Flat Feet

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The foot of a person affected by PTTD or flat feet
Foot of a person affected by PTTD or flat feet

Posterior tibial tendon dysfunction (PTTD) is a condition under which the posterior tendon of the foot becomes injured and is eventually unable to provide the required support to the foot. As a result, the arches of the foot eventually collapse. As a result, PTTD is closely associated with adult acquired flatfoot or flat feet. It is in fact the most common cause of adult acquired flatfoot. The initial symptoms of flat feet are pain and swelling on the inner ankle, eventually spreading to the outer ankle as well. Treatment of flat feet will usually start conservatively and include rest, icing and the use of shoe orthotics or ankle braces. If these approaches do not work, your doctor may decide to try cortiscosteroid injections or one of various types of surgery.


The posterior tibial tendon connects one of the small calf muscles to the bottom of your foot. It passes through the middle of your ankle and helps to maintain the arches of your foot as well as keep the foot optimally aligned with the rest of your body. This alignment is important in helping you to walk properly and support the weight of your body. Damage to the posterior tendon can therefore cause flattening of your foot arches and misalignment of your foot.

The most common cause of flat feet that appears in adulthood  is overuse of the posterior tibial tendon. The activities that can give rise to this overuse include high impact forms of exercise like extensive running, walking, hiking or climbing stairs.

In other cases, flat feet can be the result of trauma of the posterior tibial tendon due to ankle fracture or a direct blow.


In many cases, PTTD may occur in one foot only. However, there are also cases in which it occurs in both feet.

According to the Journal of Family Medicine & Primary Care, PTTD typically occurs in obese middle aged women and has a prevalence of up to 10% among this group. Up to 60% of individuals with the condition also have conditions like obesity, hypertension or diabetes, use steroids or have experienced foot or ankle trauma.


The symptoms of flat feet are usually pain and swelling on the inside of the foot, near the ankle. In the advanced stages of the condition, this pain and swelling may spread to the outer foot. The area in which you experience pain and swelling may also appear red and warm to the touch.

Other symptoms that you may observe if you have flat feet are:

  • Inward rolling of the affected ankle (toward the center of your body);
  • Outward turning of your forefoot and toes.

As the condition reaches its advanced stages, it may evolve into arthritis in the foot and ankle.


As can be seen from the above, PTTD or flat feet can develop into a serious problem if left untreated. You should seek urgent help if you suspect that you have this condition.

After confirming that you indeed have this condition, your doctor will likely try a conservative (non surgical) treatment option as a first option. If the PTTD proves resistant to these treatments, your doctor may consider and attempt a more aggressive approach like injections or surgery.

Conservative Treatments

As a first option, and if your PTTD is mild, your doctor may first suggest resting the posterior tibial tendon. To do this, you can refrain from high impact activities for a period in order to give the posterior tibial tendon a chance to recover. Consider switching to low impact activities as alternative forms of exercise, like swimming or cycling. In addition, your doctor may suggest:

  • Icing your ankle or applying a cold compress. Try this for periods of 20-30 minutes every couple of hours to reduce pain and inflammation;
  • If your pain is severe, you can also try an over the counter pain relief medication like aspirin;
  • For mild flat feet, you can try an over the counter pair of shoe inserts. If the condition is a more pronounced, you can visit a podiatrist (chiropodist) who can measure you for custom made orthotics. These are more expensive but also much more effective than over the counter inserts at addressing flat feet. Inserts will provide arch support and, in so doing, take the pressure off the posterior tibial tendon and possibly allow it to recover.
  • Another conservative treatment option involves the use of a walking boot to immobilize the foot and allow healing to occur. The drawback of this approach is the risk of atrophy (weakening) of the foot muscles if you wear the boot for too long.
  • You can also consider wearing an ankle brace that is designed to take pressure off the posterior tibial tendon and allow it to heal.
  • In addition to the above treatments, your doctor may consider cortisone injections to reduce inflammation. He or she will inject the cortisone near to the tendon. Injecting it into the tendon introduces a risk of tendon rupture, so your doctor will likely avoid doing this.

Surgical Treatments

If your PTTD does not respond to conservative treatments, your doctor may decide to try surgical intervention. Surgery may be performed to:

  • Lengthen the calf muscles (known as gastrocnemius recession). This can be a successful procedure but you may then experience difficulty pushing off the foot with adequate force. This can then affect your ability to jump or sprint;
  • Clean the tendon (a procedure also known as tenosynovectomy) by removing the inflamed tissue around it. If your flat feet condition is still in the mild stages, this can be effective in solving the problem. However, unless your doctor takes additional steps to address the root causes of your PTTD, the posterior tibial tendon may continue deteriorating and the condition can return;
  • Replace the tendon with another foot tendon, or attach the transplanted tendon to the damaged tendon;
  • Reshape the arches of the foot to recover their original shape. This represents a step up in treatment aggressiveness as the surgeon will usually need to cut into the bones of the foot;
  • Fuse the joints at the rear of the foot to restore its original, more natural shape.

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