Information Sheet
Tibialis Posterior Tendon Dysfunction
Introduction
Tibialis posterior is a muscle that originates in the top third of the shin.
It primarily attaches to the navicular as well as other tarsals. Tibialis posterior
tendon dysfunction (TPTD) is described as a sudden or progressive loss of
strength of the tibialis posterior tendon.
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Primary Function
The tibialis posterior is the dynamic stabilizer of the medial longitudinal
arch. From a functional point of view, it stabilizes the sub-talar joint
during initial contact and enables supination or inversion of the
mid-foot during mid-stance. This enables the strong calf
muscles to engage and propel the foot forward off the
metatarsals.
Aetiology
There are many suggested factors that can lead to this condition. The most common are
diabetes mellitus, hypertension, congenital flat foot, obesity, rheumatoid arthritis and trauma.
Prevalence
Research has identified women over 40 years of age as the most commonly affected. The
elderly population have also been highlighted as a risk, leading to instability and falls. It can
present in children but only as stage 1 and may correlate with an accessory navicular.
Mechanism of Injury
The majority of the high energy mechanisms will involve eversion and dorsiflexion of the foot
and are likely to have visited A&E where a diagnosis of a sprain was given and a fracture
ruled out. Please be aware that a sprain of the medial ligaments is very rare in isolation and it
is more likely that the tibialis posterior tendon has been injured.
In general practice it is the low energy presentations that are more common. Although
research suggests that the diagnosis is missed it also acknowledges that patients do not visit
their GP practice for many months as it has not been painful. This patient group have had a
flat foot all their life and a trivial knock or turn has lead to the tendon becoming inflamed, torn
or ruptured.
Nick Gallogly
Authors
Mr Ian Nugent
Assessment
Ensure that both socks and shoes are removed and assess the feet from behind, checking for
symmetry. Ask your patient to go onto tip toe. If they are unable to do this or if the heel does
not invert, it is likely that a TPTD diagnosis can be given. Symptoms are found around the
posterior aspect of the medial malleolus and over the navicular tuberosity where it primarily
attaches. Pain and swelling can also be found on the lateral aspect of the ankle where bony
impingement has occurred secondary to the excessively pronated posture. TPTD is a clinical
diagnosis
Classification
There are four stages to this condition. Please be aware that this condition does progress if
left unmanaged
Stage
Presentation
1
The tendon is intact and functioning but is painful and inflamed. There is foot
symmetry and a single heel rise can be performed. The foot is correctable.
2
The tendon has become dysfunctional and there is now asymmetry in the foot
posture. There is pain on the lateral aspect of the ankle and the patient has difficulty
or is unable to perform a single heel rise.
3
The foot deformity has become fixed and there are degenerative changes to the subtalar joint. There is a significant flat foot deformity.
4
As stage 3 but degeneration has progressed into the ankle joint
Referral pathway
Stage
Presentation
1
Rest, NSAIDs, Supportive footwear advice, Off the shelf insoles +/- physiotherapy
input. If unsettled after 6 weeks, refer to the Orthotics department.
2
Rest and advice on support footwear with no barefoot walking or slippers. Refer to
Orthotics Department. Refer also to orthopaedic department if the pain is significant.
3
Advise supportive footwear as much as possible and refer to Orthotics department
Please note that should the Orthotist feel that an orthopaedic input is required a letter will be
sent to inform you of this.
Imaging
X-rays are not generally required. As the tendon is superficial it can be well detected with an
ultrasound. MRI is a useful tool for those that have significant degeneration and are likely to
require surgical intervention.
Nick Gallogly
Authors
Mr Ian Nugent