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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

Tibialis Posterior Insufficiency

Dr. N. Craig Stone

Nov 21, 2002

tibialis posterior insufficiency2
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
tibialis posterior insufficiency etiology7
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 presentation10
Tibialis Posterior InsufficiencyPresentation
  • Tenosynovitis
  • Deformity
    • Rigid or passively correctable
  • Equinus contracture
  • “too many toes sign”
  • Single limb heel raise
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
treatment type 2 non operative22
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 224
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