Posterior Tibial Tendon Dysfunction

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Original Editor - Brian Duffy, Hennebel Lien, Nele Postal

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Search Strategy

Databases searched: Pubmed, Pedro and Web of Knowledge

Keywords searched: Tibialis Posterior, Dysfunction, Examination, Ankle phatology, Review, Randomised Controlled/Clinical Trial, Physiotherapy, PTTD, Aquired flatfoot, Gait, Treatment

Definition/Description

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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

Characteristics/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

Clinical characterizes per class of posterior tibial tendon dysfunction:

• Stage I dysfunction: medial ankle pain, a mild swelling, no change in footshape;
• Stage II dysfunction: less pain and swelling, a flattened arch, abducted midfoot, change in footshape, instability;
• Stage III en IV: patients have also pain on the lateral hindfoot. 

The posterior tibial tendon during gait:

When the tendon is in health the functions of this tendon are plantar flexion of the ankle, inversion of the foot and elevating the medial longitudinal arch of the foot (it appears as the primary stabiliser of this arch). This elevating of the medial longitudinal arch causes a locked entire of the mid-tarsal bones, so the midfoot and hindfoot are stiff. All of this allows the muscle gastrocnemius to act more efficiently during gait. When the tibial posterior tendon isn't in health anymore and he doesn't do his work, the other joint capsules and ligaments become weak. There is an eversion of the subtalar joint, abduction of the foot (talonavicular joint) and valgus of the heel. Also a flattened arch develops what can cause an adult aquired flatfoot. And the muscle gastrocnemius is unable to act without the posterior tibial tendon what results in affected balance and gait. 

In this figure, they use 'tibialis posterior intramuscular EMG' to quantify the tibial posterior activation during walking. They used participants (female) with acute stage II PTTD. Differences in muscle activation: the participants with PTTD shows a significantly greater tibialis posterior EMG amplitude during the second half of stance phase. They walk with a pronated foot and exhibit an increased tibialis posterior activitie compared to the participants without PTTD.

Diagnostic Procedures

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Radiographs may be beneficial for assessing degree of deformity and degenerative changes, if present. ¹

Outcome Measures

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Examination

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The diagnosis of posterior tibial tendon dysfunction can be made clinically based on history and objective testing.

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

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Physical Therapy Management

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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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