Posterior Tibial Tendon Insufficiency (PTTI)

Topic updated on 08/04/16 9:12pm
  • 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
      • hypertension
      • diabetes
      • increased age
      • corticosteroid use
      • seronegative inflammatory disorders
  • Mechanism
    • exact etiology is unknown
      • acute injury (e.g., ankle fractures caused by pronation and external rotation) vs. long-standing tendon degeneration
  • Pathoanatomy
    • early disease
      • early tenosynovitis progresses to PTTI 
        • leads to loss of medial longitudinal arch dynamic stabilization  
    • late disease  
      • PTTI contributes to attritional failure of static hindfoot stabilizers and collapse of the medial longitudinal arch
        • spring ligament complex (e.g., superomedial calcaneonavicular ligament) 
        • plantar fascia
        • plantar ligaments
      • fixed degenerative joint changes occur at late stages
    • foot deformity
      • pes planus
      • hindfoot valgus
      • forefoot varus
      • forefoot abduction
  • Associated conditions
    • inflammatory arthropathy 
      • young males with mild pes planus may have one of the following conditions
    • tarsal coalition
      • young person with rigid pes planus and/or recurrent ankle sprains
  • Muscle
    • tibialis posterior 
      • originates from posterior fibula, tibia, and interosseous membrane
      • innervated by 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 

Physical exam
Stage I • Tenosynovitis
• No deformity
• (+) single-heel 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)
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 
  • 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
      • forefoot varus
        • place flexible heel in neutral position
        • observe the relationship of metatarsal heads
          • flexible = MT heads perpendicular to long axis of tibia and calcaneus
          • fixed = lateral border of foot is more plantar flexed than medial border
      •  tenderness just posterior to tip of medial malleolus
        • often associated with an equinus contracture q
    • range of motion
      • single-limb heel rise
        • unable to perform in stages II, III, and IV
      • PTT power
        • foot positioned in plantar and full inversion
        • unable to maintain foot position when examiner applies eversion force 
      • 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)
  • 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
  • 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
  • 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 q
          • 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 q q
          • 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, +/- lateral column lengthening, +/- PTT debridement q q q
      • indications
        • stage II disease
      • contraindications
        • hypermobility
        • neuromuscular conditions
        • severe subtalar arthritis
        • obesity (relative)
        • age >60-70 (relative)
    • first TMT joint arthrodesis, calcaneal osteotomy, TAL, +/- lateral column lengthening, +/- PTT debridement q
      • indications
        • stage II disease with 1st TMT hypermobility, instability or arthritis 
    • triple arthrodesis and TAL   
      • indications
        • stage III disease 
        • stage II disease with severe subtalar arthritis
        • Isolated subtalar arthrodesis can be considered 
    • 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
      • Stage II disease
    • relative contraindications
      • rigidity of subtalar joint (<15 degrees of motion)
      • fixed forefoot varus deformity (>10-12 degrees)
    • technique
      • find FDL and FHL at knot of Henry
      • 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 q
  • Calcaneal osteotomy 
    • indicated to correct hindfoot valgus q
    • techniques include
      • medial displacement calcaneal osteotomy (MDCO) post
        • used in stage IIA (insignificant forefoot abduction)
      • Evans lateral column lengthening osteotomy post
        • 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 q 
        • 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 (23 Questions)

(OBQ13.68) A 58-year-old female with a history of acquired flatfoot deformity is taken to the operating room for surgical intervention. Representative radiographs are shown in Figures A and B. The position of the forefoot after the subtalar joint is aligned is shown in Figure C. What maneuver is indicated to prevent the development of weight-bearing based lateral border foot pain in this patient? Topic Review Topic
FIGURES: A   B   C      

1. Dorsiflexion osteotomy of the medial cuneiform
2. Isolated talonavicular fusion
3. No further maneuvers are indicated
4. Derotation of the forefoot through the transverse tarsal joints
5. Derotation of the forefoot through the calcaneocuboid alone

(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   B   C      

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

(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

(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

(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

(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, lateral column lengthening, 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

(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   B        

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

(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

(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

(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   B        

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

(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 arthrodesis 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

(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

(OBQ05.33) A 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 fasciitis
2. Equinus contracture
3. Claw toes
4. Hallux varus
5. Hallux valgus

(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

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