Tendon Disorders of Foot and Ankle Part 3- Tibialis Posterior

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2010 38: 2133 originally published online March 29, 2010Am J Sports MedGeorge S. Gluck, Daniel S. Heckman and Selene G. Parekh

Tendon Disorders of the Foot and Ankle, Part 3 : The Posterior Tibial Tendon

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Tendon Disorders of the Foot andAnkle, Part 3

The Posterior Tibial Tendon

George S. Gluck,* MD, Daniel S. Heckman,* MD, and Selene G. Parekh,yz§ MD, MBAFrom the *Department of Orthopaedic Surgery, University of North Carolina School of Medicine,Chapel Hill, North Carolina, and the zDivision of Orthopaedic Surgery and §Fuqua BusinessSchool, Duke University, Durham, North Carolina

This article provides a review of posterior tibial tendon pathology and the authors’ preferred management. The tibialis posteriormusculotendinous unit is the most powerful inverter of the foot and an important dynamic stabilizer of the arch. In the stancephase of the gait cycle, it serves as an initiator of both ankle plantar flexion and subtalar inversion. This creates a rigid midfootby stabilizing the transverse tarsal joint, and allows for increased power generation by the gastrocsoleus complex through toe-off.Injuries to the posterior tibialis tendon include traumatic laceration and dislocation, as well as tenosynovitis and tendinopathy,which can lead to attenuation and rupture. If these injuries are not addressed, significant clinical deformity and disability canresult.

Keywords: posterior tibial tendon deficiency; tenosynovitis; accessory navicular; subtalar arthrodesis

ANATOMY

The tibialis posterior muscle is the most central musclein the leg. Located in the deep posterior compartment, itoriginates at the upper third of the leg on the posteriorborders of the tibia, fibula, and interosseous membrane.The tendon forms in the distal third of the leg and passesimmediately posterior to the medial malleolus where itchanges direction acutely.32 A groove in the posteromedialaspect of the distal part of the tibia holds the posteriortibial tendon (PTT) but is not deep enough to keep thetendon from bow-stringing or dislocating after an injury.56

The flexor retinaculum, which is adjacent to the medialmalleolus, tethers the tendon and keeps it in the groove,preventing dislocation. Distally, this retinaculum blendswith the sheath of the tibialis posterior tendon and thesuperficial deltoid ligament. The PTT does not have a mes-otenon, and there is an area of relative hypovascularityimmediately distal to the medial malleolus that may

contribute to degenerative changes of the tendon.20 ThePTT divides anterior to the tuberosity of the navicular.An anterior slip, which is in direct continuity with themain tendon, inserts onto the tuberosity of the navicular,the inferior aspect of the capsule of the medial naviculocu-neiform joint, and the inferior surface of the medial cunei-form. A second slip attaches to the plantar surfaces of themiddle and lateral cuneiforms and the cuboid, as well as tothe bases of the corresponding metatarsals.50 The tibialisposterior tendon is an important dynamic stabilizer ofthe arch and the most powerful inverter of the foot.35,36

It is roughly twice the size of the flexor hallucis longus(FHL) and flexor digitorum longus (FDL) tendons, andslightly smaller than the tibialis anterior tendon.50

The clinical deformity associated with PTT dysfunction(PTTD) reflects the loss of support from the spring, deltoid,and talocalcaneal interosseous ligaments as well as fromthe talonavicular capsule and the plantar fascia. Normally,the deltoid ligament provides stability to the tibiotalocalca-neal joint complex.16,58 With clinical progression of PTTD,the deltoid ligament becomes attenuated and the talusbegins to tilt in the ankle joint, leading to a valgus defor-mity of the hindfoot.13 Deland et al13 demonstrated thatno abnormality can be seen radiographically in a cadavericmodel when there is dysfunction of the PTT alone, and thata static deformity occurs only when there is also associatedligamentous damage.

Clinical Sports Medicine Update

M

yAddress correspondence to Selene G. Parekh, MD, MBA, 3609 SWDurham Dr., Durham, NC 27707 (e-mail: [email protected]).

The authors declared that they had no conflicts of interests in theirauthorship and publication of this contribution.

The American Journal of Sports Medicine, Vol. 38, No. 10DOI: 10.1177/0363546509359492� 2010 The Author(s)

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ACUTE INJURY

Traumatic Lacerations of the PTT

Traumatic lacerations of the PTT can occur directly or indi-rectly in association with an ankle fracture or dislocation,46

a calcaneal fracture, or a traumatic fall. If left untreated, thetraumatic PTT tear can result in the same pes planus defor-mity seen in attritional ruptures.23 Imaging of the soft tissuestructures is not usually required with a laceration, as localwound exploration should lead to an accurate diagnosis. Inthe setting of delayed treatment where the wound wasclosed primarily without exploration, or in the setting ofa closed injury, MRI can be helpful. An ‘‘empty’’ tendonsheath can be diagnosed with high accuracy with MRI,with a sensitivity of 95%, a specificity of 100%, and an overallaccuracy of 96%.59 Ultrasonography, although highly user-dependent, can allow for real-time dynamic examination ofthe tendon.30 If possible, primary repair should be attemp-ted at the time of wound exploration, followed by cast immo-bilization to allow for adequate healing to occur.2,17 In theevent that primary repair is not possible, an FDL tendontransfer may be performed.66 If a hindfoot valgus deformityhas occurred, a medial calcaneal slide osteotomy may also benecessary.

Authors’ Preferred Treatment of Primary Tears of thePTT. In the setting of an acute rupture of the PTT, ourpreference is to proceed with a primary repair as acutelyas possible to minimize contracture of the proximal PTTstump and scarring of the tendon ends due to a delay intreatment. The patient is placed supine on the operatingroom table and a thigh tourniquet is applied. A rolledbump may be placed under the contralateral hip if the nor-mal external rotation of the ipsilateral limb will not allowfor adequate visualization of the posteromedial aspect ofthe ankle. An incision is centered along the course of thePTT, from the navicular to approximately 3 cm proximalto the tip of the medial malleolus. The tendon sheath iscarefully opened with a knife, taking care to protect theremaining portion of the PTT. If possible, the rupturedends are reapproximated with a running Krackow stitchplaced in each of the free ends with a nonabsorbablesuture. The ends of the tendon are brought together andthe sutures are tied while holding the foot in maximalplantar flexion and inversion. A 0 Vicryl suture (Ethicon,Johnson & Johnson, Somerville, New Jersey) is thenplaced in a running fashion around the rupture site toenhance the repair.

If the tendon ends cannot be opposed, or if the tear ischronic in nature with fraying and discoloration (Figure 1),then an FDL tendon transfer is performed. If the ruptureis chronic in nature and a hindfoot valgus deformity hasoccurred, then a medial calcaneal slide osteotomy is alsoperformed. See the discussion below of our preferred treat-ment for stage 2 PTTD for details of this procedure.

In the operating room, the patient is placed in a bulkyJones splint in slight plantar flexion and inversion. Twoweeks following surgery, sutures are removed anda short-leg nonweightbearing cast is applied. Four weekslater, the patient is allowed to bear weight, protected in

a controlled ankle motion (CAM) boot. Physical therapyis started for range of motion (ROM), strengthening, andmodalities as needed. Ten weeks following surgery, theCAM boot is discontinued and physical therapy is main-tained until the tendon repair or transfer has achievedmaximal strength.

Dislocation of the PTT

Dislocation of the PTT is an uncommon injury, with lessthan 40 cases reported in the English literature. Themost common mechanism is forced dorsiflexion and ever-sion of the ankle with the foot inverted while the PTT iscontracted. It has been reported in association with medialmalleolar fractures, and both minor and major ankletrauma.54 Magnetic resonance imaging is useful for demon-strating a dislocation of the PTT medial to the medialmalleolus. Moderate edema surrounding the tendon canalso be seen.51

A few case reports exist in the literature, with the largestseries by Ouzounian and Myerson.54 Their series included 6acute traumatic dislocations and 1 chronic dislocation thatwas attributed to multiple local steroid injections. Theaverage length of time to diagnosis was 9 months, with allpatients requiring surgery after failed nonoperativetreatment. The retinaculum was found to be absent, torn,redundant, or avulsed with a fibrocartilaginous rim. Recon-struction was performed with either reattachment throughdrill holes, imbrication, or primary repair where appro-priate. If the retromalleolar groove was found to be shallow,a deepening procedure was also performed. All patients hadpostoperative immobilization in a short-leg cast followed by

Figure 1. Intraoperative photograph of a chronic rupturewith fibrous healing of the posterior tibial tendon.

2134 Gluck et al The American Journal of Sports Medicine



physical therapy. Five patients were asymptomatic onfollow-up, with 1 patient having continued difficulty.

Various other methods of stabilization have been used.These include suture anchor repair of the retinaculum andreconstruction using a periosteal sleeve or Achilles tendonflap. Overall, most authors report good to excellent resultswith the majority of patients returning to preinjury activitylevels.24,51,54

Authors’ Preferred Treatment of PTT Dislocation. Thepatient is placed supine on the operating room table anda thigh tourniquet is applied. A bump may be placed underthe contralateral hip if the normal external rotation of theipsilateral limb will not allow for adequate visualization ofthe posteromedial aspect of the ankle. An incision iscentered along the course of the PTT, from the navicular toapproximately 4 cm proximal to the tip of the medial mall-eolus. The retinaculum is examined; if it is torn off of themedial malleolus, the tear is extended to expose the PTT.If thesheath isattenuated, it is carefully openedwith aknife,taking care to protect the PTT. The PTT is then examined forany longitudinal tears. If present, the PTT tear is repairedwith a nonabsorbable running suture.

The malleolar groove is examined. If shallow, it must bedeepened. Under fluoroscopic guidance, a guide pin froma 4-0 cannulated screw system is placed, starting fromthe tip of the medial malleolus, and inserted proximallyand posteriorly, parallel to the cortex of the groove. Theguide pin is advanced proximally until the tip of the pintouches the posterior cortex on the lateral view. The guidepin is then overdrilled with a 4.0-mm drill bit and checkedradiographically. The guide pin is removed and the malleo-lar groove is deepened with a bone tamp and mallet.

Next, the retinaculum is repaired; if it is torn from themedial malleolus, the sheath is reattached to the bonethrough drill holes, using a nonabsorbable suture. If thesheath is attenuated, it is imbricated with a nonabsorbablesuture. Care is taken to ensure that the retinaculum is notovertightened, to prevent constriction of the PTT.

In the operating room, the patient is placed in a bulkyJones splint with the foot in slight plantar flexion and inver-sion. Two weeks following surgery, sutures are removed anda short-leg nonweightbearing cast is applied. Four weekslater, the patient is allowed to bear weight, protected ina CAM boot. Physical therapy is started for ROM, strength-ening, and modalities as needed. Ten weeks following sur-gery, the CAM boot is discontinued and physical therapy iscontinued until maximal strength is achieved.

SYMPTOMATIC ACCESSORY NAVICULAR

The accessory navicular is one of 38 accessory bones thathave been identified in the foot.53 It can be unilateral orbilateral and is significantly more prevalent in females.Symptoms usually develop after 5 years of age and aremost common in early adolescence.41 Patients often com-plain of pain over the medial aspect of the midfoot withweightbearing,walking,and strenuous activity or from wear-ing narrow shoes. Pain can be reproduced by palpation

over the accessory navicular and PTT insertion, or byresisting active foot inversion.14 Symptoms are more likelyto be acute in adults, especially after trauma with a footeversion injury. In children, the presenting complaint isoften more chronic and related to pressure on the medialprominence from the shoe.10

The classification system includes 3 types, which arebased on radiographic appearance. Geist22 was the firstto perform a radiographic study on the accessory navicular,and he expanded on previous work to include the 3 typesthat are recognized today. When the accessory navicularexists as an ossicle within the substance of the PTT, it isconsidered type 1. Type 2 is defined by a synchondrosisthat joins it to the navicular.62 In cases where it has fusedto the navicular, it is considered a type 3.22 In addition toplain radiographs and CT scans of the foot (Figure 2),bone scintigraphy and MRI can help to identify a symptom-atic accessory navicular by localizing increased technetiumuptake or fluid and marrow edema, respectively.

Nonoperative treatment, regardless of classification,consists of shoe wear modification to relieve pressureover the tender area, nonsteroidal anti-inflammatory med-ication, braces, and orthotics such as a University of Cali-fornia at Berkeley Laboratory–type orthotic device (UCBL)or medial heel wedge to minimize tension of the PTT at theinsertion. Some advocate corticosteroid injections targetedat the synchondrosis.10 In the acute setting, in patientswho are exquisitely tender, a short-leg walking cast orremovable fracture boot may be tried. Results of non-operative treatment range in success from 13% to 33%.22,25

Operative treatment generally incorporates removal ofthe accessory navicular with either primary PTT repairin stage 1 or reconstruction in stages 2 and 3. Kidner34 iswell known for his classic description of the procedure forsymptomatic accessory navicular. It involved accessorynavicular excision and PTT reconstruction by reattachinga wafer of bone and the PTT to the navicular with chromicsuture. Leonard et al39 proposed the modification of pass-ing the PTT through a drill hole. Successful outcomeshave been achieved with both primary repair and recon-struction of the PTT, regardless of stage.22,37,39,42 Someauthors advocate other modifications, such as the use ofsuture anchors in the navicular or resection of thesynchondrosis and fusion with screw fixation.42,61,67

Authors’ Preferred Treatment of the Accessory Navicu-lar. The patient is placed supine on the operating roomtable and a thigh tourniquet is applied. A bump may beplaced under the contralateral hip if the normal externalrotation of the ipsilateral limb will not allow for adequatevisualization of the posteromedial aspect of the ankle. Anincision is centered along the course of the PTT, from thenavicular to 1 cm proximal to the tip of the medial malleo-lus. The PTT sheath is identified and carefully openedsharply. The PTT is identified and followed distally tothe accessory navicular. The accessory navicular is pal-pated. The PTT is sharply dissected off the accessory navic-ular and the navicular bone as distally as possible. Theaccessory navicular is then excised. The distal attachmentsof the PTT are preserved if the accessory navicular can beremoved from the tendon without complete tenotomy. A

Vol. 38, No. 10, 2010 Posterior Tibial Tendon Disorders 2135



nonabsorbable suture is placed in a modified Kessler-typefashion over the distal aspect of the PTT. A drill hole isthen placed in a dorsal to plantar direction with a drillbit to create a hole large enough to allow passage of thetendon. With use of a suture passer, the PTT is broughtthrough the hole plantar to dorsal. The foot is held in max-imal inversion and plantar flexion. A series of No. 2 nonab-sorbable horizontal mattress sutures are placed throughthe tendon and into the surrounding periosteum and cap-sule at the dorsal aspect of the drill hole. The 2 free endsof the No. 2 nonabsorbable suture from the tip of thePTT are then tied back onto the PTT proximally. Thesheath is closed with 2-0 Vicryl sutures. The subcutaneoustissue is closed with 2-0 Vicryl sutures. Staples are used toclose the skin.

The patient is placed in a bulky Jones splint with thefoot in slight plantar flexion and inversion. Two weeks fol-lowing surgery, staples are removed and a short-legnonweightbearing cast is applied. Four weeks later, thepatient is allowed to bear weight, protected in a CAMboot. Physical therapy is started for ROM, strengthening,and modalities as needed. Ten weeks following surgery,the CAM boot is discontinued and physical therapy ismaintained until maximal strength is achieved.

POSTERIOR TIBIAL TENDON DEFICIENCY ANDACQUIRED FLATFOOT DEFORMITY

The first published description of tendinitis and insuffi-ciency of the PTT is credited to Kulowski in a 1936 article.38

Subsequently, articles by Fowler19 and Williams70 dis-cussed the syndromic nature of the disease and the role of

surgical intervention to alter its natural history. The useof an FDL transfer to treat progressive flatfoot deformitywas originally described by Goldner et al23 in 1974 and pop-ularized in the early 1980s by Jahss31and Mann andThompson.45

Although PTTD is a common clinical entity, an exactincidence is difficult to determine. Causative risk factorshave not been definitively identified, but certain associa-tions have been made. Several authors have noted the inci-dence of PTT pathology or rupture as higher in middle-aged women who have coexisting obesity.21,28,32,45 Otherclinical entities that have been found to contribute to thedevelopment of PTTD include diabetes mellitus, hyperten-sion, steroid exposure, or previous trauma or surgery inthe medial foot region. Holmes and Mann28 studied 67patients with PTT rupture. The authors noted that almost60% of their patients had a history of at least 1 of theseaforementioned conditions.

Insufficiency of the PTT is mainly a clinical diagnosis.Symptoms early in the disease process are predominantlypain around the posteromedial aspect of the ankle. It isoften worsened with activity and can radiate along to thearch of the foot. Fatigue or weakness of the foot and ankleis also associated with this condition, and patients maycomplain of decreased endurance with walking or difficultywalking on uneven surfaces. Swelling and pain along thecourse of the PTT, particularly several centimeters proxi-mal to the insertion on the navicular, are also common.Patients may also begin to complain of pain on the lateralaspect of the ankle and progressive ‘‘turning out’’ of thefoot as the disease progresses and deformity with impinge-ment of lateral structures occurs. Although PTTD can leadto flatfoot deformity, there are other potential causes ofthis deformity that must be considered. Other causes

Figure 2. Imaging of an accessory navicular: A, AP view of a synchondrosis type; B, axial CT image.




include tarsal coalition, inflammatory arthritis, traumaticdisruption of the ligaments of the midfoot, tarsometatarsalosteoarthritis, Charcot arthropathy, and neuromusculardisease.

On physical examination, after both legs, ankles, andfeet are exposed, inspection should be made for any areasof swelling or malalignment. Gait analysis should be per-formed to identify any asymmetries or antalgic compo-nents. Forefoot abduction and pes planus deformitiesshould be noted. Observation of the alignment of theextremity from behind with the patient facing away fromthe examiner will reveal pes planovalgus deformity bythe ‘‘too-many-toes’’ sign. Heel valgus should also be noted.Once heel valgus exceeds the normal range of about 5� to10�,63 the Achilles tendon moves lateral to the axis of thesubtalar joint and contractures of the Achilles tendon candevelop. Single-limb heel raise should always be testedor, more easily, a patient can be asked to walk on his orher toes for a short distance. Individuals with normalfoot and ankle strength and mechanics should be able tocomplete 5 to 10 single-limb heel raises without difficulty.Incomplete inversion of the heel, difficulty or inability toraise the heel, or sensations of weakness or pain while per-forming this test are highly suggestive of PTTD. Tender-ness is first noted over the course of the PTT, but candevelop over the tip of the lateral malleolus as lateralimpingement occurs in the latter stages of disease.56

Strength should be assessed by having the examiner holdthe patient’s foot in plantar flexion, eversion, and abduc-tion. The patient is then asked to plantar flex and invertthe foot against resistance. Strength deficits of 20% to30% or more can be detected in stage 2 disease.29 Subtalarmobility should also be checked. If mobile, dorsiflexion ofthe ankle should be tested with the knee both flexed andextended while passively correcting any valgus angulationof the heel. This allows for the evaluation of an Achillestendon contracture.

A widely accepted classification system, proposed byJohnson and Strom32 and later modified by Myerson,48

clarifies treatment recommendations based on the severityof PTTD and adaptation of the foot to collapse of the mediallongitudinal arch (Table 1).

Stage 1

Stage 1 disease is characterized by tenderness over thePTT with a variable amount of edema and warmth, consis-tent with tendinosis or tenosynovitis. Mild weakness maybe present with single-limb heel raise or manual testing,which should reproduce posteromedial pain at a minimum.Tenderness along the course of the PTT is present. Hind-foot inversion and overall clinical alignment and mobilityshould be normal. Radiographs should not show anydegenerative changes or deformity, while MRI may showenhancement surrounding the PTT on T2-weighted imag-ing (Figure 3), consistent with inflammation and edema.Ultrasound may show fluid around the PTT.

Nonoperative treatment depends on the level of symp-toms reported by the patient. With acute or severe disease,

immobilization is recommended with a cast or removablefracture boot. Weightbearing is allowed, and nonsteroidalanti-inflammatory drugs are used for pain relief. Aftera 4- to 6-week period of immobilization, patients areencouraged to use an arch support with a medial heelwedge and a medial column post.63 In those with morechronic or mild symptoms, orthotic support may be the ini-tial recommendation. Physical therapy for ankle strengthand flexibility, with focus on the tibialis posterior, is intro-duced as the patient improves and symptoms allow. Treat-ment is continued for 3 to 6 months before surgicalintervention is considered. Prolonged orthotic use and peri-odic evaluations to monitor for progression may be neces-sary in patients who respond to nonoperative treatment.

Operative treatment of stage 1 disease includes tenosy-novectomy, in addition to debridement or repair of degen-erative areas or tears.64 Both open and tendoscopictechniques have been described. An open procedure allowsclear identification and inspection of the local anatomy.One, small, retrospective study reported complete reliefin 6 of 7 patients 11 months after synovectomy with orwithout tendon debridement. These patients all failed atleast 6 weeks of immobilization. The 1 operative failurehad extensive intrasubstance degeneration and requiredtendon transfer after further disease progression.11 Poste-rior tibial tendoscopy allows for improved cosmesis andpotentially less surgical pain and scarring. Two publica-tions on tendoscopic techniques had similar results insmall patient groups without reported complication otherthan entering the wrong tendon sheath initially.4,7,68

Authors’ Preferred Treatment of PTTD Stage 1. We donot routinely use corticosteroid injections, as the diseaseis considered more degenerative than inflammatory.28,32,48

The patient is placed supine on the operating room tableand a thigh tourniquet is applied. A bump may be placedunder the contralateral hip if the normal external rotationof the ipsilateral limb will not allow for adequate visualiza-tion of the posteromedial aspect of the ankle. An incision iscentered along the course of the PTT, from the navicular to4 cm proximal to the tip of the medial malleolus. The PTTsheath is identified and carefully opened sharply. Often-times, there are dense adhesions between the tendon andthe sheath, such that dissection of the tendon must be per-formed extremely carefully. Synovitic tissue will appearbrownish red. This is meticulously removed with a rongeur.The tendon is examined for any fusiform edema or tears. Ifpresent, tears of the tendon should be repaired with a tubu-larization procedure using a nonabsorbable suture.

The sheath is then reapproximated and closed with anabsorbable suture. The subcutaneous tissues are alsoclosed with absorbable suture. The skin is closed with sta-ples. The patient is placed in a bulky Jones splint withslight plantar flexion and inversion.

Two weeks following surgery, sutures are removed andthe patient is allowed to bear weight as tolerated ina CAM boot. Aggressive physical therapy is started forROM, strengthening, and modalities as needed. Six weeksfollowing surgery, the CAM boot is discontinued andphysical therapy is maintained until maximal strengthis achieved.




Stage 2

Stage 2 disease is characterized by the presence of clinicalpes planus deformity that is flexible with a varying degreeof heel valgus and a positive too-many-toes sign. This sign

is characterized by the visibility of the lateral toes extendinginto the field of view when the foot is viewed from behind theheel (Figure 4). Tenderness and swelling persist, but weak-ness and difficulty with single-limb heel raises increases.Common radiographic findings are decreased lateral talo-calcaneal pitch angle and uncovering of the talar head. OnMRI, enlargement and abnormal signal of the PTT can beappreciated when compared with the peroneal, FDL, andFHL tendons (Figure 5).

Radiographic analysis of the foot and ankle is impor-tant, not only to evaluate for arthrosis but also to docu-ment preoperative deformity. Evaluation should includebilateral weightbearing AP and lateral views of the footand ankle. A variety of angular and linear methods of mea-surement have been described.5 The AP view of the ankleis obtained to evaluate valgus tilt of the talus and subfibu-lar impingement. On the AP view of the foot, the talo–firstmetatarsal angle can be measured, and should be close toparallel. On the lateral weightbearing view of the foot,the lateral talocalcaneal and calcaneal pitch angles arenoted. Loss of calcaneal pitch and an increased lateral talo-calcaneal angle can be seen in flatfoot deformity. Diver-gence of the talo–first metatarsal angle can also be seen(Figure 6). Magnetic resonance imaging can be a helpfuladjunct when planning the treatment for PTTD, and canhelp identify ligamentous and PTT pathology. Relevantfindings include intrasubstance tears or degeneration ofthe PTT, enlargement of the PTT to more than twice thediameter of the FHL or FDL tendons, edema surrounding

TABLE 1Stages of Posterior Tibial Tendon Dysfunctiona

Stage 1 Stage 2 Stage 3 Stage 4

Tendonpathology

Tenosynovitis 6

degenerationDegeneration 1

elongationDegeneration 1

elongationDegeneration 1 elongation

Deformity Absent Flexible pesplanovalgus

Fixed pesplanovalgus

Fixed pes planovalgus

Clinicalfindings

Medial painMild pain with

heel raiseMild weakness

with hindfootinversion

Medial 6 lateral painToo-many-toes signMarked pain with

heel raise 6 unableto perform

Marked weakness withhindfoot inversion

Medial 6 lateral painToo-many-toes signUnable to perform

heel raiseMarked weakness with

hindfoot inversion

Medial 6 lateral painToo-many-toes signUnable to perform

heel raiseMarked weakness

with hindfootinversion

Pain/crepitus withtibiotalar motion

Nonoperativetreatment

Medial heel 1 solewedge

Period ofimmobilization

Therapy

Orthotic support (molded,articulated AFO)

Rigid AFO Rigid AFO

Operativetreatment

TenosynovectomyRepair

FDL tendon transferCalcaneal osteotomyLateral column

lengtheningHeel cord lengthening

Triple arthrodesis Tibiotalocalcanealarthrodesis

Triple arthrodesiswith total anklearthroplasty(experimental)

aAFO, ankle-foot orthosis; FDL, flexor digitorum longus

Figure 3. A T2-weighted MRI axial cut showing increasedfluid within the posterior tibial tendon sheath.




the PTT, and gross tears or attenuation of the spring liga-ment complex. In one report, MRI was found to haveincreased sensivitiy for the extent of PTT degenerationwhen compared with intraoperative evaluation.9

The presence of a deformity suggests that elongation ordisruption of the PTT has occurred, along with attenuationof stabilizing ligamentous structures. These include the del-toid ligament, the talocalcaneal interosseous ligament, andthe spring ligament complex consisting of the superomedialcalcaneonavicular ligament (incorporated with the medialtalonavicular capsule) and the inferior/plantar calcaneona-vicular ligament.12 The deformity remains flexible with rel-atively normal subtalar motion, but a gastrocnemius-soleuscontracture may be present. This stage can be further

separated into patients without lateral ankle pain (stage2A) and those with lateral ankle pain (stage 2B). Lateralpain indicates further progression with symptomatic col-lapse of the medial arch.

Nonoperative treatment is similar to that for stage 1 dis-ease, except that the prescribed orthosis must be more rigid,with increased lateral buttressing of the forefoot. A supra-malleolar orthotic or molded articulated ankle-foot orthosis(AFO) may serve to control deformity and reduce symp-toms.6 A rigid orthosis can provide a permanent solutionfor patients who find it helpful. One study by Lin et al40

demonstrated a 70% success rate at a 7- to 10-year follow-upfor nonoperative treatment of stage 2 PTTD using a doubleupright AFO for an average bracing period of 14 months.

Operative treatment remains an area of some con-troversy. Treatment usually incorporates dynamic supportwith tendon transfer to replace or augment the PTT, alongwith bony procedures to improve static alignment. Main-stays include a flexor tendon transfer, usually with theFDL, and a medializing calcaneal osteotomy.21,33,47,50 Useof the FHL for reconstruction has been recommended aswell,23 but requires a more complicated dissection andhas increased donor morbidity secondary to functional def-icit. Furthermore, while the FHL is significantly strongerthan the FDL, the FDL is located in a more optimalanatomic position for transfer.50 Heel cord or a gastroc-nemius recession and lateral column lengthening throughthe neck of the calcaneus or the calcaneocuboid jointhave also been incorporated into reconstructive proceduresto correct equinus contracture and forefoot adduction,respectively.15,49,52 A repair of the spring ligament is anadditional soft tissue procedure that can be used to aug-ment the reconstruction.28 Some authors also advocate

Figure 4. Too-many-toes sign.

Figure 5. A T1-weighted MRI axial cut showing enlargementand abnormal signal within the posterior tibial tendon (PTT).FDL, flexor digitorum longus; FHL, flexor hallucis longus.

Figure 6. Clinical diagrams showing normal and pathologicalignment of the flatfoot in AP and lateral views.




a lateral column lengthening through the calcaneocuboidjoint with arthrodesis, as opposed to an Evans-type osteot-omy at the calcaneal neck to prevent increased pressureacross the calcaneocuboid joint.50A clinical study address-ing this issue found no significant differences in objectiveoutcome measures or patient satisfaction at 1 year.65

Authors’ Preferred Treatment of PTTD Stage 2. Thepatient is placed supine on the operating room table anda thigh tourniquet is applied. A bump may be placed underthe contralateral hip if the normal external rotation of theipsilateral limb will not allow for adequate visualization ofthe posteromedial aspect of the ankle. If the patient hasa hindfoot valgus deformity and a gastrocsoleus complexcontraction, an Achilles tendon lengthening is performedfirst. The foot is held by an assistant approximately 1foot off of the table. Three hemisections are performed per-cutaneously in the Achilles tendon. Two exit the tendonlaterally and one exits medially in an alternating fashion.A No. 15 blade is brought through the tendon parallel tothe long axis of the tibia. It is then turned 90� and a hemi-section is performed. This is done 1 to 2 cm proximal to theinsertion site, then at approximately 4 cm, and finally atapproximately 6 cm proximal to the insertion site. Afterthe 3 hemisections are completed, the foot is held in neu-tral and the Achilles tendon is slowly lengthened suchthat 10� to 15� of dorsiflexion is obtained. All 3 woundsare closed with staples.

Next, attention is directed to the posteromedial ankle.An incision is centered along the course of the PTT, fromthe navicular to approximately 4 cm proximal to the tipof the medial malleolus. The PTT sheath is identified andopened sharply. The PTT is examined to ensure that a ten-don transfer is required. If a transfer is needed, the PTT istransected at the proximal extent of the incision. The resid-ual distal portion is then mobilized and resected off of thenavicular. Dissection is continued medially along the foot.The abductor hallucis is reflected inferiorly. The origin ofthe flexor hallucis brevis is identified and released togain access in the midfoot. The FDL and FHL tendonsare then identified (Figure 7A). Any connection betweenthe 2 tendons is released. With all of the toes held in max-imal plantar flexion at the same level, a tacking suture isplaced at the level of the knot of Henry, tenodesing theFDL and FHL tendons together. The FDL tendon is thentransected at the level of the first metatarsal, proximal tothe tenodesis. A Kessler suture is placed in the tip of theFDL tendon with a No. 2 nonabsorbable suture (Figure7B). The spring ligament is carefully examined. If attenu-ated, it must be repaired, in a pants-over-vest manner.

To perform a spring ligament repair, the talonavicularjoint is held reduced and the amount of attenuated tissueis marked. Nonabsorbable suture is placed from the distalsegment to the proximal marks and from the proximal seg-ment to the distal mark. A small incision is made in thefloor of the PTT sheath to communicate with the FDL ten-don sheath. The FDL is transferred into the PTT sheathproximally. The medial pole of the navicular is identified.A drill hole is made dorsal to plantar through the medialpole of the navicular. The FDL is then pulled from plantarto dorsal through the drill hole (Figure 7C). The foot is

placed into maximum plantar flexion and inversion andthe FDL is sewn back on itself with No. 2 nonabsorbablesuture (Figure 7D). An additional nonabsorbable sutureis placed into the periosteum to secure fixation. The springligament sutures are then tied. The tendon sheath is closedwith running absorbable sutures. The subcutaneous tissueis closed with absorbable sutures. The skin is closed withstaples.

If there is a hindfoot valgus deformity, a medial calca-neal slide osteotomy is performed prior to fixation of thetendon. An incision is made over the lateral aspect of thecalcaneus just posterior to the peroneal tendons. It is car-ried down through subcutaneous tissues with care to avoidinjury to the sural nerve. Dissection is carried down to thelevel of the lateral wall calcaneus. Subperiosteal dissectionis carried out around the lateral wall. The guidewire froma 7.0-mm cannulated screw system is introduced into theposteroinferior aspect of the calcaneus, perpendicular tothe plane of the planned osteotomy. It is introduced up tothe depths of the threads. The osteotomy is then performedwith a sagittal saw through the posterior aspect calcaneus.The posterior fragment is displaced approximately 5 to 10mm medially. The guidewire is driven across for provi-sional fixation. The prominent lateral shelf of the calca-neus osteotomy is tamped down to avoid impingement onthe peroneal tendons. The position of the pin is checkedradiographically. It is then overdrilled and fixed witha 7-mm partially threaded screw (Figure 8). Rigid fixationmust be obtained. The guidewire is then removed from thewound. The wound is irrigated and closed with absorbablesutures followed by staples for the skin.

The patient is placed in a bulky Jones splint with slightplantar flexion and inversion. Two weeks following sur-gery, sutures are removed and a short-leg nonweightbear-ing cast is applied. Four weeks later, the patient is allowedto bear weight, protected in a CAM boot. Physical therapyis started for ROM, strengthening, and modalities asneeded. Ten weeks following surgery, the CAM boot is dis-continued and physical therapy is maintained until maxi-mal strength is achieved.

Stages 3 and 4

Stage 3 is characterized by loss of hindfoot deformity flex-ibility and an increase in lateral-sided ankle pain. Forefootsupination may be present to compensate for fixed hindfootvalgus in order to maintain a plantigrade foot. This isa fixed deformity that cannot be passively corrected. Inaddition to clinical and radiographic malalignment, degen-erative changes of the subtalar, talonavicular, andcalcaneocuboid joints may be present. Routine plain radio-graphs of the foot and ankle may be further supplementedby CT imaging to help identify arthrosis in these joints.Over time, without surgical correction or treatment to pre-vent progression, patients with stage 3 PTTD progress tostage 4. This is characterized by arthrosis involving theankle joint as well.48

Nonoperative treatment of stage 3 and stage 4 diseaseincorporates a progressively more rigid AFO, such as an




Arizona-type brace or an articulated AFO. At this point,the goal is to prevent progression by accommodating anyrigid deformity, correcting any correctable deformity, andcontrolling pain.34,64 Bracing will prevent progressivedeformity, but progressive arthrosis can still occur becauseof abnormal mechanics during weightbearing.6 Surgicalintervention should be considered if patients do not obtainrelief within 3 to 6 months, or if they cannot toleratebracing.

The goals of operative treatment in stage 3 disease areto re-create a plantigrade weightbearing surface and main-tain the integrity of the ankle through arthrodesis byrealigning the hindfoot.50 Single, double, and triple fusionshave been used to treat stage 3 PTTD. Fusions can beselective with an isolated talonavicular arthrodesis, talo-navicular and calcaneocuboid arthrodesis, or an isolatedsubtalar arthrodesis. Double fusions of the talonavicularand calcaneocuboid joints may be indicated in cases whereclinical deformity consists of forefoot abduction and varus,but the subtalar joint remains painless and passively

correctable.8,43 Similarly, isolated subtalar arthrodesismay be indicated where forefoot abduction and varus arereducible, and the transverse tarsal joints are pain-freeand without evidence of arthrosis.44,60

Isolated talonavicular arthrodesis can be performed tofacilitate limited correction in the setting of a painless, flex-ible subtalar joint, but it will still significantly limit forefootmotion.1 It can be complicated by the development ofpain at the intact calcaneocuboid joint. It is not commonlyperformed, but can be successful in older, lower demandpatients.27,45,55

Lengthening the Achilles tendon to increase ankle dorsi-flexion and decrease midfoot loading is also an importantaspect of surgical treatment, and it may serve to limit pro-gressive arthrosis.18 Triple arthrodesis is commonly per-formed for this condition, and a 2-incision technique isrecommended as it provides superior visualization for prep-aration of all fusion sites.50 Triple arthrodesis can providereliable pain relief, but patients often continue to havesome residual pain.69 It is important to ensure proper

Figure 7. Intraoperative photographs of flexor digitorum longus (FDL) transfer for posterior tibial tendon (PTT) reconstruction. A,the flexor hallucis longus (FHL) as it passes superior to the FDL at the knot of Henry. B, the FDL after tenotomy and tagging witha suture. C, the FDL after it has been pulled through a drill hole in the navicular. D, the FDL tied to itself after the PTTreconstruction.




alignment of the hindfoot, as not doing so can alter tibiotalarjoint mechanics and loading.57 There is a high rate of post-operative complications, and some patients will still developankle arthrosis.3,48 Despite these problems, patient satis-faction remained high in multiple studies.3,8,18,55

Stage 4 PTTD represents the end of the natural progres-sion of the disease. It can also develop after triple arthrod-esis with residual malalignment. Treatment options arebased on whether the valgus ankle deformity can bereduced. It is also important to rule out fibular stress frac-tures and lateral talar dome osteonecrosis. If the anklejoint is reducible, fusion can be revised if previously per-formed.26 Medial displacement calcaneal osteotomy,58 del-toid ligament reconstruction,37 or a combination of the twocan also be considered, but there are no reports of the long-term results available. If the ankle joint is irreducible,options include arthrodesis or arthroplasty. Arthrodesiscan be performed using external fixation, internal fixation,or retrograde intramedullary nailing. A variety of implantsare available for ankle arthroplasty, but the procedure isstill not widely accepted and long-term results are notavailable in this subset of patients.

Authors’ Preferred Treatment of PTTD Stage 3. Thepatient is placed supine on the operating room table anda thigh tourniquet is applied. A bump may be placed underthe contralateral hip if the normal external rotation of theipsilateral limb will not allow for adequate visualization ofthe posteromedial aspect of the ankle. If the patient hasa hindfoot valgus deformity and a gastrocsoleus complexcontraction, an Achilles tendon lengthening is performedfirst. This is performed as described in our preferred treat-ment for stage 2 PTTD.

An incision is made from the tip of the fibula toward thebase of the fourth metatarsal. It is carried down throughthe subcutaneous tissues. Care is taken to avoid injury tothe sural nerve and lateral branches of superficial peronealnerve. Dissection is carried down to the interval betweenthe peroneal tendon, sinus tarsi, and extensor digitorumbrevis muscle. The extensor digitorum brevis is elevatedand reflected medially. This gives access to both the subta-lar and calcaneocuboid joints. The interosseous ligament is

then divided off the origin of the superior aspect of the cal-caneus. Using a series of rongeurs and curets, the remain-ing subchondral bone from the posterior, middle, andanterior facets of the subtalar joint is removed to the levelof cancellous bone. The joint surfaces are then featheredwith a 0.25-in osteotome. A 2-mm drill bit is used to createpuncture holes in the subchondral bone of both bony surfa-ces. The surfaces are prepared so that when they arereduced, the heel remains in 5� of residual valgus.

Attention is then turned to the calcaneocuboid joint. Adistractor is placed. Again, using a series of rongeurs andcurets, all remaining subchondral bone is removed downto the level of cancellous surfaces, taking care to preservethe saddle shape of the calcaneocuboid joint. The joint sur-faces are then feathered with a 0.25-in osteotome. A 2-mmdrill bit is used to create puncture holes in the subchondralbone of both bony surfaces.

Attention is then directed dorsomedially. An incision ismade over the dorsal aspect of the talonavicular joint. Thisis carried out through the subcutaneous tissue with care toavoid injury to the saphenous nerve and vein. Dissection iscarried down to the level of the joint capsule. A dorsal cap-sulotomy is created and the talonavicular joint is exposedby dissecting the capsule off the dorsal surface of the navic-ular. Using a distractor, all remaining subchondral bone isremoved from the head of the talus and proximal undersur-face of the navicular. This is removed down to the level ofcancellous bony surfaces. Once this is completed, the can-cellous surfaces are feathered with a 0.25-in osteotome.A 2-mm drill bit is used to create puncture holes in thesubchondral bone of both bony surfaces.

The subtalar joint is first reduced, giving the heel 5� ofresidual valgus. A guidewire from a 7.0-mm screw systemis introduced into the neck of the talus, through the body ofthe talus, and into the calcaneus. Fluoroscopic views areobtained to confirm good position of the guidewire. Thetalus is overdrilled and a 7.0-mm screw is placed. The talo-navicular joint is then reduced to restore normal alignmentof the arch and bring the forefoot into neutral alignment.With the talonavicular joint held reduced, the guide froma staples system is placed and overdrilled. Two staples

Figure 8. Radiographs of the calcaneal osteotomy after fixation with a 7-mm cannulated compression screw: A, lateral view;B, Harris axial heel view.




are placed to span the talonavicular joint. Attention is thenturned to the calcaneocuboid joint. Reduction is confirmed,and a locking staple system guide is placed and overdrilled.A locking staple and respective screws are placed and thestaple is compressed. Final fluoroscopic views are obtained.

The patient is placed in a bulky Jones splint in neutraldorsiflexion and plantar flexion, with 5� of valgus. Twoweeks following surgery, sutures are removed anda short-leg nonweightbearing cast is applied. Four weekslater, the patient is placed in a CAM boot, but remains non-weightbearing. Eight to 10 weeks following surgery, afterradiographic evidence of healing is seen, patients areallowed to bear weight in a CAM boot. The CAM boot is dis-continued at week 12.

SUMMARY

Both acute and chronic PTT injury can result in significantdisability for the patient. As such, it is important that clini-cians be able to recognize PTT pathology and be familiarwith treatment options. This article serves to provide a briefreview of PTT disorders and presents surgical methods fortreatment. We would like to emphasize that the techniquespresented in this article represent our preferred methods forsurgical treatment. Although we have been pleased with ourclinical outcomes, we do recognize that controversy remainsregarding the appropriate treatment for some of theseconditions.

An online CME course associated with this article isavailable for 1 AMA PRA Category 1 CreditTM athttp://ajsm-cme.sagepub.com. In accordance with thestandards of the Accreditation Council for ContinuingMedical Education (ACCME), it is the policy of TheAmerican Orthopaedic Society for Sports Medicinethat authors, editors, and planners disclose to the learn-ers all financial relationships during the past 12 monthswith any commercial interest (A ‘commercial interest’ isany entity producing, marketing, re-selling, or distrib-uting health care goods or services consumed by, orused on, patients). Any and all disclosures are providedin the online journal CME area which is provided to allparticipants before they actually take the CME activity.In accordance with AOSSM policy, authors, editors, andplanners’ participation in this educational activity willbe predicated upon timely submission and review ofAOSSM disclosure. Noncompliance will result in anauthor/editor or planner to be stricken from participat-ing in this CME activity.

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Tendon Disorders of Foot and Ankle Part 3- Tibialis Posterior