Background & Etiology
The ankle is made up of two joints. These joints need to be strong because they support the weight of the entire body. The ankle is one of the most versatile joint complexes in the body. It is built for weight bearing, mobility, adaptability and stability. The foot and ankle allow us to walk, stand, run and jump, and serves as our connection to the ground. The ankle must be able to withstand the stress of our body weight, and also be able to adapt to, and react quickly to changes in environment and walking surface.
Tendons are connective tissues that attach muscle to bone. They are strong, fibrous structures that are responsible for transferring the forces generated by the muscle to the bone, thus producing movement at the joint. When a tendon becomes irritated or inflamed it becomes painful, causing tendonitis. The tendons in the ankle region are subject to significant stress, and can rupture under extreme pressure.
Tendon Rupture
When a tendon ruptures it can be extremely painful and cause a disability of the foot that then subsequently causes damage to the ankle joints. The tendons in the ankle include: The peroneals (peroneus brevis, peroneus longus,) anterior tibialis, posterior tibialis, and Achilles tendon. Any of these structures can become ruptured, which is a serious condition that will typically require surgery to fix.
Posterior Tibialis Tendon
The posterior tibialis tendon is located along the inner side of the ankle. It connects the posterior tibial muscle (located at the back of the shin bone) to the foot. Problems with this tendon typically occur underneath the prominence of the medial malleolus (inner ankle bone) because the blood supply to this area can be poor. This makes it easier for overuse injuries to cause a tendon rupture. Pain with this type of injury typically occurs along the inside of the foot and ankle.
Common causes of posterior tibialis tendon rupture include:
- The progression of or the final result of longstanding tendonitis of the posterior tibialis tendon or an overuse injury.
- An injury to the ankle or a direct blow to the posterior tibialis tendon.
- From a fall where an individual lands awkwardly or directly on the ankle
- Laceration of the posterior tibialis tendon
- Weakness of the associated muscle in people with existing tendonitis places increased stress on the involved tendon.
- Steroid use has been linked to posterior tibialis tendon weakness
- Certain systemic diseases have been associated with posterior tibialis tendon weakness.
- A sudden deceleration or stopping motions that cause an acute injury of the ankle.
- Injection of steroids to the posterior tibialis tendon or the excessive use of steroids has been known to weaken tendons and make them susceptible to rupture.
- Ankle pain and swelling or feeling that the ankle has “given out” after falling or stumbling.
- Possible audible pop when the ankle is injured.
- Patient may have a history of prior ankle pain or tendonitis, and may be active in sports.
- Swelling, tenderness and possible discoloration or ecchymosis in the ankle region.
- Indentation above the injured tendon where the torn tendon may be present.
- Difficulty moving around or walking.
- Individual has difficulty or is unable to move their ankle with full range of motion.
- MRI can confirm disruption or tear in the tendon.
- Immediate pain at time of injury.
Early diagnosis and treatment is the key to a successful outcome for a rupture of any of the tendons in the ankle. If diagnosis or treatment is delayed the integrity of the healing tissue can be compromised as a result of scarring and decreased blood flow. Surgical repair followed by structured and aggressive physical therapy is the treatment of choice for complete ruptures. In the case of a small partial tendon tear conservative treatment without surgery is an option.
Partial (small) Posterior Tibialis Tendon Tear
- Immobilization of the ankle for 3-6 weeks to rest and promote healing. Individual will be placed in an immobilizer or brace and will move around with crutches to keep weight off of the leg.
- Physical Therapy: following the period of immobilization your physician will decide when you are ready for physical therapy. Treatment will emphasize gradual weaning off the immobilizing device, increasing weight bearing, restoration of ankle range of motion and strengthening of the associated muscles. It is important that the physician and therapist communicate during the early stages and progress your recovery program based on the principles of healing so as not to compromise the injured tendon.
- Patient will be progressed to more functional activities as normal ankle range of motion and strength is restored.
Treatment of Complete Posterior Tibialis Tendon Ruptures
- Immediate surgical repair of the tendon is indicated in complete tears. Delaying surgery can lead to shortening of the tendon, formation of scar tissue and decreased blood flow, which can lead to a poor outcome.
- Following surgery your ankle will be put in an immobilizing device and you will be instructed to use crutches to limit weight bearing and protect the joint.
- Over the next 2-4 weeks weight bearing will be increased and physical therapy will be initiated.
- The surgeon will determine the physical therapy timeline and program.
- Physical Therapy: treatment will emphasize gradual weaning off the immobilizing device, increasing weight bearing, restoration of ankle range of motion and strengthening of the associated muscles. It is important that the physician and therapist communicate during the early stages and progress your program based on the principles of healing so as not to compromise the involved tendon.
- Patient will be progressed to more functional activities as normal ankle range of motion and strength is restored.
Physical therapy for posterior tibialis tendon rupture must remain conservative at the onset in order to protect the repair. Emphasis will be on rest, tendon protection, reducing the inflammation and increasing the blood circulation for healing. Following the surgeon’s timeline and protocol, a program of progressive weight bearing, stretching and strengthening will be initiated.
Common Physical Therapy interventions in the treatment of Posterior Tibialis Tendon Rupture include:
- Manual Therapeutic Technique (MTT): hands on care including soft tissue massage, stretching and joint mobilization of the ankle by a physical therapist to improve joint mobility and range of motion of the ankle. Use of mobilization techniques also helps to modulate pain.
- Therapeutic Exercises (TE) including stretching and strengthening exercises to regain range of motion and strengthen the muscles of the ankle and lower extremity.
- Neuromuscular Reeducation (NMR) to restore stability, retrain the lower extremity and improve movement techniques and mechanics (for example, running, kneeling, squatting and jumping) of the involved lower extremity to reduce stress on the tendons in daily activities. Taping, strapping or bracing may be indicated to rest the tendon and promote healing.
- Modalities including the use of ultrasound, electrical stimulation, ice, cold, laser and others to decrease pain and inflammation of the involved tendon and bursa.
Prognosis
If repair and treatment are initiated immediately, individuals with posterior tibialis tendon rupture or tear generally do well. Delay can result in the formation of scar tissue and retraction of the tendons. Other factors that can affect recovery are:
- Age: Older individuals are generally weaker and take longer to heal affecting the functional outcome.
- Strength: Individuals who are strong and in good condition prior to the injury generally do better following surgical repair.
- Tissue: Tissue quality prior to the surgical repair will effect healing and recovery following surgery. Poor circulation and presence of scar tissue will interfere with the healing process.
The healing time for posterior tibialis tendon repair will take up to 8-12 weeks but restoration of function and ability to accept full activity, load and stress can take up to one year.
