Posterior Tibial Tendon Dysfunction:
An Overview and Soft Tissue Repair

by  Samuel S. Mendicino, DPM, FACFAS
Director of Residency and Fellowship Training
West Houston Medical Centers
Harris County Podiatric Surgical Residency Houston, Texas  

Twenty years ago, Posterior Tibial Tendon Dysfunction (PTTD) was a condition that was not recognized by most lower extremity specialists.  At that time, we considered  Gastrocnemius Equinus, Peroneal Spasm, and the Enlarged Navicular to be the main etiologies associated with Collapsing Pes Plano Valgus Deformities.  Posterior Tibial Tendon Dysfunction is the sudden or progressive loss of strength in the Tibialis posterior tendon and its secondary effect of progressive flatfoot deformity.

PRESENT Courseware has devoted three lectures by three distinguished educators to this topic.  We urge you to also view Adult Acquired Flatfoot by Douglas H Ritchie, DPM and Tibialis Posterior Dysfunction, The Columnar Approach by John M. Schuberth, DPM. 

In addition to being a world class foot and ankle surgeon, Dr. Sam Mendicino is a brilliant educator.  He discusses this topic in a clear, easy to understand manner.  The photographs and streaming video that accompany this lecture help to crystallize a topic that is often difficult to completely understand.  

Dr. Mendicino first discusses the four main etiologies associated with PTTD.  The first, tenosynovitis,  is often considered to be a precursor to this disorder.  In another type of presentation, we will see longitudinal tearing of the tendon, with functional weakening, rendering it  ineffective as a supinator of the foot.  One may also see a midstance tear, typically occurring at the level of the medial malleolus.  Lastly, there may be an avulsion of the tendon away from the tuberosity of the navicular.

Dr. Mendicino strongly emphasizes the following points.  1.  The diagnosis of this condition is made predominantly by clinical evaluation.  He does not dissuade the use of MRI, but feels the results can be misleading.  2.  Early intervention may prevent the need for aggressive reconstruction or arthrodesis.  3.  Conservative care for this problem may also involve early surgical intervention.  

Recognizing the subjective complaints is extremely important.  Pain and swelling along the medial ankle with associated complaints of decreased endurance are real bell ringers.  The patient may also report a sense that they are walking on the medial ankle and notice a progressive loss of the arch.  Tarsal tunnel, sinus tarsitis, and arthritic type pain may also be reported.  Clinically, the physician will notice that the patient has difficulty maintaining the toe raised position.  He may also see a lack of heel varus in the toe raised position.  The "too many toes sign" may also rear its ugly head.  

Conservative and surgical repairs are discussed.  Dr. Mendicino reminds us that there is no one procedure for Stage I or Stage II PTTD.  Soft tissue procedures are reserved for patients with tendon pain and arthrodesis procedures for those with arthritic pain.  Soft tissue procedures run the gamut from tenolysis with synovectomy to primary repair with debulking and augmentation.  Dr. Mendicino also discusses the medial displacement calcaneal osteotomy and its ability to medialize the pull of the achilles tendon and help the flexor digitorum longus act as a secondary inverter of the foot.

Posterior Tibial Tendon Dysfunction, as an entity, becomes easier to understand as a result of Dr. Mendicino's ability to artfully present the material.  
 

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