Tibialis Posterior Tendinosis and Tibialis Posterior Tenosynovitis

Introduction:

Tough, dense connective tissue fibers which attach the muscles to the bones are called tendons. Tendons help in the movement of structures and transmit the mechanical forces of muscle contraction to the bones, preventing muscle injury. Tendons act as levers to move the bones when the muscles contract and relax. Tendons are mainly made up of collagen, and degeneration of the collagen in the tendon due to overuse is called tendinosis. Inflammation of the tendons is termed tendonitis, and inflammation of the tendon along with inflammation of the tendon sheath is called tenosynovitis.

What Is Tibialis Posterior Tendinosis?

The posterior tibialis tendon connects the posterior tibialis muscle with the bones of the foot and provides stability to the foot on movement. It lies behind the medial malleolus (bony bump on the inner aspect of the ankle) and passes behind and around the inner aspect of the ankle, and helps to maintain the normal arch of the foot. The wear and tear of the posterior tibialis tendon are called tibialis posterior tendinosis.

What Is Tibialis Posterior Tenosynovitis?

The inflammation of the protective covering around the posterior tibialis tendon (tendon sheath) is termed tibialis posterior tenosynovitis. It usually presents as ankle pain posterior to the medial malleolus.

What Are the Causes of Tibialis Posterior Tendinosis and Tibialis Posterior Tenosynovitis?

Some causes of tibialis posterior tendinosis include:

• Obesity can cause additional weight on the tendon, leading to its breakdown.

• Wear and tear of the tendon due to aging.

• The ankle joint or foot injuries may tear the tendon.

Some causes of tibialis posterior tenosynovitis include:

• Inflammatory diseases such as rheumatoid arthritis, gout, etc.

• Overuse or age-related wear and tear may lead to inflammation.

• Autoimmune diseases like spondyloarthropathy (a disease that affects the spine, bones, and nearby joints) may cause tendon inflammation.

What Are the Signs and Symptoms of Tibialis Posterior Tendinosis and Tibialis Posterior Tenosynovitis?

Signs and symptoms of tibialis posterior tendinosis include:

• Pain behind the inner side of the ankle.

• Severe pain, in some cases associated with swelling.

• Difficulty in standing and walking.

• Increased pain on standing on the toes.

• Complete tendon tears may lead to pain in the sole and flattening of the foot (arch collapse).

Signs and symptoms of tibialis posterior tenosynovitis include:

• Sudden pain in the ankle.

• A feeling of thickness or swelling in the ankle region.

How Are Tibialis Posterior Tendinosis and Tibialis Posterior Tenosynovitis Diagnosed?

• Tibialis posterior tendinosis and tibialis posterior tenosynovitis can be diagnosed clinically by the medical history, signs, and symptoms of the condition, followed by a physical examination. Pain and swelling associated with tenderness of the tendon behind the medial malleolus indicate tenosynovitis. Unilateral flattening of the foot with bulging of the medial ankle indicates advanced tendon pathology or suggests tendon rupture.

• Ultrasound may be preferred in some cases, as it is inexpensive and accurate in diagnosing tibialis posterior tenosynovitis.

• Magnetic resonance imaging (MRI scan) may be advised, which helps to determine cases of tendon rupture and the extent of chronic tendon degradation. The collection of fluid around the tendon indicates tibialis posterior tenosynovitis.

How Are Tibialis Posterior Tendinosis and Tibialis Posterior Tenosynovitis Managed?

The management of tibialis posterior tendinosis and tibialis posterior tenosynovitis depends on the severity of the symptoms. Tibialis posterior tenosynovitis can usually be managed by rest and nonsteroidal anti-inflammatory medications (NSAIDs). Nonsurgical methods are preferred in the earlier stages of the condition, which include the following measures:

• Optimization of the load on foot by using adequate footwear and foot orthoses. Depending on the progression of the disease, foot orthoses that are non-individualized (available over the counter), customized, or semirigid ankle-foot orthoses can be used.

• Rest or limitation of physical activities that cause or worsen the pain.

• Application of ice packs and medications to relieve pain, such as Ibuprofen, Naproxen, Acetaminophen, etc.,

• The practice of low-impact exercises like yoga, swimming, cycling, etc.

• Application of ice packs for about 20 minutes three times a day over areas of the foot or the ankle, which helps to relieve the pain.

• Physical therapy, like eccentric exercises characterized by lengthening muscle contraction exercises that are slow and specific, is beneficial.

In severe cases, surgical management may become necessary, which includes:

• Tenosynovectomy: It is the surgical removal of the inflamed tissue followed by debridement to prevent the progression of the disease. An incision is made below the medial malleolar tip, and the posterior tendon is exposed. Small tears in the tendon are treated by debridement, whereas large tears require repair in addition to debridement. Bioengineered products can be used to augment the tendon if it has been subjected to severe debridement. Following tendon repair, below knee fiber cast is recommended for around three to four weeks, followed by an air cast and supportive shoes.

• Wedge Osteotomy: The flexor digitorum longus tendon can be transferred to the posterior tibialis tendon in severe cases. It can be performed alone or with wedge osteotomy (removal of the bone) of the calcaneus and reconstruction of the medial arch of the foot.

• Arthrodesis: In the case of patients with severe and rigid deformities, arthrodesis may be performed. It involves the surgical fusion of the two bones at a joint by removing the remaining cartilage. It restores the normal shape of the foot and removes inflammation. The joints are glued together over time and become one large bone without a joint, eliminating joint pain. Metal screws and plates are used, which hold the bones while they heal. This procedure reduces the pain, but side-to-side motion may not be possible after the surgery.

• Tendon Transfer: In the case of a flexible flat foot and damaged posterior tibial tendon, a tendon transfer procedure may be performed. It involves the removal of the damaged tendon and replacement with another tendon from the foot, which helps the patient in walking and standing, but participation in sports activities may be difficult.

Conclusion:

Tibialis posterior tendinosis occurs due to the wear and tear of the posterior tibial tendon, characterized by pain, swelling, and difficulty in walking and standing. It is usually age-related or occurs due to injury or obesity. It can be managed by conservative treatment or surgeries such as tendon transfer or osteotomy. Tibial posterior tenosynovitis is the inflammation of the tendon sheath characterized by sudden pain in the ankle region. It is caused due to aging or arthritis and can be treated by rest and medications.