight months my greatest "healing spurt" took place when we were in Europe in March. I walked 6-8 miles a day, but wore tights or long socks with loose-fitting boots. When we came back, I could walk around barefoot (and my affected foot is super-flat and pronates) with ZERO pain. Went for a run the next day (socks around navicular area, tight-ish shoes) and boom, back to pain in that specific area.

    Saw a foot/ankle ortho who told me I needed orthotics (I'm skeptical, but he's saying it's that, stop running, or get surgery) and I have a pair of accommodative orthotics until my pedorthist can get me the rigid ones in three weeks. I've worn them twice for biking and both times was unable to bike more than ten minutes without my navicular hurting and that irritating the rest of the area. There's a really high medial post on my orthotics, and I'm wondering if that is also one of the culprits as I know my navicular is hitting it. Even more frustrating, that slight AM irritation seems to linger through the day even with icing. I didn't bike yesterday...no pain. Biked this AM, more pain. Once that PTT flares up...even just a smidge...it takes a long time to quiet back down with me. One step forward, two steps backwards. No problems BTW, wearing the orthotics just walking around...not as much impact hitting the medial part of my shoes, I suppose.

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    1. Stacy - lot of information here. First off, if you can wear the orthotics out of the bike shoes pain free, but with pain in them, it's a shoe issue should you choose to continue with these orthotics. Maybe you can put a "shoe tree" in the painful shoe when not in use and stretch it just a bit. I'm no orthotic expert but in my experience, those made for bikers seem to be more "arch-heavy" than those for runners. But that's just an observation. If you talk to your orthotist, bike shoes in hand, I'll bet a middle ground could be found with not much more than a little trial and error. Some athletes have old bike shoes that could even be split over the area of pain for a further measure of relief. Then, if the PTT can be unloaded sufficiently, as your care giver seems to be trying to do, the potential to exercise pain-free increases. Just as the symptoms didn't come on over night, neither will relief be instantaneous. I suspect you've had other run/bike related injuries to realize this and PTT problems may be among the slower to resolve. I would try to avoid surgery if I could, being patient with the care your "team" presents gives you the highest likelihood of relief.
      Good Luck.
      John

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  63. Thanks for responding! And I should've been more clear - the orthotics are in my running shoes (and were made for them), which I'm also using for biking at the gym. These are also the "accommodative" softer orthotics I have until my rigid ones come in...concerned those might cause more problems.

    PTT has definitely been the slowest to resolve, and that includes three months on crutches w/a pelvic stress fracture when I started running 7 yrs ago (caused by overcorrecting my gait with motion control shoes, I believe).

    Had I known what this was 12 weeks into marathon training last year (I wasn't diagnosed until after the marathon and the pain never lasted more than the day after my Saturday long runs during training), I probably could've shut all this down then. Who knows. Could've, should've, would've! :)

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    1. A positive attitude goes a long way. Keep it up.
      John

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  64. Hi Dr. Post,
    I have been struggling with ankle issues for over 4 years now I am a 55 year old female. I used to walk about 5 miles every other day, but not so in the last 3 years. I started off having pain in the joints of my second toes they started going numb at the tips. I also had swelling on the outside of my ankle around the outside of the bone. I went to one foot doctor and was given steroid shots and they helped a little but it always came back and it seemed that was all that was offered. I was told I had metatarsalgia and to take anti-inflammatory medication. After 1 1/2 years of this I went to an orthopaedic who told me I had peroneal tendonitis and was put in a lace up brace and given steroid shots. The shots worked and the brace helped somewhat. After about 8 months the pain had returned and the numbness was awful. I went back to the orthopedic and he asked if I wanted more shots. I told him no I wanted a better explanation and solution. Was told to wear the brace again. One morning it became so painful on the outside of my ankle and was so swollen that I could hardly walk and my toes were so numb that I decided to try another foot doctor. I went to the new doctor the next day. She said that I had osteoarthritis in my toes and metatarsalgia. She had me go for blood work to rule out rheumatoid arthritis and gout thank God I dont't. She asked me to do a tip toe test. I could on the right foot but the left foot I could not. I was surprised by this and she told me that I had posterior tibial tendonitis dysfunction. My ankle was pronating in badly also. I was given meloxicam 15 mg and told to go have an AFO brace and orthodics made. I did this and now comes the questions that I have from this.
    1) I never had any kind of swelling or burning on the inside of my ankle before..can you have pttd to only affect the outside of the ankle?
    2) The rigid brace is causing the bones on the inside of my ankle to protrude up and outward and the tendons on the outside (Peroneal area) and in the Achilles tendon area are burning. It hurts so bad when I take it off that I ice it and then use a heating pad with voltaren crème. Do you think this brace is hampering or could it be hindering healing.
    3) Could blood flow stimulation therapy help with the healing of these tendons in addition to the brace and orthodics?
    I really want to be follow doctor orders but I don't want surgery either. Any insight would be appreciated especially for the blood flow stimulation therapy.
    Thanks you so much!
    Jeanie

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  65. Jeanie -sorry you're so slowed down by this constellation of symptoms but let's see if we can't help you out. Let's start by breaking this problem into parts, addressing each, and perhaps helping a little. Metatarsalgia is pretty common, and separate from the above. It can be helped by different types of insoles, shoe inserts and the like, weight loss (no idea if appropriate in your situation,) and choice of footwear. Many different types of running shoes seem to be of benefit. I know our local running shoe store is prepared for this customer request. Peroneal tendonits, as you're aware is an outside or lateral ankle issue where PTTD is medial, or more correctly posteromedial. It's not easy to join the two diagnostically. Any bracing that's recommended is supposed to help, not hurt the patient. It's not uncommon for initial brace recommendations to be "close but no cigar" and need to be adjusted/fine tuned/changed to help the patient as an individual. From what you say, sounds like reevaluation of the recommended brace is a next step. It shouldn't make you reach for the heating pad and Voltaren gel when it comes off. Why not try those two first steps, see if they don't improve your overall well being, and then discuss the next step with your doc. Sorry but I'm not familiar with blood flow stimulation therapy. Good luck.
    John

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  66. Hello Dr. Post:
    My question to you is about foot pain post-op of PTTD surgery. How much is normal and for how long? Is the pain and swelling just part of the healing process as the foot finds it new configuration?

    My 17-year old son is just over 9 months post-op from his PTTD surgery (left foot) and is experiencing more pain as he starts to test and use his foot. At 7 months post-op he was feeling pretty good. But now he is experiencing pain and is feeling down. He expected to be back to running by now or at least pain free. Currently though, he is just trying to walk without it hurting and enjoy being a teen. He continues to go to PT and the pain subsides somewhat, but it is considerably more than when he was 7 months post-op. I'm considering moving up his follow up appointment with his surgeon.

    His procedure included a PTT tendoscopy, calcaneal osteotomy, arthrex internal brace, and slight achilles tendon release. He was a youth distance runner. His PTT issue began 2+ years ago and after more than 12 months with pain, even after casting, booting, bracing, and physical therapy, we opted for the surgery. His MRI showed a spring ligament tear and and inflamed tendon. The surgeon said the tendon was intact and healthy so a tendon transfer was not necessary.

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    1. Darryl - while each patient is an individual, you would anticipate that he'd be further along than this. Time to express those feelings to his doc.
      John

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  67. Hi Dr. Post! I'm a 17 year old athlete and was diagnosed with PTT nearly three months ago. I was immobilized right away, and it has progressively gotten worse in the walking boot. My podiatrist continues to tell me that it may take up to twelve weeks(which will be next week for me) for the tendon to fully settle down. But I feel as though my tendon has been doing anything from that!! I have also been on crutches/knee scooter for three weeks. It just doesn't seem to be getting any better. Do you think I should try and find a new doctor? Senior year is approaching, which means it is my last year to play the sports I love. I don't want anything more than to be able to do them. Thanks in advance!!

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  68. Good Morning - I don't know you name since you didn't sign your request. (Something you'd like to change.) PTT is not just a problem with adults. Your age group is also at risk. I've heard it described as a disease of patience since it can take months to resolve. I don't know anything about your care giver but always encourage a 2nd opinion if the patient has unanswered questions or feelings. In my (biased) opinion, I'd look for an orthopedic surgeon, member of the American Academy of Orthopedic Surgeons. Until then, this may provide you with a little knowledge. http://www.pedortho.com/files/PIFoPostTibTendonitis.pdf
    Good luck,
    John Post, MD

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