Clinically relevant Anatomy
“The tibialis posterior muscle is innervated by the tibial nerve. It originates from the posterior interosseous mem- brane and the proximal 2/3 of the adjacent posterior tibia and fibula, forming the deep posterior compartment with popliteus, flexor hallucis longus and digitorum longus. It condenses to form a tendinous structure in the distal third of the calf before passing behind the medial malleolus. Unlike ankle muscles of similar power, a larger part of tibialis posterior is tendinous proximal to the malleolus, where it runs along a groove deep to the deltoid ligament, changing direction in its sheath towards the navicular tuberosity. It then inserts into the navicular tuberosity and the plantar surface of the medial cuneiform by an anterior slip. The posterior slip inserts into the plantarsurfaces of the cuneiforms and the base of the second to fourth metatarsals.”
(Edwards et al 2008)
Sudden or progressive loss of strength of the tibialis posterior tendon (Medicino, 2000). Can also result it a complete degenerative rupture.
- Acute traumatic injury; inflammatory synovitis secondary to mechanical overuse or systemic disease; and chronic tendon degeneration (Meehan and Brage, 2003; Bare and Haddard, 2001)
- Underlying pathological mechanism in chronic TPTD suggest degenerative tendinosis rather than tendinitis, with disruption in collagen bundle structure and orientation (Mosier et al, 2001)
- A slow, pathological tendon rupture could result as degeneration progresses (Rosenberg, 1999)
- Difficulty walking long distances
- Pain along the medial aspect of the ankle alongthe course of the tendon
- Loss of function
- Difficulty performing heel raises
- Flat foot
(Other conditions of painful flat feet)
- Neuropathic Foot
- Failure of supporting anatomy
- Abnormal bony anatomy
- Vascular necrosis (Kholers disease)
- Entrapment neuropathies(Tarsal tunnel Sundrome)
(Edwards et al 2008)
- Deep tissue massage
- Patient education (activity modification)
- Weight loss
The following have all been suggested for the treatment of tibialis posterior dysfunction however the trails are of poor quality with inconclusive findings (Bowring and Chockalingham, 2010). Steriod injections are not advised due to the risk of tendon rupture.
- Increase ROM of the tibialis posterior
- Encourage normal collagen alignment
- Removed causative factors
- Deep transverse frictions
- Muscle stretches
- Normal loading through tendon.
MUST READ paper for this condition: Edwards MR, Jack C and Singh SK Tibialis posterior dysfunction. Current Orthopaedics 2008; 22, 185e192
Bare AA, Haddad SL. Tenosynovitis of the posterior tibial tendon. Foot Ankle Clin 2001; 6 (1):37–66.
Bowring B and Chockalingham N Conservative treatment of tibialis posterior tendon dysfunction—A review. The Foot 20 2010; 18–26.
Edwards MR, Jack C and Singh SK Tibialis posterior dysfunction. Current Orthopaedics 2008; 22, 185e192
Meehan RE, Brage M. Adult acquired flat foot deformity: clinical and radiological examination. Foot Ankle Clin North Am 2003;8:431–52.
Mendicino SS. Posterior tibial tendon dysfunction. Clin Podiatr Med Surg 2000;17(1):33–53.
Mosier SM, Luca DR, Pomeroy G, Manoli A. Pathology of the posterior tib- ial tendon in posterior tibial tendon insufficiency. Foot Ankle Int 1998;19(8): 520–4.
Rosenberg ZS. Chronic rupture of the posterior tibial tendon. Clin Podiatr Med Surg 1999;16(3):423–38.