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Tibialis Posterior Tendinopathy: Causes & Treatment
Tibialis posterior tendinopathy is a condition affecting the posterior tibial tendon, causing pain and swelling at the inner ankle and often leading to a progressive flatfoot deformity.
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Tibialis posterior tendinopathy is a condition affecting the posterior tibial tendon, causing pain and swelling at the inner ankle and often leading to a progressive flatfoot deformity.
What is Tibialis Posterior Tendinopathy?
Tibialis posterior tendinopathy is a degenerative or inflammatory condition involving the tendon of the tibialis posterior muscle. This tendon runs behind the medial malleolus (inner ankle bone) and plays a critical role in supporting the arch of the foot and stabilising the foot during walking and standing. When the tendon becomes damaged or dysfunctional, it can lead to a progressive collapse of the medial longitudinal arch, commonly known as Adult Acquired Flatfoot Deformity (AAFD).
Causes
The condition typically develops due to a combination of overuse and degenerative changes in the tendon. Common causes and risk factors include:
- Overuse from repetitive activity such as running, prolonged standing, or high-impact sports
- Obesity, which places chronic excessive load on the tendon
- Pre-existing flatfoot deformity (pes planus) that overstresses the tendon
- Systemic conditions such as diabetes mellitus, rheumatoid arthritis, and inflammatory joint diseases
- Trauma such as ankle sprains or direct injuries to the medial ankle region
- Advancing age and associated natural tendon degeneration
Symptoms
Symptoms often develop gradually and worsen without appropriate treatment. Common signs include:
- Pain along the inner ankle and foot, especially during walking, climbing stairs, or prolonged activity
- Swelling behind and below the medial malleolus
- Progressive flattening of the foot arch on the affected side
- Weakness on single-leg heel rise (inability to rise onto the toes on the affected foot)
- Altered gait with the foot turning outward excessively
- In advanced stages: lateral ankle pain due to impingement or bone-on-bone contact
Stages of the Condition
Tibialis posterior tendinopathy is clinically classified into four stages:
- Stage I: Tendon inflammation with intact arch; pain but no deformity
- Stage II: Partial tendon tear with flexible flatfoot deformity that is still correctable
- Stage III: Complete tendon insufficiency with rigid flatfoot deformity
- Stage IV: Involvement of the ankle joint with associated arthritis
Diagnosis
Diagnosis is established through clinical assessment and imaging studies:
- Clinical examination: Palpation along the tendon, assessment of arch height, and the single-leg heel rise test
- Ultrasound: Identifies tendon thickening, tears, and peritendinous fluid accumulation
- MRI (Magnetic Resonance Imaging): Gold standard for detailed assessment of tendon integrity and surrounding structures
- X-ray: Evaluates bony alignment, arch collapse, and signs of arthritis
Treatment
Conservative Treatment
In early stages (I and II), non-surgical management is the first line of care:
- Rest and immobilisation using a walking boot, cast, or ankle-foot orthosis (AFO) to reduce tendon stress
- Orthotic insoles with medial arch support to offload the tendon
- Physiotherapy including eccentric strengthening of the calf and tibialis posterior muscle
- Anti-inflammatory medications (NSAIDs) for short-term pain and swelling relief
- Weight management to reduce mechanical load on the tendon
Surgical Treatment
For advanced stages (III and IV) or failure of conservative management, surgical options include:
- Tendon transfer (e.g., flexor digitorum longus tendon) to replace the dysfunctional posterior tibial tendon
- Calcaneal osteotomy to correct heel alignment
- Arthrodesis (joint fusion) for severe arthritis in Stage IV
Prognosis
When diagnosed and treated early, the prognosis is generally favourable. Patients in Stages I and II who follow a structured conservative programme often achieve significant or complete symptom relief. Advanced stages typically require surgical intervention to restore long-term foot function and reduce pain.
References
- Beals TC, Pomeroy GC, Manoli A: Posterior tibial tendon insufficiency: diagnosis and treatment. Journal of the American Academy of Orthopaedic Surgeons. 1999;7(2):112-118.
- Ross MH, Smith MD, Mellor R, Vicenzino B: Exercise for posterior tibial tendon dysfunction: a systematic review of randomised clinical trials and clinical guidelines. BMJ Open Sport and Exercise Medicine. 2018;4(1):e000270.
- Geideman WM, Johnson JE: Posterior tibial tendon dysfunction. Journal of Orthopaedic and Sports Physical Therapy. 2000;30(2):68-77.
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