Posterior tibial tendon
dysfunction (PTTD), also known as posterior tibial tendonitis, is one of
the leading causes of acquired flatfoot in adults. The
onset of posterior tibial tendon dysfunction may be slow or abrupt. An abrupt
onset is typically linked to some
form of trauma, whether it be simple (stepping down off a curb or
ladder) or severe (falling from a
height or automobile accident). PTTD is seldom seen in children and
increases in frequency with age.
The characteristic finding
of posterior tibial tendon dysfunction include;
medial arch height.
Edema (swelling) of the medial ankle.
Loss of the ability to resist force to abduct or push the foot out from
the midline of the body.
the medial ankle with weight bearing.
Inability to raise up on the toes without pain.
Too many toes sign.
Lateral subtalar joint (sinus tarsi) pain.
A common test to evaluate
PTTD is the 'too many toes sign'. The 'too many toes sign' is a test
used to measure abduction (deviation away from the midline of the body) of
the forefoot. With damage to the posterior tibial tendon, the
forefoot will abduct or move out in relationship to the rest of the
foot. In cases of PTTD, when the foot is viewed from behind, the
toes appear as 'too many' on the outside of the foot due to abduction of
In advanced cases of PTTD,
in addition to the pain of the tendon itself, pain will also be noted in the
subtalar joint and sinus tarsi. The sinus tarsi refers to a small tunnel or divot
on the outside of the subtalar joint that can actually be felt. This tunnel
is the entry to the subtalar joint. The subtalar joint is the
joint that controls the side to side motion of the foot, motion that
would occur with uneven surfaces or sloped hills. As PTTD
progresses and the ability of the posterior tibial tendon to support the
arch becomes diminished, the arch will collapse overloading the subtalar
joint. As a result, there is increased pressure applied to the
joint surfaces of the lateral aspect of the subtalar joint, resulting in
been many proposed explanations for PTTD over the years since this
condition was first described by Kulkowski in 1936. The most
contemporary explanation refers to an area of hypovascularity (limited
blood flow) in the tendon just below the ankle. Tendon derives
most of its' nutritional support from synovial fluid produced by the
outer lining of the tendon. Extremely small blood vessels also
permeate the tendon sheath to reach tendon. This makes all tendon
notoriously slow to heal. In the case of the posterior tibial
tendon, this problem is exacerbated by a distinct area of poor blood
flow (hypovascularity). This area is located in the posterior
tibial tendon just below or distal to the inside ankle bone (medial
Tendon is most susceptible
to fatigue and failure at an area where the tendon changes
direction. As the posterior tibial tendon descends the leg and
comes to the inside of the ankle, the tendon follows a well defined
groove in the back of the tibia (bone of the inside of the ankle).
The tendon then takes a dramatic turn towards the arch of the
foot. If the tendon is put into a situation where significant load
is applied to the foot, the tendon responds by pulling up as the load of
the body (in addition to gravity) pushes down. At the location
where the tendon changes course, the tibia acts as a wedge and may apply
enough force to actually damage or rupture the tendon.
Equinus is also a
contributing factor in cases of posterior tibial tendon dysfunction. Equinus is the term used to describe
the ability or lack of ability to dorsiflex the foot at the ankle (move
the toes towards the shin). Equinus is usually due to tightness in the
calf muscle, also known as the gastroc-soleal complex (a combination of
the gastrocnemius and soleus muscles). Equinus may also be due to
a bony block in the front of the ankle. The presence of equinus
forces the posterior tibial tendon to accept additional load during
factors that contribute to the onset of posterior tibial tendon
dysfunction may include obesity, hypertension, diabetes,
peripheral neuropathy, smoking or arthritis.
PTTD is a progressive condition, meaning to say, that if
left untreated, PTTD will become worse over time. The progression of PTTD
begins with focal tendonitis. If left untreated, tendonitis will progress
to partial and then complete tears of the posterior tibial tendon. Several classifications have been developed to describe
posterior tibial tendon dysfunction. The classification as described by Johnson and Strom is most
commonly used today.
Posterior tibial tendonitis without tendon tear
Tendon status - Attenuated
(lengthened) with tendonitis but no rupture. Clinical findings -
Palpable pain in the medial
arch. Foot is supple, flexible. Too many toes sign may be positive or
X-ray/MRI - Mild to moderate tenosynovitis on MRI, no X-ray changes
Posterior tibial tendonitis with partial tendon tear
Tendon status - Attenuated with
possible partial or complete rupture.
Clinical findings - Pain in arch. Unable to raise on toes. Too
many toes sign positive.
X-ray/MRI - MRI notes tear in tendon. X-ray noting abduction of forefoot, collapse of
Posterior tibial tendonitis with partial to complete tendon tear.
Tendon status - Severe
degeneration of the tendon with likely rupture.
Clinical findings - Rigid flatfoot with
inability to raise up on toes. Too many toes sign positive.
X-ray/MRI - MRI shows tear in tendon. X-ray noting abduction of forefoot,
collapse of talo-navicular joint
An additional consideration in diagnosing PTTD pain is the presence of an accessory bone called an
os tibiale externum. The os tibiale externum, or what is frequently called
and accessory navicular, is a small bone that resides
within the body of the PT tendon. The os tibiale externum functions to
facilitate motion around the navicular. The os tibiale externum functions much
in the same way that the knee cap (patella) works to guide the quadraceps tendon
around the knee as it bends. The os tibiale externum can undergo degenerative
wear called chondromalacia. The os tibiale externum also can fracture.
Therefore, the os tibiale externum must also be considered when diagnosing PT
Treatment of posterior
tibial tendon dysfunction
for PTTD is dependant upon the clinical stage and the health status of
the patient. It is important to recognize that PTTD is a
mechanical problem that requires a mechanical solution. This means
that treating PTTD with medication alone is fraught with failure.
Prompt introduction of some form of mechanical support is imperative.
PTTD is a condition that
increases in frequency with age and the prevalence of poor health
indicators such as diabetes and obesity. As a result, many patients
with PTTD are poor surgical candidates for correction of PTTD.
Prosthetics such as an ankle foot orthotic (AFO), Arizona
Brace or other bracing may be
very helpful to control the symptoms of PTTD.
Surgical procedures which
focus on primary repair of the posterior tibial tendon have been very unsuccessful.
This is due to the fact that tendon heals slowly following injury and
cannot be relied upon as a sole solution for PTTD cases. Surgical
success is usually achieved by stabilization of the rearfoot (subtalar
joint) which significantly reduces the work performed by the posterior
Stage I PTTD may respond to treatment that includes
variations of rest. Variations in rest include an
ankle brace,walking cast with
an elevated heel
or a hard, below the knee non-weight bearing cast. Pain and inflammation may be controlled
with anti-inflammatory medications. It is important to be sure
that Stage I patients realize that the use of shoes with additional
arch support and heel elevation is
imperative. Arch support and
should be continued
indefinitely. Arch support, whether built into the shoe or added as
helps support the posterior tibial tendon and decrease the amount of
mechanical load applied to the posterior tibial tendon.
Elevation of the heel, reduces equinus, one of the most significant
contributing factors to PTTD. If Stage I patients return to low heels
without arch support, PTTD will recur.
Stage II patients typically require surgical
correction to stabilize the subtalar joint prior to further damage to
the posterior tibial tendon. Subtalar arthroeresis is a
procedure used to stabilize the subtalar joint. Subtalar arthroeresis
may only be used in flexible feet. Arthroeresis is a
term that means the motion of the joint is blocked without fusion.
Subtalar arthroeresis can only be used in cases of Stage II posterior
tibial tendonitis where mild to moderate
deformation of the arch has occurred and MRI findings show the tendon to
be only partially ruptured. Subtalar arthroeresis is typically performed in
conjunction with an Achilles tendon lengthening procedure or endoscopic
gastrocnemius recession to correct
equinus. These procedures require casting for a period of weeks
following the procedure.
The following video shows placement of a subtalar joint implant
for control of pronation in a flexible foot with PTTD. The sinus tarsi is
dissected free of capsule and ligament and the implant is placed in the sinus
tarsi. This procedure is completed in a hospital or out-patient surgery
center using a general anesthetic. Patients can walk immediately following
subtalar arthroeresis if an Achilles tendon lengthening is not performed.
If an Achilles tendon lengthening is performed, a 6 week period of non-weight
bearing casting is required.
When an os tibiale externum is present, a modified Kidner
procedure is typically performed. The following images show
excision of the os tibiale externum and transposition of the posterior
tibial tendon. This procedure is performed in a hospital or
out-patient surgery center using a general anesthetic. Weight
bering following the surgery is dependent upon the integrity of the
tendon following excision of the os tibiale externum. Most
modified Kidner procedures do require a period of non-weight bearing.
Stage III patients require
stabilization of the rearfoot with procedures that fuse the primary
joints of the arch and foot. Rearfoot stabilization is used to correct
rigid deformities of the foot. These procedures are salvage
procedures and require prolonged casting and disability following
surgery. A common procedure for Stage III is called triple arthrodesis
which is a technique used to fuse the subtalar joint, the talo-navicular
joint and the calcaneal cuboid joint (picture at left).
Arthroeresis - to surgically limit or block range of motion of a
PTTD - posterior tibial tendon dysfunction.
Sinus tarsi - a cavity or sinus and the entry of the subtalar
The posterior tibial tendon is the extension of
the posterior tibial muscle that lies deep to the calf. The origin of the
posterior tibial muscle is the posterior aspect of both the tibia and fibula and
the interosseus membrane. The insertion of the posterior tibial muscle is
the medial navicular where the tendon divides into nine different insertion site
on the bottom of the foot.
The function of the posterior tibial tendon is to
plantarflex the foot at the toe off phase of the gait cycle and to stabilize the
medial arch and subtalar joint as the body passes over the foot.
As PTTD becomes more severe, the ability of the posterior tibial
tendon become less able to support the arch. Hence the collapse of the
arch associated with PTTD.
The symptoms of stage I PTTD include a dull ache
of the medial arch. The pain becomes worse with activity and better on days
with limited time on the feet. Continued weight bearing may result in a partial
rupture of the tendon, moving to stage II. Stage I typically shows no
swelling but presents with pain along the course of the PT tendon from the
medial ankle to the insertion of the PT tendon on the medial arch.
Stage II symptoms are persistent and only partially relieved by
rest. Pain is present at the onset of weight bearing and continues throughout
the day. Some
limitation of the ability to raise up on the toes will be present and limited by
pain in the medial arch. Mild swelling may be present in the medial arch.
Stage III symptoms are severe with an inability
to complete most normal daily activities. Collapse of the medial arch will be obvious. Abduction of the
forefoot will show 'too many toes sign'. Patients are unable raise up on their
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