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Tibialis Posterior Tendonitis

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Ovid: 5-Minute Sports Medicine Consult, The


Tibialis Posterior Tendonitis
Christopher D. Meyering
Basics
Description
  • Overuse injury resulting in tendon degeneration with pain typically located posterior to the medial malleolus
  • Various presentations of condition divided into 3 stages:
    • Stage 1: Mild swelling, medial ankle pain, normal but painful heel rise, and no foot or ankle deformity
    • Stage 2: Progressive flattening of the arch, flexible hindfoot, abducted midfoot, incompetent or ruptured tendon, and inability to perform a heel rise
    • Stage 3: All signs of stage 2 except the hindfoot deformity is fixed
  • Synonym(s): Posterior tibial tendon dysfunction; Posterior tibial tendinopathy
Epidemiology
  • Incidence of 2.3–3.6% in runners presenting to sports medicine clinics in earlier studies (1)
  • Posterior tibial tendon dysfunction is the major cause of acquired flatfoot deformity in adults.
Risk Factors
  • Recent increase or change in training or type of activity
  • Surgical or accidental trauma to the foot
  • 60% of cases in patients over 50 yrs of age associated with HTN, diabetes, and obesity; no association of these factors with younger patients
  • Severe pronation of the foot with planovalgus foot deformity
  • Association with rheumatoid arthritis and seronegative inflammatory disease
  • Prior exposure to steroids; local injection reported as a possible cause of rupture
Diagnosis
History
  • Patients mostly complain of pain along the length of the posterior tibialis tendon, particularly near the medial malleolus.
  • May relate a recent change in activity frequency, type, and intensity
  • Medial arch pain
  • Occasional radiation of pain into the medial calf area
  • Usually symptoms worsen with prolonged or strenuous activity, especially activities with a strong push-off motion.
  • Initially painful but normal heel raise progressing to gait changes and inability to toe-raise
Physical Exam
  • Pain with palpation over the posterior tibialis tendon with greatest tenderness posterior to the medial malleolus
  • Medial ankle and possible foot swelling
  • Flattened longitudinal arch compared with unaffected foot
  • Increased hindfoot valgus and “too many toes sign,” where more toes are seen laterally when viewing the patient from behind (late finding)
  • Single-limb heel-rise test: Patient stands on affected foot and attempts to rise up on the ball of the foot while the other foot is off the ground. With tendinopathy, patients will be able to raise the affected heel, but with medial ankle pain. Repetitive heel raises may show some weakness in the tendon with persistent valgus hindfoot position through the toe raise or decreased function owing to pain.
  • Tendon strength can be further tested by placing the foot in a plantarflexed and everted position. The patient then is instructed to attempt to invert the foot. If the foot is dorsiflexed or moves past the neutral position, the anterior tibialis may help to invert the foot.
Diagnostic Tests & Interpretation
Imaging
  • Sensitivity, specificity, and accuracy for detection of surgically created longitudinal tears in cadaveric models were similar for MRI and dynamic US (2)[B].
  • Clinicians assessing for tendon dysfunction or alignment issues are likely able to identify tendinopathy, but if the clinician is inexperienced or uncertain, US can confirm an abnormality. MRI is preferred by some clinicians to establish anatomic diagnosis, but it was more sensitive for posterior tibialis tears (3)[B]. One study published opposite results, finding that US was 100% sensitive and 89.9% specific compared with MRI, which was 23.4% sensitive and 100% specific, when evaluating intrasubstance or complete tendon tears.
  • Weight-bearing anteroposterior and lateral plain radiographs of the foot, plus anteroposterior, lateral, and mortise views of the ankle, should be obtained. These likely will show normal findings or minimal angular changes in earlier stages. Plain films may be helpful to rule out other differential diagnoses.
Differential Diagnosis
  • Flexor hallucis or flexor digitorum longus tendinopathy
  • Subluxation or dislocation of the posterior tibialis tendon
  • Tarsal tunnel syndrome or other entrapment neuropathy
  • Stress fracture to the navicular or accessory navicular (will present as point tenderness over the navicular)
  • Fracture of sustentaculum, medial talar process, or talar dome (with acute trauma)
Treatment
  • Care must be taken that a patient with stage 1 findings does not progress to stage 2 or 3 with conservative care.
  • Use the Education, Unloading, Reloading, and Prevention (EdUReP) Model for nonsurgical management of tendinopathy (4)[A]:
    • Education: 5 A's construct for behavioral counseling: Assess, advise, agree, assist, and arrange.
    • Unloading: OTC or custom-made orthotics to provide medial arch support; relative rest using alternative exercises such as pool running or swimming, where there is limited weight bearing during activity. The alternative activity should not result in continued or worsening pain.
    • Reloading: Controlled reloading of the tendon through focused concentric or eccentric exercises, transition to weight-support training (treadmill in pool), and weaning from unloading braces or orthotics. One randomized controlled trial evaluated 36 patients with posterior tibial tendon dysfunction randomly assigned to 1 of 3 groups: Custom orthoses and calf stretching; custom orthoses, calf stretching, and a concentric exercise program; or custom orthoses, calf stretching, and an eccentric exercise program. All 3 groups showed significant reduction in pain after 3 mos, with the greatest improvement seen in the eccentric exercise group (5)[B].
    • Prevention: Prevention of disease progression and disease recurrence through gradual resumption of activity

    • P.595


  • One study found that treatment with an orthosis, gastrocsoleus stretches, and structured exercises is effective for patients with stage 1 or 2 posterior tibial tendon dysfunction (6)[B].
  • Some authors advocate aggressive treatment using immediate immobilization with a short-leg cast or cam walker for 2–8 wks (7)[C]. If symptoms are improved with immobilization, then patients are fitted with a custom orthotic or an ankle-foot orthosis (AFO). Physical therapy then is added, focusing on Achilles tendon stretching and posterior tibialis tendon strengthening.
Medication
  • Medication management should focus on pain control and not inflammation control because changes are associated more with a degenerative process.
  • Local steroid injections into the synovial sheath are not recommended and have been associated with tendon rupture.
Complementary and Alternative Medicine
Glyceryl trinitrate patches, extracorporeal shock wave therapy, and sclerotherapy have not been evaluated specifically with posterior tibialis tendinopathy, and a recommendation cannot be made for their use.
Surgery/Other Procedures
  • Patients with stage 1 or 2 disease should be managed with conservative therapy for ∼3–4 mos before surgery is considered.
    • Tendon sheath release, scar tissue excision, and partial synovectomy are the typical surgical management approach.
    • Posterior tibial tendon sheath endoscopy has been shown to be effective, with less postoperative pain, smaller scars, and shorter hospital stays (8)[C].
  • Patients with stage 3 disease have a fixed deformity, and tendon reconstruction will not correct the problem. Subtalar or triple arthrodesis is usually needed to block hindfoot motion.
References
1. Macintyre JG, Taunton JE, Clement DB, et al: Running injuries: a clinical study of 4,173 cases. Clin Sports Med. 1991;1:81–87.
2. Gerling MC, Pfirrmann CW, Farooki S, et al. Posterior tibialis tendon tears: comparison of the diagnostic efficacy of magnetic resonance imaging and ultrasonography for the detection of surgically created longitudinal tears in cadavers. Invest Radiol. 2003;38:51–56.
3. Perry MB, Premkumar A, Venzon DJ, et al. Ultrasound, magnetic resonance imaging, and posterior tibialis dysfunction. Clin Orthop Relat Res. 2003;408:225–231.
4. Davenport TE, Kulig K, Matharu Y, et al. The EdUReP model for nonsurgical management of tendinopathy. Phys Ther. 2005;85:1093–1103.
5. Kulig K, Reischl SF, Pomrantz AB, et al. Nonsurgical Management of Posterior Tibial Tendon Dysfunction With Orthoses and Resistive Exercise: A Randomized Controlled Trial. Phys Ther. 2008.
6. Alvarez RG, Marini A, Schmitt C, et al. Stage I and II posterior tibial tendon dysfunction treated by a structured nonoperative management protocol: an orthosis and exercise program. Foot Ankle Int. 2006;27:2–8.
7. Fink BR, Mizel MS. Management of posterior tibial tendinitis in the athlete. Oper Tech Sports Med. 1999;7:28–31.
8. van Dijk CN, Kort N, Scholten PE. Tendoscopy of the posterior tibial tendon. Arthroscopy. 1997;13:692–698.
Additional Reading
Andres BM, Murrell GA. Treatment of tendinopathy: what works, what does not, and what is on the horizon. Clin Orthop Relat Res. 2008.
Augustin JF, Lin SS, Berberian WS, et al. Nonoperative treatment of adult acquired flat foot with the Arizona brace. Foot Ankle Clin. 2003;8:491–502.
Chao W, Wapner KL, Lee TH, et al. Nonoperative management of posterior tibial tendon dysfunction. Foot Ankle Int. 1996;17:736–741.
Geideman WM, Johnson JE. Posterior tibial tendon dysfunction. J Orthop Sports Phys Ther. 2000;30:68–77.
Johnson KA, Strom DE. Tibialis posterior tendon dysfunction. Clin Orthop Relat Res. 1989;239:196–206.
Krause F, Bosshard A, Lehmann O, et al. Shell brace for stage II posterior tibial tendon insufficiency. Foot Ankle Int. 2008;29:1095–1100.
Lysholm J, Wiklander J. Injuries in runners. Am J Sports Med. 1987;15:168–171.
Premkumar A, Perry MB, Dwyer AJ, et al. Sonography and MR imaging of posterior tibial tendinopathy. AJR Am J Roentgenol. 2002;178:223–232.
Richie DH. Biomechanics and clinical analysis of the adult acquired flatfoot. Clin Podiatr Med Surg. 2007;24:617–644.
Codes
ICD9
726.72 Tibialis tendinitis
Clinical Pearls
  • The main tendon that supports the arch in your foot has been overworked and needs relative rest. This includes using the orthotic or brace you are given by your clinician, performing any home exercise program as directed, and avoiding weight-bearing activities other than daily living. Cardio training activities such as swimming or pool running are safe because no excessive stress is being placed on the damaged tendon.
  • Most patients will need ∼3–4 mos of therapy and treatment before they are able to return to previous activities.
  • Even patients with a flattened arch and functionally incompetent tendon can be treated nonoperatively. The need for surgery hinges on the progression of symptoms and adherence to treatment and therapy. Definitive treatment for patients with a fixed hindfoot deformity is surgery, however.


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