Prof/Dr Rothbart's Research Website
Posterior Tibial Tendon Dysfunction
Anatomy: The posterior tibialis muscle orginates from the proximal, posterior surfaces of tibia and fibula (leg bones). Its tendon inserts primarily into the tuberosity of the navicular bone (See Animation below).
Posterior Tibial Tendon Dysfunction (PTTD)
PTTD is a progressive painful condition in which the tendon of the posterior tibialis muscle is stretched and possibly torn (Figure A below) or completely ruptured (Figure B below) from its attachment into the navicular bone (the keystone bone in the inner arch of the foot).
The Single Foot Raise is a test to determine if the posterior tibialis tendon is ruptured or not:
- The patient steps with his full body's weight on the painful foot, keeping the unaffected foot off the ground.
- The patient then raises his painful foot 'up onto his tip toes'.
- If the posterior tibial tendon is ruptured, the patient will experience difficulty keeping his foot from rolling inward as he lifts his heel off the ground.
- If the posterior tibial tendon is not ruptured, the patient will experience no difficulty in keeping his foot from rolling inward as he lifts his heel off the ground.
PTTD affects women four times as frequently as men. It typically occurs in middle to older age people with a mean age of 40 years. Clinically, the foot begins to flatten (compared to the non involved foot). Pain and swelling developes along the inside of the ankle. Muscle testing reveals a strength deficit in the involved foot.
Obesity increases the risk of rupturing the tendon of the posterior tibial muscle.
There are three stages of PTTD:
- Stage I: Inflammation and swelling of the posterior tibial tendon around the inside of the ankle. Negative for 'Too-Many-Toes-Sign'
- Stage II: Visible deformity (comparing one foot to the other). The involved foot becomes flatter and more deformed (Figure C below). Positive for 'Too-Many-Toes-Sign'
- Stage III: The foot can progress to a rigid, non-movable flat foot deformity that is painful, primarily on the outside of the ankle. Positive for 'Too-Many-Toes-Sign'
Etiology
The cause of PTTD is still highly contested in the medical literature. However, most researchers (see references below) do agree that:
- foot twist (abnormal pronation) is the most common precursor observed PTTD
-
foot twist, which places the posterior tibialis tendon on a stretch, may in fact be the principle biomechanical factor in the development of PTTD
My research suggests that he most common causes of foot twist are (1) Rothbarts Foot and (2) the PreClinical Clubfoot Deformity.
PTTD is not a foot pathology. Rather, PTTD is one of the many possible symptoms that can develop in patients having excessive foot twist.
Treatment
In order to eliminate the debilitating symptoms resulted from PTTD, the cause of the patient's foot twist must be determined and eliminated.
Unfortunately, it is not uncommon that once the diagnosis of PTTD is made, all attention is directed towards supporting or repairing the weakened/ruptured tendon of the posterior tibial muscle. Traditionally, this is done via a variety of therapies, ranging from supportive type orthotics (arch supports) and/or AFOs to surgical interventions. In the end, these therapies frequently fail if the underlying cause of PTTD is not eliminated.
If the underlying cause of PTTD (and the resulting foot twist) is Rothbarts Foot or the PreClinical Clubfoot Deformity, supportive type orthotics, in my opinion, should never be used. They will only further weaken the foot and increase the disability associated with the dysfunctional posterior tibial tendon.
Magnetic Resonance Images - differentiating between a tear and complete rupture of the posterior tibial tendon:
Figure A: Partial Tear Posterior Tibial Tendon Figure B: Rupture Posterior Tibial Tendon
- Figure A (left MRI above): Coronal T1-weighted MRI image shows thickening of the posterior tibial tendon (white arrow) with increased internal intensity.
- Figure B (right MRI above): Coronal T1-weighted MRI image shows absence of the posterior tibial tendon (red arrow) resulting from a complete tear with fluid signal filling the tendon sheath and soft tissue edema replacing the surrounding subcutaneous fat.
Foot Xrays - flattening of the inner longitudinal arch occurs in the second stage of PTTD
- Figure C (Xrays above): Lateral radiographs, standing position. The height of the medial longitudinal arch is assessed by comparing the position of the base of the fifth metatarsal to that of the anterior-inferior corner of the medial cuneiform bone. This distance between these two points is decreaed in the involved (right) foot, as the foot becomes flatter and more painful.
References:
Anderson, A. F., and Fowler, S. B.: Anterior calcaneal osteotomy for symptomatic juvenile pes planus. Foot and Ankle, 4: 274-283, 1984.
Dyal, C. M.; Feder, J.; Deland, J. T.; and Thompson, F. M.: Pes planus in patients with posterior tibial tendon insufficiency: asymptomatic versus symptomatic foot. Foot and Ankle Internat., 18: 85-88, 1997.
Funk, D. A.; Cass, J. R.; and Johnson, K. A.: Acquired adult flat foot secondary to posterior tibial-tendon pathology. J. Bone and Joint Surg., 68-A: 95-102, Jan. 1986.
Jahss, M. H.: Spontaneous rupture of the tibialis posterior tendon: clinical findings, tenographic studies, and a new technique of repair. Foot and Ankle, 3: 158-166, 1982.
Johnson, K. A., and Strom, D. E.: Tibialis posterior tendon dysfunction. Clin. Orthop., 239: 196-206, 1989.
Mann, R. A.: Rupture of the tibialis posterior tendon. In Instructional Course Lectures, American Academy of Orthopaedic Surgeons. Vol. 33, pp. 302-309. St. Louis, C. V. Mosby, 1982.
Professor/Dr. Brian A. Rothbart
Chronic Pain Elimination Specialist
Discovered the Rothbarts Foot and PreClinical Clubfoot Deformity
Developer of Rothbart Proprioceptive Therapy
Designer of Rothbart Proprioceptive Insoles
Founder of International Academy of Rothbart Proprioceptive Therapy
Author of Forever Free From Chronic Pain
