Posterior tibial tendon dysfunction (PTTD) is a condition caused by changes in the tendon, impairing its ability to support the arch. This results in flattening of the foot. PTTD is often called adult-acquired flatfoot because it is the most common type of flatfoot developed during adulthood.
Posterior tibial tendon dysfunction is the most common cause of adult acquired flatfoot disease. The changes of advanced disease are obvious and have significant morbidity associated with it. Tendon degeneration, however, begins far before the clinical disease is apparent.[rx] By detecting early posterior tibial tendon disease, progression may be halted with nonoperative means; if left to progress, surgical reconstruction with osteotomy and arthrodesis becomes necessary.[rx]
Other Names
- Tibialis Posterior Tendinopathy
- Posterior Tibial Tendon Dysfunction (PTTD)
- Posterior Tibialis Tendon Insufficiency
- Tibialis Posterior Tendon Rupture
- Tibialis Posterior Tendonitis
- Tibialis Posterior Dysfunction
- Peroneal Tendon Instability
Background
- This page refers to both acute and chronic injuries of the Tibialis Posterior tendon
- Generally, this refers to posterior tibial tendon dysfunction (PTTD)
- Other tendinopathies of the tibialis posterior are also discussed here
- Epidemiology is poorly described in the literature
- Typically unilateral, the bilateral disease is uncommon
- Prevalence
- Estimated to be between 3.3% and 10% of the population (need citation)
Pathophysiology
- General
- Posterior Tibial Tendon Dysfunction (PTTD)
- Progressive, degenerative condition of the tibialis posterior tendon
- Typically occurs in obese, middle-aged women
- Results in progressive pes planus, hindfoot valgus, and dysfunction of the posterior foot
- This can cause limitations in mobility, significant pain, and weakness
Causes
- Acute/Traumatic
- Inflammation of the tendon can be seen after an acute injury such as an ankle fracture, direct trauma to tendon
- Tendinitis/ Tendonosis
- Repetitive microtrauma leading to tendinopathy is more common than an acute traumatic injury
- Tends to occur in the hypovascular region along the medial malleolus
- Chronic
- Degeneration of tendon can be seen with overuse or chronic tendinopathies that are untreated
- Once the tendon becomes inflamed or torn, or loses function, the medial longitudinal arch of the foot begins to collapse
- The patient will develop a relative internal rotation of the tibia and talus
- Eversion of subtalar joint, heel moves into valgus alignment, abduction of talonavicular joint
- Contracture of the Achilles tendon can occur with a lateral shift of the normal axis
- Anatomic contributions may include
- Sharp turn behind the medial malleolus taken by the tibialis posterior
- The Flexor Retinaculum
- Abnormal anatomy of the talus
- Degenerative changes associated with osteoarthritis
- Pre-existing Pes Planus (as opposed to acquired pes planus from PTTD)
Associated Conditions
- Pes Planus
- Hindfoot Valgus
- Posterior Tibialis
- Originates in the Deep Posterior Compartment of the Leg
- Attaches along plantar surface of multiple tarsal, metatarsal bones
- Aids in plantarflexion, inversion and supports medial arch of foot
- Pathology
- Hypovascular area prone to degeneration is approx. 0.6 to 2.2 cm proximal to the medial malleolus[5]
Risk Factors
- General
- Recent increase or change in activity or training
- Morbid Obesity
- Older age
- Systemic
- Hypertension
- Diabetes Mellitus
- Seronegative Spondyloarthropathies
- Iatrogenic
- Oral Corticosteroids or Corticosteroid Injection[6]
- History of previous surgery
- Orthopedic/ Biomechanical
- Pes Planus
- Overpronation
- Other
- Foot and ankle trauma
Differential Diagnosis
- Fractures & Dislocations
- Distal Tibia Fracture
- Distal Fibular Fracture
- Talus Fracture
- Calcaneus Fracture
- Subtalar Dislocation
- Ankle Fracture (& Dislocation)
- Peroneal Subluxation
- Muscle and Tendon Injuries
- Peroneal Tendon Injuries
- Achilles Tendonitis
- Achilles Tendon Rupture
- Posterior Tibial Tendon Dysfunction
- Flexor Hallucis Longus Tendinopathy
- Ligament Injuries
- Lateral Ankle Sprain
- Medial Ankle Sprain
- Syndesmotic Sprain
- Chronic Ankle Instability
- Intersection Syndrome Foot
- Bursopathies
- Retrocalcaneal Bursitis
- Nerve Injuries
- Peroneal Nerve Injury
- Tarsal Tunnel Syndrome
- Arthropathies
- Osteoarthritis of the Ankle
- Osteochondral Defect Talus
- Pediatrics
- Fifth Metatarsal Apophysitis (Iselin’s Disease)
- Calcaneal Apophysitis (Sever’s Disease)
- Other
- Haglunds Deformity
- Posterior Ankle Impingement Syndrome
- Sinus Tarsi Syndrome
Symptoms
Signs of PTTD may include:
- Pain and swelling along the ankle or inside of the foot. This pain may increase with activity, including standing or walking.
- Pain when standing on toes.
- Ankle rolls inward.
- Difficulty walking on uneven surfaces.
- Difficulty walking up and downstairs.
- A previous limp that gets worse.
- Unusual or uneven wear on shoes.
Diagnosis
Clinical demonstration of ‘too many toes’ sign on the right side. Note the hindfoot valgus.
- History
- Typically insidious without an acute cause
- Pain is most commonly located posterior to the medial malleolus, medial hindfoot
- I May have medial longitudinal arch pain
- Pain worse with activity, especially push-off phase during gait
- Trouble walking on uneven surfaces, up or downstairs
- In more chronic patients, they may have hindfoot pain
- Abnormal shoe wear pattern
- Physical Exam: Physical Exam Foot And Ankle
- Tenderness with palpation of the tibialis posterior tendon, especially posterior to the medial malleolus
- Pain and/or weakness with resisted inversion and plantarflexion of the ankle
- Medial ankle pain with standing heel raise
- May have overpronated foot and/or planovalgus foot deformity
- Valgus hindfoot, equinus contracture may be present
- Special Tests
- Too Many Toes Sign: Too many toes seen on the affected limb from posterior evaluation
- Single Limb Heel Rise: The patient performs a single-limb heel raise
Lateral foot radiograph demonstrating severe pes planus with plantar facing talus reduced calcaneal inclination angle consistent with PTTD
Radiographs
- Standard Radiographs Ankle, Standard Radiographs Feet
- Should be weight-bearing
- Findings
- It Maybe normal early on
- The collapse of the medial longitudinal arch
- Joint degeneration
- Increased talonavicular uncoverage
- Increased talo-first metatarsal angle (or Simmons angle)
MRI
- Findings
- Tendon changes (early)
- Degeneration (later)
Ultrasound
- Can evaluate
- Tendon size
- Degree of degeneration
- Presence of fluid
Classification
US of the posterior tibialis tendon showing hypoechoic areas within the tendon and peritendinous fluid consistent with tendinosis and tenosynovitis[8]
Johnson and Strom Classification
- I: Inflamed, intact tendon without clinical deformity
- Able to perform single-leg heel rise
- Mild tenosynovitis
- IIA: Ruptured or non-functional tendon with planovalgus deformity
- Arch collapse on a radiograph
- Unable to perform single-heel raise
- IIB: Ruptured or non-functional tendon with planovalgus deformity
- Arch collapse and talonavicular uncoverage (over 40%) on a radiograph
- Unable to perform single heel raise
- Flexible flatfoot deformity
- Characteristic forefoot abduction
- “too many toes” sign
- Flexible flatfoot deformity
- III: Advanced foot deformity with subtalar joint osteoarthritis
- Subtalar arthritis on a radiograph
- Unable to perform single heel raise
- Flatfoot deformity with rigid forefoot abduction, hindfoot valgus
- IV: Ankle joint involvement with tibiotalar degeneration
- Valgus deformity of talus in the ankle mortise visualized on AP radiograph of the ankle
- Talar tilt due to deltoid ligament compromise
- Subtalar arthritis on radiographs
- Unable to perform single heel raise,
- Flatfoot deformity with rigid forefoot abduction and hindfoot valgus
Treatment
Prognosis
- PTTD
- A progressive degenerative process which will get worse if left untreated
- Stage I/II patients due well with the orthosis and physical therapy, most patients returned to full strength at 4 months[9]
- Surgical outcomes in more severe cases produce less predictable results (need citation)
Nonoperative
- Indications
- Most PTTD Stage I, some stage II
- Most forms of tendonitis or tendinosis
- Patients who are a mostly sedentary or poor surgical candidate
- Activity modification
- Immobilization with Tall Walking Boot
- Duration 3-4 weeks (followed by PT)
- Orthotics including Shoe Inserts, Ankle Foot Orthosis
- Physical Therapy
- Emphasis on stretching Achilles tendon, strengthening tibialis posterior
- Eccentric exercises
- NSAIDS
Operative
- Indications
- Some PTTD stage II, most stage III/IV
- Failure of conservative management after 3-4 months
- Technique
- II: calcaneal osteotomy, posterior tibial tendon excision, flexor digitorum longus transfer, and achilles tendon lengthening
- III: triple arthrodesis (calcaneocuboid, talonavicular and subtalar joints)
- IV: Ankle arthrodesis
