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Foot & Ankle Problems Message Board

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I have a little different situation. My 16 year-old son had a posterior tibial tendon transfer for a drop foot in February of 2010. His functional PTT was transferred to the mid-foot to allow him to dorsiflex. To make a very, very long story short, since the surgery he has full use of the ANTERIOR tibialis muscle for dorsiflexion. Now his transferred PTT is anchored adjacent to tibialis anterior tendon not doing anything but causing him pain. He essentially now has PTTD from his previous surgery.

He is a very, very active and athletic boy. He plays football in high school and is a fitness enthusiast. Now with the lack of a PTT and subsequent flattening of his arch, constant pain and many other negative effects of the previous surgery, we are seeking professional consultations with foot & ankle specialists. We have seen two so far. Today, the Orthopod he saw advised the FDL transfer with removal of the previously transferred PTT. The PTT is not long enough to put back in its native spot on the navicular bone, so he would sew the PTT to the FDL tendon. Fortunately, his PTT has been working secondarily so it may add some extra strength to the FDL. He also would do a calcaneal osteotomy (maybe 5mm or so) and gastrocnemius recession to give him more plantar flexion.

We know my son's foot problems will only get worse. Because we went through similar discussions last year prior to his surgery and didn't really understand how taking away one muscle to provide another important function could cause so many problems. Before or recent consultations, we didn't want to have him get any surgery that would require transfer of one tendon to another site. Got burned on that once. However, I am not sure there are any other good options.

We are letting my son decide, with me and my wife backing him 100%. The main concerns we have are:

1) How much function do you lose in the toes without the FDL? How does it effect your activity level?
2) How much gastrocnemius function do you lose (push off with running) with the gastrocnemius recession (I think the doc called it a "gastroc slide")?

We have other questions and concerns. My son understands this is a major surgery and recovery is long...been there, done that.

Please, please, please understand that my son is very, very active. I am not looking to have him sign a multi-million dollar NFL contract anytime soon. But he wants to be able to be a normal, healthy active kid...and adult. If you saw him walking down the street now after the initial surgery, you would probably think that he looks great and walks normally. If that was all he cared about, we'd be fine as is. When he is running and changing directions and falls to the ground suddenly because of the lack of PTT function like he was shot by a sniper, we realize this cannot continue. I get concerned that he is going to tear up his ankle or blow his knee out in his current condition.

I really want to hear from people who are active and do activities that require change of direction and sudden starting and stopping. This would be very helpful.

Thanks in advance for your reply.
Hello Di,

Unfortunately, my son knows all too well how painful this procedure will be. It adds a little extra spice with the calcaneal osteotomy and screws. His initial PTT transfer was very painful. Six weeks in a cast and then physical therapy for a time after that. As far as pain and needing pain pills after the surgery, he used heavy pain meds for maybe three days. Again, he is realistic that this procedure will be equally or more uncomfortable. His doc says three months of immobilization and no running until 6 months after the procedure.

As you have read, my son is very athletic and active. Certainly this will be to his benefit. For the first surgery, we perhaps took the surgeon's advice to be so aggressive because we thought this would be the "cure" for his progressive drop foot. We did follow the advice for immobilization, PT, recovery and return to full activity. I think, even though he did not push it beyond what he was allowed, he continued to have pain mainly on the navicular bone and below the outside of the ankle. He probably has had a stress fracture of his navicular bone for many months that was just discovered on an MRI last week. Decisions were made then, not only for what we thought would be a long term debilitating drop foot, but so that he could get back to playing (American) football last year. Well, he did, but it was a disaster. He was amazingly practicing without a posterior tibial tendon last year and off season for the upcoming year. It became all too evident that it is impossible to function as an athlete without a PTT--just too much instability of the ankle. Hence, we are taking the upcoming plunge (my son's decision). This year of football is out. We are not even contemplating him making a return to football this year. Furthermore, as much as he wants to play the year after this one for his final year in high school, we will take things very, very slowly.

Di, as you mentioned, if he does not go through the surgery, then what do we expect to happen? He wants function back and even said in the past that he would rather have his leg cut off so he could use a prosthesis. A bit drastic and off the cuff remark, but that shows how frustrating seeing your leg appearing normal and not being able to make it do what it should and used to was. He has wanted a fix to the initial surgery for months, so that is not an issue. We were initially taken aback with knowing that there had to be a "transfer" of the FDL. Losing function of a muscle is what got us into this mess in the first place.

What he was able to do with his activities, although much less effective than he was originally capable, was amazing. That gives us confidence that once he gets a good part of the posterior tib function back, he will be much better off.

It has been a trying experience for our family. We are trying to focus on what he has and could regain and not justt he negative. It is very, very hard to completely dampen the anger, I must admit. I can understand the initial injury. Accidents happen. What is most bothersome is that the initial surgery wasn't necessary. That is very, very, very difficult to deal with.

When my son's drop foot first became clinically evident, he was slowing down, fatiguing easily with running, having difficulty changing directions and looking a bit clumsy. He had a major medical workup. As a physician myself, I could only think of things like leukemia, and progressive neuromuscular disorders. Fortunately, all test were negative and the drop foot was noticed at the tail end. So, as angry as I can get about what has happened, I know how I was feeling when the fear of a life threatening disease was on our minds.

Our family has smiled a bit more over the last week. We are cautiously optimistic for this surgery. I know there is always a chance for failure. I am an ER doctor and have seen people have complications from surgeries and even die from a routine tooth extraction. Less than that, everything can be put in the proper place with the PTT to FDL, osteotomy, etc. and he may only have 50% of normal function. I must say I would be surprised if he doesn't make a phenomenal recovery. He is just so darn strong and healthy...and young.

Thanks for your input. I will be a regular on these boards. It is very therapeutic for me to read these posts and post myself.

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