- Foot & Ankle Surgery Posterior Tibial Tendon Problems – Kaiser Permanente Santa Rosa
- What can I do for myself?
- What can my doctor add?
- The Most Common Reason People Develop a Flatfoot Deformity
- Posterior tibial tendon injury
- Symptoms of posterior tibial tendon injury
- Treatment for posterior tibial tendon injury
- Tibialis posterior rupture
- Epidemiology /Etiology
- Characteristics/Clinical Presentation
- Differential Diagnosis
- Diagnostic Procedures
- Outcome Measures
- Medical Management 
- Physical Therapy Management 
- Key Research
- Adult Acquired Flatfoot: An Overview | HSS Foot & Ankle
- What are the symptoms of posterior tibial tendon insufficiency?
- What causes posterior tibial tendon insufficiency?
- What are the stages of posterior tibial tendon insufficiency?
- Nonsurgical treatments
- Flatfoot surgery
- Posterior Tibialis Tendon Surgery
- Why might I need posterior tibialis tendon surgery?
- What are the risks of posterior tibialis tendon surgery?
- How do I get ready for posterior tibialis tendon surgery?
- What happens during posterior tibialis tendon surgery?
- What happens after posterior tibialis tendon surgery?
- Next steps
Foot & Ankle Surgery Posterior Tibial Tendon Problems – Kaiser Permanente Santa Rosa
The posterior tibial muscle originates at the back and inside of the main bone of the leg (the tibia). The muscle becomes a tendon just above the ankle, which then runs from behind the inner knob of the ankle (the medial malleolus) to below this knob.
The tendon continues towards the arch, eventually attaching to a bone at the inner side of the arch (the navicular bone) and extending under the arch to the various bones of the arch. The muscle and tendon together are one of the most important supporting structures of the arch.
The tendon uses the knob (medial malleolus) as a pulley while supporting the arch.
There are several different locations and scenarios where the posterior tibial muscle or tendon can become painful. One of the most common locations where the tendon can become injured is just below the inner knob of the ankle (the medial malleolus). This condition is often called tibialis posterior dysfunction (TPD).
A second location is at the tendon’s attachment to bone at the inner arch (the navicular bone). This condition is called posterior tibial enthesopathy. A third location is along the back edge of the main bone of the leg and ankle. This condition is called posterior tibial stress syndrome.
In all of the conditions involving the posterior tibial muscle/tendon can be caused when the posterior tibial muscle/tendon is overwhelmed in trying to support the arch.
Any factor that causes flattening of the arch (pronation) makes the posterior tibial muscle/tendon work harder, and can cause problems to arise over the many repetitions of daily weight-bearing activity.
Factors that cause overuse of the posterior tibial muscle/tendon include: overweight, tight calf muscle, inherited flatfoot, poorly supporting footwear, and increased exercise load or workload on the feet.
Alternatively, but more infrequently, the tendon can be injured by a sudden injury that rolls the foot outward (pronation). Compounding the potential to develop problems involving the posterior tibial tendon is the fact that the tendon can weaken, particularly as the circulation within the tendon can diminish with age, or with ingested medications, such as prednisone or ciprofloxacin.
TPD – tibialis posterior dysfunction. This condition can be quite disabling. The tendon degenerates and begins to tear, usually in the area just below the inner knob of the ankle (the medial malleolus).
As the tendon begins to tear, it slides upon itself and lengthens. Once the tendon dramatically lengthens, the foot begins to flatten and roll outward from under the leg.
In late cases, when the foot has been dislocated for awhile, arthritis can develop in the joints below the ankle.
Early in the course of TPD, you might notice pain and swelling in the area just below the inner knob of the ankle (the medial malleolus), particularly with weight-bearing activities, or upon standing after sitting or lying down for awhile. Later, you might notice the arch becoming flatter and/or the foot rolling out from under the leg. In late cases, you might also notice pain just below and in front of the outer side of the ankle.
TPD can be treated initially with a cast and crutches for 6-12 weeks, followed by a custom ankle brace for at least one year. Alternatively, TPD can be treated with major reconstructive surgery.
The decision to treat this condition by non-surgical or surgical means is dependent upon a number of circumstances, and is ultimately a decision made between you and your provider. The foot malalignment associated with TPD cannot be restored without surgery.
Late cases of TPD and those failing non-surgical measures are usually best treated with surgery.
Posterior tibial enthesopathy. This condition usually responds well to non-surgical treatment within weeks to months, but infrequently requires surgery if non-surgical care fails.
Pain is located at the knobby bone at the inner side of the arch (navicular bone), particularly with weight-bearing activities, or upon standing after sitting or lying down for awhile. You might notice swelling at this area as well. Usually, there is no dislocation of the foot as a result of this condition.
In some cases, there is an extra bone, called the Os Tibiale Externum, located at the knobby bone at the inner side of the arch (navicular bone).
Posterior tibial stress syndrome. This condition is more common in athletes. The pain is felt along the inner side of the main bone of the leg (tibia), just above the ankle. Usually, there is no swelling. The condition usually responds to non-surgical care within several weeks.
What can I do for myself?
You should use as many of these treatments as possible concurrently:
- Wear supportive shoes at all times when standing/walking.
- Add an arch support to your shoe. The following is the recommended option: green Superfeet.
- Avoid standing or walking barefoot. Avoid flat footwear slippers or sandals.
- Perform calf stretching exercises for 30-60 seconds on each leg at least two times per day. (Stand an arm’s length away from the wall, facing the wall. Lean into the wall, stepping forward with one leg, leaving the other leg planted back. The leg remaining back is the one being stretched. The leg being stretched should have the knee straight (locked) and the toes pointed straight at the wall. Stretch forward until tightness is felt in the calf. Hold this position without bouncing for a count of 30-60 seconds. Repeat the stretch for the opposite leg.)
- Healthy weight
- Modify your activities. (Decrease the time that you stand, walk, or engage in exercise that put a load your feet. Convert impact exercise to non-impact exercise – stationary cycling, swimming, and pool running are acceptable alternatives.)Use ice on the painful area for 15-20 minutes, at least 2-3 times per day. (Option A – Fill a styrofoam or paper cup with water and freeze it. Peel back the leading edge of the cup before application. Massage the affected area for 15-20 minutes. Option B –Apply an ice pack for 15-20 minutes. CAUTION: AVOID USING ICE WITH CIRCULATION OR SENSATION PROBLEMS.)
- Use an oral anti-inflammatory medication. (We recommend over-the-counter ibuprofen. Take three 200mg tablets, three times per day with food – breakfast, lunch, and dinner. To obtain the proper anti-inflammatory effect, you must maintain this dosing pattern for at least 10 days. Discontinue the medication if any side effects are noted, including, but not limited to: stomach upset, rash, swelling, or change in stool color. IF YOU TAKE ANY OF THE FOLLOWING MEDICATIONS, DO NOT TAKE IBUPROFEN: COUMADIN, PLAVIX, OR OTHER PRESCRIPTION OR OVER-THE-COUNTER ORAL ANTI-INFLAMMATORY MEDIACTIONS. IF YOU HAVE ANY OF THE FOLLOWING HEALTH CONDITIONS, DO NOT TAKE IBUPROFEN: KIDNEY DISEASE OR IMPAIRMENT, STOMACH OR DUODENAL ULCER, DIABETES MELLITUS, BLEEDING DISORDER.)
- See your doctor when you have failed to respond to the above regimen after 1-2 months of application.
What can my doctor add?
- Prescribe physical therapy. (Ultrasound and interferential electric current therapy can be useful methods of reducing inflammation.)
- Refer you for custom-made foot orthotics. (Custom foot orthoses are not a covered benefit of the Kaiser Permanente Health Plan. However, custom foot orthoses are available at the Santa Rosa Kaiser Permanente facility on a fee for service basis through a non-Kaiser Permanente provider. The fee is currently $275/pair.)
- Refer you for a custom-made foot and ankle brace. (The brace is made for the affected side in cases of TPD. Kaiser Permanente usually pays for 80% of the cost.)
- Put you in a cast. (A cast is applied from below the knee to the toes typically for 6 or more weeks. You are encouraged to use crutches and not put weight on the foot while the cast is on.)
- Perform surgery. (There are a variety of surgical procedures that may be applicable in the surgical management of your problem. Although the natures of these procedures differ, there are some generalizations that can be made about surgery for your problem: The anesthesia is usually general or spinal. A below-knee cast is utilized for 6-12 weeks. Weight bearing is usually not allowed for 6 or more weeks. Recovery takes 4-12 months. The success rate is about 80%. About 15% are better, but still have some problems. About 5% are no better or worse. Risks include, but are not limited to: infection, nerve injury or entrapment, prolonged healing/recovery, wound or scar problems, incomplete relief of pain, no relief of pain, worsened pain, recurrent pain, calf atrophy, weakness, limping, incomplete arch restoration, failure of bone cuts or fusions to heal, and transfer of pain to other sites or joints.)
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The Most Common Reason People Develop a Flatfoot Deformity
Posterior tibial tendon dysfunction is a problem that occurs in one of the tendons on the inner side of the ankle.
Verywell / Cindy Chung
A review of your anatomy is helpful in understanding how this occurs. The posterior tibial muscle attaches to the back of the shin bone; the posterior tibial tendon connects this muscle to the bones of the foot.
It passes down the back of the leg, not far from the Achilles tendon, then turns under the prominence of the inner side of the ankle.
It then attaches to the bone of the inner side of the foot, just adjacent to the arch of the foot.
Posterior tibial tendon problems usually occur just underneath the prominence of the inner side of the ankle, called the medial malleolus.
The medial malleolus is the end of the shin bone (the tibia) and the posterior tibial tendon wraps just underneath the medial malleolus.
This area of the tendon is particularly prone to developing problems because it lacks a robust blood supply to nourish and repair the tendon.
This part of the tendon exists in a “watershed zone,” where the blood supply is weakest. So when the tendon becomes injured, as a result of trauma or overuse, the body has difficulty delivering the proper nutrients for healing.
When left untreated, posterior tibial tendonitis can gradually progress to a problem called adult-acquired flatfoot deformity (AAFD).
This condition typically begins with pain and weakness of the posterior tibial tendon, but as the condition progresses, the ligaments of the foot are affected and the foot joints can become malaligned and rigidly deformed.
For this reason, most physicians prefer the early treatment before the later stages of AAFD.
Most commonly, patients with posterior tibial tendonitis complain of pain on the inner of the foot and ankle and occasionally have problems associated with an unsteady gait. Many patients report having had a recent ankle sprain, although some will have had no recent injury.
As posterior tibial tendonitis progresses, the arch of the foot can flatten and the toes begin to point outwards. This is the result of the posterior tibial tendon not doing its job to support the arch of the foot.
Diagnosis of posterior tibial tendonitis is commonly made by physical examination. Patients have tenderness and swelling over the course of the posterior tibial tendon. Usually, they have weakness inverting their foot (pointing the toes inward). Also common in patients with posterior tibial tendonitis is an inability to stand on their toes on the affected side.
When the examination is unclear, or if a patient is considering surgery, an MRI may be obtained. The MRI is an effective method to detect ruptures of the tendon, and it can also show inflammatory changes surrounding the tendon.
Posterior tibial tendon insufficiency can be classified according to the stage of the condition. The classification is from stage 1 through stage 4 with increasing deformity of the foot as the condition progresses.
- Stage 1: The earliest stage of posterior tibial tendon insufficiency is having pain and swelling along the tendon. The foot may appear completely normal, or people may notice their foot has a mild flatfoot deformity, probably something they feel they have always had.
- Stage 2: As the condition progresses, the arch of the foot begins to collapse. While the arch of the foot can be corrected, when people stand the foot appears flat along its inner side.
- Stage 3: Once into stage 3 of the condition, the foot cannot be easily corrected, a condition called a rigid flatfoot deformity.
- Stage 4: Once in stage 4, not only is the foot involved but the adjacent ankle joint also become involved in the condition.
As these stages progress, the treatment to correct the problem becomes more invasive.
While nonsurgical treatment can be used at any stage, the lihood of success with less invasive treatments may decrease as the condition progresses.
The initial treatment of posterior tibial tendonitis is focused on resting the tendon to allow for healing. Unfortunately, even normal walking may not adequately allow for the tendon to rest sufficiently. In these cases, the ankle must be immobilized to allow for sufficient rest. Options for early treatment include:
- Shoe inserts and arch supports
- Walking boots
By providing a stiff platform for the foot, shoe inserts and walking boots prevent motion between the midfoot and hindfoot. Preventing this motion should decrease the inflammation associated with posterior tibial tendonitis. Casts are more cumbersome but are probably the safest method to ensure the posterior tibial tendon is adequately rested.
Other common treatments for early-stage posterior tibial tendonitis include anti-inflammatory medications and activity modification. Both of these treatments can help to control the inflammation around the posterior tibial tendon.
Surgical treatment of posterior tibial tendonitis is controversial and varies depending on the extent of the condition. In the early stages of posterior tibial tendonitis, some surgeons may recommend a procedure to clean up the inflammation called a debridement. During a debridement, the inflamed tissue and abnormal tendon are removed to help allow for the healing of the damaged tendon.
In more advanced stages of posterior tibial tendonitis, the arch of the foot has collapsed and a simple tendon debridement may be insufficient to correct the problem. Reconstruction of the posterior tibial tendon is occasionally performed.
In reconstructive procedures, a neighboring tendon, called the flexor digitorum longus, is moved to replace the damaged posterior tibial tendon. This procedure is often combined with a bone reconstruction as well. Finally, in the most advanced cases of posterior tibial tendonitis, when the arch of the foot has become rigid, a fusion procedure is the preferred treatment.
Posterior tibial tendon dysfunction and adult-acquired flatfoot deformity can be frustrating problems. Often, people feel their symptoms are ignored by a doctor who may not see much in the way of deformity, but people experience discomfort and instability of the ankle.
Once in the later stages, treatment can be invasive and limit in terms of the function of the foot. For these reasons, early efforts with noninvasive treatments, including footwear modifications and therapeutic activities, are the most preferred methods to control symptoms of the condition.
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Ling SK, Lui TH. Posterior Tibial Tendon Dysfunction: An Overview. Open Orthop J. 2017;11:714-723. doi:10.2174/1874325001711010714
Bubra PS, Keighley G, Rateesh S, Carmody D. Posterior tibial tendon dysfunction: an overlooked cause of foot deformity. J Family Med Prim Care. 2015;4(1):26–29. doi:10.4103/2249-4863.152245
Deland JT, Page A, Sung IH, O'Malley MJ, Inda D, Choung S. Posterior tibial tendon insufficiency results at different stages. HSS J. 2006;2(2):157–160. doi:10.1007/s11420-006-9017-0
Ikpeze TC, Brodell JD Jr, Chen RE, Oh I. Evaluation and Treatment of Posterior Tibialis Tendon Insufficiency in the Elderly Patients. Geriatr Orthop Surg Rehabil. 2019;10:2151459318821461. doi:10.1177/2151459318821461
Wake J, Martin K. Posterior Tibial Tendon Endoscopic Debridement for Stage I and II Posterior Tibial Tendon Dysfunction. Arthrosc Tech. 2017;6(5):e2019–e2022. doi:10.1016/j.eats.2017.07.023
Marks RM, Long JT, Ness ME, Khazzam M, Harris GF. Surgical reconstruction of posterior tibial tendon dysfunction: prospective comparison of flexor digitorum longus substitution combined with lateral column lengthening or medial displacement calcaneal osteotomy. Gait Posture. 2009;29(1):17-22. doi:10.1016/j.gaitpost.2008.05.012
- Deland JT. Adult-acquired flatfoot deformity. J Am Acad Orthop Surg. 2008 Jul;16(7):399-406.
Posterior tibial tendon injury
Posterior tibial tendon injury (posterior tibial tendonitis) occurs when the posterior tibial tendon becomes inflamed or torn.
The posterior tibial tendon provides support to the arch of the foot and gives stability when walking. Also known as the tibialis posterior tendon, it attaches the calf muscle to the bones of the inside of the foot.
The tendon is located at the back of the leg and passes underneath the inside knob of the ankle bone (medial malleolus) and then inserts onto a small bone in the arch of the foot called the navicular. The posterior tibial tendon helps to invert the foot (turn the foot in).
Posterior tibial tendonitis injury may involve inflammation, overstretching, or even rupture of the tendon.
Symptoms of posterior tibial tendon injury
- Pain or tenderness occurs on the inside of the shin, ankle or foot. Pain is usually worse with weight-bearing activity such as walking, but standing for long periods is also often painful.
- Swelling is seen along the course of the tendon towards the foot, which can often be seen as a thick cord when the foot is turned inwards.
- In longstanding cases the arch along the length of the inside foot will gradually collapse, and as this occurs the foot appears to become flat as the ankle rolls in and the toes turn outwards. This is called an acquired flat foot – and is quite different to those in people who are born with flat feet.
- The person will be unable to raise their heel and go onto their tiptoes on the affected side.
Posterior tibial tendon injury can result from overuse of the tendon or from a specific incident such as a fall.
Sudden injuries usually occur in athletes from a distinct injury, but may occur as an overuse injury in people with poor lower limb alignment. Dysfunction usually occurs in older people, particularly women and is progressive.
Overuse may be caused by walking, running, hiking, stair-climbing or high-impact sports, such as tennis and basketball.
Diagnosis is often possible just from the signs and symptoms and a physical examination, but sometimes imaging, such as X-ray, ultrasound or MRI is needed to assess the injury or to rule out other conditions. Your sports doctor or orthopaedic surgeon should perform the appropriate assessment and investigations.
Treatment for posterior tibial tendon injury
Initial treatment may include the RICE regimen:
- compression; and
- elevation of the affected limb.
Anti-inflammatory medicines are often required to reduce pain and inflammation.
Sometimes a walking boot is needed for a few weeks to rest the tendon. Often wearing a supportive lace-up shoe a running shoe is helpful to reduce symptoms.
Orthotics to reposition the affected foot and take the strain off the tendon may be required and should be worn in the supportive shoe.
Exercises to strengthen the tibialis posterior muscle can be prescribed by a physiotherapist or sports physician.
If left untreated, this injury may lead to irreversible damage, such as a flat foot, painful degenerative arthritis and mobility problems.
In advanced cases, or those that have not responded to conservative measures after 3 months or more, surgery may be recommended.
Cortisone injections are generally not recommended as they are associated with a risk of tendon rupture.
1. American Academy of Orthopaedic Surgeons. OrthoInfo: Posterior tibial tendon dysfunction. Last reviewed Dec 2011. http://orthoinfo.aaos.org/topic.cfm?topic=a00166 (accessed Jan 2016).2. Kohls-Gatzoulis JK, Angel JC, Singh D et al.
Tibialis posterior dysfunction: a common and treatable cause of adult acquired flatfoot. BMJ 2004: 329: 1328-1333.
3. Physio Advisor. Tibialis Posterior Tendonitis. http://www.physioadvisor.com.au/8205450/tibialis-posterior-tendonitis-posterior-tibial-t.
htm (accessed Jan 2016).
Tibialis posterior rupture
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Keyword Searches: tibialis posterior tendon (TPT) , tibialis posterior rupture (TPR), tibialis posterior tendon rupture (TPTR), TPTR treatment, TPTR postoperative treatment, flatfoot, pes planovalgus, tendinitis
Whenever the tibialis posterior muscle contracts or is stretched, tension is placed through the tibialis posterior tendon.
If this tension is excessive due to too much force or repetition, damage to the tibialis posterior tendon may occur.
This can range from minor tearing of the tendon with subsequent inflammation to a complete tibialis posterior tendon rupture. Early diagnosis and surgical repair will restore full normal function. 
A rupture of the posterior tibial tendon can be easily missed because the symptoms of this injury resemble the symptoms of a normal ankle sprain. Some physicians may feel that posterior tibial tendon rupture is a rare condition, one that they have never seen.
Posterior tibialis tendon ruptures occur predominantly in the late middle-aged population (average age 57 years). For posterior tibialis dysfunction, the patient is typically a female over the age of 40 who exhibits ligamentous laxity in multiple joints and has an occupation that requires extended periods of standing.
They usually do not recall any acute traumatic event. There is another subset of the populations in which posterior tibial tendon insufficiency occurs and that consists of the 20- to 40-year old athletes. They usually recall a traumatic event, usually a direct blow to the medial malleolus.
Or, they present with years of involvement in athletics with a pronated foot.
• Swelling along the medial aspect of the foot and ankle• Absence of the classical sudden severe pain of a tendon rupture• Tenderness along the posterior tibialis tendon• Progressive loss of longitudinal arch → pes planus and heel valgus• Palpable pain between medial malleolus and navicular• Pain in the plantar medial arch
• Attenuation or rupture of the calcaneonavicular (spring) ligament complex• Degenerative arthritis of the ankle joint with valgus talar• Arthritis of the talonavicular joint• Posttraumatic tarsometatarsal (Lisfranc) joint arthritis• Inflammatory arthritis of the hindfoot, usually secondary to rheumatoid disease
add text here related to medical diagnostic procedures
add links to outcome measures here (also see Outcome Measures Database)
Posterior tibialis tendon rupture is strongly suspected in patients presenting a complex of findings. These include:
• Eversion ankle injury• Generalized medial ankle pain• Medial ankle swelling• Flexible, asymmetric pes planus and forefoot pronation• Gait disturbance secondary to deformity
• Talonavicular sag in lateral standing radiograph
The first four findings are nondiagnostic, however, seen together they are helpful in identifying patients with posterior tibialis tendon pathology. Manual testing of the posteroir tibialis tendon should be performed in the presence of these findings to confirm the tendon's functional status.
• Palpation from area between malleolus medialis and os naviculare• “Too many toes” sign secondary to an increase in forefoot abduction and heel eversion• Nonfunctional posterior tibialis tendon on manual testing• Motion of the ankle and subtalar joints• Positive first metatarsal rise sign test• Positive single-limb heel rise-test
• Ottawa ankle rules test to exclude fractures within the first week after an ankle injury
Medical Management 
Postoperative rehabilitation for tendon transfer procedure:
• With attenuation or rupture of the posterior tibial tendon, the medial longitudinal arch of the foot collapses and there is a relative internal rotation of the tibia and talus• The subtalar joint everts, causing the heel to assume a valgus position and the foot to abduct at the talonavicular joint.
A compensatory forefoot varus deformity ensues• As the heel assumes an increased valgus alignment, the Achilles tendon becomes positioned lateral to the axis of rotation of the subtalar joint.
Over time, the shortened position of the hindfoot results in an Achilles tendon contracture• As the deformity progresses, the fibula abuts against the lateral wall of the calcaneus, causing pain in the lateral hindfoot
Physical Therapy Management 
Furthermore, Woods and Leach (1991) pointed out that “the key” to successful treatment is early diagnosis23.(Randall E. Marcus, 1993)Phase I:• Ice• Non steroidal anti inflammatory drugs
• Passive ROM exercice for eversion and dorsiflexion such as manual mobilisation ankle
• Closed kinetic chain activities and eccentric strengthening exercises such as single leg standing toe raises with controlled lowering eccentric loads
Phase III excercices:
without moving your leg, pull theraband away lateral with your foot
without moving your straight leg, invert your feet of your bended leg
without moving your leg, pull theraband away from you to the ground
place towel on the floor, keep the heel on the floor, use toes to pull towel towards you
add links and reviews of high quality evidence here (case studies should be added on new pages using the case study template)
Adult Acquired Flatfoot: An Overview | HSS Foot & Ankle
Posterior tibial tendon insufficiency (also called posterior tibial tendon dysfunction or adult acquired flatfoot) literally means the failure of the posterior tibial tendon.
However, this condition also involves the failure of associated ligaments and joints on the medial (inner) side of the foot and ankle.
This results in collapse of the arch of the foot (commonly called “flatfoot” or “flat foot”), along with foot and sometimes ankle deformities that can become debilitating or disabling in later stages.
Figure 1: Anatomical diagram of the foot and ankle highlighting effects of posterior tibial tendon insufficiency.
[Illustration courtesy of the Journal of Musculoskeletal Medicine]
What are the symptoms of posterior tibial tendon insufficiency?
- Pain over the tendon in the inner part of your hindfoot (rear portion of your foot) and midfoot is the first common symptom.
- A deformity in the foot may develop, and this can make it difficult for you to walk. A common deformity is for the foot to sag downward and inward toward the opposite foot.
- As the tendon degenerates and loses its function, ligaments on the same inner side of the foot will also deteriorate and fail. Ligaments are soft tissues that hold bones in place. When they fail, those bones shift place, leading to a deformity. This deformity causes malalignment of the foot bones, which leading puts more stress on the already failing ligaments. This snowball effect of degeneration can significantly affect how you move.
What causes posterior tibial tendon insufficiency?
The cause of posterior tibial tendon insufficiency is not completely understood. The condition commonly does not start from one acute trauma but is a process of gradual degeneration of the soft tissues supporting the medial (inner) side of the foot.
It is most often associated with a foot that started out somewhat flat or pronated (rolled inward). This type of foot places more stress on the medial soft tissue structures, which include the posterior tibial tendon and ligaments on the inner side of the foot.
Children nearly fully grown can end up with flatfeet, the majority of which are no problem. However, if the deformity is severe enough it can cause significant functional limitations at that age and later on if soft tissue failure occurs.
Also, young adults with normally aligned feet can acutely injure their posterior tibial tendon from a trauma and not develop deformity. The degenerative condition in patients beyond their twenties is different from the acute injuries in young patients or adolescent deformities, where progression of deformity is ly to occur.
People who have recurring posterior tibial tendonitis (inflammation of the posterior tibial tendon) are at greater risk of developing posterior tibial tendon dysfunction.
What are the stages of posterior tibial tendon insufficiency?
Posterior tibial tendon insufficiency is divided into stages by most foot and ankle specialists:
- Stage I – Pain is present along the posterior tibial tendon without deformity or collapse of the arch. The patient has the somewhat flat or normal-appearing foot they have always had.
- Stage II – A deformity from the condition has started to occur, resulting in some collapse of the arch, which may or may not be visible or noticeable to you or others. You may experience it as simply a feeling of weakness in your arch. Many patients don't realize they have a problem until stage II, because the ligament failure can occur at the same time as the tendon failure and therefore deformity can begin at the same time that pain in the tendon is first being felt.
- Stage III – The deformity has progressed to the extent where the foot becomes fixed (rigid) in its deformed position.
- Stage IV – In this, most severe, stage, the deltoid ligament on the inside of the ankle fails, resulting in a deformity in the ankle as well as a deformity in the foot. Over time, this can lead to arthritis of the ankle.
The first treatment is to support the medial longitudinal arch (the arch that spans the underside of your foot). This relieve strain on the soft tissues of the medial (inside) portion of your foot. The most effective way provide to support to relieve pain on the tendon is to use a walking boot or brace.
Once the tenderness and pain goes away, an orthotic device may alleviate symptoms and may slow the progression of deformity, particularly if it is mild. However, the deformity may progress despite the use of orthotics.
A boot, brace, or orthotic has not been shown to correct or even prevent the progression of the foot deformity.
Surgery is usually necessary if you experience persistent pain and/or have a significant deformity.
Sometimes the foot just feels weak and the assessment of deformity is best done by a foot and ankle specialist.
If surgery is appropriate, a combination of soft tissue and bony procedures may be considered to correct alignment and support the medial arch, taking strain off failing ligaments.
Depending upon the tissues involved and extent of deformity, the foot and ankle specialist will determine the necessary combination of procedures, which may include one more the following types of foot surgery:
- Medial slide calcaneal osteotomy – to correct position of the heel
- Lateral column lengthening – to correct position in the midfoot
- Medial cuneiform osteotomy or first metatarsal-tarsal fusion – to correct elevation of the medial forefoot.
- Posterior tibial tendon reconstruction (tendon transfer) – grafting a healthy tendon or portion of tendon from another part of the body to replace the dysfunctional tendon.
In severe stage III cases, surgical reconstruction may include fusing bones of the hindfoot (rear portion of the foot). This results in stiffness of the hindfoot but achieves the desired pain relief.
Posterior Tibialis Tendon Surgery
Posterior tibialis tendon surgery is a way to fix the tendon on the back of your calf that goes down the inside part of your ankle. A surgeon can do a few different types of surgery to fix this tendon.
The posterior tibialis tendon is a strong cord of tissue. It is one of the most important tendons in your leg. It attaches the posterior tibialis muscle on the back of your calf to the bones on the inside of your foot. It helps support your foot and hold up its arch when you are walking.
An injury might tear this tendon or cause it to become inflamed. Your tendon might also tear or become inflamed from overuse. Surgery tries to correct this damage.
During the surgery, you will probably be sedated so that you sleep. The surgeon will make a cut in the back of your lower calf. Then he or she will either remove or fix the damaged portion of your tendon.
If there is damage to a lot of your tendon, the doctor might replace part or all of it with a tendon taken from another place in your foot. He or she may use other methods to repair your tendon as well.
In some cases, a surgeon may do the surgery as a minimally invasive procedure. This means he or she will make several small cuts (incisions) instead of one large one. Then the surgeon may use a tiny camera and small tools to do the repair.
Why might I need posterior tibialis tendon surgery?
If you recently tore your posterior tibialis tendon, you might need this surgery. A tear can happen during a fall. It can also happen if you recently broke (fractured) your ankle or dislocated it. Surgery may also be done for chronic inflammation from overuse. You may also have problems with the tendon if you have diabetes or high blood pressure, or are obese or an older woman.
If your tendon becomes inflamed or torn, the arch of your foot may start to slowly fall. This can cause pain and swelling in your foot and ankle.
Your healthcare provider may try other treatments first. These can include things resting your foot, using ice, pain medicines, a brace, steroid shots (injections), or physical therapy.
If you still have symptoms after several months, your provider might advise surgery.
Your provider might be more ly to advise surgery right away if you hurt your posterior tibialis tendon very badly or if the injury happened suddenly.
Depending on your problem, one or more types of surgery might work for you. Talk with your provider about the risks and benefits of all your options.
What are the risks of posterior tibialis tendon surgery?
Every surgery has risks. Risks for this surgery include:
- Excess bleeding
- Nerve damage
- Blood clot
- Weakness of your calf muscles
- Complications from anesthesia
- Continued pain in your foot and ankle
Your risk of complications may vary by your age, the anatomy of your foot, your general health, and the type of surgery done. Talk with your provider about any concerns you might have. You can discuss the risks that most apply to you.
How do I get ready for posterior tibialis tendon surgery?
Talk with your provider about how best to get ready for your surgery.
Tell your provider about any medicines you are taking, including:
- All prescription medicines
- Over-the-counter medicines such as aspirin or ibuprofen
- Street drugs
- Herbs, vitamins, and other supplements
Ask if there are any medicines you should stop taking, such as blood thinners.
If you smoke, try to quit before your surgery.
Don’t eat or drink after midnight the night before your procedure.
Tell your provider about changes in your overall health, such as a recent fever.
Before your procedure, you may need imaging tests such as an X-ray or MRI.
You may need to plan changes to your home or activities. This is because you won’t be able to walk on your foot normally for a while. Plan to have someone available who can drive you home from the hospital.
Follow any other instructions from your healthcare provider.
What happens during posterior tibialis tendon surgery?
Surgeons use a variety of methods for posterior tibialis tendon surgery. Ask your doctor about the details of your surgery. An orthopedic surgeon will do your surgery, helped by a team of healthcare providers. The procedure may take 2 or more hours. In general, you can expect the following:
- You may have spinal anesthesia, so you won’t feel anything from your waist down. You will also be sedated so you’ll sleep through the procedure and won’t remember it afterwards.
- A healthcare provider will carefully watch your vital signs, such as your heart rate and blood pressure.
- Your surgeon will make an incision through the skin and muscle of your lower calf.
- If you are having a minimally invasive procedure, your doctor will make a small incision. He or she may then use small tools and a tiny camera to perform your surgery.
- Your surgeon will make an incision through the sheath that surrounds the tendon. He or she will then remove or repair parts of your damaged tendon.
- In some cases, your doctor may remove another tendon from your foot. This is then used to replace part or all of your posterior tibialis tendon.
- The layers of skin and muscle around your calf are stitched closed.
What happens after posterior tibialis tendon surgery?
A healthcare provider will watch you for a few hours after your surgery. When you wake up, your ankle will be immobilized in a splint. Often, posterior tibialis tendon surgery is an outpatient procedure. This means you can go home the same day. Follow all of your provider’s instructions about pain medicines and wound care.
You will have some pain after your surgery, especially for the first few days. Medicines can help lessen your pain. Keeping your leg raised after the procedure may help reduce swelling and pain as well.
You’ll need to use crutches and keep your weight off your leg for a few weeks.
Make sure to tell your provider right away if you have a high fever, chills, or if the pain from your ankle or calf is getting worse.
About 10 days or so after your surgery, you will probably have your stitches or staples removed. Your provider might replace your splint with a cast at this time. If so, follow all instructions about keeping your cast dry. In other cases, your provider may give you a special removable boot instead of a cast.
Your provider will give you instructions about when you can put weight on your leg and how to strengthen your ankle and leg muscles as you recover. You may need to do physical therapy as well.
You may have pain for months before you start to notice major benefits from your surgery. Follow all of your provider’s instructions about post-surgery exercises.
This will help ensure your surgery is a success for you.
Before you agree to the test or the procedure make sure you know:
- The name of the test or procedure
- The reason you are having the test or procedure
- What results to expect and what they mean
- The risks and benefits of the test or procedure
- What the possible side effects or complications are
- When and where you are to have the test or procedure
- Who will do the test or procedure and what that person’s qualifications are
- What would happen if you did not have the test or procedure
- Any alternative tests or procedures to think about
- When and how will you get the results
- Who to call after the test or procedure if you have questions or problems
- How much will you have to pay for the test or procedure