Tibialis Posterior Tendonitis

Ovid: 5-Minute Sports Medicine Consult, The

Tibialis Posterior Tendonitis
Christopher D. Meyering
  • 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
  • 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
  • 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
  • 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)
726.72 Tibialis tendinitis

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