Tibialis Posterior Tendon

Dysfunction
WRITTEN BY WILL RAFFLE-PAUL WILSON-GRACE BYRNES....
PRESENTING COMPLAINT

Courtney presented to the clinic with left medial ankle pain that has been ongoing for six months. It appears this pain has
amplified since overloading her tennis training in preparation for University Games, with the pain rated at worst a 7 to 8 out of 10
on a visual analogue pain scale. With Courtney’s history of plantar fasciitis, a high FPI and taking into consideration that she has
asymmetrical feet; a custom made orthotic will be issued so as Courtney can participate when the season starts again in 6 weeks.
Before an orthotic is made a thorough biomechanical assessment needs to be done.

PRONE EXAMINATION

Courtney has approximately 20 degrees inversion to 10 degrees eversion at the subtalar joint on both feet. Her left forefoot was
abducted relative to the rearfoot whereas her right was perpendicular. Courtney had an ankle equines in both feet failing to
achieve the required 10 degrees dorsiflexion.

SUPINE EXAMINATION

Courtney experienced a decreased ROM of the midtarsal joint on her left foot and reported both the longitudinal and
obtuse tests produced pain. Her ROM at the first ray and first MPJ was adequate. During a basic muscle testing proce-
dure Courtney had good strength on both feet for dorsiflexion and eversion. On her left foot she only had fair strength
for plantarflexion and poor strength for inversion. Given this the tibialis posterior muscle was isolated and tested. Court-
ney was asked to bring her foot into an inverted and plantar flexed position from an everted and dorsiflexed position
against resistance. The tendon was notably weak and pain was produced. Courtney could only complete four heel raises
on her left foot before fatiguing yet completed the 10 asked of her on her right.

WEIGHTBEARING EXAMINATION

Right foot RCSP= 2 degrees everted NCSP= 1degree inverted

Left foot RCSP= 6 degrees everted NCSP= 3 degrees everted

The FPI-6 results of +9 left foot and +4 right foot can simply be used as confirmation of other findings suggesting that
Courtney has a Pronated left foot.
A supination resistance test was very difficult on the left foot. BMI was 25

DYNAMIC GAIT ANALYSIS

The notable findings from the gait analysis were a minor pelvic tilt with a drop to the left side and the presence of an
abductory twist on the left side. The left rearfoot remained relatively neutral throughout gait indicating a lack of resu-
pination. On the left side due to a pronated position the midtarsal joint remained unlocked and the foot was not a rigid
structure. Supination was delayed contributing to the abductory twist.

ADDITIONAL NOTES
Overuse
In order for Courtney to avoid her medial ankle pain from reoccurring she needs to ensure she doesn’t overload
her training. This can be done by leaving adequate rest time in between each session, increasing her training load
and volume gradually and continuing with preventative measures such as ice and massage.

oRTHOTIC MANAGEMENT
The tibialis posterior tendon is the primary dynamic
stabiliser of the medial longitudinal arch, and when
it contracts inversion and plantar flexion of the foot
results. This causes the medial longitudinal arch to
rise which locks the mid-tarsal bones, making the
midfoot and rearfoot rigid. This allows gastrocne-
mius to act with greater efficiency during gait. Court-
ney’s tibialis posterior muscle is experiencing ten-
donopathy or a grade I dysfunction. This has caused
a degree of “flat foot” in her left foot and influenced
her gait. The big giveaways are the unilateral difficult
supination resistance test and her lack of re supina-
tion on the left side upon gait analysis.
In the Courtney’s case the STJ Axis is also medially
deviated, resulting in a short moment arm for the
posterior tibial muscle (close to the STJ axis) thus
creating a mechanical disadvantage, requiring the
posterior tibial muscle to exert a much greater force
to supinate the STJ (compared with a central or later-
ally deviated STJ axis). The pronatory force in a medi-
ally deviated STJ axis is also greater, so the post tibial
muscle has to work harder to also overcome this
force and to produce adequate supination moment.
The ideal orthotic modality should help to overcome
the posterior tibial dysfunction over a period of time
with the use of an orthotic that address’s the pa-
tient’s main problems.
In this Courtney case the prescribed orthotic may consist of:
Devise: Full Length Custom Mod root device
Shell material: 3mm polypropylene shell
Top cover: poron and cambrelle top cover
Modifications: 3-6 degrees of inversion balance position
3-6 mm medial heel skive
Rear foot post
12-18mm heel cup height
Minimal medial arch fill
A custom devise is recommended as the use of a
generic devise would not be able to be tailored ade-
quately to the patient’s symptoms. And the use of
generic devise may not be suitable as the patient’s can
encounter problems if they have asymmetrical feet,
which is the case for Courtenay.
The main purpose of these modification is that when
the medial arch fill, the inverted balance position of
the orthotic and a medial heel skive are combined the
effect on the patient’s feet should be an increase in
the magnitude of the STJ supinator moment therefore
overtime reducing the discomfort of a posterior tibial
muscle.
The other purposes of the orthotic plate modifica-
tions are the increased polypropylene thickness pre-
vents excessive deformation of the devise as a lower
medial longitudinal arch exerts more pressure and can
deform orthoses at a greater rate than that of a higher
arch height.
The Rearfoot post along with the deep heel cup
height would help to stabilise the rearfoot and increase
the control over the forefoot during gait. The rearfoot