Tibialis posterior rupture

Original Editors - Tim Hendrikx from Vrije Universiteit Brussel's Evidence-based Practice project Top Contributors - Tim Hendrikx, Uchechukwu Chukwuemeka, Kim Jackson, 127.0.0.1, Admin, WikiSysop and Wanda van Niekerk  

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.

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.

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. 

Characteristics/Clinical Presentation

• 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

• 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

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Outcome Measures

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Examination

Observation:

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 posterior tibialis tendon should be performed in the presence of these findings to confirm the tendon's functional status.

Tests:

• Palpation from the area between the medial malleolus 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

Medical Management

Postoperative rehabilitation for tendon transfer procedure:

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

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: 

without moving your leg, pull theraband away lateral with your foot

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

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

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

Key Research

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Resources

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Clinical Bottom Line

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References

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