PT Tip of the Month Archive

Posterior Tibialis Tendon Dysfunction

Foot and ankle anatomy

The posterior tibialis muscle originates on the proximal, posterior portion of the tibia bone, the interosseous membrane, and the proximal fibula. The posterior tibialis tendon wraps around the medial malleolus of the ankle and inserts into the navicular and adjacent tarsal and metatarsal bones on the plantar aspect of the foot. This muscle is responsible for inversion of the foot (rolling the foot inward) and plantarflexion (pointing the foot and toes downward) of the ankle. The tendon also plays a role in stabilizing the longitudinal arch of the foot.

What is Posterior Tibialis tendon dysfunction?

Posterior tibialis tendon dysfunction (PTTD) is one of the most common acquired flatfoot deformities among adults and is a degenerative process that results in tendinosis and elongation of the posterior tibial tendon. Degenerative tears usually occur posterior and distal to the medial malleolus, as this area has a limited blood supply and is also an area subject to compression beneath the flexor retinaculum. PTTD begins with a tenosynovitis (or inflammation of the sheath around the posterior tibialis tendon) or injury to the tendon itself. There is currently a lack of research to predict factors of PTTD, which may explain why the tenosynovitis progresses to a chronic, disabling disorder, and eventual rupture of the posterior tibial tendon. Dysfunction of the tendon and muscle results in altered foot biomechanics: the antagonist muscle (peroneus brevis) contracts and results in hindfoot aversion, which causes stretching of the medial ankle ligaments and soft tissue of the ankle; the spring ligament, which helps to support the medial longitudinal arch of the foot, begins to fail; and the Achilles tendon shifts, all of which position the foot into an even more exaggerated "flatfoot" deformity. These altered foot and ankle mechanics lead to difficulty with activities such as walking, standing, and stair climbing without experiencing pain and fatigue.

The literature describes 4 stages of PTTD:
-Stage I: characterized by tenosynovitis, no deformity, and preservation of posterior tibialis strength. Patients may note a history of flatfoot deformity.
-Stage IIa: characterized as a mild/moderate deformity (some abduction through the talonavicular joint, or flatfoot).
-Stage IIb: characterized as severe flexible deformity with more flatfoot positioning noted than in IIa.
-Stage III: characterized as a fixed deformity with lateral pain due to fibular impingement.
-Stage IV: characterized as foot and ankle deformity secondary to deltoid ligament incompetence.

Causes

According to Wukich (2010), approximately 25% of patients presenting with PTTD have a history of medial ankle sprains. Upon exam, these patients have a pes planus deformity, also known as flat foot, which is exacerbated as the tendon elongates. Degeneration may be initiated by a traumatic event, however most cases are insidious in nature.

According to Squires (2006), patients with certain conditions may be predisposed to tendinopathies. These conditions include: hypertension, diabetes mellitus, and obesity. Other factors include: systemic inflammatory diseases, seronegative arthropathy (i.e. Reiter's syndrome, ankylosing spondylitis, and psoriatic arthritis), a history of previous surgery, a history of systemic steroid use or local steroid injection, or a prominent navicular tubercle. Older, obese women are also a common population to present with PTTD.

Signs and symptoms

Patients presenting with PTTD experience pain in the posteromedial ankle and swelling over the posterior tibialis tendon. In chronic cases of PTTD, patients experience more lateral pain due to fibular impingement at the calcaneofibular joint. During clinical examination, the patient may demonstrate a positive "too many toes" sign from behind and may not be able to raise the heel off the ground (or averts the foot while doing so) while performing a single-leg heel raise.

Treatment

Nonoperative treatment may involve wearing a boot, cast, or customized brace, along with taking nonsteroidal anti-inflammatory drugs or oral steroids prescribed by a physician. From a physical therapy perspective, a thorough lower extremity alignment will be conducted to look for any deformity. Physical therapy goals will focus on reducing pain, improving or maintaining alignment, and preventing progression of deformity. Modalities may be used, including ultrasound, iontophoresis with dexamethasone, and cryotherapy. Other intervention may include foot and ankle exercises, stretches, or use of an ankle-foot orthosis. Research indicates patients should be managed nonoperatively for at least 3 months prior to considering surgical options. If you feel that you are experiencing signs or symptoms of posterior tibialis tendonitis, and you would like to schedule an evaluation, call 617-232-PAIN for our Brookline office, and 617-325-PAIN for our West Roxbury office.

References

  1. Geideman WM and Johnson JE. Posterior tibial tendon dysfunction. J Orthop Sports Phys Ther. 2000;30:68-77.

  2. Kulig K, Reischl SF, Pomrantz AB, et al. Nonsurgical management of posterior tibial tendon dysfunction with orthoses and resistive exercise: a randomized controlled trial. Phys Ther. 2009;89:26-37.

  3. O'Connor K, Baumhauer J and Houck JR. Patient factors in the selection of operative versus nonoperative treatment for posterior tibial tendon dysfunction. Foot Ankle Int. 2010;31(3):197-202.

  4. Squires NA and Clifford CL. Posterior tibial tendon dysfunction. Oper Tech Orthop. 2006;16:44-52.

  5. Wukich DK and Tuason DA. Diagnosis and treatment of chronic ankle pain. J Bone Joint Surg Am. 2010;92:2002-16.

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