1) Posterior tibial tendon dysfunction is a spectrum of pathology that can lead to acquired adult flatfoot deformity. It most commonly affects middle-aged women and risk factors include obesity, diabetes, and steroid use.
2) Diagnosis involves physical exam findings like tenderness over the posterior tibial tendon and inability to do a single heel rise, as well as radiographic evidence of flatfoot deformity.
3) Treatment ranges from non-surgical options like bracing to help offload the tendon in mild cases to various surgical procedures depending on the severity of deformity, including tendon repair/reconstruction, osteotomies, and arthrodesis.
3. Subcutaneous rupture of the anterior tibial
tendon ď few reported ď little attention
⢠The anterior tibial tendon functions: major dorsiflexor of
the ankle, primarily during the swing phase, heel strike, and
early stance phase of the walking cycle.
It originates from the proximal half of the
anterior tibia, and inserted into the medial
cuneiform and base of the first metatarsal
⢠At the level of the lower and middle thirds of the tibia, it
becomes tendinous and is surrounded by a synovial sheath.
4. Petersen et al
Despite a well-vascularized posterior surface of the tendon, they
found an avascular zone where the tendon runs under the superior
and inferior retinacula. This results in an area 1 to 2 cm from the
insertion that is at risk for rupture.
investigated the structure and vascular pattern of the tibialis anterior
tendon, They found a well-vascularized peritenon, with blood vessels
penetrating the tendon and anastomosing with a longitudinally
oriented intratendinous network.
6. have described âacute on
chronicâ tears manifesting as a
degenerative tear usually
occur in men between the fifth
and seventh decades of life
and most often are reported in
the seventh decade
Markarian et al
7. Clinical
Manifestation
swelling of the anterior ankle
and foot
weak dorsiflexio
catching the foot on irregular or
uneven ground
Footdrop, footslap, or steppage
gait, typically after heel strike
Mild pain
Palpable defect/Lump/Mass
Burma and Moberg reported
development of a spontaneous
flatfoot deformity
This condition can be misdiagnosed
as a peroneal palsy or confused with
an L4-5 radiculopathy (ruled out on
neurologic examination with normal
sensation on the dorsum of the foot,
normal sensation in the first web
space, and normal function of the
other extensor tendons with active
dorsiflexion of the toes)
Open injuries after a fracture or
laceration can occur but require
assessment of motion and strength
of the anterior tibial tendon so that a
tendon disruption is not overlooked
8. IMAGING
⢠MAGNETIC RESONANCE IMAGING CAN
BE HELPFUL IN DEFINING AN ANTERIOR
TIBIAL TENDON RUPTURE
⢠NORMAL TENDONS HAVE A LOW
SIGNAL INTENSITY AND CONTRAST
WELL WITH SURROUNDING FAT, WHICH
HAS A HIGH SIGNAL INTENSITY.
⢠MRI CAN BE HELPFUL IN MAKING A
DIAGNOSIS OF RUPTURE OR TENDON
DEGENERATION
9. Treatment No consensus in the literature appears to exist regarding reccommendations of
surgical vs nonsurgical treatment
foot and ankle experts generally agree that surgical repair ď achieve the ultimate
goal of improved function without a brace especially younger patient
For the older patient, bracing or a polypropylene AFO or a double upright brace
may be prescribed, no different between op vs non op (Markarian et al)
surgical and conservative treatments should be tailored to the individual patient
depending on age, level of activity, time elapsed since the rupture occurred,
current level of disability, and local and systemic contraindications to surgery.
10. Acute Surgical
Treatment
â˘Lipscomb and Kelly and others ď have
recommended a direct repair of the anterior tibial
tendon. Its reinsertion into the navicular with a
suture anchor or into a bony tunnel are
alternatives with an avulsion fracture or distal
rupture
â˘With delay in diagnosis and retraction of the
proximal tendon stump or with injury to a large
segment of tendon, reconstruction is then an
option. An extensor tendon graft, tendon
transfer, or partial tendon advancement are
surgical options for reconstruction
11. PRIMARY REPAIR OF RUPTURED
ANTERIOR TIBIAL TENDON
Supine position +
torniquete
Anteroinferior extensor retinaculum is
divided anterior tibial tendon is
identified and traced to its insertion in
the first cuneiform
An anterior curvilinear incision is made on the
inferomedial aspect of the anterior tibial tendon
and extended from the level of the first
cuneiform proximally to the level of the
superior extensor retinaculum
12. ⢠DORSALIS PEDIS ARTERY AND DEEP
PERONEAL NERVE LIE ON THE LATERAL
ASPECT OF THE EHL, AND THE
DISSECTION IS DEEPENED ON THE
MEDIAL ASPECT OF THE EHL TO
PROTECT THE NEUROVASCULAR
BUNDLE
13. Exploration should proceed
proximally to
identify the end of the tendon
ď No. 1 nonabsorbable suture is used to
approximate the tendons with a Bunnell,
Krackow or modified Kessler technique
(gambar)
The tendon sheath is
incised longitudinally and
the hematoma debrided
14. If the tendon has avulsed or is
lacerated from its distal
attachment, a suture anchor can
be inserted into the cuneiform
and the tendon secured to the
periosteum
The synovial sheath is repaired,
but the inferior extensor
retinaculum is not repaired to
prevent formation of adhesions
15. ALTERNATE TECHNIQUES
⢠THE ANTERIOR TIBIAL TENDON ALSO
MAY BE LENGTHENED USING A
SLIDING ANTERIOR TIBIAL TENDON
GRAFT THAT SPANS THE RUPTURE
SITE, ANASTOMOSING THE PROXIMAL
AND DISTAL SEGMENTS OF THE
TENDON
16. DELAYED SURGICAL TREATMENT
There are five
options in
delayed
treatment of an
anterior tibial
rupture:
primary
repair
Reconstructio
n with a free
graft
(allograft or
autograft)
Reconstruc
tion with a
turn-down
procedure
Reconstructio
n with an
adjacent
tendon
transfer
Conservativ
e
manageme
nt.
17. EXTENSOR HALLUCIS LONGUS TRANSFER
The EHL tendon is dissected distally at
the level of the first MTP joint and is
anastomized to the extensor hallucis
brevis tendon before transection
The EHL tendon is tunneled
into the cuneiform and
tensioned with the ankle in
dorsiflexion (gambar)
18. POSTOPERATIVE CARE
A below-knee
cast or splint is
applied with
the foot in
maximum
dorsiflexion.
Weight bearing
and walking is
permitted in a
cast, boot
brace, or an
AFO 2 to 3
weeks after
surgery.
Dorsiflexion
exercises with
deep knee
bends,
performed five
times a day for
20 minutes for
each episode
Full range-of-
motion
exercises are
initiated 6 to 8
weeks after
surgery.
Immobilization
is continued for
12 weeks
Progressive
resumption of
walking
without the
brace is
initiated 12
weeks after
surgery
19. RESULTS AND CONCLUSION
Although ruptures of the anterior tibial tendon occur infrequently,
accurate early diagnosis enables a patient and physician to choose
between conservative and surgical treatment.
The ultimate goal is improved function, and treatment should be
adapted to the patientâs needs
Nonsurgical treatment is probably sufficient in the older, less
active patient, and surgical repair is indicated in the more active,
younger patient.
22. Posterior tibial tendon (PTT) dysfunction encompasses a spectrum of
pathology ranging from isolated tendinosis to secondary acquired adult
flatfoot deformity that can be flexible or fixed depending on the severity.
đş>đš peak incidence at age 55 year
Because the PTT has a limited excursion of only 2 cm, any insult that
lengthens the tendon has an adverse effect on its function
Obesity, congenital flatfoot, and high impact sports have been associated
with development of posterior tibial tendon dysfunction presumably as a
result of higher repetitive mechanical stresses on the tendon
23. Diabetes and steroid use
have also been linked to
posterior tibial tendon
dysfunction further
supporting the theory of
hypovascularity as a
contributing factor
A hypovascular zone in the
tendon has been described
by many at the level of the
medial malleolus, the region
at which tendon failure most
often occurs
Adult-acquired flatfoot deformity
secondary to PTT dysfunction
begins with progressive weakness
of the tendon which leads to the
sup- porting capsular and
ligamentous structures beginning
to fail.
24. Downward and medial pressure of the talar
head stretches the spring ligament complex,
resulting in plantar sag and forefoot
abduction through the talonavicular joint.
Weakness of tendon function results in the
transverse tarsal joint being unable to lock, As
a result, the talonavicular joint becomes the
primary moment arm of plantar flexion force,
leading to attrition of the medial arch
ligaments, Eventually, the medial arch
collapses, and a flatfoot deformity results.
25. The diagnosis of
posterior tibial
tendon
dysfunction and
the degree of
adult-acquired
flatfoot deformity
are based on
patient history,
physical
examination, and
standing
radiographs of
the foot and
The standard
series of plain
radiographs
includes three
views of the foot
and an
anteroposterior
(AP) view of the
ankle.
DIAGNOSIS
26. Early acute medial foot pain and
swelling
Tendon elongates or
ruptures causing the
pain to improve or be
absent.
Hindfoot deformity
progresses, lateral foot
pain may develop due
to talocalcaneal or
subfibular impingement
Arthritis becomes a
more significant
27. ⢠SWELLING AND TENDERNESS WITH
PALPATION ALONG THE POSTERIOR
TIBIAL TENDON IS AN IMPORTANT
FINDING.
⢠ALIGNMENT IS INSPECTED WITH THE
PATIENT STANDING BAREFOOT WITH
BOTH KNEES FACING FORWARD, WITH
ATTENTION PAID TO ANY FLATFOOT
DEFORMITY, HINDFOOT VALGUS
COLLAPSE, AND FOREFOOT
ABDUCTION (âTOO MANY TOESâ SIGN)
28. ⢠THE FUNCTION OF THE TENDON IS
EVALUATED WITH THE SINGLE HEEL
RAISE TEST.
⢠WITH THE KNEE HELD STRAIGHT, THE
PATIENT IS ASKED TO STAND ON THE
TIPTOES OF THE INVOLVED
EXTREMITY, WHILE THE
CONTRALATERAL EXTREMITY IS OFF
THE GROUND.
⢠IN NORMAL HEEL RISE, THE SUBTALAR
JOINT INVERTS, LOCKING THE
TRANSVERSE TARSAL JOINT AND
ALLOWING THE HEEL TO RISE
THROUGH PULL FROM THE
GASTROCNEMIUS-SOLEUS.
⢠THE TEST IS CONSIDERED POSITIVE
WHEN THE PATIENT IS UNABLE TO LIFT
THE HEEL OFF THE GROUND OR
29. FOUR CLINICAL STAGES OF PTTD HAVE BEEN
DESCRIBED AND ARE BASED ON
EXAMINATION AND RADIOGRAPHIC
PARAMETERS
31. CONSERVATIVE
Conservative treatment has been shown to be effective in
alleviating symptoms, particularly when initiated in the early
stages of disease
In acutely symptomatic patients with medial arch pain, resting
or relieving the tension on the posterior tibial tendon may be
achieved through immobilization with a removable boot or cast
33. ⢠MILD ď UNIVERSITY OF CALIFORNIA
BIOMECHANICS LABORATORY (UCBL)
ORTHOSIS
⢠MORE SEVERE AND RIGID
DEFORMITIES ď ANKLE-FOOT
ORTHOSIS (AFO)
Stabilizes the heel in neutral and
prevents abduction of the forefoot
Allows ankle motion and provides
support via the tibia and the medial longitudinal arch
35. STAGE 1
Patients present with
pain and swelling just
distal to the medial
malleolus overlying
the posterior tibial
tendon. Tenosynovitis
is the predominant
source of pain.
Generally, the length
and motor strength of
the tendon is
preserved, and
deformity is absent.
The patient is able to
perform a single heel
rise with normal varus
tilt
36. STAGE II
The tendon has undergone degeneration and elongation, resulting in deformity. The hindfoot is in
valgus, and forefoot abduction is noted due to collapse and abduction at the talo- navicular joint.
However, these deformities remain passively correctible, The majority of patients are unable to
perform a single heel rise.
37. Stage IIa involves limited collapse
and mild to moderate abduction
deformity through the mid- foot
with <30 % talonavicular
uncoverage on standing AP
radiographs of the foot.
Stage IIb involves more substantial
failure of the spring ligament and
secondary restraints, resulting in
greater forefoot abduction and >30
% talonavicular unconverage
39. STAGE III
Rigid deformity of the triple joint complex (subtalar, talonavicular,
and calcaneocuboid joints) has occurred. Hindfoot valgus and
abduction through the talonavicular joint are not passively
correctable to neutral position. Rigid forefoot supination develops
secondary to the hindfoot valgus
41. STAGE IV
Chronic eccentric loading of the ankle
joint in valgus leads to failure of the
deltoid ligament and, frequently,
ankle arthritis
Stage IV was described by Myerson and
involves attenuation of the deltoid
ligament, resulting in additional valgus
deformity of the ankle joint
