Tibialis posterior dysfunction: a common and treatable cause of adult acquired flatfoot
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《英国医生杂志》
1 Royal National Orthopaedic Hospital, Stanmore HA7 4LP, 2 Middlesex Hospital, London W1N 8AA, 3 Barnet General Hospital, Barnet EN5 3DJ, 4 McGill University Health Centre, H?pital Général de Montréal 1650, Avenue Cedar, Montreal, Canada H3G 1A4
Correspondence to: J Kohls-Gatzoulis gatzoulis@ntlworld.com
Introduction
We seached PubMed for publications by using the keywords "flatfoot" and "tibialis posterior dysfunction".
Tibialis posterior dysfunction: a common condition
Tibialis posterior dysfunction is well recognised by orthopaedic surgeons specialising in foot and ankle surgery and by podiatrists. However, greater general awareness of this condition is required,2 as most patients presenting to a general practitioner receive a diagnosis of ankle sprain or arthritis. By the time most patients present to a specialist foot and ankle clinic they have had the condition for several years and have consulted numerous doctors.3 Even general orthopaedic surgeons and physiotherapists often miss the diagnosis.3 However, tibialis posterior dysfunction need not remain a "specialist diagnosis" as it is usually diagnosed without any investigations, from a history and physical examination.2 Many patients benefit from relatively simple treatment, such as orthotic devices.4 Population based studies to identify the prevalence of tibialis posterior dysfunction are under way. In elderly people the condition may reach a prevalence of 10% in women5 and it is often seen in general practice (unpublished data).
Tibialis posterior tendon: the key dynamic support of the medial longitudinal arch of the foot
Understanding the importance of the tibialis posterior tendon for the normal foot clarifies the role that the dysfunctional tibialis posterior has in the development of an acquired flatfoot. This tendon courses just posterior to the medial malleolus inserting into the navicular tuberosity (on the medial aspect of the foot) and the mid-part of the plantar aspect of the tarsus. The tibialis posterior tendon is the primary dynamic stabiliser of the medial longitudinal arch,6 and its contraction results in inversion and plantar flexion of the foot and serves to elevate the medial longitudinal arch, which locks the mid-tarsal bones, making the hindfoot and midfoot rigid.7 This later action allows the gastrocnemius muscle to act with much greater efficiency during gait. Without the tibialis posterior, the other ligaments and joint capsules gradually become weak, and thus flatfoot develops. Furthermore, without the tibialis posterior the gastrocnemius is unable to act efficiently, and therefore gait and balance are seriously affected.
Summary points
Dysfunction of the tibialis posterior tendon is a common condition and a common cause of acquired flatfoot deformity in adults
Women older than 40 are most at risk
Patients present with pain and swelling of the medial hindfoot. Patients may also report a change in the shape of the foot or flattening of the foot
The foot develops a valgus heel (the heel rotates laterally when observed from behind), a flattened longitudinal arch, and an abducted forefoot
Conservative treatment includes non-steroidal anti-inflammatory drugs, rest, and immobilisation for acute inflammation; and orthoses to control the more chronic symptoms
Surgical treatment in the early stages is hindfoot osteotomy combined with tendon transfer
Arthrodesis of the hindfoot, and occasionally the ankle, is required in the surgical treatment of the later stages of tibialis posterior dysfunction
Box 1: Causes of an adult acquired flatfoot
Neuropathic foot (Charcot foot) secondary to:
Diabetes mellitus
Leprosy
Profound peripheral neuritis of any cause
Degenerative changes in the ankle, talonavicular or tarsometatarsal joints, or both, secondary to:
Inflammatory arthropathy
Osteoarthropathy
Fractures
Acquired flatfoot resulting from loss of the supporting structures of the medial longitudinal arch:
Dysfunction of the tibialis posterior tendon Tear of the spring (calcaneoanvicular) ligament (rare)
Tibialis anterior rupture (rare)
Painful flatfoot can have other causes, such as tarsal coalition, but as such a patient will not present with a change in the shape of the foot these are not included here.
Box 2: Symptoms suggesting tibialis posterior dysfunction
Pain and/or swelling behind the medial malleolus and along the instep
Change in foot shape
Decrease in walking ability and balance
Ache on walking long distances
Pathogenesis
Middle aged women are most commonly affected, and the prevalence is known to increase with age.19 20 Pes planus (flatfoot),11-14 hypertension,19 diabetes mellitus,19 steroid injection around the tendon,7 and seronegative arthropathies7 21 have all been identified as risk factors in patients with insufficiency of the tibialis posterior tendon.
Classification
History
In stage I, patients typically present with an insidious onset of vague pain in the medial foot and swelling behind the medial malleolus along the course of the tendon (fig 1).2 5 Patients usually have no history of acute trauma. As the condition progresses to stage II, patients have more complaints related to loss of function and change in the shape of the foot. They report either a unilateral worsening of a pre-existing bilateral flatfoot or a newly acquired flatfoot deformity.22 We tested survey questions and found that medial pain or swelling behind the medial malleolus together with a change in foot shape picked up 100% of patients with tibialis posterior dysfunction and had a specificity of 98% (box 2).5 Also the patient may have a feeling of instability, a limp, a restricted walking distance, and an inability to walk on uneven surfaces. This also leads to an increased awareness of other foot pathologies, such as bunions, hallux rigidus, and metatarsalgia, which may be the reason why the patient seeks medical attention. In the later stages, as the flatfoot deformity worsens, patients have less medial pain and swelling and may even have lateral hindfoot pain secondary to impingement of the fibula on the sinus tarsi.20
Fig 1 Arrows indicate swelling along the tibialis posterior tendon
Box 3: Definitions
Valgus: Angulation of an extremity at a joint or fracture site such that the distal part deviates away from the midline
Varus: Angulation of an extremity at a joint such that the distal part deviates toward the midline
Examination
In stage I tibialis posterior dysfunction the signs are of swelling and tenderness behind and below the medial malleolus (along the course of the tendon), and some weakness or pain with inversion of the foot (fig 2).2 The patient may have some difficulty rising on one heel only, or weakness after multiple heel rises.7 20
Fig 2 Left tibialis posterior dysfunction deformity is easily visible. The medial longitudinal arch is flattened. The left heel is in valgus. Also visible is the "too many toes sign," which results from abduction of the left forefoot
In the later stages the patient may have less swelling and pain but will have developed an acquired flatfoot deformity.2 Looking at the standing patient from the back best shows the asymmetry of a unilateral acquired flatfoot deformity (fig 2). The affected heel is in a valgus position (box 3), and flattening of the medial longitudinal arch and forefoot abduction are visible. This leads to the commonly quoted "too many toes sign" where more than the normal (one and a half to two) toes are seen along the lateral border of the foot.2 In later stages the tendon may not be palpable at its insertion site (the navicular tuberosity)1; this is best assessed with the patient attempting to invert and point the foot downwards. The most commonly applied functional test is the single heel rise (fig 3)2: patients with tibialis posterior dysfunction are unable to perform an ipsilateral unsupported single heel rise (to go from a flatfooted stance to standing on only the toes of their affected foot).
Fig 3 (top) Unsupported single heel rise on patient's good (right) side. (bottom) Attempt to perform a single heel rise on the affected left side. The patient was unable to do so unsupported but for the purpose of this photo was allowed to lean forward and support herself on the counter in front of her. The heel of the left foot has not inverted into varus
Someone with a normal foot can perform a single heel rise eight to 10 times, but by stage II patients are unable (or barely able) to perform a single unsupported heel rise. Even if the patient is supported to facilitate the attempted heel rise, the heel will not invert as it normally does (fig 3).16 In stages III and IV, in addition to the findings in stage II, the flatfoot deformity has become fixed. This is examined by grasping the heel and attempting to correct the valgus of the hindfoot (box 4).
Imaging
The diagnosis of tibialis posterior dysfunction is essentially clinical. However, plain radiographs of the foot and ankle are useful for assessing the degree of deformity and to confirm the presence or absence of degenerative changes in the subtalar and ankle articulations. The radiographs are also useful to exclude other causes of an acquired flatfoot deformity.1 The most useful radiographs are bilateral anteroposterior and lateral radiographs of the foot and a mortise (true anteroposterior) view of the ankle. All radiographs should be done with the patient standing (figs 4, 5).20 In most cases we see no role for magnetic resonance imaging or ultrasonography, as the diagnosis can be made clinically.
Fig 4 Before surgery (top) and five years after surgery (bottom) for a patient with stage II tibialis posterior dysfunction. The surgical reconstruction included a Cobb split tibialis anterior tendon transfer and a Rose varus calcaneal osteotomy
Stages of tibialis posterior dysfunction and treatment options
Fig 5 Stage III tibialis posterior dysfunction before and after surgery (a triple arthrodesis). (top) Preoperative film shows a plantar flexed talus (arrows point to head of talus) and loss of arch contour and height. (bottom) Postoperative film shows union and reconstitution of the arch
Box 4: How to examine for tibialis posterior dysfunction
Both of patient's legs visible from knee down
Observe heel alignment with patient standing with feet shoulder width apart, feet parallel. (Heel becomes valgus, arch collapses, and forefoot adducts in cases of tibialis posterior dysfunction)
Inspect for swelling behind medial malleolus
Ask patient to stand on tiptoes. Normally the heel should bend inwards. A patient with tibialis posterior dysfunction will have great difficulty standing on tiptoes, and the heel will not bend inwards
Ask the patient to perform 10 unsupported heel rises on each leg. A patient with tibialis posterior dysfunction will not be able to do this
Palpate along the tibialis posterior tendon for tenderness
Test tibialis posterior tendon for power. Ask the patient to bring foot into an inverted and plantar flexed position from an everted and dorsiflexed position against your resistance
Examine for hindfoot movement. In stages I and II, the foot is supple and the flatfoot deformity can be corrected by rotating the heel inwards (the arch of the foot will be reconstituted). In stage III and IV subtalar arthritis is present, and movement of the subtalar joint will be lessened and painful. Additionally in stage IV, ankle arthritis has set in and the ankle becomes stiff and painful
Treatment
The tibialis posterior muscle is the key dynamic support of the medial longitudinal arch of the foot. When it fails progressively, the arch slowly collapses, the heel drifts into valgus, and the forefoot gradually abducts, resulting in painful acquired flatfoot. Tibialis posterior dysfunction is often misdiagnosed as a chronic ankle sprain, osteoarthritis, or collapsed arch as a result of ageing or obesity, and it leaves the patient debilitated. Prompt diagnosis prevents frustration for the patient and allows treatment to be started at an earlier, more easily managed stage (fig 6). The diagnosis of tibialis posterior tendon dysfunction is largely a clinical one. An increased awareness of the existence of tibialis posterior should serve to help patients with earlier referral and treatment and by limiting the amount of disability they experience.
Fig 6 Treating tibialis posterior dysfunction
A film showing left sided tibialis posterior dysfunction is on bmj.com. Please note that the file is very large, so you will probably need broadband to watch this film
Contributors: JK-G wrote the paper. JL gave podiatric advice. FH and GB are involved in collaborative research on tibialis posterior dysfunction and have worked with senior authors JCA and DS. DS is guarantor.
Funding: None.
Competing interests: None declared.
References
Mann RA. Acquired flatfoot in adults. Clin Orthop Rel Res 1983;181: 46-51.
Johnson KA. Tibialis posterior tendon rupture. Clin Orthop Rel Res 1983;177: 140-7.
Haddad FS, Berry G, Singh D, Angel J. Tibialis posterior tendonitis: the forgotten epidemic. Presented at the British Orthopaedic Association, September 1999. J Bone Joint Surg 2000;82B(suppl 1): 80.
Chao W, Wapner KL, Lee TH, Adams J, Hecht PJ. Non-operative treatment of posterior tibial tendon dysfunction. Foot Ankle Internat 1996;17: 736-41.
Kohls-Gatzoulis JA, Singh D. Tibialis posterior dysfunction as a cause of flatfeet in elderly patients. Foot 2004;14: 207-9.
Basmajian JV, Stecko G. The role of muscles in arch support of the foot. J Bone Joint Surg 1963;45A: 1184-90.
Myerson MS. Adult acquired flat foot deformity. J Bone Joint Surg 1996;78A: 780-92.
Mosier SM, Lucas DR, Pomeroy G, Manoli A II. Pathology of the posterior tibial tendon in posterior tibial tendon insufficiency. Foot Ankle Int 1998;19: 520-4.
Frey C, Shereff M, Greenidge N. Vascularity of the posterior tibial tendon. J Bone Joint Surg 1990;72A: 884-8.
Mosier SM, Pomeroy G, Manoli A II. Pathoanatomy and aetiology of posterior tibial tendon dysfunction. Clin Orthop Rel Res 1999;365: 12-22.
Dyal CM, Feder J, Deland JT, Thompson FM. Pes planus in patients with posterior tibial tendon insufficiency: asymptomatic versus symptomatic foot. Foot Ankle Int 1997;18: 85-8.
Kohls-Gatzoulis JA, Singh D, Angel JC. Tibialis posterior insufficiency occurring in a patient without peronei: a mechanical aetiology. Foot Ankle Int 2001;22: 950-2.
Mann RA, Thompson FM. Rupture of the posterior tibial tendon causing flat foot. J Bone Joint Surg 1985;67A: 556-61.
Yeap JS, Singh D, Birch R. Tibialis posterior tendon dysfunction: a primary or secondary problem? Foot Ankle Int 2001;22: 51-5.
Mizel MS, Temple HT, Scranton PE II, Gellman RE, Hecht PJ, Horton GA, et al. Role of the peroneal tendons in the production of the deformed foot with posterior tibial tendon deficiency. Foot Ankle Int 1999;20: 285-9.
Monto RR, Moorman CT III, Mallon WJ, Nunley JA II. Rupture of the posterior tibial tendon associated with closed ankle fracture. Foot Ankle 1991;11: 400-3.
Borton DC, Saxby TS. Tear of the plantar calcaneonavicular (spring) ligament causing flatfoot. A case report. J Bone Joint Surg 1997;79B: 641-3.
Beals TC, Manoli A II. An unusual cause of posterior tibial tendon degeneration. Foot Ankle Int 1998;19: 177-9.
Holmes GB II, Mann RA. Possible epidemiological factors associated with rupture of the posterior tibial tendon. Foot Ankle 1992;13: 70-9.
Pomeroy GC, Pike RH, Beals TC, Manoli A II. Current concepts review. Acquired flatfoot in adults due to dysfunction of the posterior tibial tendon. J Bone Joint Surg 1999;81A: 1173-82.
Myerson M, Solomon G, Shereff M. Posterior tibial tendon dysfunction: its association with seronegative disease. Foot Ankle 1989;9: 219-25.
Johnson KA, Strom DE. Tibialis posterior tendon dysfunction. Clin Orthop Rel Res 1989;239: 196-206.
Wapner KL, Chao W. Nonoperative treatment of posterior tibial tendon dysfunction. Clin Orthop Rel Res 1999;365: 39-45.
Teasdall RD, Johnson KA. Surgical treatment of stage I posterior tibial tendon dysfunction. Foot Ankle Int 1994;15: 646-8.
Wacker JT, Hennessy MS, Saxby TS. Calcaneal osteotomy and transfer of the tendon of flexor digitorum longus for stage-II dysfunction of tibialis posterior. Three- to five-year results. J Bone Joint Surg 2002;84B: 54-8.
((Julie Kohls-Gatzoulis, sp)
Correspondence to: J Kohls-Gatzoulis gatzoulis@ntlworld.com
Introduction
We seached PubMed for publications by using the keywords "flatfoot" and "tibialis posterior dysfunction".
Tibialis posterior dysfunction: a common condition
Tibialis posterior dysfunction is well recognised by orthopaedic surgeons specialising in foot and ankle surgery and by podiatrists. However, greater general awareness of this condition is required,2 as most patients presenting to a general practitioner receive a diagnosis of ankle sprain or arthritis. By the time most patients present to a specialist foot and ankle clinic they have had the condition for several years and have consulted numerous doctors.3 Even general orthopaedic surgeons and physiotherapists often miss the diagnosis.3 However, tibialis posterior dysfunction need not remain a "specialist diagnosis" as it is usually diagnosed without any investigations, from a history and physical examination.2 Many patients benefit from relatively simple treatment, such as orthotic devices.4 Population based studies to identify the prevalence of tibialis posterior dysfunction are under way. In elderly people the condition may reach a prevalence of 10% in women5 and it is often seen in general practice (unpublished data).
Tibialis posterior tendon: the key dynamic support of the medial longitudinal arch of the foot
Understanding the importance of the tibialis posterior tendon for the normal foot clarifies the role that the dysfunctional tibialis posterior has in the development of an acquired flatfoot. This tendon courses just posterior to the medial malleolus inserting into the navicular tuberosity (on the medial aspect of the foot) and the mid-part of the plantar aspect of the tarsus. The tibialis posterior tendon is the primary dynamic stabiliser of the medial longitudinal arch,6 and its contraction results in inversion and plantar flexion of the foot and serves to elevate the medial longitudinal arch, which locks the mid-tarsal bones, making the hindfoot and midfoot rigid.7 This later action allows the gastrocnemius muscle to act with much greater efficiency during gait. Without the tibialis posterior, the other ligaments and joint capsules gradually become weak, and thus flatfoot develops. Furthermore, without the tibialis posterior the gastrocnemius is unable to act efficiently, and therefore gait and balance are seriously affected.
Summary points
Dysfunction of the tibialis posterior tendon is a common condition and a common cause of acquired flatfoot deformity in adults
Women older than 40 are most at risk
Patients present with pain and swelling of the medial hindfoot. Patients may also report a change in the shape of the foot or flattening of the foot
The foot develops a valgus heel (the heel rotates laterally when observed from behind), a flattened longitudinal arch, and an abducted forefoot
Conservative treatment includes non-steroidal anti-inflammatory drugs, rest, and immobilisation for acute inflammation; and orthoses to control the more chronic symptoms
Surgical treatment in the early stages is hindfoot osteotomy combined with tendon transfer
Arthrodesis of the hindfoot, and occasionally the ankle, is required in the surgical treatment of the later stages of tibialis posterior dysfunction
Box 1: Causes of an adult acquired flatfoot
Neuropathic foot (Charcot foot) secondary to:
Diabetes mellitus
Leprosy
Profound peripheral neuritis of any cause
Degenerative changes in the ankle, talonavicular or tarsometatarsal joints, or both, secondary to:
Inflammatory arthropathy
Osteoarthropathy
Fractures
Acquired flatfoot resulting from loss of the supporting structures of the medial longitudinal arch:
Dysfunction of the tibialis posterior tendon Tear of the spring (calcaneoanvicular) ligament (rare)
Tibialis anterior rupture (rare)
Painful flatfoot can have other causes, such as tarsal coalition, but as such a patient will not present with a change in the shape of the foot these are not included here.
Box 2: Symptoms suggesting tibialis posterior dysfunction
Pain and/or swelling behind the medial malleolus and along the instep
Change in foot shape
Decrease in walking ability and balance
Ache on walking long distances
Pathogenesis
Middle aged women are most commonly affected, and the prevalence is known to increase with age.19 20 Pes planus (flatfoot),11-14 hypertension,19 diabetes mellitus,19 steroid injection around the tendon,7 and seronegative arthropathies7 21 have all been identified as risk factors in patients with insufficiency of the tibialis posterior tendon.
Classification
History
In stage I, patients typically present with an insidious onset of vague pain in the medial foot and swelling behind the medial malleolus along the course of the tendon (fig 1).2 5 Patients usually have no history of acute trauma. As the condition progresses to stage II, patients have more complaints related to loss of function and change in the shape of the foot. They report either a unilateral worsening of a pre-existing bilateral flatfoot or a newly acquired flatfoot deformity.22 We tested survey questions and found that medial pain or swelling behind the medial malleolus together with a change in foot shape picked up 100% of patients with tibialis posterior dysfunction and had a specificity of 98% (box 2).5 Also the patient may have a feeling of instability, a limp, a restricted walking distance, and an inability to walk on uneven surfaces. This also leads to an increased awareness of other foot pathologies, such as bunions, hallux rigidus, and metatarsalgia, which may be the reason why the patient seeks medical attention. In the later stages, as the flatfoot deformity worsens, patients have less medial pain and swelling and may even have lateral hindfoot pain secondary to impingement of the fibula on the sinus tarsi.20
Fig 1 Arrows indicate swelling along the tibialis posterior tendon
Box 3: Definitions
Valgus: Angulation of an extremity at a joint or fracture site such that the distal part deviates away from the midline
Varus: Angulation of an extremity at a joint such that the distal part deviates toward the midline
Examination
In stage I tibialis posterior dysfunction the signs are of swelling and tenderness behind and below the medial malleolus (along the course of the tendon), and some weakness or pain with inversion of the foot (fig 2).2 The patient may have some difficulty rising on one heel only, or weakness after multiple heel rises.7 20
Fig 2 Left tibialis posterior dysfunction deformity is easily visible. The medial longitudinal arch is flattened. The left heel is in valgus. Also visible is the "too many toes sign," which results from abduction of the left forefoot
In the later stages the patient may have less swelling and pain but will have developed an acquired flatfoot deformity.2 Looking at the standing patient from the back best shows the asymmetry of a unilateral acquired flatfoot deformity (fig 2). The affected heel is in a valgus position (box 3), and flattening of the medial longitudinal arch and forefoot abduction are visible. This leads to the commonly quoted "too many toes sign" where more than the normal (one and a half to two) toes are seen along the lateral border of the foot.2 In later stages the tendon may not be palpable at its insertion site (the navicular tuberosity)1; this is best assessed with the patient attempting to invert and point the foot downwards. The most commonly applied functional test is the single heel rise (fig 3)2: patients with tibialis posterior dysfunction are unable to perform an ipsilateral unsupported single heel rise (to go from a flatfooted stance to standing on only the toes of their affected foot).
Fig 3 (top) Unsupported single heel rise on patient's good (right) side. (bottom) Attempt to perform a single heel rise on the affected left side. The patient was unable to do so unsupported but for the purpose of this photo was allowed to lean forward and support herself on the counter in front of her. The heel of the left foot has not inverted into varus
Someone with a normal foot can perform a single heel rise eight to 10 times, but by stage II patients are unable (or barely able) to perform a single unsupported heel rise. Even if the patient is supported to facilitate the attempted heel rise, the heel will not invert as it normally does (fig 3).16 In stages III and IV, in addition to the findings in stage II, the flatfoot deformity has become fixed. This is examined by grasping the heel and attempting to correct the valgus of the hindfoot (box 4).
Imaging
The diagnosis of tibialis posterior dysfunction is essentially clinical. However, plain radiographs of the foot and ankle are useful for assessing the degree of deformity and to confirm the presence or absence of degenerative changes in the subtalar and ankle articulations. The radiographs are also useful to exclude other causes of an acquired flatfoot deformity.1 The most useful radiographs are bilateral anteroposterior and lateral radiographs of the foot and a mortise (true anteroposterior) view of the ankle. All radiographs should be done with the patient standing (figs 4, 5).20 In most cases we see no role for magnetic resonance imaging or ultrasonography, as the diagnosis can be made clinically.
Fig 4 Before surgery (top) and five years after surgery (bottom) for a patient with stage II tibialis posterior dysfunction. The surgical reconstruction included a Cobb split tibialis anterior tendon transfer and a Rose varus calcaneal osteotomy
Stages of tibialis posterior dysfunction and treatment options
Fig 5 Stage III tibialis posterior dysfunction before and after surgery (a triple arthrodesis). (top) Preoperative film shows a plantar flexed talus (arrows point to head of talus) and loss of arch contour and height. (bottom) Postoperative film shows union and reconstitution of the arch
Box 4: How to examine for tibialis posterior dysfunction
Both of patient's legs visible from knee down
Observe heel alignment with patient standing with feet shoulder width apart, feet parallel. (Heel becomes valgus, arch collapses, and forefoot adducts in cases of tibialis posterior dysfunction)
Inspect for swelling behind medial malleolus
Ask patient to stand on tiptoes. Normally the heel should bend inwards. A patient with tibialis posterior dysfunction will have great difficulty standing on tiptoes, and the heel will not bend inwards
Ask the patient to perform 10 unsupported heel rises on each leg. A patient with tibialis posterior dysfunction will not be able to do this
Palpate along the tibialis posterior tendon for tenderness
Test tibialis posterior tendon for power. Ask the patient to bring foot into an inverted and plantar flexed position from an everted and dorsiflexed position against your resistance
Examine for hindfoot movement. In stages I and II, the foot is supple and the flatfoot deformity can be corrected by rotating the heel inwards (the arch of the foot will be reconstituted). In stage III and IV subtalar arthritis is present, and movement of the subtalar joint will be lessened and painful. Additionally in stage IV, ankle arthritis has set in and the ankle becomes stiff and painful
Treatment
The tibialis posterior muscle is the key dynamic support of the medial longitudinal arch of the foot. When it fails progressively, the arch slowly collapses, the heel drifts into valgus, and the forefoot gradually abducts, resulting in painful acquired flatfoot. Tibialis posterior dysfunction is often misdiagnosed as a chronic ankle sprain, osteoarthritis, or collapsed arch as a result of ageing or obesity, and it leaves the patient debilitated. Prompt diagnosis prevents frustration for the patient and allows treatment to be started at an earlier, more easily managed stage (fig 6). The diagnosis of tibialis posterior tendon dysfunction is largely a clinical one. An increased awareness of the existence of tibialis posterior should serve to help patients with earlier referral and treatment and by limiting the amount of disability they experience.
Fig 6 Treating tibialis posterior dysfunction
A film showing left sided tibialis posterior dysfunction is on bmj.com. Please note that the file is very large, so you will probably need broadband to watch this film
Contributors: JK-G wrote the paper. JL gave podiatric advice. FH and GB are involved in collaborative research on tibialis posterior dysfunction and have worked with senior authors JCA and DS. DS is guarantor.
Funding: None.
Competing interests: None declared.
References
Mann RA. Acquired flatfoot in adults. Clin Orthop Rel Res 1983;181: 46-51.
Johnson KA. Tibialis posterior tendon rupture. Clin Orthop Rel Res 1983;177: 140-7.
Haddad FS, Berry G, Singh D, Angel J. Tibialis posterior tendonitis: the forgotten epidemic. Presented at the British Orthopaedic Association, September 1999. J Bone Joint Surg 2000;82B(suppl 1): 80.
Chao W, Wapner KL, Lee TH, Adams J, Hecht PJ. Non-operative treatment of posterior tibial tendon dysfunction. Foot Ankle Internat 1996;17: 736-41.
Kohls-Gatzoulis JA, Singh D. Tibialis posterior dysfunction as a cause of flatfeet in elderly patients. Foot 2004;14: 207-9.
Basmajian JV, Stecko G. The role of muscles in arch support of the foot. J Bone Joint Surg 1963;45A: 1184-90.
Myerson MS. Adult acquired flat foot deformity. J Bone Joint Surg 1996;78A: 780-92.
Mosier SM, Lucas DR, Pomeroy G, Manoli A II. Pathology of the posterior tibial tendon in posterior tibial tendon insufficiency. Foot Ankle Int 1998;19: 520-4.
Frey C, Shereff M, Greenidge N. Vascularity of the posterior tibial tendon. J Bone Joint Surg 1990;72A: 884-8.
Mosier SM, Pomeroy G, Manoli A II. Pathoanatomy and aetiology of posterior tibial tendon dysfunction. Clin Orthop Rel Res 1999;365: 12-22.
Dyal CM, Feder J, Deland JT, Thompson FM. Pes planus in patients with posterior tibial tendon insufficiency: asymptomatic versus symptomatic foot. Foot Ankle Int 1997;18: 85-8.
Kohls-Gatzoulis JA, Singh D, Angel JC. Tibialis posterior insufficiency occurring in a patient without peronei: a mechanical aetiology. Foot Ankle Int 2001;22: 950-2.
Mann RA, Thompson FM. Rupture of the posterior tibial tendon causing flat foot. J Bone Joint Surg 1985;67A: 556-61.
Yeap JS, Singh D, Birch R. Tibialis posterior tendon dysfunction: a primary or secondary problem? Foot Ankle Int 2001;22: 51-5.
Mizel MS, Temple HT, Scranton PE II, Gellman RE, Hecht PJ, Horton GA, et al. Role of the peroneal tendons in the production of the deformed foot with posterior tibial tendon deficiency. Foot Ankle Int 1999;20: 285-9.
Monto RR, Moorman CT III, Mallon WJ, Nunley JA II. Rupture of the posterior tibial tendon associated with closed ankle fracture. Foot Ankle 1991;11: 400-3.
Borton DC, Saxby TS. Tear of the plantar calcaneonavicular (spring) ligament causing flatfoot. A case report. J Bone Joint Surg 1997;79B: 641-3.
Beals TC, Manoli A II. An unusual cause of posterior tibial tendon degeneration. Foot Ankle Int 1998;19: 177-9.
Holmes GB II, Mann RA. Possible epidemiological factors associated with rupture of the posterior tibial tendon. Foot Ankle 1992;13: 70-9.
Pomeroy GC, Pike RH, Beals TC, Manoli A II. Current concepts review. Acquired flatfoot in adults due to dysfunction of the posterior tibial tendon. J Bone Joint Surg 1999;81A: 1173-82.
Myerson M, Solomon G, Shereff M. Posterior tibial tendon dysfunction: its association with seronegative disease. Foot Ankle 1989;9: 219-25.
Johnson KA, Strom DE. Tibialis posterior tendon dysfunction. Clin Orthop Rel Res 1989;239: 196-206.
Wapner KL, Chao W. Nonoperative treatment of posterior tibial tendon dysfunction. Clin Orthop Rel Res 1999;365: 39-45.
Teasdall RD, Johnson KA. Surgical treatment of stage I posterior tibial tendon dysfunction. Foot Ankle Int 1994;15: 646-8.
Wacker JT, Hennessy MS, Saxby TS. Calcaneal osteotomy and transfer of the tendon of flexor digitorum longus for stage-II dysfunction of tibialis posterior. Three- to five-year results. J Bone Joint Surg 2002;84B: 54-8.
((Julie Kohls-Gatzoulis, sp)