Tibialis posterior dysfunction

Question 1

Where does the tibialis posterior insert?

Answer 1

Predominantly the medial navicular, supporting the medial arch of the foot

Question 2

What are some risk factors for tibialis posterior dysfunction?

Answer 2

• Obese middle aged female
• Risk increases with age
• Hypertension
• Diabetes
• Steroid injection
• Seronegative arthropathies
• Idiopathic tendonosis

Question 3

Describe the pathophysiology of tibialis posterior dysfunction

Answer 3

The tendon is under repeated stress and particularly with degeneration, can develop tendonitis, elongation and eventually rupture

Elongation or rupture leads to loss of the medial arch, with resulting valgus of the heel and flattening of the medial arch of the foot

Question 4

How will tibialis posterior patients present?

Answer 4

• Pain or swelling to medial malleolus (Specific)
• Change in foot shape
• Diminished ability to walk
• Dislike of uneven surfaces
• Hallus valgus
• Lateral wall impingement pain in midfoot and ankle

Question 5

What are the 4 stages of tibialis posterior dysfunction based on examination findings?

Answer 5

• Stage 1 - Swelling, tenderness over tibialis posterior tendon, slightly weak muscle power
• Stage 2 - Flatfoot, midfoot abduction (”Too many toes” sign), deformity is passively correctable
• Stage 3 - Flatfoot and rigid forefoot and hindfoot deformities
• Stage 4 - Fixity and mortise signs (Arch collapse and talar tilt)

Question 6

What are some non-operative management strategies used in tibialis posterior dysfunction?

Answer 6

• Physiotherapy
• Insole to support medial longitudinal arch
• Orthoses to accomadate foot shape
• Footwear

Question 7

What are some surgical managements in tibialis posterior dysfunction to prevent rupture?

Answer 7

decompression and tenosynovectomy

Question 8

What is performed in cases of a ruptured tibialis posterior if there is no secondary OA?

Answer 8

A tendon transfer may be performed to try to prevent secondary OA with a calcaneal osteotomy to reduce stress

Question 9

What is performed in cases of a ruptured tibialis posterior if there is secondary OA?

Answer 9

Arthrodesis (Fusion)