Tendons connect muscles to bones and stretch across joints, enabling you to bend that joint. One of the most important tendons in the lower leg is the tibialis posterior tendon. This tendon starts in the calf, stretches down behind the inside of the ankle and attaches to bones in the middle of the foot.

The tibialis posterior tendon helps hold your arch up and provides support as you step off on your toes when walking. If this tendon becomes inflamed, degenerated or torn, you may experience pain on the inner aspect of your ankle and gradually lose the arch on the bottom of your foot, leading to a flatfoot.

Signs and symptoms of tibialis posterior tendon dysfunction

  • Pain and swelling on the inside of the ankle
  • Loss of the arch and the development of a flatfoot
  • Gradually developing pain on the outer side of the ankle or foot
  • Weakness and an inability to stand on the toes
  • Tenderness over the midfoot, especially when under stress during activity

Risk factors

Tibialis posterior tendon dysfunction often occurs in women over 50 years of age and may be due to an inherent abnormality of the tendon. But there are several other risk factors, including:

  • Obesity
  • Diabetes
  • Long-standing or lifelong “physiological” flatfootedness
  • Previous surgery or trauma, such as an ankle fracture on the inner side of the foot
  • Local steroid injections
  • Inflammatory diseases such as rheumatoid arthritis
Athletes who are involved in sports such as basketball, tennis, soccer or hockey may tear the tibialis posterior tendon. The tendon may also become inflamed if excessive force is placed on the foot, such as when running on a banked track or road.

Diagnosis

The diagnosis is based on both a history and a physical examination. You may be asked to stand to stand and walk to view how your foot functions. As the condition progresses, the front of the affected foot will start to slide to the outside. From behind, it will look as though you have "too many toes" showing. You may also be asked to stand on your toes or to do a single heel rise: stand with your hands on the wall, lift the unaffected foot off the ground, and raise up on the toes of the other foot. Normally, the heel will rotate inward; the absence of this sign indicates tibialis posterior tendon dysfunction. X-rays, an ultrasound or a magnetic resonance image (MRI) of the foot may be required.

Treatment

Without treatment, the flatfoot that develops from tibialis posterior tendon dysfunction eventually becomes rigid. Arthritis develops in the hindfoot. Pain increases and spreads to the outer side of the ankle. The way you walk may be affected and wearing shoes may be difficult.

The treatment will depend on how far the condition has progressed and how old you are. In the early stages, tibialis posterior tendon dysfunction can be treated with rest, non-steroidal anti-inflammatory drugs such as aspirin or ibuprofen, and immobilisation of the foot for 6 to 8 weeks with a rigid below-knee cast or boot to prevent overuse. After the cast is removed, shoe inserts such as a heel wedge or arch support may be helpful. If the condition is advanced, you may require a custom-made ankle-foot orthosis or support.

If conservative treatments doesn’t work, surgery may be needed. Several procedures can be used to treat tibialis posterior tendon dysfunction. Often, more than one procedure is performed at the same time. Treatment will be individualised. Surgical options include:

  • Tenosynovectomy. In this procedure, any inflamed tissue surrounding the tendon will be cleaned away (debrided) and removed (excised)
  • Lengthening of the achilles tendon.
  • Osteotomy: This procedure changes the alignment of the heel bone (calcaneus).
  • Tendon transfer: This procedure uses another tendon (the flexor digitorum longus, which helps bend the toes) to repair the damaged posterior tibial tendon.
  • Lateral column lengthening: In this procedure, a small wedge-shaped piece of bone is taken from the hip and placed into the outside of the calcaneus. This helps realign the bones and recreates the arch.
  • Spring ligament repair. This is a sling-shaped supportive ligament in the arch of the foot which often tears as part of the disease process
  • Arthrodesis: This procedure welds (fuses) one or more bones together, eliminating movement in the joint. This stabilizes the hindfoot and prevents the condition from progressing further.

  All surgical procedures involve risks. The information provided here is for general educational purposes only. For specific advice regarding tibias posterior tendon dysfunction, please book an appointment with Dr Newman.

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