Posterior Tibial Tendon Rupture
October 2003, a 72 year old female presented with a complaint of callus, thickened nails, with a possible fungal infection and painful ankles.
Overweight, 73 year old female.
Biomechanical examination revealed both feet to have extreme hypermobility at all joints including the subtalar. At relaxed calcaneal stance, both feet were everted with midtarsal joint (MTJ) hypertrophy and deformity. A positive Helbing’s sign was noted with medially rotating halluxes. There was a forefoot varus of greater than 20ºin both feet, plus right hallux abducto-valgus and bunion.
ROM at the MTJ was limited, but was normal at the knee and hip joints.
Gait was unsteady and antalgic. The patient stumbled and was unable to place her feet comfortably on the ground, thus adopting a Trendelenberg type gait.
The plantar callus patterns at the right 1st mpj, and hypertrophic big toe nails reflected the foot function. It was difficult to diagnose fungal infection on observation only.
Osteo-arthritic changes were suspected due to the patient’s age.
Footwear: moccasin type or Nike trainers
Management: Temporary orthotics produced an immediate improvement in foot alignment. It was decide to take neutral impressions casts and make a pair of prescription orthotics.
In November 2003 the orthotics were fitted successfully. Footwear was advised and discussed. A follow up appointment in two weeks was booked.
The patient failed to keep this appointment.
On 30 January 2009, the patient presented again. The complaint was that “the left foot is giving me hell. It has been going on for the past year. I have sought professional advice but nothing helps.”
Current medication: Celebrex, Arthro-Choice, Omega3 &6, Stilnox.
Patient was unable to stand for more than a few seconds.
The left foot was medially rotated to a full pes planus. The navicular was prominent medially and palpation of the medial aspect of the subtalar joint was painful. Palpation along a course from the navicular, posteriorly to the medial malleolus and proximally following the course of the posterior tibial muscle tendon was extremely painful.
Provisional diagnosis: posterior tibial tendon tear or rupture
Immediate referral for High Definition Smallparts Ultrasound Examination and X-ray.
Diagnosis: [Extract from ultrasound report]
There is a complete rupture of the posterior tibial tendon and the distal stump could be identified approximately 14 mm from the malleolus. The navicular is irregular consistent with repetitive micro trauma.
The proximal stump was identified approximately 20 mm proximal to the malleolus.
Dynamic studies during inversion and eversion of the foot demonstrated some movement of the distal stump, but no movement of the proximal stump.The appearance of the complete rupture is chronic in nature and the quality of the tendon appears poor.
The deltoid ligament is hypertrophic but intact.
The anterior tibial tendon demonstrates moderate inflammation and tenosynovitis, almost certainly secondary to overload as a result of the posterior tendon rupture………
Generalised osteoarthrosis of the talar joints is noted.
X-rays not yet seen
Referral to an orthopaedic foot surgeon for possible repair.
No treatment to date, due to the fact that the patient developed an urgent ophthalmic problem which requires resolution before foot surgery.
March 28 2009