What Is Posterior Tibial Insufficiency?

It is a semi-feather muscle, located on the deep side of the calf triceps, between the toe longus and long flexors. It starts from 2/3 of the calf interosseous membrane and behind the adjacent tibia and fibula, and moves down to the long tendon that passes behind the medial malleolus, passes through the deep side of the flexor support band (split ligament) to the medial edge of the foot, and stops at the boat Bone tuberosity and the basal plane of three wedge bones. This muscle contracts to allow plantar flexion, external rotation and adduction. In addition, it has the effect of maintaining the longitudinal arch of the foot, and is the most powerful varus foot muscle in the calf posterior muscles. The posterior tibial muscle is innervated by the tibial nerve.

Chinese name: Posterior tibia
Foreign name: tibialis posterior

Location: Between the long toe flexor and the long flexor hallucis longus
Question: Medial tibial stress syndrome
Inducement: Worn outdated sneakers

Clinical anatomy of posterior tibial muscle

Posterior tibialis tenosynovitis

It is a strained lesion of the posterior tibial tendon. The main reason for the injury is running and skipping too much. Repeated rubbing and squeezing of the tendon and tendon sheath can cause tenosynovitis. Over time, the sheath wall thickens and can develop into stenosing tenosynovitis. There was local pain after the injury, and the pain aggravated when the ground was pressed hard, and there was tenderness at the lower back of the medial malleolus. It should be braked in the early stage, fixed with plaster, and can also be injected with sheath of prednisolone. A tenosynovectomy is available in refractory cases.

Posterior tibial tendon dysfunction (back tibial tendon dysfunction), also known as posterior tibial tendinitis, is one of the main causes of adult acquired flat feet, and it is also considered to be the most common type of adult acquired flat feet. The disease can occur slowly or acutely, the latter being more common in trauma. Children with posterior tibial tendon dysfunction are rare and often develop with age.

Applied Anatomy of Posterior Tibia

1. Posterior tibial muscle

The posterior tibialis muscle is located between the long flexor and long flexors of the deep posterior space of the calf. It starts behind the tibia and fibula and the periosteum and moves down to the long tendon. It is deep behind the tibialis long flexor. Face, located behind the medial malleolus in front of the long flexor tendon, turning forward through the lower medial malleolus, passing through the medial talus, partly ending at the scaphoid tuberosity, divided into several thin tendons running below the scaphoid, stopping at the medial, The medial wedge is just below the proximal side.

2. Posterior tibial muscle 2. blood supply

By means of arterial perfusion, the microvasculature of the posterior tibial tendon has been studied. The blood supply of the tendon mainly comes from the blood vessels of the muscular branch, the paratendular tissue and the synovial sheath, and the blood vessels of the bone and periosteum at the junction of the bone and the tendon. The intra-tendon vessels are mainly anastomotic anastomosis vessels, which are connected to the adventitia tube from a control branch. The vessels of the tendon are abundant at the stopping point and the junction of the tendon, and there is an avascular segment or a lack of vascular segment on the far side of the medial malleolus. . The specific location of the posterior tibial tendon avascular segment is 1.5 cm from the distal end of the lateral malleolus and 1.4 cm from the proximal end of the lateral malleolus.

Causes of posterior tibial muscle

1. Posterior tibial muscle

It is generally accepted that the cause of posterior tibial tendon insufficiency is due to the presence of a vascular region of the posterior tibial tendon below the medial malleolus. Most of the nutrition of tendons comes from the synovial fluid produced by the synovium of the tendon sheath, and a small part of the nutrition comes from the small blood vessels passing through the tendon sheath into the tendon. For the posterior tibial tendon, the nutritional dependence of the tendon on synovial fluid is more prominent due to the lack of vascular areas.

2. Tibialis posterior muscle 2. Physical properties of tendons

At the direction of change in travel, the tendon is particularly sensitive to fatigue and damaging external forces. The posterior tibial tendon makes a sharp turn in the direction as it travels from the medial malleolus to the soles behind the medial malleolus. When external force acts on the foot, the posterior tibial tendon responds to the tension and responds to the load. At this time, the medial malleolus tapers the posterior tibial tendon like a "wedge", which is sufficient to cause longitudinal tear and fracture of the posterior tibial tendon.

3. Posterior tibial muscle 3. Fracture of medial malleolus

Holmes et al. Believe that ankle injury is a cause of posterior tibial tendon insufficiency, which leads to acquired flat feet. Therefore, in the treatment of ankle joints, it is necessary to prevent damage to the posterior tibial tendon, especially when screwing the medial malleolus. Because the tibialis posterior tendon slides in the posterior and lower part of the posterior mound, the direction of the guide needle should be parallel to the medial articular surface. If multiple screws are driven, the screws should be fixed in areas 1 and 2 as much as possible.

4. Posterior tibial muscles 4. Hypertrophy of parascapular and medial scaphoid nodules

It is an autosomal dominant hereditary disease, and the chance of parascapularis in normal feet is less than 15%. In most cases, the presence of parascapularis indicates abnormalities in the posterior tibial tendon.

5. Tibia posterior muscle 5. Other possible causes

Horseshoe foot, ankle arthritis, diabetes, hypertension, obesity, peripheral neurological diseases and smoking.

Clinical manifestations of posterior tibial muscle

Posterior tibial tendon insufficiency is a gradual process. Onset is generally slow. It is more common in middle-aged women and young adults who like sports. In the early stage, there may be pain and discomfort behind, below, or below the medial malleolus. Later, the pain gradually increases, and the pain changes from early activity to rest. Pain can also be felt, and local swelling can occur; as the disease progresses, the medial The longitudinal arch began to collapse, forefoot abduction, polyphagia, limited movement of the subtalar and middle metatarsal joints, calcaneus valgus, and positive iliac crest test; patients often had contractures of the Achilles tendon and gastrocnemius spasms.

The above clinical manifestations can be summarized as the following characteristics:

Medial longitudinal arch height loss; medial malleolus edema; forefoot varus weakness; pain in medial malleolus; difficulty in standing with raised palate even without pain; positive toe syndrome; pain under lateral malleolus.

Posterior tibial tendon dysfunction results from posterior tibial tendinitis, which gradually develops into a partial tear of the tendon resulting in a complete tear or rupture.

There are many clinical types, and Johnson and Strom types are still generally accepted:

Stage : Tendonitis and / or tenosynovitis occurs, no increase in tendon length, but no tearing of the tendon;

Clinical manifestations: obvious pain at the medial longitudinal arch, weak foot varus, normal hind foot movement, soft and bendable feet;

X-ray / MRI manifestations: MRI showed mild to moderate tenosynovitis, no X-ray was found (this period: dull pain in the medial longitudinal arch, increased weight-bearing activity, reduced after rest, and continued weight-bearing activity can lead to posterior tibia Part of the tendon tears, or progresses to stage II. Stage I patients generally do not have obvious foot edema, but may experience pain in the longitudinal arch between the medial malleolus and the posterior tibial tendon.)

Stage : Increased tendon length and possible partial or complete tearing;

Clinical manifestations: Pain in the arch, obvious swelling below the medial malleolus, lower arches, valgus deformity in the hind feet, unable to stand with raised hips, and polydactysia positive;

X-ray / MRI manifestations: signs of tendon tearing, abduction of forefoot, and dislocation of talar joint dislocation (Phase I: Symptoms continue to exist, the pain is only partially relieved after rest, and pain can occur as soon as the foot is loaded. Throughout the day, the lift test began to be partially limited due to pain and edema at the medial longitudinal arch).

Stage : Tendon more severe degeneration;

Clinical manifestations: Positive lift test and stiff flat foot deformity; signs of rupture of tendon, abduction of forefoot, dislocation of talar joint dislocation (this period: worsening foot pain symptoms, difficulty in completing a day of normal weight-bearing walking, arch collapse Obviously, forefoot abduction, polydipsia, positive lift test).

X-ray manifestations: Anterior and posterior weight-bearing radiographs are visible: insufficient coverage of the talus by the scaphoid, increased talar angle, and lateral dislocation of the scaphoid; lateral radiographs: reduced medial foot arch height, talar axis and 1st metatarsal axis The angle between them decreases or becomes an inverse angle, and the angle of the talar axis and the longitudinal axis of the calcaneus increases; in addition, the degeneration and proliferation of different levels of the zygomatic joint can be seen.

Stage : inflammation of the posterior tibial tendon, normal tendon length and mild symptoms;

Stage : relaxation of the posterior tibialis tendon, tenderness of the tendon path, often thickening or loss of the palpable tendon, positive one-leg lift test, positive polyphagia, and flat foot deformity;

Stage III: Obvious flatfoot deformities, namely hindfoot eversion and forefoot abduction, polyphagia is obvious, and calcaneus and lateral ankle often collide;

Stage : Stiff flat foot deformity, which can be accompanied by talus eversion, triangular ligament damage, and tibiofilotarsal joint degenerative arthritis.

MRI manifestations: The posterior tibial tendon tear can be divided into three stages on MRI:

Phase I: Partial tear with tendon thickening, sometimes vertical slits can be seen, and line-like high signal shadows are present on both T1WI and T2WI. High-signal liquid shadows are common in the synovial sheath on T2WI.

Phase II: Partial tendon tearing with local thinning, the section is smaller than that of the long toe flexor tendon.

The third stage: refers to the complete tear of the tendon fissure, the fluid between the stump of the retracted tendon, and the granulation tissue can be seen in the near term.