AJR 2000; 175:627-635
© American Roentgen Ray Society
MR Imaging of Disorders of the Posterior Tibialis Tendon
Mark E. Schweitzer1 and
David Karasick
1
Both authors: Department of Radiology, Thomas Jefferson University Hospital,
111 S. 11th St., 3390 Gibbon, Philadelphia, PA 19107.
Received July 12, 1999;
accepted after revision February 22, 2000.
Address correspondence to M. E. Schweitzer
Introduction
Although posterior tibial tenosynovitis was first described in 1930
[1], it was not until the 1980s
that posterior tendon dysfunction became recognized as a clinical entity
[2,
3]. It is best to think of
posterior tibialis tendon abnormalities as a continuum of disorders that
causes dysfunction because the predominant manifestations of pathoanatomy are
functional rather than symptomatic
[4]. Because most of these
disorders are not clinically painful, patients seek medical attention
relatively late [5]. Therefore,
on imaging, we usually see the later stages of the disorder
[6]. More recently, many
patients, particularly those with inflammatory processes such as rheumatoid
arthritis, are presenting earlier, and the imaging spectrum of the disease is
becoming better understood [7,
8].
Anatomy
The tibialis posterior muscle originates from the interosseous membrane and
adjacent tibial posterior surface in the proximal third of the leg. The tendon
forms in the distal third of the leg and lies closely apposed to the tibia
posteromedially. Distally, the posterior tibialis tendon sits in a medial or
posterior concavity on the medial edge of the posterior tibia. Just lateral to
the posterior tibialis tendon lies the flexor digitorum tendon. The posterior
tibialis tendon curves distally around the medial malleolus. It is at this
level that the tendon lies beneath the flexor retinaculum, which prevents the
flexor tendons from bowstringing as they curve around the malleolus
[9].
The flexor retinaculum is the roof of the tarsal tunnel. The tarsal tunnel
contains the three ankle flexor tendons, the adjacent posterior tibial artery
and vein, and the tibial nerve
[10]
(Fig. 1).
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Fig. 1. —Drawing shows relationship of posterior tibialis tendon to remainder
of tarsal tunnel. Note relative sites and distal extent of tendon sheaths in
black. Also note that flexor hallucis and flexor digitorum tendons cross
distally at knot of Henry (straight arrow). Last, note tibial artery
and nerve (curved arrow) between flexor digitorum longus tendon and
flexor halluceus longus tendon in tarsal tunnel. PTT = posterior tibialis
tendon, FR = flexor retinaculum, FDL = flexor digitorum longus tendon, FHL =
flexor halluceus longus tendon, ATT = anterior tibialis tendon.
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Past the tarsal tunnel, the posterior tibialis tendon has a complex
insertion. Several slips of the posterior tibialis tendon extend to the
cuneiforms and the bases of the second, third, and fourth metatarsals.
However, the bulk of the tendon inserts on a prominence on the medial aspect
of the navicular (Fig. 2). This
prominence is called the navicular tubercle. This tubercle prevents the
navicular from being perfectly symmetric on axial images. Excessive prominence
of this tubercle is likely the result of a fused accessory navicular and is
called a cornuate navicular (Fig.
3).
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Fig. 2. —Drawing shows complex insertions of posterior tibialis tendon
beneath undersurface of foot with muscle dissected away. Note main slip
inserting onto tubercle of navicular (arrow). Also note close anatomic
relationship of distal tendon, spring ligament, and distal deltoid ligament.
PTT = posterior tibialis tendon, C = calcaneus, N = navicular.
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Fig. 3. —30-year-old man at risk for posterior tibialis dysfunction. Axial
T2-weighted fat-suppressed MR image (TR/TE, 6000/70) shows hypertrophy of
navicular tubercle (arrow), consistent with cornuate navicular.
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A true accessory navicular is present in approximately 4% of the population
[11]; however, accessory
naviculars are present in a much higher percentage of patients with posterior
tibialis tendon disorders [12]
(Fig.
4A,4B).
The accessory navicular acts as if it were a native navicular with the bulk of
the posterior tibialis tendon inserting onto the accessory navicular. The
presence of either an accessory navicular or a cornuate navicular is a risk
factor for posterior tibialis tendon tears. However, most people with an
accessory or cornuate navicular will not have a disorder of the posterior
tibialis tendon [12].
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Fig. 4A. —28-year-old man at risk for posterior tibialis dysfunction. Sagittal
T2-weighted MR image (TR/TE, 6000/70) reveals accessory navicula (a). Note
normal low signal intensity between accessory navicular and native navicular
(curved arrow). Also note straight line (instead of normal smooth
curve) that posterior tibialis tendon makes as it extends from medial
malleolus. This abnormality causes focal point of friction at medial malleolus
(straight arrow).
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Blood Supply
The proximal aspect of the posterior tibialis tendon is fed by branches of
the posterior tibial artery. The distal aspect of the tendon, at the enthesis,
is supplied by the posterior tibial and dorsalis pedis arteries
[13]. The mid tendon, similar
to the Achilles tendon, is poorly supplied with blood. In addition, the
mesotenon is absent distally because the synovial sheath ends at the mid
portion of the talus. Because of the absence of a mesotenon
[14] and the zone of
hypovascularity, the level of the medial malleolus in relation to the tubercle
is the most common location for posterior tibialis tendon dysfunction
[3].
Posterior tibialis tendon disorders are predominantly ischemic and, similar
to strokes and myocardial infarction, are senescent diseases. Impingement also
plays a role in posterior tibialis tendon dysfunction because the posterior
tibialis tendon has a focal point of stress as it curves around the medial
malleolus [5]. This point of
stress can be analogous to the pressure on the rotator cuff in the subacromial
space [15]. This combination
of ischemia and mechanical compression causes most posterior tibialis tendon
disorders.
Functional Anatomy
The posterior tibialis muscles act to plantarflex the ankle and invert the
foot. During normal gait, this unit locks the calcaneus to the cuboid and the
talus to the navicular, creating a rigid midfoot lever for forward propulsion
[16]. If posterior tibialis
dysfunction is present, the lack of a rigid midfoot causes gastrocnemius and
soleus flexion to occur at the midfoot instead of at the metatarsal heads
[17]. This problem will
eventually lead to midfoot collapse, forefoot abduction, and heel valgus.
These deformities are exacerbated by the action of the peroneus brevis, the
antagonist muscle to the posterior tibialis. Because the cross-sectional area
of the peroneus brevis is half that of the posterior tibialis tendon, a
significant degree and length of time of posterior tibialis dysfunction must
be present before these abnormalities appear
[17].
Epidemiology
Posterior tibialis tendon dysfunction is a disorder primarily occurring in
women who are middle-aged or elderly
[2]. Systemic risk factors are
noted more frequently in dysfunction of the posterior tibialis tendon than in
disorders of the Achilles tendon. The most important of these risk factors are
hypertension, obesity, lupus, gout, rheumatoid arthritis, and, somewhat less
commonly, Reiter's syndrome
[18,19,20].
Patients with rheumatoid arthritis more frequently develop synovitis than
tears [20]. This synovitis
causes fibrosis from recurrent inflammatory episodes and then posterior
tibialis tendon dysfunction.
A subtype of seronegative arthropathies with a positive Cw6 human leukocyte
antigen is associated with tears of the posterior tibialis tendon
[21]. Prior trauma and surgery
are not strong predictors of posterior tibialis tendon disorder nor is
systemic steroid exposure
[18]. However, direct
injection of steroids into the tendon can cause posterior tibialis tendon
tears [22].
MR Imaging
The technical aspects of performing MR imaging of the posterior tibialis
tendon are controversial. The axial plane is optimal; however, some
institutions prefer oblique axial imaging perpendicular to the long axis of
the posterior tibialis tendon. Sagittal imaging is the secondary plane, with
coronal used only as a supplement. Two sets of axial images are ideal. One set
of images should be morphology weighted to optimize the signal-to-noise ratio
(fast spin echo; TR/TE, 4000/38; echo train length, four; field of view, 14;
matrix, 256 x 256), and one set of images should be T2-weighted using
fat suppression and fast spin-echo (6000/
70) protocols. Sagittal images
should be T1-weighted and either T2-weighted with fat suppression or short tau
inversion recovery. The sagittal images depict the distal posterior tibialis
tendon and its malleolar curve (Figs.
5 and
6), and the axial images depict
perimalleolar abnormalities. A dedicated extremity coil is necessary, and some
institutions slightly plantarflex the foot to minimize the "magic
angle" artifact.
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Fig. 5. —30-year-old healthy man. Sagittal short tau inversion recovery MR
image (TR/TE, 4000/48; inversion time, 150) reveals normal smooth malleolar
curve of posterior tibialis tendon (arrows).
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Fig. 6. —60-year-old woman with posterior tibial tendon tear. Sagittal
T1-weighted MR image (TR/TE, 500/15) reveals straightening of normal malleolar
curve in patient with markedly thickened posterior tibialis tendon (black
arrows) with large segment of internal signal intensity (white
arrows).
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Contrast material is useful only in some patients. We use contrast material
when unenhanced MR imaging shows subtle or no findings suggestive of
abnormality but the clinician suspects an abnormality of the posterior
tibialis tendon. We also use contrast material for suspected synovitis,
infection, or inflammatory arthritis. Last, contrast material is helpful for
insertional tendonitis.
On MR imaging, the posterior tibialis tendon is normally black without any
internal signal intensity
[23]. The exception to this
lack of signal intensity is the result of the magic angle artifact because the
posterior tibialis tendon curves around the medial malleolus (Fig.
7A,7B).
In comparison with the Achilles tendon, the distal posterior tibialis tendon
has no normal internal signal intensity. However, there is variability of
signal intensity distally related to volume averaging of the spring ligament
(extremely distally), tibial navicular, and tibiotalar components of the
deltoid ligament (slightly more proximally)
[24] (Figs.
2 and
8).
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Fig. 7B. —38-year-old healthy man. Axial T2-weighted fat-suppressed MR image
(6000/78) reveals internal signal intensity in posterior tibialis tendon that
fades on long TE images, consistent with "magic angle" artifact
(arrow).
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Fig. 8. —42-year-old man with normal posterior tibialis tendon. MR image
(TR/TE, 3000/38) shows close proximity of posterior tibialis tendon
(straight solid arrow), spring ligament (curved arrow), and
tibial navicular ligament (open arrow), giving appearance of
thickened distal posterior tibialis tendon.
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On sagittal images, the posterior tibialis tendon should have a smooth
curve around the medial malleolus to limit focal compression and impingement
(Fig. 5). A small amount of
fluid in the synovial sheath of the posterior tibialis tendon is normal,
measuring no more than 1-2 mm and almost never circumferential
[25]. Because, anatomically,
there is no normal sheath around the distal posterior tibialis tendon (Figs.
1 and
9A,9B),
fluid observed at the distal 1-2 cm is abnormal and related to the metaplastic
synovium [25].
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Fig. 9B. —50-year-old man with tenonitis synovitis. Axial T2-weighted
fat-suppressed MR image (6000/82) reveals posterior tibialis tendon with
multifocal speckled internal signal intensity surrounded by excessive synovial
fluid (arrow).
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Abnormal Anatomy
A similar continuum of posterior tibialis tendon disorders exists in the
Achilles tendon, and a similar concept of cumulative injury is useful in
understanding posterior tibialis tendon disorders
[26]. However, in
contradistinction to the Achilles tendon, complete tears with a gap that show
no evidence of fibrosis are a fairly unusual manifestation of posterior
tibialis tendon dysfunction, and ischemia appears to be a more important
causal factor [5].
Clinically, the first presenting stage of posterior tibialis tendon
dysfunction is paratendonitis or synovitis. The MR imaging appearance of this
paratendonitis is similar to that seen in the Achilles tendon, with partially
circumferential high signal intensity located distally around the posterior
tibialis tendon. This signal intensity is usually slightly hypointense to
fluid. Because normally no fluid is present distally around the posterior
tibialis tendon on MR imaging, the term synovitis should be used to describe
this disorder only when it occurs more proximally
[23] (Fig.
10A,10B).
If apparent synovitis is seen distally, it is anatomically a paratendonitis
and often reveals fluid slightly lower in signal intensity than is typical for
bland fluid (Fig.
9A,9B).
At this stage of the disorder, the tendon itself is normal and should not show
intratendon signal. Posterior tibialis tendon disorders manifested by
synovitis are often acutely symptomatic.
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Fig. 10A. —48-year-old woman with posterior tibialis tenosynovitis. Axial
intermediate-weighted MR image (TR/TE, 4000/28) reveals speckled internal
signal intensity of posterior tibialis tendon (arrow).
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The next stage of posterior tibialis tendon dysfunction is tendonitis,
which is correctly termed tendonosis. Tendonitis is a less preferred
nomenclature because the pathophysiology is degenerative dysfunction without a
true inflammatory component
[26]. True tendonitis of the
posterior tibialis tendon is unusual (Fig.
11). Many cases that are clinically believed to be tendonitis are
in fact synovitis.
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Fig. 11. —52-year-old woman with insertional tendonitis. Sagittal fast short
tau inversion recovery MR image (TR/TE, 6000/50; flip angle, 50°) reveals
fluid and diffuse flocculent signal intensity in distal posterior tibialis
tendon consistent with insertional tendonitis (arrow). Note adjacent
soft-tissue edema. Also note longitudinal areas of high signal intensity in
tendon consistent with interstitial tear.
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In tendonosis, patients have degeneration in the posterior tibialis tendon.
Histologically, there is no inflammation, but evidence of intratendinous
collagen degeneration, local necrosis, calcification, and hypocellularity,
similar to that seen in Achilles tendon degeneration, is present
[27]. Although degeneration is
histologically common, in our experience, signal abnormalities caused by
degeneration on MR images are seen infrequently. In most patients,
degeneration presents with an apparently normal posterior tibialis tendon on
MR imaging. There is a transition stage of posterior tibialis tendon disorder
in which there are microscopic and eventually macroscopic tendon fiber tears.
Few partial tears are seen on MR imaging, although most are seen on sonography
[28]
(Fig. 12). On MR imaging, if
visible, subtle focal high signal intensity is visible in the tendon. At
surgery, the disruption is often more extensive than it appears on MR imaging.
Therefore, what may appear on imaging as synovitis or tendonitis may in fact
be a partial tear.
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Fig. 12. —56-year-old man with synovitis and interstitial tear. Axial
contrast-enhanced fat-suppressed MR image (TR/TE, 600/8) reveals excessive
contrast enhancement around posterior tibialis tendon (arrow) in
region of medial malleolus, consistent with synovitis. Enhancement is also
seen in posterior tibialis tendon and is consistent with component of
interstitial tear.
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Partial tears can scar over and lead to tendon thickening, retract and lead
to tendon thinning, or severely weaken the tendon and result in a gap
[23]. Thin tendons are
atrophic (Fig. 13) and thick
tendons are hypertrophic (Fig.
14). Most patients have mixed regions of hypertrophic and atrophic
tendons. This mixture occurs because there are interstitial tendon tears with
bulbous hypertrophic proximal tendon fibers and because of retraction,
atrophic fibers distally (Fig.
15).
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Fig. 14. —53-year-old man with hypertrophic tear. Axial T2-weighted MR image
(TR/TE, 6500/65) reveals enlarged tendon (black arrow) adjacent to
deltoid ligament (white arrow). This posterior tibialis tendon is
roughly three to four times the size of adjacent flexor hallucus and flexor
digitorum tendons, consistent with hypertrophic dysfunction.
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Fig. 15. —48-year-old man with mixed hypertrophic and atrophic tendon tear.
Sagittal short tau inversion recovery MR image (TR/TE, 4800/48; flip angle,
15[UNK]) reveals focal tear of submalleolar (thick arrow) with tendon
thinning. Retracted fibers cause spurious tendon thickening (thin
arrow).
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Because abnormal size may be the only indicator of tendon dysfunction, the
relative sizes of the posterior tibialis tendon, flexor digitorum tendon, and
flexor hallucis tendon should be examined. In a healthy person, the posterior
tibialis tendon is roughly twice the size of the two adjacent tendons
[26]
(Fig. 16). Additionally, the
posterior tibialis tendon should be slightly smaller than the anterior
tibialis tendon, and the posterior tibialis tendon should be slightly smaller
than the summated measurements of the peroneus brevis and peroneus longus
tendons (Fig.
17A,17B).
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Fig. 16. —20-year-old healthy man. T1-weighted fat-suppressed MR image (TR/TE,
500/18) shows size ratio of posterior tibialis tendon (open arrow) to
flexor digitorum tendon (solid straight arrow). Also note how normal
posterior tibialis tendon is slightly smaller than summated peroneal tendons
(curved arrow).
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Fig. 17A. —60-year-old woman with hypertrophic tendon dysfunction. Axial
T1-weighted MR image (TR/TE, 500/12) (A) and T2-weighted MR image
(6500/90) (B) reveal posterior tibialis tendon tear with thickening
synovitis and internal signal intensity (white arrow). Note enlarged
posterior tibialis tendon relative to flexor digitorum and flexor hallucis
(black arrows) tendons. Also note how abnormal posterior tibialis
tendon is larger than tibialis anterior (open arrow).
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Fig. 17B. —60-year-old woman with hypertrophic tendon dysfunction. Axial
T1-weighted MR image (TR/TE, 500/12) (A) and T2-weighted MR image
(6500/90) (B) reveal posterior tibialis tendon tear with thickening
synovitis and internal signal intensity (white arrow). Note enlarged
posterior tibialis tendon relative to flexor digitorum and flexor hallucis
(black arrows) tendons. Also note how abnormal posterior tibialis
tendon is larger than tibialis anterior (open arrow).
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Normally, there may be a small amount of fluid around the tendon. If too
much fluid is present, the patient may have pain and dysfunction.
Additionally, fibrotic synovium contributes to the pathophysiology, causing a
thickened tendon. Also, fibrosing tenosynovitis, related to paratendonitis and
synovitis, causes thickening of the tendon
[29]. In fibrosing
tenosynovitis, the synovium may appear black on MR images
[30]. The dark adherent
synovium makes the tendon appear hypertrophic.
A posterior tibialis tendon tear with a gap is unusual. Usually, what is
seen is severe thinning of the posterior tibialis tendon with thin residual
threads clinically presenting as a dysfunctional tendon. The presence of an
interstitial tear with a longitudinal split of the posterior tibialis tendon
is also common (Figs. 18). This is the only type of posterior tibialis tendon disorder that appears with
high signal intensity on T2-weighted MR imaging, and it is almost invariably
associated with synovitis. Additionally, involvement of the spring ligament
may be seen with severe posterior tibialis tendon tears and some of the foot
deformities discussed next.
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Fig. 18. —58-year-old man with interstitial tendon tear. Axial
intermediate-weighted MR image (TR/TE, 4000/48) reveals enlarged posterior
tibialis tendon with several linear regions of signal splitting posterior
tibialis tendon into fasicles (arrow).
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The typical location of posterior tibialis tendon disorders is
perimalleolar, although they are epicentered somewhat distal to the malleolus
[31]. A second location at
which disorders occur is distal
[12]. Distal is a typical
location for injury in young athletic individuals and in patients with
inflammatory arthropathies.
Secondary Signs of Posterior Tibialis Tendon Dysfunction
The abnormal mechanics of the posterior tibialis tendon can result in
anatomic changes that appear on MR imaging. Although most MR imaging is not
performed while the tendons are bearing weight, MR imaging is a tomographic
technique, and subtle mechanical disturbances may be apparent. These secondary
signs can increase diagnostic confidence in describing subtle posterior
tibialis tendon disorders. Most of these signs are not pathognomonic of
posterior tibialis tendon dysfunction because they can be seen with other
causes of pes planus and foot faults. In addition, separation is made between
reducible and nonreducible deformities clinically. On MR imaging, the only
distinction is that nonreducible deformities tend to be more severe with
secondary osteoarthritic changes.
One mechanical disturbance is termed talonavicular fault
[12]. This is the result of
excessive plantar flexion of the talus. To evaluate this finding, use sagittal
MR imaging. On the sagittal image in which the base of the first metatarsal is
visible, a long axis is drawn on the talus and is extended into the navicular.
Failure of this line to divide a navicular into equal superoinferior parts,
with the line positioned inferiorly, is a manifestation of the talonavicular
fault and a dysfunctional posterior tibialis tendon
(Fig. 19).
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Fig. 19. —58-year-old woman with talonavicular fault. Sagittal T2-weighted MR
image (TR/TE, 500/10) reveals that line drawn along long axis of navicular
extends inferiorly rather than bisecting navicular.
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The second morphologic abnormality results from the unopposed pull of the
peroneus brevis shifting the entire mid- and forefoot laterally. This will
result in a navicular subluxing in relationship to the talus. Normally, the
articular aspect of the talus, when evaluated on proximal axial images, is 85%
covered by the navicular. Unopposed peroneal brevis pull causes the uncovering
of the talus. In the uncovered talus, less than 85% of the articular surface
is covered by the navicular
[11,
32]
(Fig. 20).
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Fig. 20. —50-year-old man with talonavicular unroofing. MR image (TR/TE,
7000/78) shows unroofing of upper aspect of talus with navicula subluxed
laterally (solid arrow), exposing medial talonavicular head, a
secondary sign of posterior tibialis tendon insufficiency. Patient also had
interstitial tear of posterior tibial tendon (open arrow).
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Another secondary finding of a posterior tibialis tendon disorder is a
focal spur in the distal tibia
[31]. Because the posterior
tibialis tendon normally sits in a slight concavity along the posterior medial
aspect of the tibia, this spur is a sharpening of the medial or uppermost
aspect of this concavity (Fig.
21).
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Fig. 21. —60-year-old woman with atrophic tendon and tibial spur. Axial
T2-weighted MR image (TR/TE, 6000/80) reveals thinned posterior tibialis
tendon (straight arrow) adjacent to spur (curved arrow)
characteristic of posterior tibialis tendon dysfunction.
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The last secondary sign of a posterior tibialis tendon tear is a heel
valgus revealed on coronal images (Fig.
22) comparing lines along the long axes of the calcaneus and the
tibia (Table 1). The normal
range is from 0° to 6° of valgus.
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Fig. 22. —55-year-old woman with tendon dysfunction and heel valgus. Coronal
fast short tau inversion recovery MR image (TR/TE, 4000/35; inversion time,
150) reveals heel valgus. Lines of reference go through long axes of tibia and
calcaneus.
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Marrow Abnormalities
Bone marrow findings related to posterior tibialis tendon disorders include
the accessory navicular, the cornuate navicular, and marrow edema. The former
two entities lead to a more proximal insertion of the posterior tibialis
tendon reducing the curve around the malleolus. This straightening of the
curve leads to focal attritional wear and tears of the posterior tibialis
tendon [11] (Figs.
4A,4B
and 6).
Posterior tibialis tendon disorders can also cause focal areas of marrow
edema. This marrow edema is typically seen underneath the course of the
posterior tibialis tendon, typically in the tibia and less commonly in the
talus and navicular. Usually, patients with marrow edema under the course of
the posterior tibialis tendon are symptomatic (Figs.
23 and
24). The presence of marrow
edema is somewhat more frequent in people with seronegative and seropositive
arthropathies. However, most marrow edema is seen in patients with routine
degenerative posterior tibialis tendon disorders. Interestingly, marrow edema
is frequently seen around the tibial spur and may be part of the evolution of
this spur.
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Fig. 23. —63-year-old woman with tendon dysfunction and subtendonous edema.
Coronal short tau inversion recovery MR image (TR/TE, 6000/40; inversion time,
150) reveals edema in medial malleolus related to posterior tibialis tendon
dysfunction (arrow).
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Fig. 24. —45-year-old man with subtendonous edema. Axial T2-weighted
fat-suppressed MR image (TR/TE, 6000/80) reveals edema (arrow) under
posterior tibialis tendon groove caused by posterior tibialis tendon
dysfunction. Image shows reactive marrow edema.
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The development of a pseudoarthrosis between the accessory navicular and
the native navicular is related to the posterior tibialis tendon. Chronic
posterior tibialis tendon pull can lead to fracture of the normal
synchondrosis. On MR imaging, fluid will be visible between the two bones,
with "kissing" marrow edema on either side of the pseudoarthrosis
(Fig. 25).
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Fig. 25. —38-year-old man with accessory navicular pseudoarthrosis. Axial
T2-weighted MR image (TR/TE, 6000/78) reveals fluid between navicular and
accessory navicular consistent with pseudoarthritis. Also note edema in both
bones (arrows) representing altered mechanics.
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Dislocations of the Posterior Tibialis Tendon
Dislocation of the posterior tibialis tendon is a rare injury that is often
diagnosed late. Radiographically, a dislocated posterior tibialis tendon can
be diagnosed by noting the presence of a small avulsion fracture by the
insertion of the flexor retinaculum on the medial malleolus. On MR imaging,
the posterior tibialis tendon is seen subluxed anteriorly and medially,
visible as the most medial aspect of the tibia rather than behind it
(Fig. 26). Although posterior
tibialis tendon dislocation is uncommon, this is the second most common
dislocation of ankle tendons, after peroneal dislocation. It also may be true
that repetitive transient subluxation is part of the pathophysiology of more
typical posterior tibialis tendon tears. The retromalleolar groove is usually
shallow in patients who dislocate their posterior tibialis tendon, and the
retinaculum may be visibly stripped off or torn. Infrequently, a related tear
in the tendon is discovered
[33]. The posterior tibialis
tendon can also sublux, often subtly, outside its groove
(Fig. 27).
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Fig. 26. —40-year-old man with dislocated posterior tibialis tendon. Axial
T2-weighted MR image (TR/TE, 6000/90) reveals posterior tibialis tendon to be
dislocated anteriorly out of its groove (solid arrow). Note how
normal flexor digitorum tendon (open arrow) remains posterior to
tibia while posterior tibialis tendon is subluxed medially and anteriorly.
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View larger version (153K):
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[as a PowerPoint slide]
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Fig. 27. —55-year-old woman with subluxed tendon. Axial proton
density-weighted MR image (4000/48) reveals posterior tibialis tendon
(straight arrow) to be slightly subluxed medially out of its groove
(curved arrow).
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Conclusion
The posterior tibialis tendon is one of the most commonly disordered
tendons in the body. Most patients present with dysfunction. This dysfunction
is relative to failure of the posterior tibialis tendon to perform its normal
function and to the unopposed force of the peroneus brevis. Patients can also
present with symptoms related to marrow edema or synovitis.
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