Posterior Tibial Tendinopathy

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

1. Physiology
   1. Posterior Tibial Tendon function
      1. Foot inversion and plantar flexion
      2. Medial longitudinal arch stabilization
2. Epidemiology
   1. Gender predominance in women
   2. Typically over age 40 years
3. Causes
   1. Typically, no recollection of acute injury
   2. Twisting foot
   3. Stepping in hole
   4. Slipping from curb
4. Symptoms
   1. Years of pregressive pain along the lateral tarsal region
5. Signs
   1. Pain and swelling posterior to medial malleolus
   2. Flat foot deformity
   3. Medial ankle instability (severe cases where the deltoid ligament stretched)
   4. Provocative factors
      1. Weight bearing
      2. Foot inversion against resistance
      3. Plantar flexion against resistance
   5. 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)
6. Evaluation: Stages of Posterior Tibial Tendinopathy
   1. Stage 1
      1. Pain and swelling of posterior tibial tendon
      2. No foot deformity
      3. Patient can perform single-leg heel raise
   2. Stage 2
      1. Pain and swelling of posterior tibial tendon
      2. Patient cannot perform single-leg heel raise
      3. Flexible subtalar joint
      4. Pes Planus
      5. Midfoot adduction
   3. Stage 3
      1. Stage 2 and
      2. Subtalar joint is fixed
      3. Ankle Arthritis
7. 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
8. Management
   1. RICE-M
   2. Immobilization (e.g. CAM Walker boot) for 2-3 weeks
   3. Shoe Orthotic (decrease foot pronation)
   4. Posterior tibial tendon strengthening
   5. Avoid Corticosteroid Injection (risk of posterior tibial tendon rupture)
   6. Orthopedic referral indications
      1. Failed conservative therapy above
      2. Stage 3 foot deformity (consider for stage 2)
9. Complications: Occur more often in the absence of treatment
   1. Foot deformity
   2. Posterior tibial tendon rupture
10. References
    1. Simpson (2009) Am Fam Physician 80(10): 1107-13 [PubMed]