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Posterior Tibial Tendonitis

What is posterior tibial tendonitis?

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Updated April 05, 2014

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Posterior tibial tendonitis is an uncommon problem of one of the tendons on the inner side of the ankle. The posterior tibial muscle attaches to the back of the shin bone; the posterior tibial tendon connects this muscle to the bones of the foot. The posterior tibial tendon passes down the back of the leg, not far from the Achilles tendon, then turns under the prominence of the inner side of the ankle. The posterior tibial tendon then attaches to the bone of the inner side of the foot, just adjacent to the arch of the foot.

Posterior tibial tendon problems usually occur just underneath the prominence of the inner side of ankle, called the medial malleolus. The medial malleolus is the end of the shin bone, the tibia, and the posterior tibial tendon wraps just underneath the medial malleolus. This area of the tendon is prone to problems because of a lack of blood supply. This part of the tendon exists in a "watershed zone" where the blood supply is weakest. Therefore, when the tendon becomes injured, as a result of trauma or overuse, the body has difficulty delivering the proper nutrients for healing.

Symptoms of Posterior Tibial Tendonitis

Most commonly, patients with posterior tibial tendonitis complain of pain in the inside of the foot and ankle, and occasionally have problems associated with an unsteady gait. Many patients report having had a recent ankle sprain, although some will have had no recent injury. As posterior tibial tendonitis progresses, the arch of the foot can flatten, and the toes begin to point outwards. This is the result of the posterior tibial tendon not doing its job to support the arch of the foot.

Diagnosis of posterior tibial tendonitis is commonly made by physical examination. Patients have tenderness and swelling over the course of the posterior tibial tendon. Usually they have weakness inverting (pointing the toes inward) their foot. Also common in patients with posterior tibial tendonitis is an inability to stand on their toes on the affected side. When the examination is unclear, or if a patient is considering surgery, an MRI may be obtained. The MRI is an effective method to detect ruptures of the tendon, and it can also show inflammatory changes surrounding the tendon.

Treatment of Posterior Tibial Tendonitis

The initial treatment of posterior tibial tendonitis if focused on resting the tendon to allow for healing. Unfortunately, even normal walking may not adequately allow for the tendon to rest sufficiently. In these cases, the ankle must be immobilized to allow for sufficient rest. Options for early treatment include: By providing a stiff platform for the foot, shoe inserts and walking boots prevent motion between the midfoot and hindfoot. Preventing this motion should decrease the inflammation associated with posterior tibial tendonitis. Casts are more cumbersome, but are probably the safest method to ensure the posterior tibial tendon is adequately rested.

Other common treatments for early stage posterior tibial tendonitis include anti-inflammatory medications and activity modification. Both of these treatments can help to control the inflammation around the posterior tibial tendon.

Surgical treatment of posterior tibial tendinitis is controversial and varies depending on the extent of the condition. In early stages of posterior tibial tendonitis, some surgeons may recommend a procedure to clean up the inflammation called a debridement. During a debridement, the inflamed tissue and abnormal tendon are removed to help allow for healing of the damaged tendon.

In more advanced stages of posterior tibial tendonitis, the arch of the foot has collapsed, and a simple tendon debridement may be insufficient to correct the problem. Reconstruction of the posterior tibial tendon is occasionally performed. In a reconstructive procedures, a neighboring tendon, called the flexor digitorum longus, is moved to replace the damaged posterior tibial tendon. This procedure is often combined with a bone reconstruction as well. Finally, in the most advanced cases of posterior tibial tendonitis, when the arch of the foot has become rigid, a fusion procedure is the preferred treatment.

Sources:

Beals TC, et al. "Posterior tendon insufficiency: diagnosis and treatment J. Am. Acad. Ortho. Surg., Mar 1999; 7: 112 - 118.

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