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Tibialis Posterior Tendon Dysfunction

Examination

  • Shoe
    • medial wear
  • Look
    • Patient standing with whole extremity visible
    • Side
      • Loss of medial longitudinal arch
      • Swelling around medial aspect of ankle
    • Behind
      • Valgus heel angulation
      • Too many toes sign ( Johnson) from behind due to forefoot abduction
    • Repeated Single heel raise
      • best determinant ofPTT function
      • difficult or impossible
      • inability to single toe raise is because transverse tarsal joint cannot be stabilized on hindfoot; therefore gastrocnemius-soleus muscle cannot function as plantar flexor of ankle joint
      • If patients are asked to stand up on toes of both feet & then asked to stand on toes of involved side, they are often able to do so since plantar aponeurosis is now functioning through its mechanism of plantar flexing metatarsals & inverting calcaneus, which enables gastrocnemius-soleus muscle to maintain plantar flexion of ankle
  • Feel
    • Sites of tenderness evaluated
  • Move
    • Ankle
      • Ankle dorsiflexion
        • is assessed with the subtalar joint reduced to ensure occurring at ankle & not the transverse tarsal joint
    • subtalar joint
      • Look at correction of forefoot supination with reduction of subtalar joint
    • subtalar motion
      • extremely important if one is contemplating tendon transfer to restore tibialis posterior function, since, if no inversion is present, tendon transfer will fail
    • transverse tarsal joint
      • should demonstrate adequate adduction, & if not, again tendon transfer will fail. For tendon transfer to function there must be essentially full range of motion in involved joints
  • Special
    • Tib posterior strength
      • Seated patient
      • foot plantarflexed & everted
        • as this takes tibialis anterior out of equation
      • Palpate tendon
    • Contracture of TA
    • Reduce hindfoot
      • hindfoot is placed into neutral position
      • relationship of forefoot to hindfoot is then noted
        • In patients with posterior tibial tendon dysfunction, forefoot varus deformity may occur, which means that lateral border of foot is more plantar flexed than medial border
    • First metatarsal rise sign
      • Patients tested while standing & fully weight-bearing on both feet
      • heel of affected foot is taken with one hand & brought passively into varus position (or shank of affected foot is taken with one hand & externally rotated)
      • head of first metatarsal raises in case of TP dysfunction & remained on ground in normal TP function