Tibialis Posterior Insufficiency 1

Tibialis Posterior Insufficiency

References
Tibialis Posterior Insufficiency. JAAOS 1999
Essentials Foot & Ankle
Miller’s 4th ed
Campbell’s Ortho

Summary
- clinic hx, women, 50-60, hx of aquired flatfoot (started, pain, trauma, RA, DM, other), ache in PM aspect of ankle,
late will have lateral calc/fib impingement pain, obese, cipro, fxn inquiry
- exam: general laxity, gait, hindfoot valgus, swelling medially, unable to do arch correction, tender along PM TP
tendon, ROM, rigid, supple, Achilles contracture, Silverskiold test, isolate TP in PF and invert for power, then one
and two foot stances, too many toes sign
- xray: foot & ankle, WB, TN subluxation, TC angle changes (>40), talus more PF position, meary + in DF
direction, DJD, lateral impingement signs, MRI if early stage 1, stages (1 – swelling and inflammation & TP
tendonosis, no deformity, 2 – correctable deformity, 3 – rigid, 4 – ankle DJD)
- dx/summary: TP insufficiency +/- correctable/rigid +/- Achilles tightness, r/o RA, DM, charcot, #
- plan: start non op, then go to operative
- goals: pain relief, plantagrade foot, no return to sports/running, pain free walking goal, avoid comp
- nonop: try it 1st, nsaids, PT ROM and heel cord tightness, BKC x 6 wks to let tendon calm down, then UCBL x 6
wks, if still s/s, can try again, then OR
- op: 1 – debride, synovectomy, TAL (second sitting if tight), FDL transfer, 2 – that plus calc osteotomy, 3- triple, 4
– pantalar
- preop, labs, xmatch, consults, consent (NV, infection, medical, non union, pain, recurrence, no return to running or
sports, DJD adjacent joints), equipment (fluoro, 4.5 cann screws, rongeur, burr, osteotomes, Richard staples for
triple as well as small frag set)
- tech: synovectomy, FDL transfer, TAL (incision over TP proximal to MM toward navicular curving at MM, open
sheath, expose tendon, debride degenerative, repair rents, close sheath, distomedially, Abd Hall open, expose Knot
of Henry, careful NV bundle, expose FDL and FHL, cut FDL distally, drill navicular hole , run dorsal to proximal,
suture to TP and self at ½ neutral to inversion, irrigate, close, NWB 6 wk, CAM 6 wk, gentle ROM, PT), 2 – same
plus calc sliding osteotomy (lateral sub periosteal incision, elevate ST, k wire angle, slight 15 oblique anterior
achilles toward plantar, slide 1cm medial, k wire, check position under fluoro, central, 4.5 mm x 2, TAL,
exostectomy of lateral prominence, NWB x 10 wk cast, CAM WBAT, ROM, PT), 3 – triple plus TAL (do TAL if
need to get foot plantar-grade, see RA foot), 4 – pan talar fusion (transfibular, lateral incision extended proximally,
resect fibular 2-3 cm from ankle joint, denude, 7.0 compression, ICBG and fibular grafting, neutral flexion, 10 ER, 5
valgus, separate TN incision, Richards staple here, check position under fluoro, check pink foot)
- POP: NV, CS, wound, NWB (to fusion healed), xray, no running, just pain free walking (that’s goal)
- comp: recur and progress (triple, fusions), nonunion (r/o infection, revise ICBG and fuse)

1. History
a. Age/Sex
i. women
ii. 50 – 60 years old
b. CC
c. O nset
i. Lifelong, history of flat foot (how long has it been there?)
ii. Progressive ache and swelling along medial foot and ankle
iii. Acute traumatic (distant sprain – 50%) or gradual insidious onset
d. P osition
i. Early
1. medial foot and ankle
a. typically 2-3 cm proximal to insertion of tendon
ii. Late
1. Can have lateral pain late during course of disease
a. calcaneal-fibular impingement
iii. Multiple jts?
e. Q uality/Quantity
f. R adiation
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i. Pain may radiate into arch of foot

g. S ymptoms associated
i. Neurologic
ii. Mechanical
iii. Constitutional
iv. Local
1. swelling along tendon
h. T iming
i. Timing of onset (early 3months -1yr)
i. AA
i. Aggravated with activity, position?
j. PSHX, PMHX, Meds, Allergies
i. DM, RA, seronegative arthritis, HTN, obesity, steroids, cipro
ii. Trauma hx (lisfranc)
k. Family Hx, Social Hx (EtOH, tobacco)
l. Occupation, Sports
m. ADLs
i. Decreased endurance
ii. Activity limitation
n. ROS

2. Physical Exam
a. General
i. r/o generalized joint problems – RA, seronegative arthritis
ii. examine bilateral legs/feet and upper extremity
iii. r/o obesity
b. Look
i. Gait – normal varus push at step off stance
ii. S welling
1. Medial ankle swelling
iii. E rythema
iv. A trophy
v. D eformity
1. Collapse of arch, hindfoot valgus, ankle valgus, midfoot abduction on the
hindfoot
2. Plantar arch flattening with wt bearing and non wt bearing
vi. S kin changes
c. Feel
i. tender posteromedially and swelling over tib post course
ii. ?gap palpable
d. Move
i. Are the joints rigid or supple?
1. Ankle
2. Subtalar
3. TMT – stable? Unstable?
ii. Ensure tendon not subluxating
iii. Assess Achilles/plantar flexion contracture (hindfoot should be corrected in varus)
iv. Test for gastroc contracture (silverskiold test with knee in flexion and ext)
e. NV Exam
i. test tibialis posterior
1. forefoot abducted, hindfoot everted and toe flexors relaxed,
2. ankle plantarflexed to isolate tibialis posterior
3. ask pt to invert foot and test inversion strength
ii. test peroneus brevis, FHL, FDL
iii. complete neuro
iv. complete vascular
f. Special Tests
i. double heel rise – heel should invert (varus)
Tibialis Posterior Insufficiency 3

ii. single heel rise – unable to perform in stage 2,3

1. most sensitive test for diagnosis
2. hindfoot should invert with single heel rise
iii. too many toes sign –
1. view from back standing (midfoot abduction)
2. if can see 5th and entire 4th toe = abnormal midfoot abduction

3. Imaging
a. Weight bearing AP and lateral, oblique, Harris of foot, ankle views
i. AP
1. Apparent shortening of hindfoot
2. Medial ligamentous ossicle
a. Late stage
b. Failure of deltoid
3. Uncovering of talonavicular joint
a. Navicular shifts lateral on AP
ii. Lateral
1. Check talonavicular, naviculocuneiform, cuneiform-first meta sag
2. Abnormal plantarflexion of talus
a. Talus 1st meta angle should be 0 (Meary’s angle)
i. <15 mild
ii. 15-30 moderate
iii. >30 severe
3. Medial cuneiform distance to the floor
a. N = 15-20 mm
b. Standing bilateral ankle x-rays AP & lateral
i. Degenerative changes of hindfoot
ii. Talar tilt
iii. Impingement of talus on lateral malleolus
c. MRI
i. Rarely helps since diagnosis is mostly clinical one
ii. May help for early case (Stage 1 TP evaluation)
d. Classification
i. Stage 1
1. Swelling and inflammation (elongation or tear) of tendon
2. No foot deformity
ii. Stage 2
1. Dynamic deformity
a. Elongated tendon with mobile valgus position
b. Hindfoot valgus
c. Collapsed arch
2. Too many toes sign
3. Tibialis post weakness
a. Inability to do single leg heel rise
4. Stage 2 A:
a. Normal forefoot
5. Stage 2B:
a. Forefoot abduction ("too many toes", >40% talonavicular uncoverage)
iii. Stage 3
1. Elongated or ruptured tendon with fixed valgus hindfoot position
2. Irreducible talonavicular joint
3. Fixed forefoot supination deformity to compensate
4. Subtalar arthritis
iv. Stage 4
1. Fixed valgus hindfoot and ankle
2. Incompetent deltoid ligament
3. Ankle arthritis
4. Subtalar arthritis
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5. • Talar tilt in ankle mortise

4. Diagnosis or DDx
a. Tibialis post insufficiency is typically a clinical diagnosis
b. Must differentiate from deltoid insufficiency:
i. With deltoid problem they have no trouble getting up on their toes and their heel does
go into varus.
ii. With tib post problem, the hindfoot stays in valgus on toe standing, or they are unable
to stand on their toes.
iii. For usual ankle ligamentous instability  anterior drawer improves if the hindfoot is
placed in internal rotation. However, with deltoid insufficiency, the anterior drawer
worsens with internal rotation.
c. DDx
i. RA
ii. Charcot (DM, other neuropathy)
iii. OA of TMT Joint
iv. Lisfranc #
v. Normal flatfoot variant, arch recreated with PF

5. Acute Rx and work-up

a. None

6. Treatment plan
a. Non-operative Rx
i. Initial management regardless of stage of presentation
ii. Goal
1. Prevent further disability and progression
iii. Technique
1. NSAIDS
2. Rest
3. Physio with anti-inflammatory modalities
4. Short leg walking cast x 6weeks and f/u cast off and insole UCBL orthotic x 6
weeks
a. UCBL orthotic: custom-molded orthosis used to
realign flexible flat foot; it encompasses the heel
and hindfoot, providing very effective longitudinal
arch support.
b. Arizone brace (lace up)
5. If still symptomatic after 3 months conservative tx then consider OR
6. For severe case which is not op candidate
a. Treat with AFO
7. Operative Rx
a. Don’t forget to perform a gastrocs recession
b. Stage 1
i. Tibialis posterior
1. Intact
a. Debridement (synovectomy)
2. Torn
a. FDL tendon transfer and tenodesis to tibialis posterior tendon at level
of ankle.
ii. ? TAL
c. Stage 2
i. Young pt
1. FDL transfer to navicular tuberosity
a. Do rather than FHL because more in line with Tib Post and FHL tends
to stretch more easily because it is more muscular (Volesky)
Tibialis Posterior Insufficiency 5

2. Medial Calcaneal Sliding Osteotomy

a. Do even if flexible because FDL will stretch
i. FDL much smaller than Tib Post
ii. Always add bony procedure when performing ST transfer
3. Possible Evans lateral column lengthening
a. Osteotomy of the anterior calc + tricortical graft
b. Do if still not corrected adequately (risk of overcorrection)
c. More ABD correction of forefoot (MCQs)
4. Possible TAL or gastrocs recession
5. Goal
a. buy time before triple
ii. Older pt
1. Triple arthrodesis + TAL
d. Stage 3
1. Subtalar arthrodesis
a. If heel cord contraction do lengthening
b. If fixed forefoot supination deformity persists do talonavicular
arthrodesis (double arthrodesis)
2. Triple arthrodesis
a. Usually gold standard
3. TAL
e. Stage 4
1. Pan talar arthrodesis
f. Consent
i. Outcome
ii. Risks
1. Immediate
a. NV injury (medial plantar nerve, sural nerve)
b. infection, hemorrhage, DVT, fracture
2. Delayed
a. over/under correction
b. osteotomy non-union
c. recurrence/progression
d. degeneration of joints surrounding arthrodesis
e. progressive deltoid failure with ankle OA
f. overtensioned FDL transfer with cavus
g. Pre-op
i. labs (x-match), tests (ECK, CXR), old OR reports, consults
h. Post the case
i. Synovectomy vs FDL transfer vs Arthrodesis
1. Fluoro with radiolucent table
2. Supine with bump under contralateral hip
3. Tourniquet
4. Drill for tendon transfer
5. Fiberwire sutures
6. Cast cart
7. Arthrodesis
a. 7.0 mm screws cannulated and richards staples
b. Osteotomes
c. Oscillating saw
d. Rongeurs, curettes, dental mirror, high speed burr
e. Laminar spreader

8. Technique

a. Stage 1 – open synovectomy +/- FDL tendon transfer +/- percutaneous TAL
Tibialis Posterior Insufficiency 6

i. If doing tendon transfer, always combine with bony procedure. This is reserved for
stage 2 and not stage 1
ii. Contraindications
1. rigid deformity
2. advanced age
3. obesity
4. hypermobile foot
iii. Open synovectomy
1. medial incision directly over tib post tendon made from proximal to medial
maleolus to navicular
2. Tendon exposed and evaluated
3. Open sheath from 7cm proximal to medial malleolus to past mm just leaving
2.5cm pulley (flexor retinaculum) behind mm
4. excise tendon degeneration
5. repair longitudinal rents
6. close tib post sheath loosely
iv. FDL - tib post transfer (If stage 1 and Tib Post torn) – this would be stage 2
1. Incision
a. 3 cm prox to mm to metatarsalcuneiform joint
2. Identify FDL just inferior to the Tib Post tendon
a. medial aspect of talonavicular joint and follow FDL distally
3. Reflect abductor hallucis plantar
a. Expose master knot – connection between FHL and FDL
i. N.B. flexor hallucis longus crosses dorsal to the flexor
digitorum longus at Knot of Henry
4. Suture FDL to FHL?
a. Pull on FHL tendon
i. If all toes flex then do not need to suture stump of FDL to
FHL since it is already connected
ii. If only the big toe flexes then suture FHL to stump of FDL
5. release FDL at level of TMT joint
a. at knot of henry
6. Drill hole in navicular from dorsal to plantar
7. Pass FDL from plantar to dorsal through navicular hole
8. Suture tendon to itself and to tib post tendon with foot ½ way between neutral
and inverted.
9. Check if foot can be brought to neutral without excessive tension on the transfer
10. Can augment with tib post if tendon ok
v. +/- repair spring ligament – not in stage 1 (not proven yet but can be added to stage 2
along with deltoid repair)
vi. Physio
1. NWB cast x 4-6 weeks
2. at 6 weeks WBAT in CAM walker x 6 weeks
3. at 3 months progress to WBAT with orthotic UCBL
4. during first 4 months gentle inversion strengthening
5. aggressive strengthening and ROM after 4 months
6. most have persistent inversion weakness and don’t return to competitive sports

b. Stage 2
i. Tib post debridement and synovectomy, FDL transfer, Sliding Calc Osteotomy, Evan’s
calc osteotomy, TAL
ii. Calcaneal sliding osteotomy –(Lateral skin incision)
1. Indicated in flexible feet in order to take tension off of the FDL transfer and
improve pull of achilles
2. Done for flat arch
3. Oblique incision just posterior to sural nerve over posterior calcaneus
4. Calcaneus exposed subperiosteally
Tibialis Posterior Insufficiency 7

5. K-wires placed into calc and checked under fluoro to obtain correct level of
osteotomy
6. Osteotomy made with 10 – 15 degrees of obliquity oriented distal-plantar
7. Complete osteotomy medially
8. Translate osteotomy medially 1cm and fix temporarily with Kwire
9. Assess foot
a. goal is to place calcaneus out of valgus and under center of ankle joint
10. Osteotomy fixed with 2x 4.5mm cannulated screws
11. Lateral prominence of calc is beveled to avoid soft tissue irritation
iii. +/- percutaneous TAL
iv. Equinus inverted short leg cast
v. Evan’s calc osteotomy Longitudinal
1. incision just anterior to peroneal tendons
2. Retract and protect sural nerve plantar
3. Subperiosteal exposure of calcaneus
4. Osteotomy made 1.5 cm proximal to level of calc-cuboid joint, made
perpendicular to plantar aspect of foot, and marked initially with Kwires –
checked under fluoro
5. Medial side of osteotomy is made carefully
6. Laminar spreader is used to open lateral aspect of osteotomy to the desired
amount vs. small plate
7. Avoid over or under correction
8. Insert ICBG into lateral opening and fix with 2x 4.5mm cannulated screws
vi. Debridement of Tib post as above
vii. Transfer of FDL as above
viii. Percutaneous TAL if needed
ix. Physio
1. NWB x 8 – 10 weeks in cast
2. WBAT in CAM walker after cast off and start ROM
3. Goal is to return to comfortable walking
4. No return to running expected
5. Adequate correction of alignment expected with some stiffness

c. Stage 3
i. triple
– arthrodesis talonavicular, double, triple

1. Talonavicular joint arthrodesis

a. Do first because stabilizes other joints significantly
b. medial approach to TN joint
i. medial incision from tip of medial mal to talonavicular joint
ii. Interval is tib ant & tib post
iii. TN joint is debrided and articular cartilage and subchondral
bone removed
2. CC and ST joint arthrodesis
a. lateral approach to subtalar and cc joints
i. Incision tip of lat mal to base of 4th meta longitudinally above
peroneals
ii. Interval – EDL, peroneus t & peroneals
iii. between sural and intermediate branch of superficial peroneal
nerve
iv. reflect extensor digitorum brevis distally
v. remove fat from sinus tarsi
vi. laminar spreader in subtalar joint
vii. ST joint is debrided, articular cartilage and subchondral bone
decorticated
Tibialis Posterior Insufficiency 8

viii. CC joint is debrided, articular cartilage and subchondral bone

removed
3. Position foot in plantigrade – want 5 degrees of hindfoot valgus, and neutral
1st ray and forefoot
a. first ray not elevated, calc underneath tibia, navicular well centered on
talar head
b. TN joint fixed first with 2 compression staples (most common site of
non-union s/p triple) or screws
c. ST joint then fixed with 1 - 7.0mm cannulated screw inserted from
calc plantar into talus
d. Position of foot is assessed intra-op, and if further correction of
hindfoot valgus is needed can perform medial slide calc osteotomy (see
stage 1)
i. Remember to remove ST screw
ii. do osteotomy
iii. then can fix both ST arthrodesis and calc osteotomy with
cannulated 7.0mm screw, consider x 2
e. CC joint fixed last with 1 or 2 compression staples
4. Physio
a. NWB cast x 8 weeks
b. If X-Rays show callus can start WB and gradually progress over next 4
weeks in WB BK cast
c. Cast off at 12 weeks and CAM walker x 4 weeks
d. Then CAM off and WBAT
e. Goals is comfortable walking.
f. No running or competitive sports
d. Stage 4
i. Pantalar fusion
ii. Do triple arthrodesis as described for Stage 3
iii. Ankle fusion done through lateral transfibular approach
1. Incision made 10 cm proximal to tip of fibula joining CC, ST joint fusion
incision
2. Sural nerve posterior, superficial peroneal nerve anterior
3. Periosteal strip fibula anterior and posterior
4. Carry dissection in subperiosteal fashion across anterior tibia
5. Strip soft tissues subperiosteally across anterior tibia, anterior ankle, talar neck,
to medial maleolus
6. Osteotomize fibula 2 cm proximal to ankle joint and bevel it to not leave a sharp
point
7. Remove distal aspect of fibula
8. Expose posterior tibia under removed fibula subperiosteally
9. Make initial cut in distal tibia perpendicular to long axis of tibia removing
articular cartilage and subchondral bone (with oscillating saw)
10. Stop cut just before medial maleolus, and free medial aspect of osteotomy with
broad osteotome.
11. Want to remove bone fragment without removing medial malleolus.
12. If bone porotic and medial mal breaks
a. need to remove through the medial incision made for the TN joint
arthrodesis
13. Place foot into correct position (5 degrees valgus, 0 – 10 degrees plantar
flexion)
14. Cut 3 – 4 mm of talar dome with oscillating saw parallel to tibial cut
15. Approximate bone surfaces and check alignment, correct with change of angle
of tibial cut
16. Hold osteotomy together with K-wires
17. Drill, tap, and insert 2 x 6.5mm cancellous screws taking care to cross
arthrodesis site with threads and get cortical bite on tibia
Tibialis Posterior Insufficiency 9

18. Screws inserted from talus (sinus tarsi area, lateral talar process) proximally
across ankle arthrodesis and out postero-medial tibia
19. Bone graft
20. Close in layers
iv. Fuse ankle in 5 – 10 degrees of equinus
v. Physio
1. NWB in BK cast until X-Rays show signs of healing (usually 8 – 12 weeks)
2. Cast off and CAM walker x 4 weeks
3. Then WBAT in regular shoes

9. Post-op
a. NV exam
b. compartment check
c. X-ray if osteotomy or arthodesis

10. Disposition and Follow-up

a. D/C home when stable, N/V ok, compartments ok

11. Complications
a. recurrence and progression
i. final step is triple
b. arthrodesis non-union
i. r/o infection
ii. revise & bone graft
Tibialis Posterior Insufficiency 10
Tibialis Posterior Insufficiency 11

Previous OSCEs

2013 Case: Sheet- 52 yo female with progressive foot pain and collapse of arch.
Forget the details re: questions, but essentially you’re shown various xr confirming Grade IIB flatfoot (e.g. Talus
more than 30% uncovered). Shown picture with slight plano valgus deformity.

On exam, pt unable to do single heel raise. Said I would also do Silverskiold test. Asked how to do this and what it
means. Also on exam of foot, told that ankle and subtalar motion OK and void of pain. Also told that deformity
was flexible.

OK, what to do? I said initially can try conservative tx- e.g. medial post orthotic like UCBL or Arizona brace.

OK pt tries it and doesn’t do much. What you want to do?

I say FDL to Tib Post, 1st MT dorsal closing osteotomy, and medial slide calc osteotomy.

This next part is a bit hazy- essentially pt. is lost to follow up or sees someone else and undergoes triple arthrodesis.
Pt has pain. I think examiner asked give some reasons for this pain.