Tibialis Posterior Tendon Dysfunction  (Tibialis Posterior Tendinopathy)

Tibialis posterior tendon dysfunction also be known as tibialis posterior tendinopathy is an under-diagnosed cause of medial arch foot and ankle pain. The tibialis posterior is a muscle that attaches from the fibula and tibia (shin bones) to 6 small bones of the inner portion of the foot (intermediate and lateral cuneiforms, the bases of the 2^nd-4^th metatarsal bones and sometimes the cuboid).

Tibialis posterior tendinopathy is an overload syndrome of the tendon, leading to discomfort and pain where the tendon wraps under the medial malleolus (boney bump on the inside of the ankle). It is commonly associated with tenosynovitis, which is the inflammation/irritation of the tendon sheath that covers the tendon. If you are suffering from both you may feel like you have clicking or crackling of the tendon as your move your foot.

What causes tibialis posterior tendon dysfunction?

There are numerous proposed mechanisms that may cause dysfunction of the tibialis posterior, these may include;

• Excessive overload causing micro trauma and progressive failure.
• Constriction beneath the flexor retinaculum (fibrous band that extends from the bony malleolus to the heel bone)
• Abnormal anatomy of the talus (large bone in the ankle bone)
• Degenerative changes associated with osteoarthritis
• Pre-existing pes planus (flat foot)

What are the symptoms of Tibialis posterior tendon dysfunction?

• ­Slow, insidious onset of unilateral (one sided) flatfoot deformity
• Pain or difficultly standing on your toes
• Pain or difficultly walking up or down stairs or on uneven surfaces
• Tenderness and/or swelling along the medial (inner) aspect of the ankle and foot, which may be aggravated with activity
• Pain on the top on the foot
• Impaired balance
• Spasm of the peroneal tendons on the outside of the foot and ankle

What are the risk factors?

People who are more likely to end up with an injury to the posterior tibialis tendon include:

• Elderly
• Young athletes
• If you have inflammatory arthritis (i.e. Psoriatic arthritis / Rheumatoid arthritis)
• If you have hypertension, obesity, diabetes mellitus, seronegative arthropathies, ligamentous laxity or pes planus
• Previous trauma
• Overuse

Differential Diagnosis

Posterior tibial tendon dysfunction may be the most common cause of an acquired flatfoot deformity. However, there are many other related conditions that present very similarly to posterior tibial tendon dysfunction that should merit consideration. These include;

• Inflammatory arthritis
• Tarsal coalition
• Charcot arthropathy
• Neuromuscular disease
• Trauma resulting in disruption of midfoot ligaments

A health professional such as a physiotherapist, chiropractor or osteopath will be able to assess and differentiate between these conditions. This will lead to appropriate treatment or referral of your injury.

Diagnostic Procedures

Besides the clinical diagnosis (where a physio/osteo/chiro assesses the site in clinic); radiographic evaluation can be used to asses deformity and the possible presence of degenerative arthritis or other causes of pes planus. MRI has the highest sensitivity, specificity and accuracy, but ultrasound is less expensive and almost as sensitive and specific as MRI.

Clinical tests that may be preformed by your chiropractor for PTTD includes;

• Too many toes sign (pictured below)
• Mobility of talo-navicular and calcaneo-cuboid joint
• Heel raise (single leg)
• First metatarsal rise sign
• Plantar flexion and inversion of the foot against resistanc
• Weight-bearing X-Ray

What can your chiropractor do for you!

It is suggested that early conservative intervention can significantly improve quality of life regarding function, pain and disability. However, treatment for posterior tibial tendon dysfunction is a complicated condition, different variables are taken into account by your chiropractor to decide whether patients require conservative or operative treatment.

Evidence have suggest that conservative therapy, such as exercise rehab, manual therapy and orthotics are more desirable option, as they do not damage healthy surrounding tissue.¹

The importance of early detection and conservative management of posterior tibial tendon dysfunction yields a much more successful outcome.

The aim of conservative treatments include:

• Elimination of symptoms
• Improve foot alignment and mechanics
• Prevention of progressive foot deformity
• Patient education (activity modifications and restrictions)

Conservative treatment your chiropractor will include:

1. Depending on the severity of the condition, immobilization of the foot and/or ankle may be suggested. This may require a cast immobilization with crutches, a walking boot, a hinge ankle foot orthosis with supportive shoe gear, a multi-ligamentous ankle brace with supportive shoe gear, or custom foot orthotics with supportive shoe gear.
2. Patient education: Discuss activity modification finding alternatives to keep you active!
3. Strengthening exercises to stabilise the foot and ankle and well a muscles and structure higher up the chain.
4. Manual therapy and stretching to help improve movement and range of motion
5. Nutritional advice (weight loss/dieting)
6. Advice with supportive shoe gear and/or custom foot orthotics
7. If necessary – medications such as anti-inflammatory (NSAIDs) may be advised

Conservative treatment should be trailed first and may take up to 4 months. There are strong evidence supporting positive outcomes (89% of patients responded back to full strength by 4 month) for patients receiving manual therapy and exercises.¹

If all conservative intervention fails after this period, then surgical intervention will be required, however outcomes of surgical treatment are much less predictable, and a return to the pre-disease state should not be guaranteed.²

Post by: Chiropractor Steven Tran 

Reference

1. Alvarez RG, Marini A, Schmitt C, Saltzman CL. Stage I and II posterior tibial tendon dysfunction treated by structured nonoperative management protocol: an orthosis and exercise program. Foot Ankle Int 2006;27(1):2e8

2. Bubra PS, Keighley G, Rateesh S, Carmody D. Posterior tibial tendon dysfunction: an overlooked cause of foot deformity. Journal of family medicine and primary care. 2015 Jan;4(1):26. Available from:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4367001/(last accessed 13.3.2020)