Association of Tibialis Posterior Tendon Pathology with Other Radiographic Findings in the Foot: A Case-Control Study

doi:10.1053/j.jfas.2008.08.010

The Journal of Foot and Ankle Surgery

Volume 47, Issue 6, November–December 2008, Pages 546-553

https://doi.org/10.1053/j.jfas.2008.08.010 Get rights and content

The purpose of this study was to analyze the prevalence of spring ligament pathology and other radiographic changes related to flatfoot deformity in the presence of different degrees of tibialis posterior tendon pathology. A total of 72 patients (24 with tibialis posterior tendon abnormality and 48 sex- and age-matched controls) were evaluated for tibialis posterior tendon pathology, spring ligament pathology, and plain pedal radiographic angles, including cuboid abduction, talar declination, calcaneal inclination, and Meary's angles. The patients with tibialis posterior tendon pathology were subdivided into either minor (Type I) or severe (Type II/III), according to the Conti classification of tibialis posterior tendon pathology on MRI. All the continuous data of radiographic angles were dichotomized into either a flatfoot group or normal/cavus foot group. Associations between these nominal variables were analyzed. There was no association between Type I tibialis posterior tendon pathology and spring ligament pathologies (OR = 0.8, 95% CI = 0.15–4.65). Conversely, every patient with Type II/III tibialis posterior tendon pathology had spring ligament abnormality. Type II/III group also showed statistically significant associations with both increased talar declination angle (OR = 10.4, 95% CI = 1.62–109.22) and Meary's angle (OR = 7.5, 95% CI = 1.35–51.12), while no such associations were found with Type I tibialis posterior tendon pathology (OR = 1.0, 95% CI = 0.18–6.18 with talar declination angle; OR = 3.9, 95% CI = 0.65–27.71 with Meary's angle). In this investigation, only advanced tibialis posterior tendon pathology was statistically significantly associated with adult-acquired flatfoot deformity and spring ligament pathology. Level of Clinical Evidence: 3

Section snippets

Patients and Methods

This case-control study was approved by the Institutional Review Board of the University of Texas Health Science Center at San Antonio (protocol number: HSC20070219H). The sample was divided into a case group that consisted of patients with TPTP, and a control group that consisted of patients without tibialis posterior pathology. The patients with TPTP were identified in the San Antonio, Texas, University Hospital System (UHS) computer charting system, by searching the database for patients

Results

A total of 72 patients qualified for inclusion in the study. Of these, 24 subjects had MRI signs indicative of TPTP, and these comprised the case group. Forty-eight age- and sex-matched subjects without TPTP comprised the control group. There were no statistically significant differences in age and the male-to-female ratio between the case and control groups (Table 2). In the case group, there were 11 Type I and 13 Type II/III cases according to the Conti classification. There was only 1 case

Discussion

The tibialis posterior tendon functions as the main dynamic stabilizer of the arch, while the spring ligament complex, plantar fascia, and the other plantar ligaments and joint capsules act to provide static stabilization (4). The importance of these structures in maintaining the stability of the arch and hindfoot has been demonstrated in cadaveric specimens (13, 14, 15). Although cadaveric analyses provide important groundwork for clinical investigations, we believe that it is imperative to

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Khoury and colleagues36 stated furthermore that MRI characteristics of severe tendinosis and partial tear may overlap. Shibuya and colleagues37 had in 2008 found that, based on the Conti classification, and correlating MRI findings with radiographic ones, only severe TP pathology was associated with radiographic findings compatible with PCFD, suggesting that TP is not the only driving force implicated. This was confirmed in 2014 by Williams and colleagues32 who stated that MRI findings on the spring ligament were possibly at least of equal importance to TP degeneration in patients with moderate to severe PCFD.
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The combination of a descending lateral talar-1st metatarsal-angle (T1MA, Mearýs angle) and an increased pointed talar declination angle (TDA) (<21°) – both typically for a pes cavus – appears to be a good compensation and neutralisation for the total foot-shape. Contrarily, Shibuya et al. described values for the talar declination angle as a mean of 31.04 (±9.07), evaluated in the flatfoot-group of his study (against 26.97 ± 6.09 in the control group) [25] and indicated a threshold of >23° for flatfoot deformity [19]. In contrast, a mean TDA of 10.8° as shown in our cases, is typically for a pes cavus deformity.
The treatment of limb threatening trauma on the distal tibia or hindfoot often results in posttraumatic osteoarthritis requiring tibiotalocalcaneal (TTC) arthrodesis. The purpose of this study was to present a case series of patients undergoing various techniques of joint fusion after bone reconstruction and deformity correction as a salvage procedure. The study should help trauma surgeons making decisions in limb salvage and deformity correction in complex lower leg and foot injuries by presenting options and treatment strategies.
Eight patients (4 male, 4 female) after TTC arthrodesis as a definitive procedure after polytrauma or monotrauma involving the distal tibia or hindfoot were the subject of this retrospective analysis. We included patients treated by external ring fixation (1 case), external fixation + wires (1 case), external fixation + screws (1 case) and intramedullary nailing (1 ante- and 5 retrograde; 1 bilateral, 4 unilateral). Initial trauma included open fractures, subtotal foot amputations and closed fractures with failed osteosynthesis and failed ankle joint replacement. Bone defects were treated with callus distraction or segment transport in 5 cases. Various angles were measured to assess foot deformities in the lateral radiographic view and clinical results were presented.
Independent, pain-free mobilisation with full weight bearing was achieved in all 8 patients. In terms of subjective outcome, all patients reported a highly satisfying result. Complete consolidation at the fusion site was achieved in 8 out of 9 cases with a high rate of adjacent joint arthritis. Angles measures in the lateral radiographs showed values typical for a pes cavus tendency.
Tibio-talo-calcaneal (TTC) arthrodesis is a viable treatment option for severe post traumatic arthritis and deformity of the ankle and subtalar joint. Despite bad bone quality retrograde intramedullary nailing does provide acceptable results providing stability, low invasiveness and low infection rate. Simultaneous TTC-fusion and tibial lengthening using the Ilizarov ring fixator may be necessary when the surgeon is confronted with large bone defects – often followed by a nailing after lengthening procedure. This study shows that limb preservation after limb threatening trauma with hindfoot injury and multiple fractures of the lower extremity is recommenced as the method of choice with reasonable clinical results.
Level of Evidence: IV, Case series
Non–Weight-Bearing and Weight-Bearing Ultrasonography of Select Foot Muscles in Young, Asymptomatic Participants: A Descriptive and Reliability Study
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Citation Excerpt :
Patients with posterior tibialis tendinopathy have associated pathology of the spring ligament complex and sinus tarsi ligaments.18,19 These findings correlate strongly with structural flattening of the arch of the foot.20,21 What is unknown is the significance of reduced AH, FDB, and QP force production in the genesis of ligamentous failure and subsequent foot instability.
The primary aim of this study was to determine the reliability of diagnostic ultrasound imaging for select intrinsic foot muscles using both non–weight-bearing and weight-bearing postures. Our secondary aim was to describe the change in muscle cross-sectional area (CSA) and dorsoplantar thickness when bearing weight.
An ultrasound examination was performed with a linear ultrasound transducer operating between 9 and 12 MHz. Long-axis and short-axis ultrasound images of the abductor hallucis, flexor digitorum brevis, and quadratus plantae were obtained in both the non–weight-bearing and weight-bearing postures. Two examiners independently collected ultrasound images to allow for interexaminer and intraexaminer reliability calculation. The change in muscle CSA and dorsoplantar thickness when bearing weight was also studied.
There were 26 participants (17 female) with a mean age of 25.5 ± 3.8 years and a mean body mass index of 28.0 ± 7.8 kg/m². Inter-examiner reliability was excellent when measuring the muscles in short axis (intraclass correlation coefficient >0.75) and fair to good in long axis (intraclass correlation coefficient >0.4). Intraexaminer reliability was excellent for the abductor hallucis and flexor digitorum brevis and ranged from fair to good to excellent for the quadratus plantae. Bearing weight did not reduce interexaminer or intraexaminer reliability. All muscles exhibited a significant increase in CSA when bearing weight.
This is the first report to describe weight-bearing diagnostic ultrasound of the intrinsic foot muscles. Ultrasound imaging is reliable when imaging these muscles bearing weight. Furthermore, muscle CSA increases in the weight-bearing posture.
Could Failure of the Spring Ligament Complex Be the Driving Force behind the Development of the Adult Flatfoot Deformity?
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Citation Excerpt :
The patient demographics were typical for a foot and ankle clinic population, with a mean patient age of 45.9 (range 18 to 86) years; 64 patients were male and 97 were female. The measurements taken to illustrate arch collapse and hindfoot valgus on the lateral weightbearing radiographs were Meary's talo–first metatarsal angle ≥ 5°, calcaneal pitch ≤ 20°, and talocalcaneal angle ≥ 45° (13,14) (Fig. 1). All radiographic measurements were made using Cerner ProVision Web, version 7.1.1-1 (Cerner, Kansas City, MO), radiographic viewing software by 1 of the senior authors (G.W.), who was unaware of the clinical information, diagnosis, or subsequent MRI findings.
We conducted an investigation into the relative associations of magnetic resonance imaging (MRI)–defined pathologic features of the spring ligament and/or tibialis posterior tendon with radiographic evidence of a planovalgus foot position. A total of 161 patient images (MRI and plain radiographs) obtained from the foot and ankle clinic (2008 to 2011) were retrospectively reviewed. All 161 patients (64 male and 97 female; mean age 45.9 years, range 18 to 86) were included in the analysis. Lateral weightbearing radiographs were analyzed for the talo–first metatarsal angle ≥ 5°, calcaneal pitch ≤ 20°, and talocalcaneal angle ≥ 45°. A positive finding for ≥ 1 measurements identified a radiographic planovalgus position of the foot. The radiographic deformity was analyzed against the MRI evidence of either spring ligament or tibialis posterior tendon pathologic features for significance (p < .05). Evidence of a spring ligament abnormality was strongly associated with a planovalgus foot position, reaching high levels of statistical significance in all 3 categories of radiographic deformity (odds ratio 9.2, p < .0001). Abnormalities of the tibialis posterior tendon failed to demonstrate significance, unless grade I changes were excluded, and grade II and III appearances were analyzed in isolation (odds ratio 2.9, p = .04). Although absolute causal relationships were not tested, this investigation has clearly demonstrated that MRI-defined abnormalities of the spring ligament complex are possibly of at least equal importance to tibialis posterior dysfunction for the presence of a moderate to severe radiographic planovalgus foot position.
Demographic, Physical, and Radiographic Factors Associated with Functional Flatfoot Deformity
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In 1 of our previous studies, the occurrence of self-reported flatfoot was associated with self-reported increased age, male gender, Asian and African American races, veteran status, poor health, increased body mass index, callus, bunion, hammertoe, and arthritis. However, we had to rely on survey data to identify these risk factors, and the accuracy of the survey results was unknown. Therefore, we decided to identify the risk factors associated with flatfeet using objectively and more accurately measured data. A total of 94 patients were enrolled in the present study. The demographic data and physical and radiographic examination results were recorded by the investigators in the clinic. The data were then analyzed to identify the factors unique to flatfoot, measured and defined using a plantar pressure measurement system during natural gait. We learned that a painful tibialis posterior tendon was associated with flatfoot. The calcaneal inclination angle was also decreased in the flatfoot group. The talar declination, intermetatarsal, hallux abductus, and calcaneal cuboid angles, and static calcaneal stance eversion were elevated in the flatfoot group compared with the non-flatfoot group. Systematic evaluation of these associated factors will help in the understanding of the functional status of the flatfoot deformity.
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Medial column fusion is becoming increasingly popular for flatfoot reconstruction. The authors describe a new technique for medial column arthrodesis via tension band mesh plating. Plating on the tension side would provide dynamic compression of the arthrodesis sites via weightbearing. This technique may be useful to allow patients to bear weight early in the postoperative course after flatfoot reconstruction.

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Original researchAssociation of Tibialis Posterior Tendon Pathology with Other Radiographic Findings in the Foot: A Case-Control Study

Section snippets

Patients and Methods

Results

Discussion

Foot Ankle Clin

J Foot Ankle Surg

Acquired adult flat foot secondary to posterior tibial-tendon pathology

J Bone Joint Surg Am

Rupture of the posterior tibial tendon causing flat footSurgical treatment

J Bone Joint Surg Am

MR imaging findings in spring ligament insufficiency

Skeletal Radiol

Rupture of the posterior tibial tendonEvaluation of injury of the spring ligament and clinical assessment of tendon transfer and ligament repair

J Bone Joint Surg Am

Anatomy of the spring ligament

J Bone Joint Surg Am

Association of posterior tibial tendon injury with spring ligament injury, sinus tarsi abnormality, and plantar fasciitis on MR imaging

AJR Am J Roentgenol

MRI of spring ligament tears

AJR Am J Roentgenol

MR diagnosis of traumatic tear of the spring ligament in a pole vaulter

Skeletal Radiol

Clinical significance of magnetic resonance imaging in preoperative planning for reconstruction of posterior tibial tendon ruptures

Foot Ankle

MR imaging of tendons and ligaments of the midfoot

Semin Musculoskelet Radiol

Original research
Association of Tibialis Posterior Tendon Pathology with Other Radiographic Findings in the Foot: A Case-Control Study