Posterior Tibial Tendon Dysfunction Insufficiency / Rupture / Dislocation 726.72

 

synonyms: posterior tendon tenosynovitis, rupture, dislocation, adult acquired flatfoot deformity,

Posterior Tibial Tendon Insufficiency ICD-9

  • 726.72 (tibialis tendonitis)
  • 734 (flat foot)

Posterior Tibial Tendon Insufficiency Etiology / Epidemiology / Natural History

  • Degeneration of the posterior tibial tendon is the most common cause of acquired flatfoot in adults. Other structures involved = spring ligament complex.
  • Contributing Factors: obesity, rheumatoid arthritis,

Posterior Tibial Tendon Insufficiency Anatomy

  • Posterior tibial tendon functions to invert the subtalar joint and adduct the forefoot, which is countered by the peroneus brevis that functions to evert the subtalar joint and abduct the forefoot.
  • Tendon usually ruptures in a hypovascular zone from the posterior tip of the medial malleolus to the tuberosity of the tarsal navicular. Studies quote a distance of 14mm proximal to the  navicular insertion.  In contrast there is abundant vascularity at the osseous junction and the musculotendinous junction of the posterior tibial tendon. (Frey C, Shereff M, Grddnidge N:  Vascularity of the posterior tibial tendon. J Bone Joint Surg Am 1990;72:884-888)

Posterior Tibial Tendon Insufficiency Clinical Evaluation

  • Usually occurs past the age of 41
  • Symptoms are chronic and insidious.  Arches gradually becomes flatter and is associated with swelling and discomfort over medial aspect of ankle.
  • Pain & swelling in posterior medial ankle/foot. In late stage patients may complain of lateral ankle pain due to fibular impingement.
  • Tenderness along course of posterior tibial tendon
  • Weak plantarflexion and inverse with tendonitis, absent with rupture.  Inversion strength tested by having pt cross legs with affected foot on opposite knee.  Post tibialis isolated by plantarflexing.  Inversion strength=post tibialis
  • Typically overweight middle-aged with hx of pes planus
  • valgus heal, abducted mid-foot
  • "Toe-many toes" sign (lateral two toes seen when pt standing, facing away from examiner, with feet straight ahead.
  • Inability to walk on tiptoes or raise up on their toes on the affected side
  • Flattening of the medial aspect of the longitudinal arch.

Posterior Tibial Tendon Insufficiency Xray / Diagnositc Tests

  • A/P, Oblique, Lateral weight-bearing foot xrays indicated. Consider axial calcaneal view.
  • Acute injuries may show a displaced fracture of the accessory navicular, which is a sesamoid bone in the posterior tibial tendon.  This can serve as a marker for displacement of this tendon.  The injury may subsequently result in posterior tibial tendon insufficiency Johnson KA:  Tibialis posterior tendon rupture.  Clin Orthop 1983;177:140-147.
  • MRI: often helpful in acute injuries. May demonstrate tendon rupture or displacement anterior to the medial malleolus.

Posterior Tibial Tendon Insufficiency Classification / Treatment

  • Johnson and Strom stages: (Johnson KA, Strom DE:  Tibialis posterior tendon dysfunction.  Clin Orthop 1989;239:196-206).
  • Stage I=tenosynovitis only, no deformity, and preservation of posterior tibial tendon strength—cast immobilization, NSAIDS, or longitudinal arch support with a medial heel wedge orthotic.  Decompression and synovectomy/debridement if no improvement in 2-3months. 
  • Stage II=planovalgus deformity with rupture of the PTT, hindfoot flexible. Stage IIa = minimal abduction (<30% peritalar subluxation on a standing anteroposterior foot radiograph). Stage-IIb = uncoverage of >30% of the talar head—UCBL orthosis of Hinged AFO or molded insoles with medial posts(may progress and become fixed):  FDL transfer with medial displacement calcaneal osteotomy or lateral calcaneal lengthening osteotomy.(Myerson Orthopedics 19:383;1996), (Myerson MS, Foot Ankle Int 2004;25:445).
  • Stage III=fixed pes planus, fixed valgus hindfoot, forefoot abduction subtalar/midfoot degenerative changes—Triple arthrodesis is necessary when there is a fixed valgus deformity of the subtalar joint, fixed abduction of the transverse tarsal joint, or a fixed varus deformity of the forefoot. An Achilles tendon lengthening may also be indicated as a contracture can play a role in the pathology of a rigid flatfoot.  A subtalar fusion is utilized when there is a fixed deformity of the subtalar joint but supple, easily correctable transverse tarsal joint and no fixed forefoot deformity.
  • StageIV=ankle involvement secondary to deltoid ligament incompetence, although the foot deformity may be either flexible or rigid. (Myerson MS. Instr Course Lect. 1997;46:393-405)
  • Acute Posterior tibial tendon rupture: surgical repair and augmentation with local tendon transfer indicated. Patients with associated planovalgus foot may require correction with medial displacement calcaneal osteotomy, medial column stabilization, or lateral column lengthening.
  • Posterior tibial tendon dislocation: rare. Surgical exploration with tendon relocation and repair of the flexor retinaculum. Retromalleolar groove may need to be deepened in patients with shallow grooves.

Posterior Tibial Tendon Insufficiency Associated Injuries / Differential Diagnosis

  • must r/o sero-negative spndyloarthropathy, inflammatory enthesopathy or arthropathy especially in young with minimal pes planus.
  • Pes Planus
  • Tarsal Coalition

Posterior Tibial Tendon Insufficiency Complications

Posterior Tibial Tendon Insufficiency Follow-up Care

Posterior Tibial Tendon Insufficiency Review References

  1. Alvarex RG, Foot Ankle Int 2006;27:2
  2. Johnson KA:  Tibialis posterior tendon rupture.  Clin Orthop 1983;177:140-147.
  3. Johnson KA, Strom DE:  Tibialis posterior tendon dysfunction.  Clin Orthop 1989;239:196-206.
  4. Mann RA:  Acquired flatfoot in adults.  Clin Orthop 1983;181:46-51.
  5. Mann RA: Flatfoot in adults, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed.7. St Louis, MO, Harcourt Health Science, 1999, pp 733-767.
  6. Mann RA:  Acquired flatfoot in adults.  Clin Orthop 1983;181:46-51.

 

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