Johnson, Clin Orthop Relat Res 1989 - Tibialis Posterior Tendon Dysfunction - Article Summary

Tibialis Posterior Tendon Dysfunction

Johnson, Strom·Clin Orthop Relat Res·1989·905 citations·Review article

Johnson and Strom set out to describe how tibialis posterior tendon dysfunction presents at each stage and to pair each stage with a rational plan of treatment.

Methods

Design: Expert classification system
Basis: Tendon length
Hindfoot alignment and mobility
Pain symptoms
Physical findings
Radiographic changes

Key Points

Each stage of tendon dysfunction carries its own pattern of pain, examination signs and radiographic changes.
Pain usually begins gradually, and patients only infrequently recall an inciting event.
Tenderness is maximal along the tendon, from just before it rounds the medial malleolus to its navicular insertion.
Stage 1 patients can usually still rise onto the ball of the affected foot, though they find it more painful and somewhat weaker than the other side.
The FDL has only about one‑third the cross‑sectional area of the tibialis posterior, yet the authors report that it seems to hold up clinically as a transfer, perhaps through hypertrophy.

Board pearl

Stage 2 and Stage 3 differ by whether the valgus hindfoot is still flexible, and that decides treatment: the authors held that a dynamic tendon transfer against a fixed deformity is not reasonable.

Johnson and Strom stages of TPT dysfunctionJohnson, Clin Orthop Relat Res 1989

Stage	Tendon and hindfoot	Examination and radiographs	Treatment
1	Normal tendon length, normal hindfoot alignment	Mild to moderate medial ankle pain, heel rise possible but painful and weaker	Nonoperative care for 3 to 6 months, then tendon sheath release, synovectomy and debridement
2	Tendon elongated, hindfoot valgus but mobile	Marked single‑heel‑rise weakness, too‑many‑toes sign, arch collapse on radiographs	FDL transfer to the navicular
3	Tendon elongated, valgus fixed and not passively correctable	Pain may move laterally over the sinus tarsi, subtalar, talonavicular and calcaneocuboid degeneration	Realignment and subtalar arthrodesis
4 (probable)	Hindfoot fixed in eversion for years, talus tilted into valgus in the mortise	Lateral tibiotalar degeneration	Possible tibia‑to‑calcaneus arthrodesis

Tendon and hindfoot: Normal tendon length, normal hindfoot alignment
Examination and radiographs: Mild to moderate medial ankle pain, heel rise possible but painful and weaker
Treatment: Nonoperative care for 3 to 6 months, then tendon sheath release, synovectomy and debridement

Tendon and hindfoot: Tendon elongated, hindfoot valgus but mobile
Examination and radiographs: Marked single‑heel‑rise weakness, too‑many‑toes sign, arch collapse on radiographs
Treatment: FDL transfer to the navicular

Tendon and hindfoot: Tendon elongated, valgus fixed and not passively correctable
Examination and radiographs: Pain may move laterally over the sinus tarsi, subtalar, talonavicular and calcaneocuboid degeneration
Treatment: Realignment and subtalar arthrodesis

4 (probable)

Tendon and hindfoot: Hindfoot fixed in eversion for years, talus tilted into valgus in the mortise
Examination and radiographs: Lateral tibiotalar degeneration
Treatment: Possible tibia‑to‑calcaneus arthrodesis

Authors' conclusion

This staging system permits clarification and individualization of dysfunction, expected pathologic changes, and surgical treatment.