Posterior Tibial Tendon Dysfunction

Question 1

What relationship does tibialis posterior tendon have with the flexor retinaculum?

Answer 1

goes under flexor retinaculum in tarsal tunnel

Question 2

Where does tibialis posterior tendon originate? and insert?

Answer 2

origin- proximal 1/3 of tibia, fibula, and IO mb

inserts- every tarsal bone except talus

Question 3

what is the main insertion for tibialis posterior?

Answer 3

navicular tuberosity

Question 4

what relationship does PTT have to spring ligament (calcaneonavicular)?

Answer 4

PTT passes superficial to ligament and has articulation with it

Question 5

where is the most common area for posterior tibial tendon dysfunction?

Answer 5

(zone of hypovascularity)

1-1.5 cm distal to medial malleolus

Question 6

why is the most common area for PTT dysfunction the most common area?

Answer 6

because mesotenon is absent distally as the synovial sheath ends mid-portion of the talus

Question 7

what is the function of PTT?

Answer 7

-most powerful and efficient supinator
(has weak plantarflexion capabilities)
-supports longitudinal arch

Question 8

What role does tibialis posterior play in gait cycle? which phase is it most active in?

Answer 8

(during midstance)

• decelerates leg internal rotation by eccentric contraction (any excess causes STJ pronation)
• during midstance, concentric contraction (STJ supination)

Question 9

what happens in the dysfunctional tendon?

Answer 9

• excessive pronation
• talar head puts strain on spring ligament causing attentuation
• as arch colapses, deltoid strain causes ankle valgus

Question 10

etiology of PT TENDONITIS?

Answer 10

traumatic- rare

degenerative

Question 11

what are some traumatic causes? eventhough this is rare?

Answer 11

• lacerations or puncture wounds

- ankle sprains or fractures

Question 12

what are some degenrative causes of PTT?

Answer 12

• systemic inflammatory states: RA, seronegative spondyloarthropathy
• tendon hypovascularity: due to anatomy; systemic dz- DM, HTN, tobacco use
• female sex
• > 40 y/o

Question 13

what types of biomechancial abnormalities exist?

Answer 13

obesity, equinus, calcaneal valgus, pes planus

Question 14

how would you test your tibialis posterior muscle strength?

Answer 14

place foot in plantarflexed and inverted position

-have patient hold position against resistance

Question 15

which tests can you use to determine flexibile vs. rigid deformity?

Answer 15

RCSP
NCSP
Hubscher maneuver
heel rise exam

Question 16

what should your talocalcaneal angle (Kite’s angle) be on AP view?

Answer 16

17-21 deg

Question 17

what is your cuboid abduction angle?

Answer 17

less than 5 deg

Question 18

what is the normal % of talar head uncoverage?

Answer 18

20% or less

Question 19

what is Meary’s angle?what is normal

Answer 19

bisection of talus and bisection of 1st met

*normal is 0-10 deg

Question 20

what is normal talocalcaneal angle on lateral film?

Answer 20

15-35 deg

Question 21

what happens in Johnson and Strom stage 1 PTTD?

Answer 21

there is some pain and inflamamtion but “too many toes” sign is still normal

Question 22

what is stage 1 of treatment?

Answer 22

-cast immobilization 6-8 wks
NSAIDs
-full length semirigid orthotic
-physical therapy

Question 23

what is stage 2 treatment?

Answer 23

conservative care: UCBL orthosis, AFO

surgical care: soft tissue and osseous procedures

Question 24

what is stage 3 and 4 treatment?

Answer 24

• conservative: articulated brace (for stage 3) and noarticulated (for stage 3 and 4)
• surgical: arthrodesis procedures

Question 25

What is the biggest difference between stage 2 and stage 3?

Answer 25

stage 3 has become more of a rigid deformity

Question 26

what is the biggest difference between stage 3 and stage 4?

Answer 26

stage 4 has ankle involvement