Tibialis Posterior Tendon Dysfunction

Normal Anatomy Tibialis posterior part of the deep posterior compartment of the lower leg Tendon passes behind the medial malleolus Poor tendon blood supply around the medial malleolus Tibialis posterior eccentrically contracts during heel strike to resist pronation and tibial internal rotation Locks the arch and rear foot during heel rising to turn the foot into a rigid lever Stabilises the medial longitudinal arch Allows the gastrocnemius to act with greater efficiency

Pathology A sudden or progressive loss of strength of the tibialis posterior tendon Can be due to rupture or tendon degeneration Leads to a collapse of the medial longitudinal arch Most common cause of acquired adult flatfoot deformity (AAFD)

Mechanism of Injury Insidious Traumatic Mechanical Overuse Systemic disease Degeneration Traumatic Acute Traumatic rupture

Classification Stage I Stage II Stage III Stage IV Tendon degeneration or inflammation No deformity Single limb heel rise is painful but normal Stage II Tendon is ruptured or functionally incompetent with more advanced degeneration Flexible planovalgus foot Unable to perform a single limb heel rise Hind remain remains flexible Stage III Advanced foot deformity Subtalar joint osteoarthritis Hindfoot is fixed during single limb heel rise Stage IV Ankle joint involvement Valgus tilt of the talus in the ankle mortise

Subjective Examination Insidious onset of unilateral acquired flatfoot deformity (bilateral is rare) History of trauma maybe reported in some cases Pain and swelling along the medial foot and ankle, medial arch, medial calf Heel raising in standing painful and difficult Pain and difficulty walking up/down stairs, uneven surfaces Reports a sensation of walking on the medial ankle Reports uneven wearing of sole of shoes

Objective Examination Pain, swelling or fullness on palpation of the posteromedial ankle Abducted foot and loss of longitudinal arch Hindfoot valgus “Too many toes” sign- abducted forefoot Standing Single Leg Heel raise – weak or nil heel inversion Weakness of inversion in plantarflexion and eversion Limited subtalar motion

Objective Examination

Further Investigation X-ray Ultrasound MRI

Management Conservative management for stage 1 most commonly Conservative management for stages II, III, IV often completed but unsuccessful Main goal is to reduce pain, support medial arch and prevent development

Conservative Reduce pain and inflammation Ice NSAID’s Orthotics Massage Restore Normal Range of Movement Ankle and Foot Soft tissue massage Foam rolling Stretching Dry needling Joint mobilisations Joint manipulations Restore Normal Muscle Activation Intrinsic foot muscles Tibialis Posterior (Heel raises with inversion) Tibialis Anterior

Plan B Depends on the stage Stage I Stage II Stage III Stage IV Tenosynovectomy Debridement Stage II Soft Tissue reconstruction and tendon transfer Stage III Triple arthrodesis (fusion) Calcaneocuboid, talonavicular and subtalar joints Stage IV Ankle Joint Fusion plus triple arthrodesis

References Bowring, B. and N. Chockalingam (2010). "Conservative treatment of tibialis posterior tendon dysfunction--a review." Foot (Edinb) 20(1): 18-26. Bubra, P. S., G. Keighley, S. Rateesh and D. Carmody (2015). "Posterior tibial tendon dysfunction: an overlooked cause of foot deformity." J Family Med Prim Care 4(1): 26-29. Geideman, W. M. and J. E. Johnson (2000). "Posterior tibial tendon dysfunction." J Orthop Sports Phys Ther 30(2): 68-77. Howitt, S., S. Jung and N. Hammonds (2009). "Conservative treatment of a tibialis posterior strain in a novice triathlete: a case report." J Can Chiropr Assoc 53(1): 23-31. Kulig, K., S. F. Reischl, A. B. Pomrantz, J. M. Burnfield, S. Mais-Requejo, D. B. Thordarson and R. W. Smith (2009). "Nonsurgical management of posterior tibial tendon dysfunction with orthoses and resistive exercise: a randomized controlled trial." Phys Ther 89(1): 26-37.