Posterior Tibial Tendon Insufficiency (PTTI)

Author: Deborah Allen

Topic updated on 04/28/13 9:31pm

Introduction

Posterior tibial tendon insufficiency is the most common cause of adult-acquired flatfoot deformity
Epidemiology
- demographics
  - more common in women
  - often presents in the sixth decade
- risk factors
  - obesity
  - older athletes
  - inflammatory disorders
Mechanism
- exact etiology is unknown, but is assumed to be multifactorial
  - 20% report an acute injury
Pathoanatomy
- tendon degeneration occurs in the watershed region distal to the medial malleolus
- begins as tenosynovitis and progresses to significant tendinosis with an incompetent, painful tendon that lacks excursion
- fixed bony deformities occur at later stages
Associated conditions
- young males with mild pes planus may have one of the following conditions
  - seronegative spondyloarthropathy
  - inflammatory arthropathy

Anatomy

Muscle
- tibialis posterior
  - originates from posterior fibula, tibia, and interosseous membrane
  - innervated by posterior tibial nerve (L4-5)
Tendon
- posterior tibial tendon (PTT) lies posterior to the medial malleolus before dividing into 3 limbs
  - anterior limb
    - inserts onto navicular tuberosity and first cuneiform
  - middle limb
    - inserts onto second and third cuneiforms, cuboid, and metatarsals 2-5
  - posterior limb
    - inserts on sustentaculum tali anteriorly
Blood supply
- branches of the posterior tibial artery supply the tendon distally
- a watershed area of poor intrinsic blood supply exists between the navicular and distal medial malleolus (2-6 cm proximal to navicular insertion)
Biomechanics
- PTT lies in an axis posterior to the tibiotalar joint and medial to the axis of the subtalar joint
  - functions as a primary dynamic support for the arch
  - acts as a hindfoot invertor
  - adducts and supinates the forefoot during stance phase of gait
  - acts as secondary plantar flexor of the ankle
- major antagonist to PTT is peroneus brevis
- activation of PTT allows locking of the transverse tarsal joints creating a rigid lever arm for the toe-off phase of gait

Classification

	Deformity	Physical exam	Radiographs
Stage I	• Tenosynovitis • No deformity	• (+) single-leg toe raise	• Normal
Stage IIA	• Flatfoot deformity • Flexible hindfoot • Normal forefoot	• (-) single-leg heel raise • Mild sinus tarsi pain	• Arch collapse deformity
Stage IIB	• Flatfoot deformity • Flexible hindfoot • Forefoot abduction ("too many toes", >40% talonavicular uncoverage)	• (-) single-leg heel raise • Mild sinus tarsi pain	• Arch collapse deformity
Stage III	• Flatfoot deformity • Rigid forefoot abduction • Rigid hindfoot valgus	• (-) single-leg heel raise • Severe sinus tarsi pain	• Arch collapse deformity • Subtalar arthritis
Stage IV	• Flatfoot deformity • Rigid forefoot abduction • Rigid hindfoot valgus • Deltoid ligament compromise	• (-) single-leg heel raise • Severe sinus tarsi pain • Ankle pain	• Arch collapse deformity • Subtalar arthritis • Talar tilt in ankle mortise

Presentation

Symptoms
- medial ankle/foot pain and weakness is seen early
- progressive loss of arch
- lateral ankle pain due to subfibular impingement is a late symptom
Physical exam
- inspection & palpation
  - pes planus
    - collapse of the medial longitudinal arch
  - hindfoot valgus deformity
    - flexible stage II
    - rigid stage III, IV
  - forefoot abduction (Stage IIB disease)
    - "too many toes" sign
    - >40% talonavicular uncoverage
  - tenderness just posterior to tip of medial malleolus
    - often associated with an equinus contracture
- range of motion
  - single-limb heel rise
    - unable to perform in stages II, III, and IV
  - determine whether deformity is flexible or fixed
    - flexible deformities are passively correctable to a plantigrade foot (stage II)
    - rigid deformities are not correctable (stages III and IV)

Imaging

Radiographs
- recommended views
  - weight bearing AP and lateral foot
  - ankle mortise
- findings
  - AP foot
    - increased talonavicular uncoverage
    - increased talo-first metatarsal angle (Simmon angle)
      - seen in stages II-IV
  - weight bearing lateral foot
    - increased talo-first metatarsal angle (Meary angle)
      - angles >4° indicate pes planus
      - seen in stages II-IV
    - decreased calcaneal pitch
      - normal angle is between 17-32°
      - indicates loss of arch height
    - decreased medial cuneiform-floor height
      - indicates loss of arch height
    - subtalar arthritis
      - seen in stages III and IV
  - ankle mortise
    - talar tilt due to deltoid insufficiency
      - seen in stage IV
MRI
- findings
  - variable amounts of tendon degeneration and arthritic changes in the talonavicular, subtalar, and tibiotalar joints
Ultrasound
- increasing role in the evaluation of pathology within the PTT

Differential

Pes planus secondary to
- midfoot pathology (osteoarthritis or chronic Lisfranc injury)
  - treat with midfoot fusion and a realignment procedure
- incompetence of the spring ligament (primary static stabilizer of the talonavicular joint) in the absence of PTT pathology
  - treat with adjunctive spring ligament reconstruction in addition to standard flatfoot reconstruction

Treatment

Nonoperative
- immobilization in walking cast/boot for 3-4 months
  - indications
    - first line of treatment in stage I disease
- custom-molded in-shoe orthosis
  - indications
    - stage I patients after a period of immobilization
    - stage II patients
  - technique
    - medial heel lift and longitudinal arch support
      - medial forefoot post indicated if fixed forefoot varus is present
      - UCBL with medial posting
- ankle foot orthosis
  - indications
    - stage II, III, and IV patients who are not operative candidates, are sedentary and low demand (age > 60-70)
  - technique
    - AFO family of braces (Arizona, molded, articulating)
      - AFO found to be most effective
      - want medial orthotic post to support valgus collapse
      - Arizona brace is a molded leather gauntlet that provides stability to the tibiotalar joint, hindfoot, and longitudinal arch
Operative
- tenosynovectomy
  - indications
    - indicated in stage I disease if immobilization fails
- FDL transfer, calcaneal osteotomy, TAL, +/- forefoot correction osteotomy, +/- spring ligament repair, +/- PTT debridement
  - indications
    - stage II disease
  - contraindications
    - hypermobility
    - neuromuscular conditions
    - severe subtalar arthritis
    - obesity (relative)
    - age >60-70 (relative)
- triple arthrodesis and TAL
  - indications
    - stage III disease
    - stage II disease with severe subtalar arthritis
- triple arthrodesis and TAL + deltoid ligament reconstruction
  - indications
    - stage IV disease with passively correctable ankle valgus
- tibiotalocalcaneal arthrodesis
  - indications
    - stage IV disease with a rigid hindfoot, valgus angulation of the talus, and tibiotalar and subtalar arthritis

Surgical Techniques

FDL transfer
- indications
  - FDL is synergistic with tibialis posterior and therefore transfer can augment function of deficient PT
- technique
  - insert FDL into navicular near insertion of PT
  - vs. FHL transfer
    - FHL is more complicated to mobilize and has not shown improved results
    - in the midfoot, FHL runs under FDL
Calcaneal osteotomy
- indicated to correct hindfoot valgus
- techniques include
  - medial displacement calcaneal osteotomy (MDCO)
    - used in stage IIA (insignificant forefoot abduction)
  - Evans lateral column lengthening osteotomy
    - used in stage IIB (significant forefoot abduction)
    - may require additional MDCO to correct the deformity
    - overlengthening may be corrected by a first TMT fusion or medial cuneiform osteotomy
TAL or gastrocnemius recession
- indicated for equinus contracture
Forefoot correction osteotomy
- indicated for fixed forefoot supination/varus (stage IIC)
- techniques
  - plantarflexion (dorsal opening-wedge) medial cuneiform (Cotton) osteotomy
    - used with a stable medial column (navicular is colinear with first MT)
    - corrects residual forefoot varus after hindfoot correction is made surgically
  - medial column fusion (isolated first TMT fusion, isolated navicular fusion, or combined TMT and navicular fusions)
    - used with an unstable medial column (plantar sag at first TMT and/or naviculocuneiform joint)
Spring ligament repair
- indicated with spring ligament rupture in some cases
PTT debridement
- may also be required
Triple arthrodesis
- triple arthrodesis includes calcaneocuboid, talonavicular, subtalar joints
- additional medial column stabilization may be required

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Qbank (14 Questions)

TAG

(OBQ11.222) A 54-year-old female has a painful flatfoot that has not improved with over 8 months of conservative management with orthotics. Preoperatively, she was unable to perform a single-heel rise and her hindfoot was passively correctable. Figures A and B are radiographs of the affected left foot. She undergoes FDL tendon transfer to the navicular, medial slide calcaneal osteotomy, and tendoachilles lengthening procedures. Following these procedures the appearance of the foot is demonstrated in Figure C. What is the next most appropriate intraoperative procedure to be performed during her foot reconstruction? Topic

Review Topic

FIGURES: A

1. Dorsiflexion closing wedge medial cuneiform osteotomy
2. In-situ 1st-3rd tarsometatarsal joint arthrodesis
3. Plantarflexion opening wedge medial cuneiform osteotomy
4. Lateral column closing wedge shortening osteotomy
5. Subtalar arthrodesis

PREFERRED RESPONSE ▶

DISCUSSION: The history, physical examination, and images are consistent with a Stage 2B posterior tibial tendon insufficiency. In acquired flat foot deformity, the hindfoot falls into valgus with compensatory varus developing in the forefoot. Figures A and B show a loss of parallelism between the 1st metatarsal and talus on the lateral view and >30% of talonavicular uncoverage on the AP view. Plantarflexion opening wedge medial cuneiform osteotomy (Cotton osteotomy) is an adjunctive procedure used to correct the residual forefoot varus component, as shown in Figure C, of a flatfoot deformity after the hindfoot has been surgically corrected to neutral. The correction of the residual forefoot varus with the Cotton osteotomy creates a plantigrade foot and restores the tripod effect of the foot.

Hirose and Johnson performed a Level 4 study that showed that a Cotton osteotomy produced good results and may offer advantages over 1st metatarsal-cuneiform fusion including predictable union, preservation of first ray mobility, and the ability to easily vary the amount of correction.

Illustration A is a drawing of the plantarflexion Cotton osteotomy. Video A demonstrates a surgical technique of how a Cotton osteotomy can be performed.

Illustrations: A

REFERENCES:

1. Hirose CB, Johnson JE. Plantarflexion opening wedge medial cuneiform osteotomy for correction of fixed forefoot varus associated with flatfoot deformity. Foot Ankle Int. 2004 Aug;25(8):568-74. PMID:15363379 (Link to Abstract)

2. Johnson JE. Plantar flexion opening wedge cuneiform-1 osteotomy for correction of fixed forefoot varus. Techniques in Foot and Ankle Surgery; 2004;3(1):2-8.

Question Authors:

Michael Hughes MD, John Badylak MD,

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(OBQ10.70) A 44-year-old female has a Stage 2B acquired flat foot deformity that does not improve over 6 months of conservative management. She undergoes FDL tendon transfer to the navicular, calcaneal osteotomy, and tendoachilles lengthening. After this correction, it is thought that she would benefit from a opening wedge first cuneiform (Cotton) osteotomy. Which of the following best describes the Cotton osteotomy? Topic

Review Topic

1. Plantarflexion osteotomy to correct residual forefoot varus
2. Medial opening wedge osteotomy to correct residual forefoot abduction
3. Plantarflexion osteotomy to correct residual forefoot valgus
4. Medial opening wedge osteotomy to correct residual hindfoot abduction
5. Plantarflexion osteotomy to correct residual hindfoot valgus

PREFERRED RESPONSE ▶

DISCUSSION: Plantarflexion opening wedge medial cuneiform osteotomy is an adjunctive procedure used to correct the forefoot varus (Illustration A) component of a flatfoot deformity as described in the review article by Tankson. In acquired flat foot deformity, the hindfoot falls into valgus with compensatory varus developing in the forefoot. After achieving surgical correction of the hindfoot to neutral, residual forefoot varus is addressed to obtain optimal foot reconstruction (Illustration B). Johnson et al performed a Level 4 study that showed that a Cotton osteotomy produced good results and may offer advantages over 1st metatarsal-cuneiform fusion including predictable union, preservation of first ray mobility, and the ability to easily vary the amount of correction. Illustration C is a drawing of the plantarflexion Cotton osteotomy.

Illustrations: A

REFERENCES:

2. Tankson CJ. The Cotton osteotomy: indications and techniques. Foot Ankle Clin. 2007 Jun;12(2):309-15, PMID:17561203 (Link to Abstract)

Question Authors:

Michael Hughes MD,

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(OBQ10.222) A 53-year-old female has a 20 month history of left hindfoot pain that has failed to respond to AFO bracing and physical therapy. She has a unilateral planovalgus deformity, shown in Figure A, which is flexible. She is unable to do a single leg-heel rise. Which of the following surgical options is most appropriate? Topic

Review Topic

FIGURES: A

1. Triple arthrodesis
2. Isolated FDL transfer to the navicular
3. Dorsiflexion osteotomy of the 1st ray with peroneus longus-to-brevis transfer
4. Lateralizing calcaneal osteotomy with FDL to navicular transfer
5. Lateral column lengthening, medializing calcaneal osteotomy, and FDL transfer to the navicular

PREFERRED RESPONSE ▶

DISCUSSION: The patient is presenting with Stage II posterior tibial tendon dysfunction (PTTD) as she is not able to do a single leg-heel rise (Stage 1 can do a heel rise) and has a flexible deformity (Stage 3 is not flexible). First line of treatment, regardless of stage, is non-operative. Operative management of Stage II disease is convtroversial, but there is a growing interest in combining bone procedures with tendon transfer to replace the incompetent PTT which relieves pain and corrects the underlying deformity.

Alvarez et al assessed the efficacy of AFO bracing and exercise in the treatment of 47 patients with Stage I or II PTTD. At 4 months, 83% of the patients had successful subjective and functional outcomes, and 89% were satisfied.

Imhauser et al performed a cadaveric study to compare the efficacy of in-shoe orthoses and ankle braces in stabilizing the hindfoot and arch in PTTD. They concluded that treatment of flatfoot deformity should at least include use of in-shoe orthoses to partially restore the arch and stabilize the hindfoot.

REFERENCES:

1. Alvarez RG, Marini A, Schmitt C, Saltzman CL. Stage I and II posterior tibial tendon dysfunction treated by a structured nonoperative management protocol: an orthosis and exercise program. Foot Ankle Int. 2006 Jan;27(1):2-8. PMID:16442022 (Link to Abstract)

2. Imhauser CW, Abidi NA, Frankel DZ, Gavin K, Siegler S. Biomechanical evaluation of the efficacy of external stabilizers in the conservative treatment of acquired flatfoot deformity. Foot Ankle Int. 2002 Aug;23(8):727-37. PMID:12199387 (Link to Abstract)

Question Authors:

Joshua Blomberg MD, John Badylak MD, Ben Taylor MD, Daniel Farber MD,

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(OBQ09.113) The lower limb orthosis shown in Figure A is the most effective method for nonsurgical management in which of the following conditions? Topic

Review Topic

FIGURES: A

1. Hallux valgus
2. Midfoot arthritis
3. Hallux rigidus
4. Diabetic foot neuropathy
5. Acquired flexible flatfoot deformity

PREFERRED RESPONSE ▶

DISCUSSION: The orthosis in Figure A is an Ankle-foot orthosis (AFO) and is most appropriately used in the setting of a flexible flatfoot deformity. Alvarez et al studied a cohort of patients undergoing a physcial therapy program and articulating AFO use and found an 89% satisfaction rate. Chao et al found 67% good to excellent results with use of a molded AFO or UCBL orthosis (University of California Biomechanics Laboratory orthosis is constructed of plastic and is fabricated over a cast of the foot held in maximal manual correction shown in Illustration A). Augustin et al found good results with an Arizona AFO (Arizona brace combines the UCBL orthosis with a laced ankle support shown in Illustration B). Hallux valgus can be treated with a wide shoe box and cushions over the prominence. Midfoot arthritis can be treated with a rigid sole and rocker bottom. Hallux rigidus is best addressed nonsurgically with a rigid forefoot orthosis that limits 1st MTP dorsiflexion. Diabetic foot neuropathy is best addressed with pressure dissipating insoles and accomodative laced shoes.

Illustrations: A

REFERENCES:

2. Augustin JF, Lin SS, Berberian WS, Johnson JE. Nonoperative treatment of adult acquired flat foot with the Arizona brace. Foot Ankle Clin. 2003 Sep;8(3):491-502 PMID:4560901 (Link to Abstract)

3. Chao W, Wapner KL, Lee TH, Adams J, Hecht PJ. Nonoperative management of posterior tibial tendon dysfunction. Foot Ankle Int. 1996 Dec;17(12):736-41 PMID:8973895 (Link to Abstract)

Question Authors:

Michael Hughes MD,

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(OBQ09.114) A 56-year-old woman comes to your office with foot pain after a 9 month trial of orthotics. Your examination reveals the hindfoot is in valgus, the arch is depressed, and the forefoot is abducted when the foot is viewed posteriorly. She is unable to perform a single heel rise on the affected side. The hindfoot is flexible and there is an equinus contracture. What combination of surgical interventions is most appropriate Topic

Review Topic

1. Tenosynovectomy followed by UCBL orthotic use
2. Dwyer closing wedge calcaneal osteotomy, 1st metatarsal closing wedge osteotomy, and plantar fasica release
3. Medial calcaneal displacement osteotomy, FDL tendon transfer, and tendoachilles lengthening
4. Arthrodesis of the subtalar, talonavicular, and calcaneocuboid
5. Lateral calcaneal displacement osteotomy, FDL tendon transfer, and tendoachilles lengthening

PREFERRED RESPONSE ▶

DISCUSSION: This patient presents with a Stage 2B acquired flatfoot deformity. The review articles by Myerson and Pinney discuss the classification and management of adult acquired flatfoot deformity. Stage 1 presents with medial ankle pain due to posterior tibial tendon synovitis. Stage 2 presents with a hindfoot in valgus and inability to perform a single limb heel rise. Stage 2A has a normal forefoot whereas Stage 2B has an abducted forefoot, exposing “too many toes” when the foot is viewed posteriorly. Stage 3 occurs over time as the hindfoot becomes rigid in a valgus position and Stage 4 develops as the deltoid ligament becomes incompetent and the talus tilts into valgus. Tenosynovectomy can be used in Stage 1 disease that fails conservative management. Answer 2 is used as a treatment for cavovarus feet. Answer 4 is a treatment option for Stage 3 disease. Answer 5 is not an option as a lateral displacement calcaneal osteotomy would exacerbate the patient's hindfoot valgus.

REFERENCES:

1. Myerson MS. Adult acquired flatfoot deformity: treatment of dysfunction of the posterior tibial tendon. Instr Course Lect. 1997;46:393-405. Review. PMID:9143981 (Link to Abstract)

2. Pinney SJ, Lin SS. Current concept review: acquired adult flatfoot deformity. Foot Ankle Int. 2006 Jan;27(1):66-75. Review. PMID:16442033 (Link to Abstract)

Question Authors:

Michael Hughes MD,

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(OBQ09.248) A 70-year-old female complains of progressive pain of the medial ankle and foot over the past 10 years. Orthotics no longer provide relief of her pain. The hindfoot deformity is unable to be passively corrected on physical exam. Figure A is a posterior view of the patient's foot upon standing and a current radiograph is provided in Figure B. Which of the following is the best treatment option? Topic

Review Topic

FIGURES: A

1. Posterior tibialis tendon debridement
2. FDL transfer to navicular and calcaneal slide osteotomy
3. FDL transfer to navicular, calcaneal slide osteotomy, and lateral column lengthening through the cuboid
4. Talocalcaneal arthrodesis
5. Triple arthrodesis

PREFERRED RESPONSE ▶

DISCUSSION: Image demonstrates the "too many toes" sign consistent with posterior tibialis tendon dysfunction. Failure of the hindfoot to correct during physical exam renders this a fixed rather than flexible deformity (Stage III) warranting triple arthrodesis. Flexible deformity (Stage II) may be surgically treated with calcaneal osteotomy, FDL transfer, and lateral column lengthening. The review article by Deland and ICL by Myerson review the evaluation, diagnosis, and management of adult-acquired flatfoot deformity.

REFERENCES:

1. Deland JT. Adult-acquired flatfoot deformity. JAAOS. 2008. July 16;(7) 399-406 PMID:18611997 (Link to Abstract)

2. Myerson MS: Adult acquired flatfoot deformity: Treatment of dysfunction of the posterior tibial tendon. Instr Course Lect 1997;46:393-405 PMID:9143981 (Link to Abstract)

Question Authors:

John Badylak MD,

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(OBQ07.37) What is the preferred surgical treatment for painful acquired flatfoot deformity with stage III posterior tibial tendon insufficiency? Topic

Review Topic

1. FDL transfer to the navicular, medial displacement calcaneal osteotomy, and tendoachilles lengthening
2. Pantalar arthrodesis
3. FDL transfer to the navicular with lateral column lengthening through the anterior calcaneus
4. Posterior tibial tendon debridement and tenodesis to FDL
5. Arthrodesis of calcaneocuboid, talonavicular, and subtalar joints

PREFERRED RESPONSE ▶

DISCUSSION: Stage III posterior tendon insufficiency is characterized by a fixed, rather than flexible deformity, with associated subtalar and midfoot arthritis which warrants triple arthrodesis (fusion of calcaneocuboid, talonavicular, and subtalar joints). Flexible deformity (Stage II) may be surgically treated with calcaneal osteotomy, FDL transfer, and lateral column lengthening. In stage IV the talotibial ankle joint is also arthritic, or there is talar tilt, and a pantalar fusion is warranted.

The ICL by Myerson and Current Concept Review by Pinney and Lin review the evaluation, diagnosis, and management of adult-acquired flatfoot deformity.

REFERENCES:

1. Myerson MS. Adult acquired flatfoot deformity: treatment of dysfunction of the posterior tibial tendon. Instr Course Lect. 1997;46:393-405. PMID:9143981 (Link to Abstract)

2. Mizel MS, Miller RA, Scioli MW (eds): OKU: Foot and Ankle 2. pp 253-277.

3. Pinney SJ, Lin SS. Current concept review: acquired adult flatfoot deformity. Foot Ankle Int. 2006 Jan;27(1):66-75. PMID:16442033 (Link to Abstract)

Question Authors:

Charles Jobin MD, Joseph Park MD, Ben Taylor MD, Daniel Farber MD,

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(OBQ07.72) An obese 65-year-old woman has a chronic painful flatfoot with a rigid valgus hindfoot deformity. Radiographs reveal subtalar joint degenerative changes but no signs of ankle joint degenerative changes or abnormal talar tilt. She is unable to single-leg heel raise and has a "too many toes" sign. What stage of posterior tibial tendon dysfunction is she best classified as? Topic

Review Topic

1. V
2. IV
3. III
4. II
5. I

PREFERRED RESPONSE ▶

DISCUSSION: Acquired pes planus deformity in adults is most often caused by posterior tibial tendon (PTT) insufficiency. Classic cases occur in overweight, middle aged patients. Physical exam findings include too many toes sign.

In the referenced article by Pinney, 4 stages of the pathology are listed. They are:
Stage 1: tenosynovitis of the PTT and maintenance of the ability to perform a single-leg heel raise
Stage 2: flexible valgus hindfoot deformity and unable to perform single leg toe raise
Stage 3: fixed valgus hindfoot deformity
Stage 4: Stage III changes with the addition of ankle degenerative changes and possible deltoid ligament complex insufficiency

The reference by Pinney and Lin is a comprehensive review of posterior tibial tendon insufficiency, including diagnosis, staging, treatment options, and outcomes.

REFERENCES:

2. Pinney SJ, Lin SS. Current concept review: acquired adult flatfoot deformity. Foot Ankle Int. 2006 Jan;27(1):66-75. PMID:16442033 (Link to Abstract)

Question Authors:

Ben Taylor MD, Ben Taylor MD, Michael Hughes MD,

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(OBQ07.229) A 46-year-old obese female presents with foot pain and the radiographs shown in Figures A and B. Which of the following physical findings will most likely be present? Topic

Review Topic

FIGURES: A

1. Achilles tendon contracture
2. Hallux varus
3. Forefoot adduction
4. Hindfoot varus
5. Clawing of the toes

PREFERRED RESPONSE ▶

DISCUSSION: The radiographs shown in Figures A and B demonstrate adult-acquired flatfoot deformity secondary to posterior tibial tendon dysfunction. Note the uncovering of the talar head on the AP radiograph, and decreased distance between the medial cuneiform and floor on the lateral radiograph indicating collapse of the medial longitudinal arch. In patients with this deformity, the medial longitudinal arch collapses, the subtalar joint everts and the heel assumes a valgus position. As a result of the hindfoot valgus, the Achilles tendon is held lateral to axis of rotation of subtalar joint and begins to act as an evertor of the calcaneus. Untreated deformity can lead to a fixed equinus deformity of the hindfoot and an Achilles tendon contracture. Myerson reviews the etiology, classification, evaluation, and treatment of posterior tibial tendon dysfunction in his ICL. Pinney et al point out in their CCR that when testing ankle dorsiflexion, the hindfoot must be held in a neutral position to allow the true extent of equinus contracture become apparent.

REFERENCES:

1. Mann RA: Flatfoot in adults, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St. Louis, MO, Mosby, 1999, pp 733-767

2. Myerson MS. Adult acquired flatfoot deformity: treatment of dysfunction of the posterior tibial tendon. Instr Course Lect. 1997;46:393-405. PMID:9143981 (Link to Abstract)

3. Pinney SJ, Lin SS. Current concept review: acquired adult flatfoot deformity. Foot Ankle Int. 2006 Jan;27(1):66-75. PMID:16442033 (Link to Abstract)

Question Authors:

Joshua Blomberg MD,

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(OBQ06.48) A healthy 42-year-old male has a 2-year history of worsening hindfoot pain that is refractory to therapy and orthotics. Physical exam reveals a flexible planovalgus foot with an equinus contracture. He is unable to perform a single limb heel rise on the affected side. In addition to a flexor digitorum longus tendon transfer to the navicular, which of the following operative procedures is indicated? Topic

Review Topic

1. Gastrocnemius lengthening only
2. Triple artthrodesis and gastrocnemius lengthening
3. Subtalar arthrodesis and gastrocnemius lengthening
4. Lateralizing calcaneal osteotomy, medial column lengthening, and gastrocnemius lengthening
5. Medializing calcaneal osteotomy, lateral column lengthening, and gastrocnemius lengthening

PREFERRED RESPONSE ▶

DISCUSSION: This patient has stage II posterior tibial tendon insufficiency, a flexible pes planovalgus deformity and inability to perform a single limb heel rise. Operative treatment includes gastrocnemius lengthening to improve dorsiflexion, FDL transfer to the navicular to reproduce posterior tibial tendon function, lateral column lengthening, and medializing calcaneal osteotomy to correct bony deformity. Moseir-LaClair et al report 5 year follow-up of 26 patients with Stage II treated with this constellation of procedures. They reported a mean postoperative ankle-hindfoot score of 90 and no nonunions. Four patients (14%) displayed radiographic signs of calcaneocuboid arthritis at follow-up with only one that was symptomatic and required calcaneocuboid joint fusion. Arthrodesis is not indicated for flexible deformities. Myerson et al reviewed the radiographic follow-up of 18 patients who underwent FDL transfer and medializing calcaneal osteotomy for flexible pes planovalgus. Radiographs demonstrated reduction of the magnitude of deformity, and the authors hypothesized that the bony reconstruction optimizes the dynamic forces of the FDL.

REFERENCES:

1. Myerson MS, Corrigan J, Thompson F, Schon LC. Tendon transfer combined with calcaneal osteotomy for treatment of posterior tibial tendon insufficiency: a radiological investigation. Foot Ankle Int. 1995 Nov;16(11):712-8. PMID:8589811 (Link to Abstract)

2. Moseir-LaClair S, Pomeroy G, Manoli A 2nd. Intermediate follow-up on the double osteotomy and tendon transfer procedure for stage II posterior tibial tendon insufficiency. Foot Ankle Int. 2001 Apr;22(4):283-91 PMID:11354440 (Link to Abstract)

Question Authors:

John Badylak MD, Patrick McCulloch MD,

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(OBQ06.234) A 55-year-old woman presents with a planovalgus deformity of her foot. She is unable to perform a single-limb heel rise and has tenderness and swelling behind the medial malleolus. Her hindfoot valgus is passively correctable and she has failed a trial of orthotics. What is the most appropriate treatment? Topic

Review Topic

1. posterior tibial tendon debridement
2. medial displacement calcaneal osteotomy and posterior tibial augmentation with flexor digitorum longus tendon transfer
3. triple arthrodesis
4. ankle fusion
5. Lapidus procedure

PREFERRED RESPONSE ▶

DISCUSSION: Stage I disease involves mild weakness of the posterior tibial tendon (seen best with heel rise) and a mobile and well aligned hindfoot. Stage I posterior tibial tendonitis (PTT) insufficiency is treated nonoperatively. Stage II PTT is characterized by flexible flatfoot, stage III is a rigid flatfoot, and stage IV has a rigid hindfoot, valgus angulation of the talus and tibiotalar arthritis. Medial displacement calcaneal osteotomy and flexor digitorum longus transfer to the navicular is a classic surgical treatment for flatfoot deformity of stage II. Stages III and IV require some type of fusion. Myerson et al retrospectively looked at their results for Stage II PTT with a FDL transfer and medial calcaneal osteotomy and found excellent clinical scores at follow up.

REFERENCES:

1. Myerson MS; Badekas A; Schon LC: Treatment of stage II posterior tibial deficiency with flexor digitorum longus tendon transfer and calcaneal osteotomy. Foot, Ankle Int 2004;25:445-450. PMID:15319100 (Link to Abstract)

2. Mizel MS, Miller RA, Scioli MW Z(eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 253-277.

Question Authors:

Greg Galano MD,

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(OBQ05.33) An 40-year-old male with a progressive planovalgus foot deformity secondary to posterior tibial tendon insufficiency (PTTI) has failed nonoperative treatment. What feature must be evaluated for that is commonly seen in patients with advanced PTTI and should be addressed at time of surgery? Topic

Review Topic

1. Plantar fascittis
2. Equinus contracture
3. Claw toes
4. Hallux varus
5. Hallux valgus

PREFERRED RESPONSE ▶

DISCUSSION: With adult aquired pes planus it is important to look at how tight the gastrocnemius-soleus complex is, so that can be addressed if surgical intervention is necessary. Posterior tibial tendon dysfunction is a commonly tested question. Acquired pes planus deformity in adults is generally caused by posterior tibial tendon insufficiency, a vital hindfoot inverter. As the dysfunction progresses, the deformity that ensues are the following: hindfoot valgus, midtarsal abduction and forefoot supination. In regards to this question, with valgus deformity of the hindfoot, the Achilles tendon insertion remains lateral to the rotation of the subtalar joint. Loss of the longitudinal arch results in a fixed equinus deformity of the hindfoot and contracture of the Achilles tendon. With the equinus contracture, the foot is further mechanically disadvantaged and this can lead to worsening of the arch collapse which then can result in worsening equinus, causing a vicious cycle. Hallux valgus has not been shown to have any increased rate in PTTI compared to the general population.

REFERENCES:

1. Pomeroy GC, Pike RH, Beals TC, Manoli A 2nd. Acquired flatfoot in adults due to dysfunction of the posterior tibial tendon. J Bone Joint Surg Am. 1999 Aug;81(8):1173-82. PMID:10466651 (Link to Abstract)

2. Myerson MS.Adult acquired flatfoot deformity: treatment of dysfunction of the posterior tibial tendon. Instr Course Lect 1997;46:393-405. PMID:9143981 (Link to Abstract)

Question Authors:

Doug Nowak MD, Patrick McCulloch MD, John Badylak MD, Daniel Farber MD,

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(OBQ04.18) When harvesting flexor digitorum longus (FDL) for a tendon transfer for stage II posterior tibialis tendon dysfunction, what anatomic structure crosses immediately deep (dorsal) to it in the midfoot region? Topic

Review Topic

1. achilles tendon
2. flexor hallucis brevis (FHB)
3. adductor hallucis
4. flexor hallucis longus (FHL)
5. abductor hallucis

PREFERRED RESPONSE ▶

DISCUSSION: In the midfoot FHL runs immediately deep (dorsal) to FDL.

When the FDL and FHL are in the ankle, FDL is medial to the FHL ("Tom, Dick and Harry"). However they cross each other at the Knot of Henry, where the FHL goes anterior to the FDL, and then tracks immediately deep (dorsal) to the FDL in the midfoot.

Illustration A shows the relative position of FDL to FHL at the ankle and plantar aspect of the foot.
Illustration B shows the relative position of FHL to FDL from a plantar view of the foot
Illustration V reviews the anatomy of the plantar surface of the foot, and at 56 seconds demonstrates the relative position of FHL to FDL.

Wrong Answers:
Answer 1: The achilles tendon should not be seen in a harvest exposure.
Answer 2: The FHB is anterior and slightly lateral to the FHL.
Answer 3: Adductor hallucis crosses too distal for harvest.
Answer 5: Abductor hallucis never crosses the FDL.

Illustrations: A

REFERENCES:

Question Authors:

Derek Moore, Derek Moore, John Badylak MD, Daniel Farber MD,

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Videos

	Triple Arthrodesis in patient with Stage 3B PTTD. General - Treatment Consult - Posterior Tibial Tendon Insufficiency (PTTI) This surgical video demonstrates a triple arthrodesis in patient with Stage 3B P...	9/7/2012 163 views 0
	Medial Displacement Calcaneal Osteotomy Foot & Ankle - Surgical Techniques - Posterior Tibial Tendon Insufficiency (PTTI) This is an osteotomy of the calcaneus for a flatfoot deformity to correct the hi...	7/21/2012 767 views 4
	Medializing Calcaneal Osteotomy - Animation Foot & Ankle - Surgical Techniques - Posterior Tibial Tendon Insufficiency (PTTI) Animation shows a Medializing Calcaneal Osteotomy using an Arthrex Step Plate. T...	7/21/2012 238 views 4
	Evans Lengthening Calcaneal Osteotomy - Animation Foot & Ankle - Surgical Techniques - Posterior Tibial Tendon Insufficiency (PTTI) This animation shows a Evans Lengthening Calcaneal Osteotomy, which can be used...	7/21/2012 717 views 4
	Plantarflexion opening wedge medial cuneiform osteotomy (Cotton) Foot & Ankle - Surgical Techniques - Posterior Tibial Tendon Insufficiency (PTTI) Demonstrates a surgical technique for correcting residual forefoot varus in post...	6/14/2012 397 views 5

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Tested Article: Stage I and II Posterior Tibial Tendon Dysfunction Treated by a Structured Nonoperative Management Protocol:...

Alvarez RG, Marini A, Schmitt C, Saltzman CL. Foot Ankle Int. 2006 Jan;27(1...

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ABOS II: Posterior TIbial Tendon Insufficiency (PTTI)

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Evidence & References Show References

Level of Evidence 2 (Prospective Cohort Study)

Alvarez RG, Marini A, Schmitt C, Saltzman CL. Stage I and II posterior tibial tendon dysfunction treated by a structured nonoperative management protocol: an orthosis and exercise program. Foot Ankle Int. 2006 Jan;27(1):2-8. PMID:16442022 (Link to Abstract)

Level of Evidence 4 (Case Series)

Hirose CB, Johnson JE. Plantarflexion opening wedge medial cuneiform osteotomy for correction of fixed forefoot varus associated with flatfoot deformity. Foot Ankle Int. 2004 Aug;25(8):568-74. PMID:15363379 (Link to Abstract)
Hirose CB, Johnson JE. Plantarflexion opening wedge medial cuneiform osteotomy for correction of fixed forefoot varus associated with flatfoot deformity. Foot Ankle Int. 2004 Aug;25(8):568-74. PMID:15363379 (Link to Abstract)
Augustin JF, Lin SS, Berberian WS, Johnson JE. Nonoperative treatment of adult acquired flat foot with the Arizona brace. Foot Ankle Clin. 2003 Sep;8(3):491-502 PMID:4560901 (Link to Abstract)
Chao W, Wapner KL, Lee TH, Adams J, Hecht PJ. Nonoperative management of posterior tibial tendon dysfunction. Foot Ankle Int. 1996 Dec;17(12):736-41 PMID:8973895 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Tankson CJ. The Cotton osteotomy: indications and techniques. Foot Ankle Clin. 2007 Jun;12(2):309-15, PMID:17561203 (Link to Abstract)
Myerson MS. Adult acquired flatfoot deformity: treatment of dysfunction of the posterior tibial tendon. Instr Course Lect. 1997;46:393-405. Review. PMID:9143981 (Link to Abstract)
Pinney SJ, Lin SS. Current concept review: acquired adult flatfoot deformity. Foot Ankle Int. 2006 Jan;27(1):66-75. Review. PMID:16442033 (Link to Abstract)
Myerson MS. Adult acquired flatfoot deformity: treatment of dysfunction of the posterior tibial tendon. Instr Course Lect. 1997;46:393-405. PMID:9143981 (Link to Abstract)
Pinney SJ, Lin SS. Current concept review: acquired adult flatfoot deformity. Foot Ankle Int. 2006 Jan;27(1):66-75. PMID:16442033 (Link to Abstract)
Elftman NW: Nonsurgical treatment of adult acquired flatfoot deformity. Foot Ankle Clin 2003;8:473-489 PMID:14560900 (Link to Abstract)
Myerson MS: Adult acquired flatfoot deformity: Treatment of dysfunction of the posterior tibial tendon. Instr Course Lect 1997;46:393-405 PMID:9143981 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Johnson JE. Plantar flexion opening wedge cuneiform-1 osteotomy for correction of fixed forefoot varus. Techniques in Foot and Ankle Surgery; 2004;3(1):2-8.
Mizel MS, Miller RA, Scioli MW (eds): OKU: Foot and Ankle 2. pp 253-277.
Review of Orthopaedics, 5th Edition, Mark D. Miller (editor), Saunders, an imprint of Elsevier, Philadelphia, Copyright 2008
Mann RA: Flatfoot in adults, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St.Louis, MO, Mosby, 1999, pp 733-767

Undefined

Alvarez RG, Marini A, Schmitt C, Saltzman CL. Stage I and II posterior tibial tendon dysfunction treated by a structured nonoperative management protocol: an orthosis and exercise program. Foot Ankle Int. 2006 Jan;27(1):2-8. PMID:16442022 (Link to Abstract)
Imhauser CW, Abidi NA, Frankel DZ, Gavin K, Siegler S. Biomechanical evaluation of the efficacy of external stabilizers in the conservative treatment of acquired flatfoot deformity. Foot Ankle Int. 2002 Aug;23(8):727-37. PMID:12199387 (Link to Abstract)
Deland JT. Adult-acquired flatfoot deformity. JAAOS. 2008. July 16;(7) 399-406 PMID:18611997 (Link to Abstract)
Myerson MS: Adult acquired flatfoot deformity: Treatment of dysfunction of the posterior tibial tendon. Instr Course Lect 1997;46:393-405 PMID:9143981 (Link to Abstract)
Pinney SJ, Lin SS. Current concept review: acquired adult flatfoot deformity. Foot Ankle Int. 2006 Jan;27(1):66-75. PMID:16442033 (Link to Abstract)
Mann RA: Flatfoot in adults, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St. Louis, MO, Mosby, 1999, pp 733-767
Myerson MS. Adult acquired flatfoot deformity: treatment of dysfunction of the posterior tibial tendon. Instr Course Lect. 1997;46:393-405. PMID:9143981 (Link to Abstract)
Pinney SJ, Lin SS. Current concept review: acquired adult flatfoot deformity. Foot Ankle Int. 2006 Jan;27(1):66-75. PMID:16442033 (Link to Abstract)
Myerson MS, Corrigan J, Thompson F, Schon LC. Tendon transfer combined with calcaneal osteotomy for treatment of posterior tibial tendon insufficiency: a radiological investigation. Foot Ankle Int. 1995 Nov;16(11):712-8. PMID:8589811 (Link to Abstract)
Moseir-LaClair S, Pomeroy G, Manoli A 2nd. Intermediate follow-up on the double osteotomy and tendon transfer procedure for stage II posterior tibial tendon insufficiency. Foot Ankle Int. 2001 Apr;22(4):283-91 PMID:11354440 (Link to Abstract)
Myerson MS; Badekas A; Schon LC: Treatment of stage II posterior tibial deficiency with flexor digitorum longus tendon transfer and calcaneal osteotomy. Foot, Ankle Int 2004;25:445-450. PMID:15319100 (Link to Abstract)
Mizel MS, Miller RA, Scioli MW Z(eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 253-277.
Pomeroy GC, Pike RH, Beals TC, Manoli A 2nd. Acquired flatfoot in adults due to dysfunction of the posterior tibial tendon. J Bone Joint Surg Am. 1999 Aug;81(8):1173-82. PMID:10466651 (Link to Abstract)
Myerson MS.Adult acquired flatfoot deformity: treatment of dysfunction of the posterior tibial tendon. Instr Course Lect 1997;46:393-405. PMID:9143981 (Link to Abstract)
Frank H. Netter, John A. Craig. Netter's Concise Atlas of Orthopaedic Anatomy, Icon Learning Systems, Teterboro, NJ, Copyright 2002

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Posterior Tibial Tendon Insufficiency (PTTI)

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