What’s the best way to deal with a posterior tibial tendon dysfunction? My doctor calls it the PTTD of middle age.

The posterior tibial tendon (PTT) is important in supporting the arch of the foot and helps turn the foot inward during walking. As we age, our tendons can degenerate, or wear down and weaken over time. Degeneration in a tendon usually shows up as a loss of the normal arrangement of the fibers of the tendon.

As the tendon heals itself from wear and tear, scar tissue forms, thickening the tendon. This process can continue to the extent that a nodule, or knot, forms within the tendon. This condition is called tendonosis.

The area of tendonosis in the tendon is weaker than normal tendon. The weakened tendon sets the stage for the possibility of rupture of the tendon. Tendonosis may develop into tendonitis if the weakened area becomes inflamed.

Treatment depends on the severity of the PTT disorder and can include conservative (nonoperative) care or surgery. Conservative care consists of adapting shoes, using an insert called an orthotic) inside the shoe, and sometimes, immobilization in a cast or boot.

Physical therapy may be helpful in regaining alignment through postural adjustments, strengthening exercises, and manual therapy to restore tissue tensegrity (balance of tension and compression). Other nonoperative forms of treatment may include a rigid (nonflexible) ankle-foot-orthosis or AFO. Some patients will end up wearing the AFO permanently to support the foot and ankle.

you may be wondering about surgery? When is that appropriate and what does the surgeon do? This is an area of considerable debate and an area for continued study. Transferring another tendon to take the place of the torn, ruptured, or degenerated PTT is one option.

One of the goals of surgery is to stabilize the joint and improve alignment. Procedures to accomplish this goal can be quite complex with lengthening of some muscles, repair of damaged ligaments, and/or fusion of certain ankle bones.

All surgical procedures are followed by immobilization, a period of non-weight bearing, and then rehab with a physical therapist. Full recovery can take 12 weeks or more. But before you see yourself in this situation, talk with your surgeon about what’s best for you. Your age, general health, physical condition, and severity of the PTT disorder are all factors in planning the best care for you.