Posterior Tibial Tendinopathy

Aka: Posterior Tibial Tendinopathy, Posterior Tibial Tendonitis, Posterior Tibial Tendinitis, Tibialis Posterior Tenosynovitis

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II. Physiology

  1. Images
    1. ankleMedialAndLateral.jpg
  2. Posterior Tibial Tendon function
    1. Foot inversion and plantar flexion
    2. Medial longitudinal arch stabilization
    3. Important functionality with walking
      1. Foot stabilization while standing
      2. Absorbs shock during heel strike
      3. Provides force on toe off and heel lift

III. Epidemiology

  1. Gender predominance in women (esp. if Overweight)
  2. Typically over age 40 years

IV. Risk Factors

  1. Decreased ankle perfusion
  2. Obesity
  3. Diabetes Mellitus
  4. Collagen vascular disease
  5. Corticosteroids
  6. Overuse
  7. Over-pronator

V. Causes

  1. Typically, no recollection of acute injury
  2. Twisting foot
  3. Stepping in hole
  4. Slipping from curb

VI. Symptoms

  1. Years of pregressive pain along the lateral tarsal region

VII. Signs

  1. Observation
    1. Flat foot deformity (pes planovalgus deformity)
    2. Too Many Toes Sign (when viewing ankle and foot from behind)
      1. Only the 5th toe and one half of the fourth toe should be visible
      2. Positive test when the third toe is visible (not hidden by the lateral malleolus)
  2. Palpation
    1. Pain and swelling posterior to medial malleolus over posterior tibial tendon
    2. Tendon insertion is on the navicular tuberosity
  3. Provocative factors
    1. Weight bearing
    2. Pain or weakness on resisted inversion of the foot when plantar flexed
    3. Medial ankle instability (severe cases where the deltoid ligament is stretched)
  4. Specific testing
    1. Heel varus is absent when standing on tiptoe
    2. Pain with single-leg toe raise and unable to complete 10
    3. Plantar flexion ability lost (peroneal tendon rupture)

VIII. Evaluation: Stages of Posterior Tibial Tendinopathy (Johnson and Strom Classification)

  1. Stage 1
    1. Pain and swelling of posterior tibial tendon (posteromedial ankle) radiating to arch of foot
    2. No foot deformity
    3. Patient can perform single-leg heel raise
  2. Stage 2
    1. Pain and swelling of posterior tibial tendon, worse with weight bearing
    2. Patient cannot perform single-leg heel raise
    3. Flexible subtalar joint
    4. Pes Planus and loss of medial longitudinal arch
    5. Midfoot adduction
  3. Stage 3
    1. Stage 2 tenderness at posterior tibial tendon has increased, but swelling has decreased
    2. Posterior tibial tendon disrupted with multiple tears on imaging
    3. Subtalar joint is fixed
    4. Ankle Arthritis

IX. Differential Diagnosis

  1. Medial Ankle Sprain (most common misdiagnosis)
  2. Flexor digitorum longus Tendinopathy
  3. Flexor Hallucis Longus Tendinopathy
  4. Tarsal Navicular Stress Fracture
  5. Tarsal Tunnel Syndrome

X. Management

  1. Acute Management
    1. RICE-M
    2. NSAIDs
    3. Shoe Orthotic (decrease foot pronation and support arch)
    4. Medial longitudinal arch support taping
    5. Posterior tibial tendon Stretching and strengthening (Eccentric Exercises)
      1. Patient sits with affected leg crossed over the unaffected leg
      2. Resistance Band (e.g. Theraband) wrapped around affected midfoot
        1. Stabilize band under the planted unaffected foot on floor
      3. Patient passively inverts their foot and ankle against band resistance
        1. Then gradually relax and repeat
    6. Immobilization (e.g. CAM Walker boot) for 2-3 weeks
      1. Consider in severe cases
    7. Avoid Corticosteroid Injection (risk of posterior tibial tendon rupture)
  2. Orthopedic referral indications
    1. Failed conservative therapy above
    2. Consider for severe refractory stage 1 Tendinopathy
      1. Consider for Debridement with or without tenosynovectomy
    3. Consider for stage 2 Tendinopathy
      1. Consider for surgical management (e.g. flexor digitorum longus transfer)
    4. Stage 3 foot deformity
      1. Arthrodesis (subtalar or triple fusion)

XI. Complications: Occur more often in the absence of treatment

  1. Foot deformity (painful Flatfoot)
    1. See Rigid Flatfoot
  2. Posterior tibial tendon rupture

XII. References

  1. Deu (2022) Am Fam Physician 105(5): 479-86 [PubMed]
  2. Simpson (2009) Am Fam Physician 80(10): 1107-13 [PubMed]
  3. Gluck (2010) Am J Sports Med 38(10): 2133-44 [PubMed]

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