pathology: tibialis posterior syndrome

yogabook / pathologie / tibialis posterior syndrome

Tibialis Posterior Syndrome / Tibialis Posterior Dysfunction / Posterior Tibial Tendon Dysfunction / Tibialis Posterior Tendinosis / PTTD

Definition of

Typically progressive degeneration of the tendon of the tibialis posterior, which is the second strongest muscle of the lower leg. The tendon of the tibialis posterior has a rather unfavorable anatomical position, as it runs directly past the medial malleolus. It begins approx. 6 cm above the medial malleolus. Under conditions that have not yet been sufficiently clarified, painful irritation of the tendon occurs, which initially does not involve any reduction in strength or dysfunction of the tibialis posterior. Later, the tendon elongates or even ruptures. Tibialis posterior syndrome usually leads to reduced support of the longitudinal arch of the foot, which is mainly held in place by the tibialis posterior and, if left untreated, almost always results in flatfoot(pes planovalgus), the most common cause of which is PTTD. Normally, the fibularis tendons on the outside of the ankle remain unaffected in this disorder, which form a restraint system with the tendon of the tibialis posterior, so that this becomes unbalanced and a valgus position of the calcaneus develops in addition to the flat foot. If this situation is not treated over a longer period of time, at least with insoles, the balance of the lower leg muscles also changes, resulting in a contracted position, which is then an indication for surgery. At this stage, a prominent medial malleolus, a hindfoot valgus and, due to the slight abduction of the foot, a too-many-toes sign and a conspicuous single heel rise test can be seen. In the single heel rise test, the valgus position of the hindfoot should straighten when the heel is lifted. If there is no correction or if it is impossible to lift the heel, the tibialis posterior tendon is completely insufficient or has already ruptured. Sometimes the navicular bone also changes in the area of the insertion of the tibialis posterior tendon and grows dorsally, thus accommodating the course of the tendon. The calcaneus not only leans outwards (below) but also leans downwards at the front with the flattening of the longitudinal arch of the foot, which makes the work of the tibialis posterior more difficult and leads to further progression. If tibialis posterior tendovaginitis is present, the pain occurs quickly and the tendon feels thick and swollen. Spontaneous healing rarely occurs. The progression increasingly precludes sporting activities. The talonavicular joint, calcaneocuboid joint and subtalar joint are at increasing risk of arthritis. Women are more frequently affected, W:M 3:1. The initial stage is so unspecific that it is often overlooked. Although the disorder of flatfoot was already sufficiently widespread and well-known 100 years ago and tibialis posterior dysfunction had been recognized as predominantly responsible in cases of acquired flatfoot for decades, it was not until 1983 that this was brought back into focus by Johnson, who then introduced a classification 6 years later together with Strom. According to this, three stages are distinguished:

  1. inflammatory stage
  2. Torn or insufficient (degenerated, overstretched) tendon
  3. Degenerative and fixed hindfoot valgus

Cause

  1. Chronic overuse, repeated microtaumata (fine longitudinal tears)
  2. Chronic tendovaginitis of the tibialis posterior tendon
  3. Chronic tendinitis of the tibialis posterior tendon
  4. Trauma

Predisposing

  1. Overweight
  2. Hypertension
  3. Runners with a flat foottendency

Diagnosis

  1. Muscle strength testing, clinical function tests
  2. Pedobarography (static and kinetic representation of the pressure conditions on the sole of the foot)
  3. Ultrasound (shows inflammation), MRI (shows tendon degeneration: grade 1 only paratendinitis, grade 2 elongated with partial rupture, grade 3 longitudinal or transverse tear), X-ray (shows bone position)
  4. Triggering / intensification of pain when standing on toes
  5. Osteoarthritis signsin grade 3
  6. Tests and signs: too many toes sign from grade 2, single heel rise test

Symptoms

  1. Initially only pain, but no reduction in strength of the tibialis posterior, later tendon weakening and dysfunction
  2. Discomfort or perceived weakness when walking, reduced walking distance
  3. Grade 1: no malalignment, grade 2: manual compensation, later (grade 3) contracted malalignment
  4. Pressure pain in the course of the tibialis posterior tendon at and in front of(distal) the medial malleolus
  5. Sudden flattening of the longitudinal arch of the foot in the event of a tendon rupture
  6. Swelling of the inner ankle
  7. Medially emphasized wear pattern of the shoes
  8. Weakness of the toe position increases with the degree

Complications

  1. Osteoarthritis of distal ankles
  2. Hallux valgus
  3. Hammer toes
  4. Rupture of the tibialis posterior tendon

Therapy

The therapy depends on the stage

  1. Rest until weight-bearing can be carried out without pain, PT, anti-inflammatory drugs/NSAIDs, support of the longitudinal arch of the foot with insoles, cushioning of the heel, strengthening training, stretching training/physiotherapeutic loosening, sturdy shoes (firm sole, high shaft) for longer periods, iontophoresis
  2. Surgery to restore physiological function of the tibialis posterior muscle and tendon insertion, calcaneus osteotomy if necessary
  3. Additional foot deformity surgery: autologous tendon graft, osteotomy with up to 3 arthrodeses

Asana practice

Strengthening the lower leg muscles as a whole is required here. Above all, of course, there is the attempt to bring the posterior tibialis into the best possible functional state, although this is unlikely to be possible with an advanced syndrome: once the foot is contracted and can no longer be reduced, many people say that this is an indication for surgery to prevent further damage to the musculoskeletal system. On the other hand, no stretches in the direction of pronation of the ankle should be practiced, of which there are very few anyway, e.g. malasana. On the contrary, many postures can be practiced with supination of the ankle in order to reduce increased tension in the lateral ankle and lower leg. Standing postures such as parsvakonasana, prasarita padottanasana with a wide distance between the feet are just as suitable for this as the lotus position and its variations, which differ significantly from the above standing postures in that they have a relatively largely plantarflexed foot and the latter do not.

The second important function of the posterior tibialis is to provide muscular support for the longitudinal arch of the foot. Here, good function of the relevant muscles in the lower leg, especially the

  1. Flexor hallucis longus
  2. Flexor digitorum longus

as well as in the foot itself, i.e. the

  1. Abductor hallucis
  2. Flexor hallucis brevis
  3. Flexor digitorum brevis
  4. Quadratus plantae
  5. Abductor digiti minimi pedis

As the posterior tibialis is a supinatingplantar flexor, its synergists should at least be checked for good functionality with regard to both movements in the triceps surae, even if their weakness is not usually part of the pathomechanism.

It is probably more important to bring the rest of the supinator muscles to a good level, even if none of them support the traction of the longitudinal arch of the foot. These are primarily supinator foot lifts such as

  1. Extensor hallucis longus
  2. Tibialis anterior

Asanas

Asanas in 862: Strengthening the supinators of the ankle