Posterior Tibial Tendon Dysfunction

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Original Editor - Brian Duffy, Hennebel Lien

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Search Strategy

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Clinically Relevant Anatomy

The posterior tibial tendon runs posterior to the medial malleolus inserting into the navicular tuberosity and the plantar aspect of the tarsus. It is the primary stabilizer of the medial longitudinal arch, aiding in mid and hind foot locking during ambulation. If compromised, a resulting pes planus foot may develop and place greater stress on the surrounding ligaments and soft tissue

Epidemiology /Etiology

Once thought to be a tendonitis, it is now commonly accepted the process is one of tendon degeneration or tendinosis. A poor blood supply has been identified as well as mechanical factors such as peroneal brevis overactivity or a pes planus foot. The later will gradually place increased stress to the posterior tibial tendon causing early degeneration. Trauma ( ankle sprain, fracture) may also can initiate the process

Clinical Presentation

1. Pain/swelling behind medial malleolus and along medial longitudinal arch
2. Change in static/dynamic foot ( pes planus)
3. Limited walking ability
4. Impaired balance
5. Impaired MMT PF/IV
6. Difficulty/inability to perform unilateral heel raise. Limited calcaneal inversion upon ascent
7. Impaired subtalar mobility

Examination

The diagnosis of posterior tibial tendon dysfunction can be made clinically based on history and objective testing. Radiographs may be beneficial for assessing degree of deformity and degenerative changes, if present. ¹

Outcome Measures

Foot Functional Index (FFI)

Interventions

The key to a successful outcome is early detection of the dysfunction. Orthoses use, static stretching of gastocnemius and soleus muscle, and concentric/eccentric training of the posterior tibialis have demonstrated success. As per Kulig et al, orthoses use and eccentric training demonstrate the most improvement over a 12 week period.

Medical Management (current best evidence)

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Physical Therapy Management (current best evidence)

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Classification 

As per Johnson and Strom :

• Stage I: Posterior tibial tendon intact and inflammed, no deformity, mild swelling
• Stage II: Posterior tibial tendon dysfunctional, acquired pes planus but passively correctable, commonly unable to perform a heel raise
• Stage III: Degenerative changes in the subtalar joint and the deformity is fixed *Stage IV ( Myerson): Valgus tilt of talus leading to lateral tibiotalar degeneration

Risk Factors

1. Middle aged women

2. Pes planus

3. HTN

4. Diabetes

5. Inflammatory arthritis

6 Obesity

Differential Diagnosis

1. Rupture of spring ligament

2. Degenerative arthritis

3. Posttraumatic tarsometatarsal joint arthritis

4. Inflammatory arthritis

5. Peripheral neuropathies

Key Research

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Resources

Myerson MS. Adult acquired flat foot deformity. J Bone Joint Surg.1996;45A:780-92

Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

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