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Duke Orthopaedics
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Wheeless' Textbook of Orthopaedics

Rupture of the Tibialis Posterior   


- Discussion:  
    - main function of the tibialis posterior is to invert the subtalar joint, which helps to stabilize the transverse tarsal joint during rheumatoid hindfoot;
    - pathophysiology:
            - degenerative tears usually occur distal to the medial malleolus, in a region which coincides with relative hypovascularity and the sharp 
                   turn of the tendon from a verticle to a horizontal position; 
            - as the tendon makes a sharp turn under the medial malleolus, there may be fibrous metaplasia, leading to rupture;
            - in the study by Mosier SM, et al (1998), gross and histological exams were carried out on 15 normal cadvaers and 15
                   surgical patients w/ posterior tibial tendon insufficiency (but no rupture);
                   - these authors noted that 12/15 cadavers had normal tendon appearance and histology, where as the surgical specimens demonstrated
                           a degenerative tendinosis w/ increased mucin content, fibroblast hypercellularity, chondroid metaplasia, and neovascularization
                           (the abnormal tendon segments were located between the medial malleolus and the navicular tuberosity;;
                           - gross examination of the surgical specimens showed incomplete splitting on the deep surface;
            - following rupture, talonavicular joint and subtalar joints collaspes, & hindfoot drifts into valgus, causing mid foot pronation & forefoot abduction;
                   - in addition, there is often injury or attenuation of the spring ligament;
                   - in the rheumatoid, rupture of the tibialis posterior leads to a collapsed pronated foot;
    - clinical manifestations:
            - early in this condition there is painful swelling along posteromedial border of ankle, fatigue, & aching along medial longitudinal arch of foot;
            - well into disease process, patients may note lateral sided pain as well as pain in sinus tarsi impingement between lateral side of foot and fibula;
            - in advanced stages, pain is present laterally, w/ an abutment between the calcaneus and the fibula;
            - peroneus brevis, continues to function & pulls foot into a valgus configuration;
            - in this case, flat foot may result from the peroneus brevis muscle, which is a natural antagonist to the tibialis posterior;
    - rupture classification:
            - stage I
            - stage II
            - stage III
    - diff dx:
            - attenuation of the spring ligament;
            - rheumatoid foot:
                  - look for involvement in the hindfoot and talonavicular joints;
                  - synovitis and joint inflammation lead to weakening of these joints which results in hindfoot valgus deformity which resembles rupture of TP;
            - tarsometatarsal degenerative arthitis
            - relaxed pes planus
            - old lisfranc fracture dislocation
            - neuroarthropathic (charcot) involvement of the midfoot or hindfoot
            - posteromedial talar osteochondral lesion;
    - associated conditions:
            - most patients will not have an associated condition;
            - rheumatoid arthitis;
            - seronegative arthritis;


- Physical Exam:


- Radiographs:
    - wt bearing lateral;
         - talus moves into flexion when viewed laterally;
              - talus will appear plantar flexed and there will be an increased angle between longitudinal axis of the talus and calcaneus;
         - decrease in the talometatarsal angle (normally 0 to 10 deg);
    - wt bearing AP view;
         - talar head uncoverage and increase in angle between longitudinal axis of talus & calcaneus
         - the displacement of forefoot into abduction w/ calcaneus is assessed;
         - lateral subluxation of the navicular on the talus correlates w/ the amount of deformity;
    - MRI:
         - ref: Clinical significance of magnetic resonance imaging in preoperative planning for reconstruction of posterior tibial tendon ruptures


- Labs: ESR, RF, ANA;


- Non Operative Rx:
    - use of arches supports, and heel cups, is usually unsuccessful in providing relief from symptoms of foot strain in these pts;
    - posterior tibial tendonitis:
         - objective is to reduce excessive midfoot motion;
         - consider total contact orthosis supporting longitudinal arch;
         - medial heel wedge;
    - references:
         - Nonoperative treatment of patients with posterior tibial tendinitis. Lin, et al. Foot and Ankle Clin. 1996;1:261-277.
         - Nonoperative treatment of posterior tibial tendon pathology. Sferra, et al. Foot and Ankle Clin. 1997;2:261-273.
         - Nonoperative management of posterior tibial tendon dysfunction.   


- Surgical Treatment:
    - tenosynovectomy:
          - indicated early in disease process (stage I - prior to rupture) after the patient has failed a trial of immobilization;
          - tenosynovectomy is performed w/ care to preserve a portion of the flexor retinaculum (to prevent subluxation of the tendon);
          - tendon sheath is opened and the tendon is inspected;
          - pathologic tissue is removed;
          - flexor retinaculum is not closed (assumming a significant portion remains intact to prevent subluxation);
    - FDL transfer and osteotomy:
          - often combined w/ repair or reconstruction of the sping ligament;
          - achilles tendon lengthening may also be required;
    - medial displacement calcaneal osteotomy;
                - shifts the achilles tendon medial to the axis of the subtalar joint, which helps support the tendon transfer medially;
                - this procedure may reduce the lever arm acting across the subtalar joint;
                - this procedure may not be of much benefit in patients w/ severe forefoot abduciton;
    - lateral column lengthening;
    - arthrodesis:
          - talonavicular joint arthrodesis:
                - if site of maximal deformity is at talonavicular joint, then an isolated talonavicular or talonavicular & calcaneocuboid may be performed;
          - sub-talar arthrodesis:
                - w/ more significant hindfoot valgus, subtalar arthrodesis may be indicated.
                - note that complete correction of the hindfoot deformity may cause a relative supination deformity of the
                       forefoot (which in turn, decreases the relative amount of wt bearing of the first metatarsal);
          - triple arthrodesis:
                - indicated only w/ severe midfoot collapse deformities;
                - achilles tendon lengthening will often be required for equinus deformity;



Rupture of the Posterior Tibial Tendon. Evaluation of Injury of the Spring Ligament and Clinical Assessment of Tendon Trasfer and Ligament Repair

Rupture of the posterior tibial  tendon associated with closed ankle fracture.

Acquired adult flat foot secondary to posterior tibial-tendon pathology.

Rupture of the tibialis posterior tendon.

Rupture of the posterior tibial tendon causing flat foot. Surgical treatment

Tibialis posterior tendon dysfunction

Posterior tibial tendon dysfunction: its association with seronegative inflammatory disease.

Pathology of the posterior tibial tendon in posterior tibial tendon insufficiency

Anatomy of the Spring Ligament.

Structure of the human tibialis posterior tendon



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Tuesday, April 10, 2012 4:58 pm