MRI tibial tendonitis

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

Click here: Second Opinion Arthritis Treatment Kit

Posterior tibial tendonitis is a common problem due to injury involving the posterior tibial tendon.

This tendon helps to support the arch of the foot and prevents the foot from rolling in too much.

When damaged, the tendon injury causes typical symptoms. Symptoms include pain at the instep of the foot, especially along the course of the tendon. The tendon runs just behind the medial malleolus (inside ankle bone). There may be burning, tingling, shooting or stabbing pain present in the foot. If a patient is asked to stand on their toes, intense pain will occur in the arch of the foot.

• This condition can be caused by strain, degeneration and rupture of the tendon. The inflammation of the tendon is a secondary reaction.
• Initially, there is irritation of the outer covering of the tendon. This is called peritendonitis. This leads to degeneration of the tendon, which causes the tendon to become thicker. The tendon then becomes weaker and loses its strength; this can lead to a complete rupture of the tendon.
• Patients with flat feet are at risk
• Tight heel cords (Achilles tendon) can lead to posterior tibial tendonitis.
• Walking or running up hill, i.e. golf courses or marathon running can be the trigger for tendonitis in this area.

The diagnosis is based on both a history and a physical examination. The physician may ask the patient to stand with bare feet facing away from him to view how the foot appears. As the condition progresses, the front of the affected foot will start to slide to the outside.

From behind, it will look as though the patient has "too many toes" showing. The heel may slant outwards. The patient may also be asked to stand on their toes or to do a single heel rise: stand with hands on the wall, lift the unaffected foot off the ground, and raise up on the toes of the other foot. Normally, the heel will rotate inward; the absence of this sign indicates posterior tibial tendon dysfunction. The doctor may request X-rays, an ultrasound or a magnetic resonance image (MRI) of the foot. MRI can not only diagnose tendonitis, it can also let the physician know if the tendon is ruptured.

Another diagnostic modality that is almost as sensitive as MRI is diagnostic ultrasound.


• Rest
• Ice
• Compression
• Anti-inflammatory medication
• Cease all sporting activities and try and stay off feet as much as possible.
• Orthoses (insoles) may be necessary. These will help to support the arch region of the foot.
• In severe cases surgery may be necessary to repair the tendon.

However, a newer treatment for tendonitis may be more effective without the need for surgery if done early enough.

Percutaneous needle tenotomy is a technique where a small gauge needle is introduced using local anesthetic and ultrasound guidance. The needle is used to poke several small holes in the tendon. This procedure is called "tenotomy." Tenotomy induces an acute inflammatory response. Then, platelet rich plasma, obtained from a sample of the patient's whole blood is injected into the area where tenotomy has been performed. Platelets are cells that contain multiple healing and growth factors. The result? Normal good quality tendon tissue is stimulated to grow with natural healing.

Without treatment, the flatfoot that develops from posterior tibial tendon dysfunction eventually becomes fixed. Arthritis develops in the hindfoot. Pain increases and spreads to the outer side of the ankle. The way a person walks may be affected and wearing shoes may be difficult.

The treatment will depend on how far the condition has progressed. In the early stages, posterior tibial tendon dysfunction can be treated with rest, non-steroidal anti-inflammatory drugs such as aspirin or ibuprofen, and immobilization of the foot for 6 to 8 weeks with a rigid below-knee cast or boot to prevent overuse. After the cast is removed, shoe inserts such as a heel wedge or arch support may be helpful. If the condition is advanced, the doctor may recommend that a custom-made ankle-foot orthosis or support.

If conservative treatments don’t work, the doctor may recommend surgery. Several procedures can be used to treat posterior tibial tendon dysfunction; often more than one procedure is performed at the same time. The doctor will recommend a specific course of treatment based on the individual case. Surgical options include:

• Tenosynovectomy. In this procedure, the surgeon will clean away (debride) and remove (excise) any inflamed tissue surrounding the tendon.
• Osteotomy: This procedure changes the alignment of the heel bone (calcaneus). The surgeon may sometimes have to remove a portion of the bone.
• Tendon transfer: This procedure uses some fibers from another tendon (the flexor digitorum longus, which helps bend the toes) to repair the damaged posterior tibial tendon.
• Lateral column lengthening: In this procedure, the surgeon removes a small wedge-shaped piece of bone from the hip and places it into the outside of the heel bone. This helps realign the bones and recreates the arch.
• Arthrodesis: This procedure fuses one or more bones together, eliminating movement in the joint. This stabilizes the hindfoot and prevents the condition from progressing further.

For more information on newest approaches to tendonitis, visit our sister site:
Tendonitis provides reliable, accurate, and useful information on tendonitis treatment written by a board-certified rheumatologist. Learn more about how to get tendonitis relief using the most up-to-date methods.

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