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Tendon Disorders

TIBIALIS POSTERIOR INSUFFICIENCY  (Adapted from the Foot & Ankle Hyperbook )

Commonest cause of adult acquired flat foot

Tears occur in the hypovascular zone 3-5 cm proximal to insertion

Causes

  • trauma
  • chronic flat foot
  • inflammatory arthropathy
  • degenerative tendonopathy

Myerson described two groups:

  • younger patients aged 30-40 with inflammatory arthropathy
  • older, typically female patients 50-60 years old with degenerative tears

  Complaints

  • post-malleolar pain
  • arch pain + aching
  • progressive flat foot
  • forefoot problems: progressive hallux valgus, metatarsalgia, lesser toe deformities
  • rarely, tarsal tunnel syndrome
tarsal tunnel syndrome tarsal tunnel syndrome

  Examination

  • gait
  • planovalgus foot
  • heel remains in valgus on double foot tiptoe standing
  • post-malleolar tenderness/swelling with no palpable tendon on resisted plantar flexion/inversion
  • single foot tiptoe test: cannot stand on tiptoe on single foot if tibialis posterior not functioning
  • tight TA in hindfoot neutral
  • hindfoot/forefoot malalignment and its degree of correctability

  Differential diagnosis

  • longstanding flat foot made symptomatic, usually by minor trauma
  • sequelae of other injuries
  • joint instability or destruction due to inflammatory arthritis
  • neuropathic foot collapse

  Imaging

  • Standing hindfoot alignment view: shows where the valgus is
  • Standing lateral footü both show talonavicular
  • Standing AP forefootþ and talometatarsal alignment
  • MR: best technique for assessing tendons


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