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Timothy C. Beals, MD, Gregory C. Pomeroy, MD, and Arthur Manoli II, MD
Abstract
Posterior tibial tendon insufficiency is the most common cause of acquired adult flatfoot deformity. Although the exact etiology of the disorder is still unknown, the condition has been classified, on the basis of clinical and radiographic findings, into four stages. In stage I, there is no notable clinical deformity; patients usually present with pain along the course of the tendon and local inflammatory changes. Stage II is characterized by a dynamic deformity of the hindfoot. Stage III involves a fixed deformity of the hindfoot and typically also a fixed forefoot supination deformity but no obvious evidence of ankle abnormality. In stage IV, ankle involvement is secondary to long-standing fixed hindfoot deformities. The initial treatment of patients in any stage should be nonoperative, with immobilization, a nonsteroidal antiinflammatory drug, and perhaps an orthotic device. The role of corticosteroid injections continues to be controversial. When nonoperative management fails, the treatment options consist of soft-tissue procedures alone or in combination with osteotomy or arthrodesis. Stage I insufficiency is generally treated with debridement and tenosynovectomy. Soft-tissue transfer does not appear to correct the underlying deformity in stage II disease; however, there is growing interest in joint-sparing operations that attempt to compensate for the underlying deformities with osteotomies or arthrodeses, supplemented with dynamic transfers to replace the insufficient posterior tibial tendon. Subtalar, double, or triple arthrodesis is the procedure of choice for stage III disease, frequently in conjunction with heel-cord lengthening. Tibiocalcaneal arthrodesis or pantalar arthrodesis is most commonly used to treat stage IV disease. J Am Acad Orthop Surg 1999;7:112-118
History
The original description of posterior tibialis insufficiency and its associated tendinitis is credited to Kulowski in a 1936 article. Fowler3 and Williams 4 described early series of patients who had apparent tendinitis of the posterior tibialis tendon that required surgical treatment. However, for many years, few reports were published about this pathologic condition. Considerable interest in posterior tibial tendon insufficiency has developed over the past 15 years. This interest has largely stemmed from efforts to understand the pathomechanics of the hindfoot as well as reports of clinical series describing a variety of methods for surgical treatment of this condition.
The loss of function of the posterior tibial tendon has been associated with the development of a progressive flatfoot deformity in adults and children.1,2 The exact etiology of this condition remains controversial. While rupture of the posterior tibial tendon has been associated with various underlying pathologic conditions, the idiopathic nature of this problem in most patients adds to a growing level of interest in the problem
among the general orthopaedic community. There is a sizable group of patients in whom symptomatic discomfort is associated with dysfunction of this tendon as well as concomitant deformities. The purpose of this report is to illustrate the spectrum of posterior tibial tendon insufficiency, to highlight recently described techniques for reconstruction, and to review options for surgical and nonoperative management.
Dr. Beals is Assistant Professor, Department of Orthopedics, University of Utah School of Medicine, Salt Lake City. Dr. Pomeroy is Clinical Assistant Professor of Orthopaedic Surgery, University of New England; and Director, Portland Orthopedic Foot and Ankle Center, South Portland, Me. Dr. Manoli is Professor and Chairman, Department of Orthopedic Surgery, University of South Alabama, Mobile. Reprint requests: Dr. Beals, University of Utah School of Medicine, 50 North Medical Drive, Salt Lake City, UT 84132. Copyright 1999 by the American Academy of Orthopaedic Surgeons.
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niques and explain the problems patients experience with insufficiency of the posterior tibial tendon. These include the fact that the posterior tibial muscle is large in comparison to those that can be transferred to replace it. It has a cross-sectional area of 16.9 cm 2 , compared with 5.5 cm2 for the flexor digitorum longus muscle and 6.7 cm 2 for the peroneus brevis muscle. The medial capsular and ligamentous structures of the hindfoot and midfoot certainly play a role in the development of flatfoot deformities. The talonavicular joint capsule, as well as the springligament 5 and deltoid-ligament complexes, have been implicated in the progressive loss of the medial longitudinal arch of the foot and the ankle dysfunction seen in longstanding cases of posterior tibial tendon insufficiency.
Diagnosis
The diagnosis of posterior tibial tendon insufficiency is primarily a clinical one. Patients typically complain of pain medially around the ankle that may radiate into the arch of the foot. Some patients in the later stages of the condition complain of pain on the lateral aspect of the foot, where the calcaneus abuts against the fibula, due to an excessive valgus position of the hindfoot. Roughly half of all patients give a history of some sort of trauma that was initially thought to be a sprain. Patients often experience swelling along the course of the posterior tibial tendon and significant pain, most typically several centimeters proximal to the insertion onto the navicular tuberosity. Pain is exacerbated by activity, and the ability to walk distances decreases. Some patients present simply with pain and apparent inflammation along the tendon without any evidence of clinical
deformity, but most patients have some collapse of the foot. The rate of development of clinical deformity is variable, and there are no adequate studies of the natural history of posterior tibial tendon insufficiency. In some patients, the deformity increases, and eventually the hindfoot valgus, notable even during relatively early stages of the condition, becomes fixed. In the latest stages of the condition, the ankle is affected and has a tendency toward valgus tilting from laxity of the medial deltoid complex. Clinical evaluation includes observing the patient in a standing position. When viewed from behind, the too many toes sign is typically seen, which is evidence of abduction of the midfoot relative to the hindfoot.6,7 Excessive hindfoot valgus is noted in the affected limb, as well as loss of the longitudinal arch when viewed from either the side or the front. Typically, softtissue swelling around the medial aspect of the ankle is evident. The tissues below the medial malleolus appear prominent due largely to excessive hindfoot valgus (Fig. 1). Patients asked to rise onto their
Fig. 1 Clinical appearance of a patient with stage II posterior tibial tendon insufficiency. Note the too-many-toes sign on the left, the excessive hindfoot valgus, and medial soft-tissue swelling.
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Fig. 2 A, Lateral weight-bearing radiograph of a foot with stage II posterior tibial tendon insufficiency. The inferior border of the medial cuneiform (medial column) is even with the base of the fifth metatarsal (lateral column). Note the plantar inclination of the talus. B, The normal contralateral foot is shown for comparison.
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tion tenography, ultrasonography, and magnetic resonance imaging, has been advocated by some. Indeed, there are case reports documenting utility in cases in which the diagnosis is uncertain. Although this is not routinely recommended, such tests should be considered.
Stage III Patients with stage III posterior tibial tendon insufficiency have a fixed deformity of the hindfoot. With the hindfoot in a fixed valgus position, it is not possible to reduce the talonavicular joint. Typically, these patients also have an accompanying fixed forefoot supination deformity that is a compensatory change to accommodate the hindfoot valgus in order to maintain a plantigrade foot. Patients with stage III disease do not have obvious evidence of ankle abnormalities. Stage IV A relatively small subset of patients have ankle involvement secondary to long-standing fixed deformities of the hindfoot. They may present with ankle arthritis due to eccentric loading of the ankle. Some have a valgus talar tilt with loss of competence of the deltoid ligament complex.
cal causes of posterior tibial tendon insufficiency have been described, including an association with a contracted gastrocnemius-soleus complex. Recent immunohistologic studies imply a lack of an inflammatory appearance in stage II disease. The histologic appearance is consistent with mechanical failure of the collagen architecture of the tendon in the area of elongation and rupture, with mucoid degeneration. Complete rupture of the tibialis posterior tendon is not common, as most patients have longitudinal failure of the tendon substance. In gross appearance, the tendon has been described as being the color of poached fish, often with longitudinal tears on the lateral side of the tendon (Fig. 3). In cases of chronic posterior tibial tendon insufficiency, the gross appearance and histologic structure of the tendon are abnormal.
Stage I Stage I is defined as the absence of a fixed deformity of the foot or ankle with the possible exception of a contracted gastrocnemius-soleus complex. The foot is in normal alignment when the patient is standing. Patients typically present with pain along the course of the posterior tibialis tendon and evidence of local inflammatory changes. Stage II Stage II is characterized by a dynamic deformity of the hindfoot. The standing patient displays an increased degree of hindfoot valgus, apparent weakness of tibialis posterior function, the characteristic toomany-toes sign, and inability to do a single-leg heel rise. However, patients still have a relatively normal arc of subtalar motion, and the foot can be placed into a neutral position, with the possible exception of contraction of the gastrocnemiussoleus complex.
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Fig. 3 Gross appearance of a degenerated posterior tibial tendon. Note the disruption of the fibers on the lateral side of the tendon.
The role, benefit, and appropriateness of corticosteroid injections for this problem continue to be controversial. Published reports associate the use of steroid injections with rupture of the tendon, although it is possible that in these instances rupture might have occurred without injection due to the underlying pathologic changes in the tendon. There are no controlled studies of the use of such injections. Therefore, at this time, routine use of injections in this area cannot be recommended as part of the nonoperative treatment of this condition.
Operative Management
The operative treatment of patients in whom nonoperative management has failed consists of either soft-tissue procedures alone or softtissue procedures combined with either osteotomies or arthrodesis. It is important to account for all the fixed and dynamic structural deformities present when defining a specific operative plan for a given patient.
Stage I Patients who have stage I posterior tibial tendon insufficiency often do not have a notable clinical deformity. They have an inflammatory condition involving the tendon, but the tendon remains competent in terms of function, and there are no secondary deformities that have developed due to the tenosynovitis. These patients have been treated with debridement of the tendon and tenosynovectomy around the posterior tibial tendon. There is only one recent study providing follow-up, and it supports the concept that the combination of debridement and tenosynovectomy is effective in relieving pain. 11 However, there are no published studies on this patient population that provide long-term follow-up data. Consideration could be given to augmentation of the posterior tibial tendon with the flexor digitorum longus and to a gastrocnemius or heel-cord lengthening. Stage II It is in the treatment of this subset of patients where there is the greatest degree of controversy
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Fig. 4 Preoperative (A) and postoperative (B) radiographic appearance of a patient who underwent a medializing calcaneal tuberosity osteotomy and lateral columnlengthening calcaneal osteotomy.
provement in function as indicated by the score on the ankle-hindfoot rating scale of the American Orthopaedic Foot and Ankle Society.15 The early reports of the success of jointsparing operations allow optimism that it may be possible to treat stage II posterior tibial tendon insufficiency with procedures that do not necessitate a significant loss of hindfoot motion and adaptability. Lateral-column lengthening through the calcaneocuboid articulation with medial soft-tissue reconstruction has been advocated. The biomechanical and radiographic implications of such procedures have been studied by Sangeorzan et al16 and Deland et al. 17 Subtalar arthrodesis is still suggested by many experienced foot and ankle surgeons, both alone and in concert with medial softtissue debridement and/or tendon transfer. The results of a study of patients treated with isolated talonavicular arthrodesis demonstrated improved function and decreased pain. 18 In another study, 19 the implications of a talonavicular fusion in terms of the effect on hindfoot motion implied a significant loss of mobility.
Stage III The foot with stage III posterior tibial tendon insufficiency has fixed deformities that cannot be corrected by osteotomies or soft-tissue procedures alone. Typically, there is some degree of arthrosis present in the subtalar joint complex. The procedures of choice in this stage of the disease include subtalar arthrodesis, double arthrodesis, and triple arthrodesis. These are frequently done in conjunction with heel-cord lengthening. The arthrodesis selected should be able to correct all of the deformities. Once the subtalar joint has been taken out of an excessive degree of hindfoot valgus, fixed forefoot supination necessitates a talonavicular arthrodesis to rotate the foot into a plantigrade position. In some cases with more extreme deformity, it may even be necessary to perform an operation to plantar-flex the first ray if full correction of the deformity cannot be accomplished with a triple arthrodesis. The fundamental goal is a plantigrade foot in a good position that supports the ankle in optimal alignment. Graves et al 20 reported on 17 patients who had undergone triple arthrodesis, 10 of whom had poste-
rior tibial tendon insufficiency. The mean follow-up interval was 3 1 2 years. The postoperative complications were significant, and the authors recommended that triple arthrodesis be reserved as a salvage procedure. They also emphasized the risk of increased arthrosis in joints adjacent to the arthrodesis.
Stage IV Patients with long-standing severe hindfoot valgus deformities and secondary ankle arthrosis are difficult to treat. Fortunately, few patients fall into this category. Most commonly, tibiocalcaneal arthrodesis or pantalar arthrodesis is performed to address all of the deformities simultaneously.
Summary
Posterior tibial tendon insufficiency is a disorder with a broad spectrum of clinical presentations. It is essential that treatment be closely correlated to the particular static and dynamic deformities in the patient. The classification system initially outlined by Johnson and Strom 7 is helpful in determining
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References
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