- Physical Exam:
- tenderness:
- w/ involvement of
PT tendon tenderness will be along course of this tendon just posterior to
medial crest of distal tibia, posterior to the medial malleolus, or along undersurface of navicular;
- after the tendon has ruptured, medial sided pain may improve;
- w/ more advanced disease, lateral pain may occur from impingement of the the fibula against the calcaneus;
- this may be more severe than the medial sided pain;
- too many toes:
- when viewed from behind, affected patients may demonstrate excessive abduction of the foot, which therefore
causes more toes to be seen on that side;
- this sign may not be very sensitive for posterior tib rupture (ie, some patients with documented rupture
will not demonstrate this sign);
- heel rise:
- most important test;
- strength of tendon is assessed by a single heel rise test;
- this is done by asking the patient to rest his or her hands on wall while the physcian views the feet posteriorly;
- while one foot is raised, pt is first asked to go up on normal foot;
- the heel should go into inversion, following which the heel will come off the ground strongly;
- the affected heel will fail to invert, & longitudinal arch fails to rise during this maneuver;
- note that some patients will be unable to perform a correct heel rise because of a painful tibialis posterior
tendinitis (vs the inability to perform heel rise due to tendon rupture);
- motor strength:
- the foot is first positioned in plantar flexion (which eliminates the
tibialial anterior
as a potential foot invertor) as well as inversion;
- the examiner than attempts to evert the foot against resistance;
- evaluate for fixed deformity:
- assess for equinus contracture (w/ heel in varus)
- ROM of the ankle and subtalar joints;
- assess for relative supination deformity of the midfoot (which is revealed when the hindfoot is
placed in a corrected position);
