What is the Tibialis Posterior Tendon?

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The Tibialis Posterior is a muscle that runs deep in the calf and its tendon inserts onto the arch of the foot. The tendon is one of the key arch supports along with several ligaments (and also the bones whose shape forms the arch of the foot).

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When the tibialis posterior tendon fails the arch collapses and the entire foot changes shape. Pain is often the most common reason for an individual to seek a specialist opinion but severe swelling can also occur in the period when the tendon ruptures.

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Patients without a normal arch find that their foot feels very inefficient. The failing arch continues to tear the damaged soft tissue which once held the arch in place. The tearing leads to episodes of pain and swelling in the medial ankle and foot.

 

What are the treatment options?

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When the tendons and ligaments which support the arch of the foot have failed there are options:

1. Insoles and stiff soled shoes such as walking boots or even custom shoes.

2. Try a steroid injection into the most painful area under Ultrasound guidance. (This will take away inflammation and pain around the injured soft tissues but it will also weaken the tissues and could lead to more rupture. It may be used in certain circumstances - for example in a patient who wants to have surgery but who needs to delay surgery for 6 months)

3. Release the tight muscle in the back of the legs to allow the insoles to work better.

4. Rebuild the arch of the foot by key hole surgery to realign the bones of the foot (without putting a new tendon into the place of the failed tibialis posterior tendon).

5. Rebuild the arch of the foot by putting a new tendon into the place of the failed tibialis posterior tendon, and surgery to realign the bones of the foot.

6. If the collapse of the arch is longstanding, there may be severe arthritis and the only surgical option might be to rebuild the arch by putting the bones into a better position and then fusing them in place.

 

Why have the arch rebuilt without having a tendon transfer?

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In relative terms surgery on bone heals very quickly and keyhole bony surgery heals even faster. By contrast surgery which requires tendons to heal is very slow. (Tendons are very specialised soft tissue made up largely of dense protein which is super-organised in order to give the tendon strength. Tendons have a poorer blood supply and only a small amount of cells within them. It is the cells which must make the proteins and because their are few cells, little blood supply of nutrients and a complex structure to heal; the end result is slow healing.)

 

1. When patients are lower demand their complaint is not of the lack of power that comes from loss of the tendon, their complaint is of pain due to ongoing tearing of the tendon.

2. Rebuilding the arch of the foot stops the tearing of the tendon. If the tendon has been so damaged that it no longer functions, it will not function again. However the tendon will not be torn because the foot is not able to move into the position which stretches and tears the tendon

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Patients have the arch rebuilt in order to have a foot which allows them to manage with shoes and insoles without going through the slow healing process of a tendon transfer

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What is a Sinus tarsi Implant?

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A sinus tarsi implant is a small metal spacer which sits between the calcaneus and the talus. It holds these bones apart and prevents the arch from collapsing. The implant is also called an arthroereisis screw.

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How Long Should a Sinus Tarsi Implant Stay in For?

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There are no clear guidelines about how long the implant should stay in for. If the implant causes no pain there is no need to remove it but if there are any symptoms, it can be removed after 6 months. There are reports that the implant produces some changes to how some patients use their arch permanently. If the implant causes no symptoms and allows the patient to resume normal life - it is unlikely that the surgeon and patient will decide to remove it.

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What are the risks and complications?

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The vast majority of patients do extremely well. A small group of patients need extra physio due to swelling or stiffness. Complications include infection, blood clots (DVT), nerve damage, non-union, painful screws requiring removal, and some patients may find that they do not have enough power and decide to opt for a tendon transfer at a later stage.