eMedicine Specialties > Radiology > Musculoskeletal
Ankle, Tibialis Posterior Tendon Injuries
Updated: Feb 5, 2008
Introduction
Background
Ankle, tibialis posterior tendon injuries. Axial T2-weighted fat-suppressed MRI in an adult man with peritendinous edema. Image reveals reactive marrow edema (open arrow) under the tibialis posterior tendon groove; this is caused by tibialis posterior tendon dysfunction.
Ankle, tibialis posterior tendon injuries. Lateral tenogram shows extrinsic compression on tibialis posterior tenograms at the level of the tibial plafond produced by the flexor retinaculum (between arrowheads). This should not to be mistaken for pathologic adhesion or stenosis. Note the injecting needle (arrow).
Ankle, tibialis posterior tendon injuries. Same patient as in Image 39 in Multimedia; transverse sonogram in a middle-aged woman with tendinosis shows an enlarged inhomogeneous tibialis posterior tendon (between calipers).
Tibialis posterior tendon dysfunction presents one of the most challenging problems that a foot and ankle specialist faces. This dysfunction often results in significant disability for the patient and in the progressive loss of function. The condition is recognized as a disabling cause of progressive flatfoot deformity.1,2 Many cases of posterior tibial tendon dysfunction may go undiagnosed. The tibialis posterior is, by far, the most frequently ruptured tendon in the rear foot, but injuries to this structure are often overlooked.3,4,5,6
Related eMedicine topics:
Ankle, Flexor Hallucis Longus Tendon Injuries
Acquired Flatfoot
Achilles Tendon Pathology
Achilles Tendon Injuries and Tendonitis
Achilles Tendon Rupture
Achilles Tendonitis
Pathophysiology
Tibialis posterior tendon dysfunction is encountered as a result of altered mechanics of the foot or as a response to systemic articular disease. Systemic risk factors are noted more frequently in dysfunction of the tibialis posterior tendon than in disorders of the Achilles tendon. These risk factors include hypertension; obesity; lupus; gout; rheumatoid arthritis; and, less commonly, Reiter syndrome. Patients with rheumatoid arthritis more frequently develop synovitis than tears. This synovitis causes fibrosis from recurrent inflammatory episodes and, eventually, tibialis posterior tendon dysfunction.7,8,9,10
Young athletes involved in tennis, soccer, ice hockey, basketball, and ballet dancing are vulnerable to traumatic injury to the tendon. Prior trauma and surgery are not strong predictors of tibialis posterior tendon disorder, nor is systemic steroid exposure. However, the direct injection of steroids into the tendon can cause tibialis posterior tendon tears. Unilateral involvement occurs in approximately 90% of cases, with a left-sided predominance.
Human leukocyte antigen Cw6 is a marker of a subtype of seronegative arthropathies, and a positive result with a Cw6 test is associated with tears of the tibialis posterior tendon.
Jahss has classified disorders of the tendons around the ankle and in the foot according to the following general categories: tenosynovitis, tears, tethering, dislocations, tumors and pseudotumors, ossification, congenital anomalies, contractures, and iatrogenic injuries.11,12
Clinically, the initial presenting stage of tibialis posterior tendon tenosynovitis is paratendinitis (or preferably peritendinosis) or synovitis (see Image 1). The next stage is tendinitis, which is correctly termed tendinosis. Tendinitis is the less-preferred nomenclature because the pathophysiology is degenerative dysfunction without a true inflammatory component. True tendinitis of the tibialis posterior tendon is unusual (see Image 2).
Many cases that are clinically believed to be tendinitis are in fact synovitis. In tendinosis, patients have degeneration in the tibialis posterior tendon. This is usually associated with paratendinosis/synovitis (see Images 3-4). Histologically, no inflammation is present, but there is evidence of intratendinous collagen degeneration, local necrosis, calcification, and hypocellularity similar to that seen in Achilles tendon degeneration.
By definition, a tethered tendon is one with a limited range of movement, owing to its abnormal fixation to an adjacent structure. Causes of such tethering include anatomic anomalies, such as a single tendon sheath surrounding 2 tendons that normally have separate sheaths or an accessory tendon that increases the volume of tissue within a single sheath; fractures with resulting deformities that lead to abnormal fixation or displacement of the tendon or its sheath; and fracture-dislocations of the ankle that may lead to tethering or even incarceration of 1 or more regional tendons.
The transition stage of tibialis posterior tendon disorder involves microscopic and eventually macroscopic tears of the tendon fibers. Partial tears can scar over and lead to tendon thickening; they can retract and lead to tendon thinning; or they can severely weaken the tendon and result in a gap.
Thin tendons are atrophic (see Images 5-6), and thick tendons are hypertrophic (see Image 7). Most patients have mixed regions of hypertrophic and atrophic tendons. This mixture occurs because of interstitial tendon tears with bulbous hypertrophic proximal tendon fibers and because of retraction of the distal atrophic fibers (see Image 8).
Partial or complete tears of the tendons of the foot and ankle may be related to laceration, especially in the sole of the foot; more commonly, they occur spontaneously. Spontaneous rupture of these tendons usually implies some type of intrinsic pathologic process because normal tendons rarely rupture in this fashion. In older persons or in younger persons (particularly athletes) with chronic inflammation, tendon degeneration may predispose them to spontaneous rupture. However, this is classically seen in persons aged 40-60 years (average age, 55 y), and two thirds of cases occur in women. A tibialis posterior tendon tear with a gap is unusual. The tibialis posterior tendon and the Achilles tendon are most frequently affected.
A similar continuum of tibialis posterior tendon disorders occurs in the Achilles tendon, and a similar concept of cumulative injury is useful in understanding tibialis posterior tendon disorders. However, in distinction to injuries of the Achilles tendon, complete tears with a gap that shows no evidence of fibrosis are fairly unusual manifestations of tibialis posterior tendon dysfunction, and ischemia appears to be a more important causal factor.
Normally, a small amount of fluid is present around the tendon (see Image 9). If too much fluid is present, the patient may have pain and dysfunction. Also, fibrotic synovium contributes to the pathophysiologic process, causing a thickened tendon. Additionally, fibrosing tenosynovitis, related to paratendinitis and synovitis, causes thickening of the tendon. In fibrosing tenosynovitis, the synovium may appear black on MRIs. The dark, adherent synovium makes the tendon appear hypertrophic.
The typical location of tibialis posterior tendon disorders is perimalleolar, although they are centered somewhat distal to the malleolus. A second location at which disorders occur is distal. Distal locations are typical for injuries in young athletes and in patients with inflammatory arthropathies.
Dislocation of the tibialis posterior tendon is a rare injury that is often diagnosed late. The tibialis posterior tendon can also sublux outside its groove, often subtly.
Frequency
United States
The tibialis posterior is, by far, the most frequently ruptured tendon in the rear foot, but injuries to this structure are often overlooked.
Bilateral abnormalities of the tibialis posterior tendon are more common in cases associated with underlying disease, particularly rheumatoid arthritis (see Risk factors, under Pathophysiology, for other systemic risk factors). Unilateral involvement occurs in approximately 90% of cases, with a left-sided predominance.
Mortality/Morbidity
No data directly link tibialis posterior tendon dysfunction with mortality. However, many comorbid states probably predispose individuals to this condition. Examples include hypertension; obesity; lupus; gout; rheumatoid arthritis; and, less commonly, Reiter syndrome.
Race
No data suggest that any particular race is more vulnerable to tibialis posterior tendon dysfunction.
Sex
Tibialis posterior tendon dysfunction is a disorder that primarily occurs in women who are middle-aged or elderly. Classically, two thirds of spontaneous ruptures occur in women in their fifth or sixth decade of life.
Age
This disorder is bimodal, manifesting in young athletes and, to a greater extent, in middle-aged and elderly women. Classically, two thirds of spontaneous ruptures occur in women in their fifth or sixth decade of life.13
Anatomy
Ankle, tibialis posterior tendon injuries. Drawing shows the relationship of the tibialis posterior tendon to the remainder of the tarsal tunnel. Note the relative sites and the distal extent of tendon sheaths in black. Also note that the flexor hallucis and flexor digitorum tendons cross distally at the knot of Henry (straight arrow). Last, note the tibial artery and nerve (curved arrow) between the flexor digitorum longus tendon and the flexor hallucis longus tendon in the tarsal tunnel. ATT, anterior tibialis tendon; FDL, flexor digitorum longus tendon; FHL, flexor hallucis longus tendon; FR, flexor retinaculum; and PTT, tibialis posterior tendon.
Ankle, tibialis posterior tendon injuries. Drawing shows the complex insertions of the tibialis posterior tendon beneath the undersurface of the foot with the muscle dissected away. Note the main slip inserting onto the tubercle of the navicular. Also note the close anatomic relationship of the distal tendon, spring ligament, and distal deltoid ligament. C, calcaneus; N, navicular; PTT, tibialis posterior tendon.
Tendons and muscles
Numerous tendons extend from the lower portion of the leg across the ankle and into the foot. With the exception of the Achilles tendon, all of these tendons change from a vertical orientation in the lower leg to a horizontal orientation near the level of the ankle or in the foot (see Image 10). This modification in direction is accomplished by means of a pulley system consisting of either bone (eg, malleoli) or retinacula to promote their smooth, angular movement about the ankle, subtending a smooth curvy course, in contradistinction to disease process when this is lost (see Image 11).14,15,16,17,18
The tibialis posterior muscle originates from the interosseous membrane and the adjacent posterior surface of the tibia in the proximal third of the leg. The tendon forms in the distal third of the leg and lies closely apposed to the tibia in the posteromedial aspect. Distally, the tibialis posterior tendon sits in a medial or posterior concavity on the medial edge of the posterior tibia. Just lateral to the tibialis posterior tendon lies the flexor digitorum tendon. The tibialis posterior tendon curves distally around the medial malleolus. At this level, the position of the tendon beneath the flexor retinaculum (laciniate) prevents the flexor tendons from bowstringing as they curve around the malleolus. The flexor retinaculum is the roof of the tarsal tunnel. The tarsal tunnel contains the 3 ankle flexor tendons, the adjacent posterior tibial artery and vein, and the tibial nerve (see Image 10).19
The tibialis posterior tendon next passes under the flexor retinaculum and over the deltoid ligament into the foot and, then, beneath the plantar calcaneonavicular ligament. The tendon contains a sesamoid fibrocartilage, as it runs under the plantar calcaneonavicular ligament. It is inserted into the tuberosity of the navicular bone and gives off fibrous expansions: one expansion passes backward to the sustentaculum tali of the calcaneus, and others pass forward and lateralward to the 3 cuneiforms, the cuboid, and the bases of the second, third, and fourth metatarsal bones (see Image 12).
Because an abnormal size may be the only indicator of tendon dysfunction, the relative sizes of the tibialis posterior tendon, the flexor digitorum tendon, and the flexor hallucis tendon should be examined. In a healthy person, the tibialis posterior tendon is roughly twice the size of the 2 adjacent tendons (see Images 13-15). Additionally, the tibialis posterior tendon should be slightly smaller than the tibialis anterior tendon, and the tibialis posterior tendon should be slightly smaller than the summated measurements of the peroneus brevis and peroneus longus tendons (see Images 13-14).
Blood supply
The proximal aspect of the tibialis posterior tendon is supplied by branches of the posterior tibial artery. The distal aspect of the tendon, at the enthesis, is supplied by the posterior tibial and dorsalis pedis arteries. The midtendon, similar to the Achilles tendon, is poorly supplied with blood. In addition, the mesotendon is absent distally because the synovial sheath ends at the mid portion of the talus. Because of the zone of hypovascularity and because of the absence of a mesotendon, the level of the medial malleolus in relation to the tubercle is the most common location for tibialis posterior tendon dysfunction.
Tibialis posterior tendon disorders are predominantly ischemic, and similar to myocardial infarction, they are senescent diseases. Impingement also plays a role in tibialis posterior tendon dysfunction because the tibialis posterior tendon has a focal point of stress as it curves around the medial malleolus. This point of stress can be analogous to the pressure on the rotator cuff in the subacromial space. This combination of ischemia and mechanical compression causes most tibialis posterior tendon disorders.
Functional anatomy
The tibialis posterior muscle plantarflexes the ankle and inverts the foot. During normal gait, this muscle unit creates a rigid midfoot lever for forward propulsion by locking the calcaneus to the cuboid and the talus to the navicular. If tibialis posterior dysfunction is present, the lack of a rigid midfoot causes gastrocnemius and soleus flexion to occur at the midfoot instead of at the metatarsal heads. This problem eventually leads to midfoot collapse, forefoot abduction, and heel valgus. These deformities are exacerbated by the action of the peroneus brevis, the antagonist muscle to the tibialis posterior. Because the cross-sectional area of the peroneus brevis is half that of the tibialis posterior tendon, a significant degree and length of time of tibialis posterior dysfunction must be present before these abnormalities appear.
Normally, a small amount of fluid is present around the tendon (see Image 9).
Presentation
Early diagnosis and treatment may prevent considerable disability and surgery.
The presenting signs and symptoms are pain, difficulty walking, and swelling along the medial malleolus and the arch of the foot. These signs and symptoms may occur gradually or suddenly as a result of trauma, and they may be difficult to attribute to a particular cause.
The clinical examination may reveal the anatomic locus of the symptoms, but the findings are often not precise in distinguishing other causes of similar symptoms, such as plantar fasciitis, tendinosis, and subtalar and talonavicular synovitis. These problems require different treatments; therefore, imaging studies play an important part in the diagnosis of posterior tibial tendon disorders. In addition, imaging studies are most useful to determine whether the abnormality is limited to the peritendinous area or the tendon itself.
See also Classification and stages in Pathophysiology.
Preferred Examination
Different imaging techniques can be used to assess tendon and tendon sheath abnormalities.14,20,21,22,23
Tendon abnormalities can be evaluated with tenography. This is accomplished with a needle puncture of the tendon sheath.24,25
Sonography is becoming an increasingly important imaging modality for evaluating musculoskeletal disorders because of its availability, noninvasiveness, lack of ionizing radiation, multiplanar and real-time capabilities, and low cost. Higher-resolution transducers and the dynamic real-time capability of sonography make it attractive for evaluating muscles and tendons. Because of its superficial location, the posterior tibial tendon is particularly amenable to evaluation with sonography.
In the delineation of tendon calcification and retinacular avulsions of bone, CT is superior to MRI. However, in analysis of tendon dislocation both CT and MRI are of nearly equal value
With its superior soft-tissue contrast resolution and multiplanar capabilities, MRI is the imaging procedure of choice for evaluating the musculoskeletal system, particularly in detecting tenosynovitis and in assessing partial and complete ruptures of the tendons. Both MRI and sonography can be used to distinguish tendinosis from peritendinosis. This distinction is important because a more rigorous treatment is needed if the tendon is involved, because it might lead to partial and complete tear.
Imaging also provides insight into the pathophysiology of the disease process. Tendinosis and peritendinosis are often seen together (45% of cases); this observation is readily explained by a common causal mechanism of injury to the 2 sites. The finding of peritendinosis by itself, without tendinosis, is more common (20% of cases) than tendinosis alone without peritendinosis (7%), possibly because the tendon is stronger than the peritendinous tissue and therefore more resistant to injury.
Limitations of Techniques
Plain radiography and bone scintigraphy lack sensitivity.
An inherent drawback of both MRI and sonographic modalities is an inability to further categorize tendon abnormalities. Inhomogeneity of the tendon on MRI could be due to tendinitis, partial tears, degeneration, or other tendinopathies. All these entities fall into a spectrum of pathologic disorders, and determining when one ends and the second begins is difficult. One can speculate that inhomogeneity alone without enhancement is indicative of partial tear or chronic tendinopathy, but those disorders cannot be diagnosed on MRIs, and sonography does not help in resolving this problem.
CT is valuable only when an associated bony abnormality is present; however, tendinous or peritendinous abnormalities are least confidently detected by using imaging.
Enhancement of the tendon and the area around it on MRIs and increased flow on color-flow Doppler sonograms are the most useful features for diagnosing tendinosis and peritendinosis. Other useful, but less specific and less sensitive, criteria are as follows: for tendinosis, a change in signal intensity of the tendon on MRIs and inhomogeneity of the tendon on sonograms; for peritendinosis, increased soft tissue and fluid in the area around the tendon.
In the diagnosis of tendinosis, use of the combined criteria of flow and inhomogeneity of the tendon yields the best positive predictive value (90%) and the best negative predictive value (83%) for sonography, as compared with MRI. The addition of the abnormal size of the tendon as a criterion does not improve the sensitivity, specificity, or predictive values in the diagnosis of tendinosis.
Similarly, in the diagnosis of peritendinosis, the combined criteria of flow and increased soft tissue in the area around the tendon yield the best positive predictive value (89%) and the best negative predictive value (75%) for sonography.
Differential Diagnoses
Ankle, Flexor Hallucis Longus Tendon
Injuries
Pes Planus
Plantar Fasciitis
Other Problems to Be Considered
Flat foot (pes planus)
Plantar fasciitis, tendinosis
Subtalar synovitis
Talonavicular synovitis
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References
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Further Reading
Keywords
tibialis posterior tendon Injury, tibialis posterior tendon dysfunction, ankle injury, tendinitis, tendonitis, tendonosis
