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 Insufficiency Introduction. Flatfoot – Acquired, congenital Acquired Tarsal Coalition

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Tibialis Posterior Insufficiency

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Tibialis posterior insufficiency

Tibialis Posterior Insufficiency

Dr. N. Craig Stone

Nov 21, 2002


Tibialis posterior insufficiency1

Tibialis Posterior Insufficiency

  • Introduction

  • Functional Anatomy

  • Etiology

  • Clinical Presentation

  • Treatment


Tibialis posterior insufficiency introduction

Tibialis Posterior InsufficiencyIntroduction

  • Flatfoot – Acquired, congenital

  • Acquired

    • Tarsal Coalition

    • Neurologic

    • Tib. Post. Insufficiency

      • Frequently not appreciated


Tibialis posterior insufficiency anatomy

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

Tibialis Posterior Insufficiency?Etiology?

  • Trauma

  • Systemic inflammatory process

  • Impingement in tunnel

  • Hypovascularity


Tibial posterior insufficiency

Tibial Posterior Insufficiency


Tibialis posterior insufficiency etiology1

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 insufficiency presentation

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 insufficiency presentation1

Tibialis Posterior InsufficiencyPresentation

  • Later

    • Lateral pain

    • Stiffness


Tibialis posterior insufficiency presentation2

Tibialis Posterior InsufficiencyPresentation

  • Tenosynovitis

  • Deformity

    • Rigid or passively correctable

  • Equinus contracture

  • “too many toes sign”

  • Single limb heel raise


Too many toes sign

Too Many Toes Sign


Single limb heel raise

Single limb heel raise


Radiographic analysis

Radiographic Analysis


Radiographic analysis1

Radiographic Analysis


Radiographic analysis2

Radiographic Analysis


Radiographic analysis3

Radiographic Analysis

  • U/S

  • MRI


Classification

Classification

  • Johnson and Strom

  • Type 1 – Tenosynovitis, no deformity

  • Type 2 – flexible deformity

  • Type 3 – Rigid Deformity

  • Type 4 – Ankle involvement


Treatment type1

Treatment Type1

  • Non-operative

    • NSAIDS, Injections

  • Operative

    • Debridement

    • Medial Displacement Calcaneal Osteotomy


Medial displacement calcaneal osteotomy

Medial Displacement Calcaneal Osteotomy


Treatment type 2 non operative

Treatment Type 2Non-operative

  • UCBL heel cup


Treatment type 2 non operative1

Treatment Type 2Non-operative

  • AFO


Treatment type 2 non operative2

Treatment Type 2Non-operative

  • ? How aggressive surgically should you be ?

  • ? What percentage will progress to a Type 3?


Treatment type 2

Treatment Type 2

  • Triple Arthrodesis

    • Older, systemic, gold standard

    • Inherent problems in young - Ankle OA


Treatment type 21

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

Treatment Type 3

  • Triple

  • Tendo-Achilles lengthening


Treatment type 4

Treatment Type 4

  • Pantalar Arthrodesis


Summary

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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