Stage I - Posterior Tibial Tendon Dysfunction
Stage I Posterior Tibial Tendon Dysfunction
may be characterized by inflammation and medial arch
pain, with no positional change in the arch (1,2,6).
Tenosynovitis will be apparent on an MRI, as well as
fluid around the tendon appearing on an ultrasound;
however, no degenerative changes will be present on
an X-ray. The objective in Stage I PTTD is to minimize
excessive midfoot movement. Stage I is successfully
treated with non-surgical methods, such as biomechanical
orthotics or heel elevators (2). However, subtalar extra-articular
arthroereisis may be used if non-surgical methods are
Performed Soft Tissue Surgical Procedures
- Tenosynovectomy / Debridement
- A synovectomy of the Posterior Tibial Tendon
sheath is performed to reduce inflammation around
the tendon, a possible cause of dysfunction. Debridement
is performed in combination with the synovectomy
to remove any dead or necrotic tissue in the surrounding
area. Augmentation with TenoGlide® can be
performed to protect the repaired Posterior Tibial
Tendon and provide a gliding surface for the surrounding
- Tendon Transfer
- Tendon transfers can be used to relieve stress
on the Posterior Tibial Tendon. These often include
transfer of the Flexor Digitorum Longus (FDL),
or the Flexor Hallucis Longus (FHL). Because the
Posterior Tibial Tendon has antagonist tendons
that are stronger than the FDL or FHL, a Medializing
Calcaneal Osteotomy is often performed in conjunction
with the transfer. This biomechanically alters
the foot, therefore avoiding long term failure
of the new tendon.
- Gastrocnemius Recession (e.g., Strayer procedure)
- Equinus is a tightening of the complex including
the achilles tendon, gastrocnemius, and soleus
muscles. Gastrocnemius Recession (Open or Endoscopic)
is used to release the tension on this complex,
thereby returning the Posterior Tibial Tendon
to functioning ability.
- Tendo-Achilles Lengthening (TAL)
- A tight achilles tendon can be a cause of a
flatfoot. To relieve pressure on the Posterior
Tibial Tendon, the achilles can be lengthened
percutaneously, or by Z lengthening.
Performed Surgical Procedures
- A subtalar implant is placed within the sinus
tarsi to limit excessive pronation of the subtalar
joint. It is often referred to as an internal
orthotic and is a minimally invasive procedure.
Solutions (Subtalar MBA®
Implant / bioBLOCK® Resorbable Subtalar Implant)
*For product full prescribing information, see package
1. Kelly, Ian P, Mark E. Easly,
TREATMENT OF STAGE 3 ADULT ACQUIRED FLATFOOT Foot and
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2. DiPaola M, Raikin SM, TENDON TRANSFERS AND REALIGNMENT
OSTEOTOMIES FOR TREATMENT OF STAGE II POSTERIOR TIBIAL
TENDON DYSFUNCTION, Foot Ankle Clin. 2007 June; 12(2):
3. Pomeroy GC, Pike RH, Beals TC, Manoli A 2nd., ACQUIRED
FLATFOOT IN ADULTS DUE TO DYSFUNCTION OF THE POSTERIOR
TIBIAL TENDO,N J Bone Joint Surg Am. 1999 Aug; 81(8):1173-82.
4. Mann RA, Thompson FM, RUPTURE OF THE POSTERIOR TIBIAL
TENDON CAUSING FLAT FOOT. SURGICAL TREATMENT, J Bone
Joint Surg Am. 1985 Apr; 67(4): 556-61.
5. Bluman EM, Title CI, Myerson MS, POSTERIOR TIBIAL
TENDON RUPTURE: A REFINED CLASSIFICATION SYSTEM, Foot
Ankle Clin. 2007 June; 12(2):233-49,v.
6. Wacker JT, Hennessy MS, Saxby TS, CALCANEAL OSTEOTOMY
AND TRANSFER OF THE TENDON OF FLEXOR DIGITORUM LONGUS
FOR STAGE II DYSFUNCTION OF TIBIALIS POSTERIOR. THREE
TO FIVE YEAR RESULTS, J Bone Joint Surg Br. 2002 Jan;