1. Tibialis Posterior Tendon Dysfunction

2. 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

3. 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)

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

5. 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

6. 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

7. 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

8. Objective Examination

9. Further Investigation
X-ray
Ultrasound
MRI

10. 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

11. 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

12. 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

13. References
Bowring, B. and N. Chockalingam (2010). "Conservative treatment of tibialis posterior tendon dysfunction--a review." Foot (Edinb) 20(1):
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):
Geideman, W. M. and J. E. Johnson (2000). "Posterior tibial tendon dysfunction." J Orthop Sports Phys Ther 30(2):
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):
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):