Successfully reported this slideshow.
Activate your 14 day free trial to unlock unlimited reading.
Posterior Tibial Tendon Dysfunction
The Role of
Extra-Osseous TaloTarsal Stabilization
Michael E. Graham, D.P.M., F.A.C.F.A.S.
Founder: GraMedica, Graham International Implant Institute
Private Practice: Shelby Township, Michigan, USA
• We need to take a critical look at this very
• We need to take action to prevent the
progression of the disease progression.
• Why does PTTD occur?
• What are the best viable treatment options.
Patient presents with symptoms or concerns
due to excessive rearfoot motion.
Is this normal or is this pathologic?
This foot has a mechanical disadvantage.
This excessive pronatory motion has been
named as the most common etiology of the
majority of foot & ankle conditions.
This patient was not born with her
foot looking like this.
This is the result of years of “conservative” treatment.
Her specialists thought that they were “doing no harm”
in reality they have caused great harm.
Normal TaloTarsal Alignment
• Talus is sitting on top
of the calcaneus.
• The articular facets are
• The two bones are
• Sinus tarsi is in its
natural open position.
TaloTarsal Mechanism Talus acting on the
articulations with the
calcaneus and navicular
Middle & Anterior Facet
You cannot talk about the motion of the subtalar joint without
also discussing the talonavicular joint as even though there are 4
separate anatomical joints they function as
The articulations of the
talus on the
With the TTM in
Malposition of the
in malposition of
facets and also
• Ligaments function as a
supportive tissue to
assist in the alignment
of the osseous
• The alignment of the
talotarsal mechanism is
so important that there
is a major complex of
• The talus is the only
“foot” bone that does
not have a tendon
• Its motion is dependent
on the articular facets of
the tarsal mechanism,
capsular and ligament
send a signal to the
CNS which in response
sends a signal to the
muscle to contract to
provide support to the
Tibialis Posterior Muscle/Tendon Complex
• Functions to
supinate the foot.
• Strongest supinator
of the mid-foot
• Has to over-come
pronatory forces to
lift the foot for toe-
Additional Important Supportive
Structures to Tibialis Posterior Function
• Tendon sheath- helps the tendon glide behind the medial
malleolus and within the flexor retinaculum.
• Flexor retinaculum- keeps the tendon aligned for
Tibialis Posterior Tendon Insertions
Primary insertion in the navicular
tuberosity and secondary insertions
plantar aspects of the medial column of
THIS IS VERY IMPORTANT
Tibialis posterior inserts into the
medial/plantar aspect of the mid-foot
to supinate the medial column at late
mid-stance to toe off.
Tibialis Posterior Tendon
Why do good tendons go bad?
There is an underlying etiology to every
The goal is not to solely treat the symptom
but to eliminate
People are not born with
At birth our tendons are very
However, if the talotarsal
mechanism is not properly aligned
as a child a good healthy posterior
tibial tendon will slowly but surely
continue to become diseased.
Let’s take a closer look at the
talotarsal mechanism and how it
can significantly implant the
function of tibial posterior
Remember- talus is sitting on top of
the calcaneus, sinus tarsi is open, and
there is a normal cyma.
The articular facets of the talus are
perfectly aligned with the articular
facets of the calcaneus and navicular.
The talus slid off its normal position
off of the calcaneus. The articular
facets are not aligned. Sinus tarsi is
partially collapsed. The talus is
plantarflexing on tarsal mechanism.
Excessive abnormal forces are acting
on the medial column of the foot.
The navicular is forced out of position due to the excessive abnormal
forces from the talar displacement. This is a dynamic deformity occurring
with every step taken.
• Imagine that during the walking cycle with no weight on the
talotarsal mechanism- it is in alignment. At heel strike the
talus quickly displaces on the tarsal mechanism, it partially
dislocates anteriomedially to push the navicular down which
is forced to “drop”.
• Not only is the
forward it is also
• The talus is
responsible to transfer
the entire weight of
the body from the leg
above to the foot
Use your imagination.
Do you think will have a negative effective on the posterior tibial tendon? With
every step excessive abnormal forces are acting on the posterior tibial tendon.
Effect of navicular drop to the
tibialis posterior tendon
Effect of navicular drop
on tibialis posterior.
The poor tendon doesn’t have a chance, think about the damage being inflicted
thousands of times a day, day after day, week after week, month after month, year
after year, decade after decade.
Talus slips off the calcaneus resulting in partial
dislocation of the talotarsal mechanism.
This forces the navicular to eventually “drop”.
Tibialis posterior tendon is immediately
strain/elongated which decreases blood flow within
The strain is continually placed on the tendon until
more and more damage ensues.
What are the treatment options for
• Oral meds.?
• External braces?
• Calcaneal osteotomy?
• Triple Arthrodesis?
• Cannot stabilize the talus
• Cannot prevent the excessive talar motion
• Have to be used in shoes
• Have to find shoes to fit the device
• Not covered by most insurance companies
• Gives a false sense of correction
• Provides only minimal support
• The list goes on …..
Medial Displacement Osteotomy?
Just doesn't make a lot of sense.
There isn’t a deformity within the
calcaneus its above…the partial
displacement of the talus on the
Extra-Osseous TaloTarsal Stabilization
• It addresses the deformity
• Completely reversible
• Not dependent on external factors-shoes
• Can be performed on a wide age-range of
• Fast recovery, dependable results
• Early ambulation
• Effective correction
• Least amount of down time
• Least amount of complications
• Return to normal function
• Do no harm
• Why wait until they need a major
rearfoot reconstructive procedure?
Fix the cause,
don’t ameliorate the symptom(s).
• FDA 510(k) Sept 2004, CE 2006
• Routinely used in pediatrics, adults, geriatrics.
• Can be a stand alone or used in conjunction
with other surgical procedures (depending on
• Thousands have been successfully placed
• Placed in athletes of almost every sport
• When orthotics don’t give enough
• Prior to more radical rearfoot surgery
• There are limitations…foot must be
For further information