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Tibialis Posterior Insufficiency. Dr. N. Craig Stone Nov 21, 2002. Tibialis Posterior Insufficiency. Introduction Functional Anatomy Etiology Clinical Presentation Treatment. Tibialis Posterior Insufficiency Introduction. Flatfoot – Acquired, congenital Acquired Tarsal Coalition

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Tibialis Posterior Insufficiency

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Tibialis Posterior Insufficiency

Dr. N. Craig Stone

Nov 21, 2002


Tibialis Posterior Insufficiency

  • Introduction

  • Functional Anatomy

  • Etiology

  • Clinical Presentation

  • Treatment


Tibialis Posterior InsufficiencyIntroduction

  • Flatfoot – Acquired, congenital

  • Acquired

    • Tarsal Coalition

    • Neurologic

    • Tib. Post. Insufficiency

      • Frequently not appreciated


Tibialis Posterior InsufficiencyAnatomy

  • Deep posterior compartment

  • Tendon in fibro-osseous groove

  • Multiple insertions –mainly navicular and med. Cuneiform

  • Posterior and medial to subtalar and ankle joint – flexes ankle and inverts hindfoot

  • Locks subtalar complex in push off


Tibialis Posterior Insufficiency?Etiology?

  • Trauma

  • Systemic inflammatory process

  • Impingement in tunnel

  • Hypovascularity


Tibial Posterior Insufficiency


Tibialis Posterior Insufficiency?Etiology?

  • Tib post has 1.5 cm excursion

  • Static supporters become overloaded and painful

    • Spring ligament, TN capsule, Plantar Fascia

  • Painful Flatfoot develops

    • Hindfoot equinus and valgus

    • Midfoot collapse and abduction


Tibialis Posterior InsufficiencyPresentation

  • 40-60 years 15% bilateral

  • 75% women

  • Obese, hypertension

  • Vague, insidious onset, activity related medial pain

  • 50% traumatic event

  • Calf pain

  • deformity


Tibialis Posterior InsufficiencyPresentation

  • Later

    • Lateral pain

    • Stiffness


Tibialis Posterior InsufficiencyPresentation

  • Tenosynovitis

  • Deformity

    • Rigid or passively correctable

  • Equinus contracture

  • “too many toes sign”

  • Single limb heel raise


Too Many Toes Sign


Single limb heel raise


Radiographic Analysis


Radiographic Analysis


Radiographic Analysis


Radiographic Analysis

  • U/S

  • MRI


Classification

  • Johnson and Strom

  • Type 1 – Tenosynovitis, no deformity

  • Type 2 – flexible deformity

  • Type 3 – Rigid Deformity

  • Type 4 – Ankle involvement


Treatment Type1

  • Non-operative

    • NSAIDS, Injections

  • Operative

    • Debridement

    • Medial Displacement Calcaneal Osteotomy


Medial Displacement Calcaneal Osteotomy


Treatment Type 2Non-operative

  • UCBL heel cup


Treatment Type 2Non-operative

  • AFO


Treatment Type 2Non-operative

  • ? How aggressive surgically should you be ?

  • ? What percentage will progress to a Type 3?


Treatment Type 2

  • Triple Arthrodesis

    • Older, systemic, gold standard

    • Inherent problems in young - Ankle OA


Treatment Type 2

  • Motion Sparing Procedure

    • FDL tendon Transfer

    • Calcaneal Osteotomy

    • Spring Lig and TN capsule reefing

    • Lateral procedure?

    • Medial column fusion

    • ?Combination?

    • Tendo-Achilles lengthening

    • Can easily be converted to a triple

    • Long time to improve


Treatment Type 3

  • Triple

  • Tendo-Achilles lengthening


Treatment Type 4

  • Pantalar Arthrodesis


Summary

  • Probably more common than we think

  • Keep high index of suspicion

  • ? Aggressive surgically

    • Especially in the younger woman

  • More study on natural history and what to do with a 1 and 2!

  • Pomeroy JBJS 1999 Vol.81-A 1173-1182


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