Posterior Tibial Tendon Dysfunction – Posterior Tibial Tendinitis

Posterior Tibial Tendinitis

Anatomy

The posterior tibial tendon is a large tendon that originates as a muscle in the back of the leg. It becomes a tendon above the ankle and courses along the inside of the ankle behind the medial malleolus to its insertion along the side of the mid-portion of the foot into the navicular bone. The posterior tibial tendon is the main inverter of the foot and helps to maintain and support the arch of the foot.

Condition

Posterior tibial tendon dysfunction also known as posterior tibial tendinitis is a condition that occurs when there is inflammation along the tendon sheath and/or tears along a portion of the tendon.  This can result in the inability of the tendon to support the arch of the foot. Advanced posterior tibial tendon dysfunction can result in a rigid adult acquired flatfoot deformity.

Diagnosis

Diagnosis is made by a comprehensive foot and ankle exam by Dr. Stewart along with x-rays of the foot. Imagining studies such as ultrasound and MRI are sometimes required to determine the extent of tendon injury.

Symptoms

  1. Pain is commonly felt approximately 2 cm above the ankle bone (medial malleolus), yet it can also occur anywhere along the course of the tendon including at the insertion of the tendon into the navicular bone on the inside of the foot
  2. Swelling
  3. Tenderness along the tendon
  4. Progressive flattening of the foot
  5. Pain on the top and outside of the foot and/or ankle along the subtalar joint or lateral ankle respectively
  6. Spasm of the peroneal tendons on the outside of the foot and ankle
  7. Heel pain
  8. Pain along the tarsal tunnel (similar to the carpal tunnel in the hand)

Common causes

  1. Overuse, which means there is too much physical activity. This commonly occurs in runners and/or walkers and in such sports as soccer, lacrosse, basketball, tennis, and football
  2. Although less common, the condition can occur acutely in weekend warriors
  3. Hypertrophic navicular or accessory navicular bone
  4. Overweight or obesity
  5. Inappropriate shoe gear including flats, flip-flops, or backless shoes
  6. Barefoot walking
  7. Genetic predisposition due to a flatfoot deformity

Treatment

Posterior tibial tendon dysfunction generally takes 6-8 weeks to improve and early activity on a healing tendon can result in a set back in recovery. Non-compliance can double the recovery time and can be very frustrating for patients.

Posterior tibial tendon dysfunction is a progressive condition. Early and aggressive conservative treatment can prevent posterior tibial tendon dysfunction from advancing to an adult acquired flat foot deformity. Dr. Stewart terms posterior tibial tendon dysfunction a pro-active condition. Although we can never offer a 100% guarantee, the majority of Dr. Stewart’s patients improve with conservative (non-surgical care).

Conservative treatment for posterior tibial tendon dysfunction includes:

  1. Immobilization of the foot and/or ankle. Depending on the severity of the condition, this may require cast immobilization with crutches, a walking boot, a hinged ankle foot orthosis with supportive shoe gear, a multi-ligamentous ankle brace with supportive shoe gear, or custom foot orthotics with supportive shoe gear
  2. Modification of physical activity including avoidance of walking, jogging, running, and the elliptical for exercise. Recommended exercises include circuit training, swimming, and bicycling
  3. Stretching and strengthening exercises with a Theraband and/or with single and double limb heel rise
  4. Compression therapy generally with prescription compression stockings
  5. Physical therapy
  6. Weight loss and dieting
  7. Medications including anti-inflammatory medications (NSAIDs), Tylenol, oral steroids, and in some cases narcotic pain medication
  8. Ice along the tendon 2-3 times per day for 20 minutes at the area of maximum tenderness. Elevation is recommended while icing
  9. Avoidance of flip-flops, flats, and barefoot walking
  10. Supportive shoe gear including a motion control running shoe such as Brooks, Asics, New Balance, or Saucony. Keen and Merrell style shoes are also recommended
  11. Custom foot orthotics
  12. Steroid injections into foot and/and or ankle joints
If all conservative intervention fails, then surgical intervention maybe required. Dr. Stewart will determine which procedure is best for you.

Surgical treatment for posterior tibial tendon dysfunction includes:

  1. Debridement and repair of the tendon with tendon advancement
  2. Tendon transfer
  3. Reduction of a hypertrophic navicular bone or removal of an accessory navicular bone
  4. Cutting of bone (osteotomy) and fixation with screws
  5. Subtalar joint implant
  6. Joint fusions (arthrodesis)

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