Posterior Tibial Tendon Problems

Anatomy
The posterior tibial tendon is a large tendon that runs along the inside of the ankle. The posterior tibial muscle is on the inside of the calf, and it's tendon arises in the lower third of the leg. That tendon runs behind the bump on the inside of the ankle called the medial malleolus. It changes direction and then goes down to a bone on the inside of the midfoot called the navicular.

The course this tendon takes means that it will plantar flex the ankle, that is “point the toes”, and also invert the hindfoot. That means that they pull the foot to the inside. The tendon is important because it helps maintain the longitudinal arch.

Injury
Tendons that change direction are susceptible to attritional injuries. That means that over time at the point that the tendon changes direction it may wear out. This usually starts off with tendinitis. That means that there is inflammation about the tendon. You will notice that as pain on the inside of the ankle.

Occasionally that problem occurs as a result of an injury, but usually this is something that just begins to bother you.

The initial treatment for this problem involves resting the foot, and using oral anti-inflammatory medications. The resting can be accomplished by limiting activities, using a Brace, or being nonweightbearing and using crutches or a walker.

Tendon Tears
Sometimes tendinitis in the posterior tibial tendon is associated with small tears in the substance of the tendon. As this problem progresses those tears may become larger.

These tears cause the tendon to lose its strength. When the tendon loses its power to help maintain the arch, the ligaments in the midfoot may stretch out.

As this occurs a flatfoot deformity will develop. You may notice that your arch collapses, and your heel may also shift into a more lateral position.  With this progression you may notice weakness, in particular when you roll onto the ball of your foot. It may be difficult to rise onto your toes. Generally there is pain associated with this on the inside of the arch and just below the ankle. As the problem progresses, sometimes the pain will shift to the lateral side.

During the evaluation of your problem, I will perform a physical examination and may ask you to get radiographic studies.  Both plain radiographs (XRays) of the foot and MRI studies of the ankle and foot are helpful in evaluating this type of problem.

If surgery is recommended, the type of procedure will depend on your symptoms, the MRI findings, and if any collapse has occurred in your arch.

If the problem has not been present for long, and the tear is localized, the treatment is usually a simple Repair of the Posterior Tibial Tendon Tear.

When the tear is more complex it may require Reconstruction with a Transfer of the Flexor Digitorum Longus Tendon.

If the problem has been present for long enough that a flatfoot deformity develops, the Tendon Transfer is Augmented with Surgery on the Heel Bone to shift it back under the weightbearing axis of the leg.

If there is a severe deformity, or arthritis has developed, the treatment is with a Triple Arthrodesis.