Tibialis posterior rupture

Welcome to Vrije Universiteit Brussel's Evidence-based Practice project. This space was created by and for the students in the Rehabilitation Sciences and Physiotherapy program of the Vrije Universiteit Brussel, Brussels, Belgium. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!

Original Editors

Top Contributors - Tim Hendrikx and Wanda van Niekerk - Your name will be added here if you are a lead editor on this page. 

Search Strategy

Databases Searched: Pubmed, ADB, web of knowledge, PEDro, The Journal of Joint and Bone Surgery, Dynamed, PhysioAdvisor

Keyword Searches: tibialis posterior tendon (TPT) , tibialis posterior rupture (TPR), tibialis posterior tendon rupture (TPTR), TPTR treatment, TPTR postoperative treatment, flatfoot, pes planovalgus, tendinitis 

Definition/Description

Whenever the tibialis posterior muscle contracts or is stretched, tension is placed through the tibialis posterior tendon. If this tension is excessive due to too much force or repetition, damage to the tibialis posterior tendon may occur. This can range from minor tearing of the tendon with subsequent inflammation to a complete tibialis posterior tendon rupture. Early diagnosis and surgical repair will restore full normal function. [1]


A rupture of the posterior tibial tendon can be easily missed because the symptoms of this injury resemble the symptoms of a normal ankle sprain. Some physicians may feel that posterior tibial tendon rupture is a rare condition, one that they have never seen.



Clinically Relevant Anatomy

 

Epidemiology /Etiology

Posterior tibialis tendon ruptures occur predominantly in the late middle-aged population (average age 57 years). For posterior tibialis dysfunction, the patient is typically a female over the age of 40 who exhibits ligamentous laxity in multiple joints and has an occupation that requires extended periods of standing. They usually do not recall any acute traumatic event. There is another subset of the populations in which posterior tibial tendon insufficiency occurs and that consists of the 20- to 40-year old athletes. They usually recall a traumatic event, usually a direct blow to the medial malleolus. Or, they present with years of involvement in athletics with a pronated foot.[1] 

Characteristics/Clinical Presentation[1]

• Swelling along the medial aspect of the foot and ankle
• Absence of the classical sudden severe pain of a tendon rupture
• Tenderness along the posterior tibialis tendon
• Progressive loss of longitudinal arch → pes planus and heel valgus
• Palpable pain between medial malleolus and navicular
• Pain in the plantar medial arch

Differential Diagnosis[2]

• Attenuation or rupture of the calcaneonavicular (spring) ligament complex
• Degenerative arthritis of the ankle joint with valgus talar
• Arthritis of the talonavicular joint
• Posttraumatic tarsometatarsal (Lisfranc) joint arthritis
• Inflammatory arthritis of the hindfoot, usually secondary to rheumatoid disease

 

Diagnostic Procedures

add text here related to medical diagnostic procedures

Outcome Measures

add links to outcome measures here (also see Outcome Measures Database)

Examination

Observation:[3]

Posterior tibialis tendon rupture is strongly suspected in patients presenting a complex of findings. These include:

• Eversion ankle injury
• Generalized medial ankle pain
• Medial ankle swelling
• Flexible, asymmetric pes planus and forefoot pronation
• Gait disturbance secondary to deformity
• Talonavicular sag in lateral standing radiograph

The first four findings are nondiagnostic, however, seen together they are helpful in identifying patients with posterior tibialis tendon pathology. Manual testing of the posteroir tibialis tendon should be performed in the presence of these findings to confirm the tendon's functional status.



Tests:[4]

• Palpation from area between malleolus medialis and os naviculare
• “Too many toes” sign secondary to an increase in forefoot abduction and heel eversion
• Nonfunctional posterior tibialis tendon on manual testing
• Motion of the ankle and subtalar joints
• Positive first metatarsal rise sign test
• Positive single-limb heel rise-test
Ottawa ankle rules test to exclude fractures within the first week after an ankle injury

Too many toes.JPG


Medical Management [1]

Postoperative rehabilitation for tendon transfer procedure:

Tabel rehab.JPG

Complications:

• With attenuation or rupture of the posterior tibial tendon, the medial longitudinal arch of the foot collapses and there is a relative internal rotation of the tibia and talus
• The subtalar joint everts, causing the heel to assume a valgus position and the foot to abduct at the talonavicular joint. A compensatory forefoot varus deformity ensues
• As the heel assumes an increased valgus alignment, the Achilles tendon becomes positioned lateral to the axis of rotation of the subtalar joint. Over time, the shortened position of the hindfoot results in an Achilles tendon contracture
• As the deformity progresses, the fibula abuts against the lateral wall of the calcaneus, causing pain in the lateral hindfoot

Physical Therapy Management [5]

Furthermore, Woods and Leach (1991) pointed out that "the key" to successful treatment is early diagnosis23.
(Randall E. Marcus, 1993)
Phase I:
• Ice
• Non steroidal anti inflammatory drugs
• massage

Phase II:
• Passive ROM exercice for eversion and dorsiflexion such as manual mobilisation ankle

Phase III:
• Closed kinetic chain activities and eccentric strengthening exercises such as single leg standing toe raises with controlled lowering eccentric loads


Phase III excercices: 


Eversie.PNG
without moving your leg, pull theraband away lateral with your foot


Juiste inversie!!.PNG


without moving your straight leg, invert your feet of your bended leg


Plantaire flexie.JPG

without moving your leg, pull theraband away from you to the ground


Towel crunch.PNG

place towel on the floor, keep the heel on the floor, use toes to pull towel towards you


Key Research

add links and reviews of high quality evidence here (case studies should be added on new pages using the case study template)

Resources

add appropriate resources here

Clinical Bottom Line

add text here

Recent Related Research (from Pubmed)

see tutorial on Adding PubMed Feed

Extension:RSS -- Error: Not a valid URL: Feed goes here!!

References

see adding references tutorial.

  1. 1.0 1.1 1.2 1.3 William M. Geideman, J. E. Posterior Tibial Tendon Dysfunction. Journal of Orthopedic & Sports Physical Therapy , 2000, (2A SR): 68-77
  2. Johnson KA, S. D. (1989). Posterior Tibialis Tendon Dysfunction. Clinical Orthopedical Rel. , 1989, 196-206
  3. Randall E. Marcus, M. E. . The enigmatic diagnosis of posterior tibialis tendon rupture. The Iowa Orthopedical Journal , 1993, 2B: 171-177
  4. A. Foster, N. T. Rupture of the tibialis posterior tendon: an important differential in the assessment of ankle injuries. Ermergency Medical Journal , 2005 (4): 915-916
  5. Gregory S. Kolt, L. S.-M. Common sport-related injuries. In L. S.-M. Gregory S. Kolt, Physical Therapies in Sport and Exercise, Philadelphia, Elsevier 2007: 428-429