What the heck is PTTD and why do I need surgery?

PTTD Defined

PTTD stands for posterior tibial tendon disorder/dysfunction.  The posterior tibial tendon provides stability and support for the arch of the foot.  When the tendon gets inflamed or torn, the entire arch structure can be compromised, resulting in a flat foot deformity. 

Minor cases may be treated with orthotics, braces, periods of rest (stabilized in walking boots or casts), and physical therapy.  More severe cases require surgery.  

Want more information? -->  Ortho Info

My Case

April 2012-  The first sign was unusual swelling of my ankle about 8 hours post a 12 mile long run.  I was about 4 weeks out from running a full marathon and I was 2 weeks away from running a half marathon.  I rested my ankle for the remaining weeks up to the marathon, while diligently icing, compressing, and elevating. Being the athlete that I am, there was no way that I was going to pull myself out of my upcoming half marathon for a little ankle pain.  Oh how hindsight is 20/20.

April 29th, 2012- My last running race, a half marathon (13.1 miles).  I woke up at 4 am on race morning to the sound of heavy rain.  I refused to let my ankle or the weather stop me from running this race.  This was the moment that I knew that I was a "real" runner, because I was ready to run rain or shine.  I was hopeful that the rain would stop at some point, but it rained the ENTIRE race.  I finished the race and literally collapsed at the end, after setting a PR, of course.  Some of my tri friends have a saying, "PR or ER." I accomplished both with this race.   Minutes after I finished the race, I experienced a rush of pain in my ankle while checking the computers for my race time, and then out of nowhere, my ankle gave out and I was on the ground.  The EMT/Firefighters had to carry me over to a table to check out my ankle.  Since I wasn't able to put any pressure on my foot, I ended up getting a thrilling ride to my car on the emergency vehicle.  When I returned to my apartment, I literally ended up crawling around the rest of the day because my ankle would simply not function.  Of course I had a million things to do the next day (a Monday), so luckily I was able to rent a pair of crutches from my health center.  

May 2012-  After a few days of crutching around, I knew that there was something really wrong with my ankle.  Even as the post-race swelling went down, putting pressure on my ankle was really painful.  I went to an urgent care hospital for some X-rays.  At the time, the doctor was really stunned as to what could be wrong with me, but he did suspect an accessory navicular bone.  They sent me home with crutches I could keep, yay!  I returned the rental crutches the next day, and convinced the health center to prescribe me a walking boot.  After 5 days, I had already had enough of those stinking crutches.  Both the health center doctors and the urgent care doctor recommended I see an orthopedic surgeon for more clarity.  

I had to wait 2 weeks before I could get an appointment.  These two weeks were the absolute worst.  Since I didn't know what was wrong, I did absolutely no exercise out of fear of injuring my ankle further.  I went from running ~40 miles a week with additional spinning and lifting workouts as cross-training to NOTHING.  When I finally got to see an orthopedic surgeon, he took more X-rays and concluded that I didn't have an accessory navicular bone.  He theorized that I likely had a few hairline fractures and a badly inflamed posterior tibial tendon.  He wanted me to spend an additional month in the boot. :/  The good news was that he did permit me to swim and bike for fitness.  Being that I hadn't done either since probably middle school, I had a lot to learn!  

June 2012-  I had a follow-up appointment with my orthopedic surgeon.  He looked at my ankle and was happy with the progress.  After 6 weeks, he freed me from the jail sentence with my boot and approved me to slowly return to running.  He recommended I run a block, walk a block, until I felt comfortable running again.  After the boot, my ankle felt much better than it did when I initially injured it, but deep down inside, I knew something still wasn't right.  I did feel like if I really slowly returned to running that I would be alright.  

For the rest of the summer, I focused primarily on swimming and biking, but I did try to run/walk approximately 20 mins, 3 times per week.  At this point, I was hooked on the combination of the three sports.  I decided that there was no better time to convert my training identity as a runner to a triathlete.  I invested in the right gear, and signed up for my first race .

August 2012- School started again.  I am a graduate student and that meant that my daily activity increased exponentially from the summer.  Bad news for my tendon.

September 9th, 2012-  My first triathlon!  It was a sprint distance (400m swim, 10 mile bike, 3.1 mile run).  I had an absolute blast!  My ankle didn't bother me too much, but I also did not push myself during the run portion.  After this experience, there was no question that I was born to compete in triathlons (hence my pen name).  I was smiling ear to ear every minute of the race.  Of all the running races I have completed, I can not list one that I had that much joy doing.

Rest of September 2012- Since I had some residual tingling and pain up the posterior tibial tendon, I decided to schedule a follow-up appointment with my orthopedic surgeon.  He checked out my ankle, and out of nowhere, he told me that I would never be able to run again!  Soon after, I found myself balling tears in his office.  I could not believe that what I thought was a minor ankle injury could take me out of not only running, but my newfound love, triathlons, FOREVER!  I was in absolute shock and disbelief.  He wanted me to get an MRI to confirm and come back and see him in a couple of weeks.  In the meantime, he prescribed me another 6-week sentence in the boot.  

The MRI results were inconclusive at best.  I had mild inflammation of the posterior tibial tendon and some partial tears around my ankle.  Much to our surprise, my MRI also revealed a cartilage tear.  He gave me two options.  He said that I could get a cortisone shot and see if that helps or finish my boot sentence and see if it gets better on its own.  I chose the boot sentence, because I didn't want to risk the shot compromising the integrity of my tendon.

October 2012- Immediately after being told that I would never run again due to this injury, I did hours and hours of research on this condition and what could be done to remedy it.  I started investigating the diagnostic techniques and analyzing my ankle to the standards.

I first noticed that I had a major problem when my foot presented the "Too many toes" sign.  It is when you can see your smaller toes when looking at your ankle from behind. The tendon can become so weak that it allows the ankle bones to completely collapse inward on the arch.  This is a picture of my feet from behind.  If you compare my ankle to the illustration in this post, it is a match for hindfoot valgus and a flat foot deformity.

I had my follow-up appointment with my orthopedic surgeon, which was one of the most frustrating days of my life.  At this point, he had been treating me for over 5 months, and he literally threw his hands up in the air and said that he didn't know what to do.  He then referred me to a foot and ankle specialist.

November 2012-  I had my first appointment with a foot and ankle specialist at a Sports Medicine Orthopedic practice.  I absolutely LOVED this new doctor.  He tested my ankle in ways the general orthopedic surgeon had no idea how to do.  He provided extraordinary detail in what exactly was wrong with my foot and why all of this happened.  At this appointment, I failed the single limb heel raise test.  I could not go up on my toes on my left foot.  I was shocked!  

The doctor suggested that I get custom orthotics and see if that helped me any and that I come back and see him in a few weeks.  At the time, he wanted me to avoid surgery at all costs.  He said, "If it were me I would give up extreme exercise and do less strenuous activity like yoga and cardio classes at the gym."  I couldn't believe this man.  He is obviously not a runner.  He only suggested surgery if I couldn't do activities of daily living without pain.

Guess what?!?! Not long after the appointment with this doctor, my activities of daily living started to become impossible.  I could not walk more than 50 feet without pain or stand longer than 10 minutes.  Showers became the worst part of my days, and still are, because I can't have any type of orthotics or shoes on my feet in the shower.  I could no longer tolerate the standing it took to cook food, walking around campus, standing while waiting in lines, grocery shopping.  None of that.  I started to feel like my tendon was shredding with EVERY SINGLE STEP OF EVERY SINGLE DAY.  The active girl that was running 40 miles a week, was now completely sedentary!  Swimming and biking became increasingly difficult as well.  I couldn't survive longer than a 30 min workout of either, and I would have to recover for 2 days before even thinking about my next training session.

I did a lot of soul searching and I knew that I could not live like this for the rest of my life.  25 years old is too young to quit living an active life.  I knew that I had to start seriously looking in to having surgery.  I scheduled another appointment with my doctor.

December 2012-  I convinced my doctor that I needed to have the surgery.  He did his very best to try to make me back away from the ledge, but nothing he said made the realization of what my life has become and its future prognosis any better.  Not even the fear of the pain and the long recovery of the surgery is bad enough to continue living like this.  Based on my life timeline, it made the most sense to have the surgery in January.  As a last ditch effort, he prescribed more severe orthotics and had me try Mobic, an NSAID, anti-arthritic medication to see if I had any improvements.   Big surprise...it didn't work!

January 2013-  I ended up switching to another surgeon in the same Sports Medicine Practice a week before the surgery upon recommendation of my former doctor.  It has been a crazy shake-up, especially considering that I have only met the surgeon that is going to do the procedure 1 time.  The good news is that he is more experienced at flat foot reconstruction surgery and typically works with younger athletes.  

I have been poked and prodded and given all of my blood away to complete the pre-operation procedures.  I have also been preparing my apartment and my life for many months of crutches + splints/casts/boots/ankle braces.

My surgery is on Tuesday, January 15th, 2013.  I will not know the time of the surgery until tomorrow afternoon.

This post is long enough!!!! On my pre-surgery eve...tomorrow, I will detail the surgical procedures I am having.

Good night!