All right.
So posterior tibial tendon dysfunction adult flatfoot deformity. Still no disclosures. All right. So I'm going to briefly go over this and then talk about some keys to successful non operative management and then provide some tools for patient education. So posterior tibial tendon dysfunctions the most common cause of adult acquired flat foot deformity. It's more common in women and it's most common in the sixth decade of life. So risk factors are obesity chronic steroid use in sero negative inflammatory disorders. So as far as the anatomy. So the posterior tibial tendon runs immediately behind the tibia behind them medial manuals and a very shallow groove it's bound tightly by a flexor retinaculum and then inserts on actually eleven different points throughout the bottom of the foot. So an extremely broad insertion. So important things that make this extra incredibly important tendon very susceptible to pathology and dysfunction are a couple of things one. There's actually a vascular watershed region closer on the left picture by that leg the lower arrow there's a poor blood supply region there. Also despite how important this tendon is there's really only two centimeters of excursion. So it doesn't always work in two centimeters. So if you imagine then you have very small disruptions or partial tears that can cause a huge effect because it's such a big percentage.
And briefly the also important for this talk is the plantar calcaneonavicular ligament or the spring ligament so that goes from the sustentaculum taliof the calcaneous to the navicular and this is responsible for maintenance of your longitudinal arch. So as I mentioned you have. A sharp turn. In a very narrow groove which is making the susceptible to repetitive micro trauma in an area that has poor blood flow which essentially can over time lead you to a non-functional tendon. So it's very rare to have a full rupture of this tendon but typically what happens is you have chronic degenerative changes small partial tears and it essentially lengthens enough to be intact but not have any to haven't two centimeters of excursion. So there's a clinical photo here. The one that's in the pickups is this posterior tibial tendon and see at least just doesn't look very good compared to the one that's immediately below it is normally a smaller tendon but not that big a difference and it's shinier than than the unhealthy posterior tip tendon. Try not to nerd out too much on this but I think this is incredibly cool and one of the reasons why that if an ankle fellowship so where this does its magic is the transverse tarsal joints so that your talonavicular and joints.
So the picture is not as incredibly important in terms of orientation but the key is when the posterior tibial table tendons relaxed and your foot is even rooted or essentially in that flat position the two joints the plains of motion are are lined up. And so imagine it hinges on a door. So they move freely it's a supple joint that puts your tip 10 and fires and that spins the four foot into super nation. So it makes the joints no longer in here. And so if you imagine two hinges on a door that aren't lined up it's not going to move. So that makes your foot able to be a rigid lever arm for your gastric to fire and allow someone like Zion Williamson's friends two hundred eighty pounds leap through the air dunk a basketball and then his push your tip relaxes just joints become supple again and he can come down and all that force and land on his foot and not have injury and can continue running.
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