Posterior Tibial Tendon Dysfunction in Children
Children can develop posterior tibial tendon dysfunction (PTTD), though it is much less common in pediatric populations than in adults and requires different evaluation considerations based on age and developmental stage.
Pediatric Presentation and Evaluation
Posterior tibial tendon dysfunction can occur in children, but clinical guidelines focus more on evaluating foot health in specific contexts:
Annual comprehensive foot examinations are recommended for children with diabetes once they reach puberty or age ≥10 years (whichever comes first) and have had diabetes for at least 5 years 1.
These examinations should include:
- Visual inspection of the foot
- Assessment of foot pulses (dorsalis pedis and posterior tibial)
- Sensory testing (pin-prick and 10-g monofilament)
- Vibration testing using 128-Hz tuning fork
- Ankle reflex testing 1
Diabetic neuropathy, which can affect posterior tibial function, rarely occurs in prepubertal children or after only 1-2 years of diabetes 1.
Differentiating PTTD from Other Pediatric Foot Conditions
When evaluating for possible PTTD in children, it's important to consider other more common pediatric foot conditions:
Congenital tibial pseudarthrosis (CPT) may present with similar symptoms but represents a different pathology requiring specific treatment approaches 1, 2.
The primary goal in treating pediatric foot deformities should be achieving a functional, pain-free lower limb with proper alignment and equal limb lengths 1.
Unlike adult PTTD which is often degenerative, pediatric cases may be related to:
- Congenital anomalies
- Trauma
- Inflammatory conditions
- Neuromuscular disorders
Diagnostic Approach
When PTTD is suspected in a child:
- Evaluate for pain along the course of the posterior tibial tendon
- Look for evidence of flatfoot deformity that worsens with single-leg heel rise
- Assess for tenderness behind the medial malleolus
- Examine for hindfoot valgus and forefoot abduction
- Compare bilateral foot structure and function
Treatment Considerations
Treatment of PTTD in children differs from adults:
Initial management should be conservative with:
- Activity modification
- Supportive footwear
- Orthotic devices
- Physical therapy focused on strengthening
Surgical intervention is rarely needed in children except in severe cases with significant functional impairment or pain that doesn't respond to conservative measures.
Growth and development considerations must be factored into any treatment plan, as the foot is still developing.
Clinical Pearls and Pitfalls
- Pitfall: Misdiagnosing PTTD as simple flexible flatfoot in children
- Pitfall: Failing to consider neuromuscular causes of flatfoot in children
- Pearl: Always compare bilateral foot structure and function
- Pearl: Consider age-appropriate functional assessment rather than just structural evaluation
While PTTD is most commonly associated with adult acquired flatfoot deformity 3, 4, 5, 6, 7, recognizing that it can occur in children is important for early intervention and prevention of progressive deformity.