The Journal of Foot & Ankle Surgery 50 (2011) 320–328

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The Journal of Foot & Ankle Surgery

journal homepage: www.jfas.org

Review Articles

3-Tesla Magnetic Resonance Imaging Evaluation of Posterior Tibial Tendon

Dysfunction with Relevance to Clinical Staging
Avneesh Chhabra, MD 1, Theodoros Soldatos, MD 2, Majid Chalian, MD 2, Neda Faridian-Aragh, MD 2,
Jan Fritz, MD 3, Laura M. Fayad, MD 4, John A. Carrino, MD, MPH 5, Lew Schon, MD 6
1
Assistant Professor of Radiology and Orthopaedic Surgery, Department of Radiology and Radiological Science, The Johns Hopkins Hospital, Baltimore, MD
2
Research Fellow, Department of Radiology and Radiological Science, The Johns Hopkins Hospital, Baltimore, MD
3
Resident in Radiology, Department of Radiology and Radiological Science, The Johns Hopkins Hospital, Baltimore, MD
4
Orthopaedic Surgeon, Department of Radiology and Radiological Science, The Johns Hopkins Hospital, Baltimore, MD
5
Associate Professor of Radiology and Orthopaedic Surgery, Department of Radiology and Radiological Science, The Johns Hopkins Hospital, Baltimore, MD
6
Director, Foot and Ankle Services, Union Memorial Hospital, Baltimore, MD

a r t i c l e i n f o a b s t r a c t

Level of Clinical Evidence: 5 The posterior tibial tendon (PTT) is the most important dynamic stabilizer of the medial ankle and longitudinal
Keywords: arch of the foot. PTT dysfunction is a degenerative disorder of the tendon, which secondarily involves multiple
foot ligaments, joint capsules, fascia, articulations, and bony structures of the ankle, hindfoot, midfoot, and forefoot.
pes planovalgus When the tendon progressively attenuates, the patient develops a painful, progressive collapsed flatfoot or pes
staging
planovalgus deformity. This comprehensive review illustrates the 3-Tesla magnetic resonance imaging (3T
surgery
MRI) features of PTT dysfunction. In addition, the reader will gain knowledge of the expected pathologic
findings on MRI, as they are related to clinical staging of PTT dysfunction.
Ó 2011 by the American College of Foot and Ankle Surgeons. All rights reserved.

Posterior tibial tendon (PTT) dysfunction is a well-defined has been in use and widely described in the orthopedic literature
progressive degenerative disorder that may present with ankle and (Table 1).
foot pain, weakness, gait abnormalities, and/or worsening foot
deformity. The diagnosis of PTT dysfunction is usually based on the
history and physical examination, although magnetic resonance Normal Anatomy, Function, and MRI Appearance of the PTT
imaging (MRI) is commonly used to confirm the clinical findings,
assess equivocal cases, exclude other related etiologies, such as The posterior tibial muscle is the most central and deepest flexor
planter fasciitis, or provide a preoperative evaluation of the ankle muscle of the calf. It originates from the posterior surfaces of the
joint, in case surgical intervention is contemplated (1, 2). Since the proximal tibia, fibula, and interosseous membrane, and courses
early reports describing the MRI features of PTT dysfunction, the inferiorly within the deep posterior compartment to converge into
incorporation of higher-field MRI scanners, optimized extremity coils, a tendon at the distal third of the leg (7). Using the medial malleolus
and novel pulse sequences have provided exquisite imaging quality as a pulley, the PTT runs along the retromalleolar groove and then
and higher diagnostic accuracy in the evaluation of ankle pathology. A enters the tarsal tunnel, held in position throughout its course by the
pictorial correlation of 3-Tesla (T) MR imaging features with clinical flexor retinaculum. The major tendon fibers attach to the tuberosity of
findings and suggestion of an MRI staging approach to the radiologist the navicular bone, whereas smaller bands insert to the second and
based on the review of the available literature and our experience in third cuneiforms, the cuboid, and the bases of the second to fourth
this arena are presented. Various primary and secondary MRI features metatarsals plantarly (7, 8). An additional small branch arises
of PTT dysfunction are correlated to the clinical staging system, which between the medial malleolus and the navicular tuberosity to insert
onto the anterior aspect of the sustentaculum tali (9). The posterior
tibial muscle inverts the hindfoot and midfoot and assists in the
Financial Disclosure: None reported. plantar flexion of the foot and ankle, acting synergistically with the
Conflict of Interest: None reported. flexor hallucis longus and flexor digitorum longus (FDL) muscles and
Address correspondence to: Avneesh Chhabra, MD, Assistant Professor of Radi- in concert with the gastrocnemius-soleus complex. During the
ology and Orthopaedic Surgery, Department of Radiology and Radiological Science,
The Johns Hopkins Hospital, 601 North Caroline Street, Room 4214, Baltimore, MD
normal toe-off stage of gait, the posterior tibial muscle locks the
21287. transverse tarsal joints (calcaneocuboid and talonavicular), creating
E-mail address: [email protected] (A. Chhabra). a rigid hindfoot and midfoot and thereby providing dynamic support

1067-2516/$ - see front matter Ó 2011 by the American College of Foot and Ankle Surgeons. All rights reserved.
doi:10.1053/j.jfas.2011.02.004
 A. Chhabra et al. / The Journal of Foot & Ankle Surgery 50 (2011) 320–328 321

Table 1
Clinical, pathological, and MRI staging along with the treatment options for posterior tibial tendon dysfunction

Stage Posterior Tibial Tendon Clinical Findings MRI Findings Treatment Options3–6
and Foot Pathology
I
PTT tenosynovitis
Pain and swelling on the
Insertional tendinosis
Immobilization

Mild hindfoot deformity medial side of the ankle
Tenosynovitis
Shoe modifications

Mild weakness
Medial arch supports

NSAIDs

Cryotherapy

Stirrup brace

Custom ankle foot orthoses

PRP injection, shockwave

Tenosynovectomy

Arthoereisis
II
PTT elongated and/or torn
Possible pain along PTT
Type I/II tear with tendinosis
Foot orthoses

Possible sinus tarsi pain and/or tenosynovitis
Stirrup brace

Weak limb
Talar fault and/or hindfoot
AFO

Inability to rise up on the forefoot valgus þ/–
Shoe modifications:
and perform heel raise
Spring ligament abnormality medial heel wedge,

Mild deformity of hindfoot at medial stabilizer medial outflare
midfoot pronation and
FDL transfer
forefoot abduction
Kidner procedure

Pes planovalgus
Cotton osteotomy

Loss of arch height (apropulsive gait)
Tendo-Achilles lengthening

Medial column instability
Medial displacement

Varus forefoot calcaneal osteotomy

Foot abduction
Spring ligament reconstruction

Too many toes sign
Lateral column lengthening

Flexible flatfoot (with stress maneuver)
Medial column fusion

Inability to plantar flex and invert
with foot past the midline

Achilles contracture
III
PTT degeneration
Fixed hindfoot valgus
Type II/III tear with severe
Custom bracing,

Sinus tarsi pain tendinosis and/or tenosynovitis if not surgical candidate

Rigid flatfoot (without stress maneuver)
Talar uncoverage
Triple arthrodesis

Inability to activate any inversion
Hindfoot valgus
Lateral column lengthening
except that which occurs through
Spring ligament abnormality
the anterior tibial tendon
Tibiospring (superficial deltoid)
ligament abnormality

Early signs of talocalcaneal and/or
calcaneofibular impingement

Subtalar joint osteoarthritis
IV
Incompetent deltoid ligament
Fixed hindfoot and tibiotalar valgus Above findings with additional:
Surgery for hindfoot valgus

Degenerative changes of the
Chronic superficial and deep deltoid sprain and associated deformity
hind- and midfoot joints
Tibiotalar and subtalar joint osteoarthritis
Deltoid reconstruction

Talocalcaneal and Calcaneofibular
Tibiotalocalcaneal or
impingement pantalar fusion osteotomy

Abbreviations: AFO, ankle-foot orthosis; FDL, flexor digitorum longus; MRI, magnetic resonance imaging; NSAIDs, nonsteroidal anti-inflammatory drugs; PRP, platelet-rich plasma;
PTT, posterior tibial tendon.

for the medial longitudinal arch of the foot (8, 10, 11). Conversely, MRI provides exquisite visualization of the PTT. Table 2 presents
during heel strike to the foot flat stage of gait, the tendon allows for a typical 3T MRI protocol for the evaluation of the ankle. At the level
unlocking of these joints, which permits gradual and controlled shock of the ankle joint, the PTT is the largest and most medial of the 3
attenuation and smooth transition from a dorsiflexed ankle to one in flexor tendons, featuring an ovoid shape with approximately twice
neutral position. the diameter of the FDL tendon (Figure 1). The normal PTT
demonstrates uniform low signal intensity on all pulse sequences,
Table 2
A typical ankle MRI protocol at 3-Tesla (Trio and Verio systems; Siemens Medical
but areas of artificially increased signal may be observed on short
Solutions, Erlangen, Germany) echo time (TE) images in the distal PTT owing to the magic angle
phenomenon (12, 13). On long-TE sequences, a minimal amount of
Imaging Step FOV TR/TE TF NSA Flip Angle
fluid may be observed around the tendon, which is considered
1. Three-plane scout GRE 28 7.3/3.6 1 20
d
normal, whereas when circumferential or greater than 2 mm in
2. Sagittal T2-weighted TSE, FS 14 3890/38 19 2 160
3. Sagittal PDW TSE, no FS 13 3000/30 15 2 160 thickness, it is considered abnormal. Near the navicular insertion,
4. Axial PDW TSE, FS 12 2830/34 11 2 137 the terminal 2 to 3 cm of the PTT may appear minimally hetero-
5. Axial PDW TSE, no FS 12 2830/34 11 2 137 geneous because of an inherent broadening and interposing of
6. Coronal PDW TSE, no FS 12 3600/31 15 2 145 connective tissue, and also because of magic angle phenomenon (9).
Abbreviations: d, no turbo factor; FOV, field of view (cm); FS, fat saturation; GRE, The PTT sheath extends up to 1 to 2 cm proximal to the navicular
gradient-recalled echo; NSA, number of signals acquired; PDW, proton density– insertion and, therefore, any amount of fluid-like signal surrounding
weighted (intermediate-weighted); TE, echo time (ms); TF, turbo factor (echo train
the distal tendon is abnormal and referred to as paratendonitis
length); TR, repetition time (ms); TSE, turbo spin echo. Flip angle is presented in
degrees. rather than tenosynovitis (13).
322 A. Chhabra et al. / The Journal of Foot & Ankle Surgery 50 (2011) 320–328

Fig. 1. Axial proton density–weighted images at the levels of the retromalleolar groove (A) and at the navicular tubercle (B) demonstrate the normal appearance of the posterior tibial
tendon (white arrows), as well as its relationship with the adjacent flexor digitorum longus (black arrows) and flexor hallucis longus (arrowheads).

At the navicular insertion, an os naviculare may exist as a normal Pathophysiology of PTT Dysfunction
variant in up to 28% of the population. Three types of os naviculare
have been described and include an ossicle located within the PTT dysfunction may be the result of acute trauma or chronic
substance of the distal PTT (type I); an ossicle connected to the progressive tendon degeneration. Physiologic PTT degeneration is
navicular bone through a synchondrosis, which may demonstrate expected with aging, although obesity, steroid exposure, and a variety
trace or no T2 hyperintense fluid-like intensity within the syn- of systemic diseases, such as collagen vascular disease, gout, and
chondrosis (type II); and an ossicle that is fused medially with the diabetes mellitus, as well as previous local surgery or trauma, may
navicular bone (type III). Of the above, type I is seen in 30% to 40% of accelerate this process. PTT dysfunction is more commonly seen in
cases and types II and III in 50% to 60% of cases. Type II has been most females during the fourth to sixth decades, and occasionally as the
commonly implicated to predispose to PTT dysfunction (14). result of an acute trauma in young athletes who participate in high-

Fig. 2. A 48-year-old man with stage I posterior tibial tendon dysfunction. Axial fat-suppressed proton density–weighted image (A) demonstrates posterior tibial tendon tenosynovitis
along with adjacent soft tissue edema. (B) Clinical photograph from another patient with Stage I disease in the left foot. During heel raise the patient’s heel assumes less varus compared to
the contralateral side because of pain-induced weakness. During seated evaluation, the patient had normal active excursion of the foot and ankle into inversion and was able to cross the
midline by 60 degrees. The tendon’s tension and mechanical ability is not affected in stage I.
 A. Chhabra et al. / The Journal of Foot & Ankle Surgery 50 (2011) 320–328 323

repetition sports activities (2, 15). The presence of an os naviculare

may accelerate the PTT degeneration process or be a focal point of
structural failure.
A wide range of PTT abnormalities may be associated with
dysfunction, ranging from insertional tendinosis and tenosynovitis to
complete tendon rupture or insertional avulsion (16). In the setting of
PTT dysfunction, the combined propulsive forces of the gastrocne-
mius and soleus muscles act at the metatarsal heads instead of the
hindfoot and midfoot, exposing the latter to excessive stress and
leading to a loss of stability at the midtarsal joint. Subsequently,
collapse of the medial longitudinal arch occurs, resulting in uncov-
ering of the talus by a laterally shifting navicular and inferomedial
migration of talus head along with a heel valgus (calcaneovalgus),
eversion of the subtalar joint, and abduction of the foot at the talo-
navicular joint (17). As a result, the shoulder of the body of the talus
rotates distally and impinges into the calcaneus at Gissane’s angle.

MRI Depiction of PTT Dysfunction

Because of its multiplanar imaging capability and superb soft

tissue contrast resolution, MRI is considered the imaging modality of
choice for the evaluation of PTT dysfunction. MRI demonstrates
a sensitivity of 95%, a specificity of 100%, and an accuracy of 96% in
identifying disorders of the tendon (18). The MRI findings may be
divided into primary, which reflect the alterations of the PTT itself,
and secondary, which correspond to the injuries of associated struc-
tures. The MRI features may be prudently categorized into an
imaging-based classification system, which corresponds to the clin-
ical staging (3, 7, 17, 19), thereby assisting in the treatment decision
process (Table 1). This classification system is based on the experience
of the authors at their respective centers. The MRI descriptions of Fig. 3. A 40-year-old woman with stage I posterior tibial tendon dysfunction. Axial proton
these findings have been individually addressed below. density–weighted image demonstrates insertional tendinosis of the posterior tibial
tendon (arrow).

Primary Findings
rupture, there is additional fibrosis or fatty atrophy of the posterior
Primary findings may include tenosynovitis, tendinosis or ten- tibial muscle (17). Finally, in the rare anteromedial dislocation of the
dinopathy, partial- or full-thickness tears, and avulsions of the PTT, there is subluxation of the tendon out of its normal osseous
navicular insertion, as well as anteromedial dislocation of the tendon groove, associated with stripping or avulsion of the overlying flexor
(16, 20). Tenosynovitis typically appears as circumferential T2 retinaculum (9). In the presence of any of the above primary findings,
hyperintense fluid around the tendon within a normal or thickened the radiologist should carefully assess for secondary findings as
tendon sheath (Figure 2). If the fluid is noncircumferential, tenosyn- detailed below.
ovitis can still be suspected if the fluid is located in the nondependent
portion of the sheath, or if the PTT is the only tendon among the Secondary Findings
medial-sided tendons exhibiting a sheath fluid collection (2). Teno-
synovitis and/or associated synovial thickening may lead to swelling Spring Ligament Failure
of the adjacent soft tissues, which may extend from the medial mal-
leolus to the navicular bone (20). In tendinosis or tendinopathy, the The spring ligamentous complex is a static stabilizer of the
PTT is thickened (greater than twice the size of the FDL tendon) and longitudinal arch of the foot (24, 25). The ligamentous complex
exhibits normal or heterogeneous signal intensity, less than fluid, on consists of the superomedial oblique, medioplantar, and inferoplantar
T1- and T2-weighted images (Figure 3). In the authors’ experience, the bundles. The superomedial bundle is the strongest and most impor-
most common early finding is the presence of insertional tendinosis tant part of the complex. In PTT dysfunction, the superomedial bundle
or tendinopathy. The latter is readily depicted on axial 3T images and is strained, due to the lost dynamic support provided by the PTT,
should be confirmed in multiple planes to avoid the pitfall of the undergoing gradual attenuation and eventually rupture (26). In the
magic angle phenomenon. PTT tears are usually located posterior to latter setting, MRI demonstrates thickening or attenuation of the
the medial malleolus, and can extend proximally or distally (2). A ligament, and less commonly abnormal signal intensity, sub-
staging system has been used to classify these tears, correlating MRI ligamentous edema, or complete rupture (Figures 5 and 6B). Although
findings with surgical observation. In type I injury, the tendon less common, similar changes may also be observed in the medi-
remains homogeneous, but is slightly enlarged (greater than twice the oplantar bundle along with ganglion formation on MR images.
size of the FDL tendon) and shows one to two longitudinal splits
(Figure 4). In type II injury, the tendon appears heterogeneous and Sinus Tarsi Syndrome
attenuated (similar to the FDL tendon in thickness), and additionally
shows wider longitudinal splits. In type III injury, there is a complete When the PTT fails, the ligaments of the sinus tarsi are exposed to
or near-complete tear of the PTT with a few or no remaining intact increased stress, and ultimately fail, leading to pain in the sinus tarsi.
fibers (21–24). Tenosynovitis is commonly associated. In chronic PTT In the early stages, MRI displays foci of obliteration of the sinus tarsi
324 A. Chhabra et al. / The Journal of Foot & Ankle Surgery 50 (2011) 320–328

Fig. 4. A 60-year-old woman with stage II posterior tibial tendon dysfunction. Axial fat-suppressed proton density–weighted image (A) demonstrates longitudinal split tear of the posterior
tibial tendon (arrow). Intraoperative photograph from another patient (B) shows hypertrophic-type posterior tibial tendon tear, which was treated by flexor digitorum longus transfer (C).

Fig. 5. A 68-year-old woman with stage III posterior tibial tendon dysfunction. Coronal proton density–weighted images with (A) and without (B) fat suppression exhibit noninsertional
near-full-thickness tear of the posterior tibial tendon (black arrow), disruption of the flexor retinaculum (black arrowhead), sprain of the superomedial oblique (white arrowhead) and
medioplantar (white arrow) bundles of the spring ligament, as well as thickening of the tibiospring ligament (asterisk). Notice the marked hindfoot valgus, midfoot abduction, and the “too
many toes sign” in the left foot (C).
 A. Chhabra et al. / The Journal of Foot & Ankle Surgery 50 (2011) 320–328 325

Fig. 6. A 58-year-old woman with stage III posterior tibial tendon dysfunction. Sagittal fat-suppressed T2-weighted image (A) demonstrates talar uncovering, thickened medioplantar
bundle of spring ligament (arrowhead), and acute on chronic plantar fasciitis (arrow). Coronal proton density–weighted images with (B) and without (C) fat suppression exhibit thickening
of the medioplantar bundle of the spring ligament (arrow) and hindfoot valgus, respectively. Axial fat-suppressed proton density–weighted image of the same patient displays insertional
tendinosis, paratenonitis, and partial tear of the posterior tibial tendon, as well as adjacent adventitial bursitis.

fat with multifocal areas of T1 hypointensity and T2 hyperintensity Talonavicular Malalignment

within the sinus tarsi, indicating edema, granulation tissue, and
developing fibrosis (Figure 6D). In chronic stages, there is complete The acquired flatfoot deformity is associated with unroofing and
obliteration of the ligaments and diffuse T1 and T2 hypointensity plantar flexion of talus. Unroofing is best depicted on axial images,
within the sinus tarsi, reflecting fibrosis (27, 28). The soft tissue where the top of the navicular now covers less than 85% of the
impingement in this location will eventually turn into bony abutment, articular surface of the talus. Plantar flexion is best demonstrated on
which may further exacerbate the pain, when the shoulder of the sagittal images, where a line drawn along the long axis of the talus lies
talus impacts into the calcaneus at Gissane’s angle. In these situations, plantar to the navicular bone and axis of first metatarsal (Figure 6A)
MRI demonstrates bone edema in one or both structures. (29).

Fig. 7. A 27-year-old woman with posterior tibial tendon dysfunction. Axial T2-weighted (A) and fat-suppressed proton density–weighted (B) images demonstrate a type II os naviculare,
along with edema across the synchondrosis (arrows). There is insertional tendinosis and paratenonitis of the posterior tibial tendon, as well as adjacent adventitial bursitis.
326 A. Chhabra et al. / The Journal of Foot & Ankle Surgery 50 (2011) 320–328

Fig. 8. A 64-year-old woman with stage IV posterior tibial tendon dysfunction. Axial proton density–weighted (A) and coronal short-tau inversion recovery (B) images demonstrate an
attenuated posterior tibial tendon (arrows), which features almost the same size as the adjacent flexor digitorum longus. Low-grade articular cartilage loss in seen in the tibiotalar joint (B).
Exaggerated hindfoot valgus has resulted in calcaneofibular impingement, with subchondral marrow edema in the opposing surfaces of the calcaneus and fibula (B). Sinus tarsi syndrome
is apparent on a T1-weighted image of the same study (C).

Plantar Fasciitis portion of deltoid, connects with the spring ligament proper. In
PTT dysfunction, this ligament fails early on, followed by other
An association between PTT dysfunction and plantar fasciitis has components of the deltoid ligament (Figure 5A, B). MRI may
been described (30). In this setting, the plantar fascia demonstrates exhibit attenuation, thickening, and loss of linear fatty striations in
focal or diffuse thickening (>4 mm) and intermediate or high T2 the deep portion of the ligament, indicating chronic sprain. In
signal intensity (Figures 6A and 7D) (29). Less common findings some cases, partial- or full-thickness tears of the deltoid may also
include edema of the perifascial planes and bone marrow edema of be associated owing to superimposed recent episodes of injury
the calcaneal tuberosity (31, 32). (19, 26).

Deltoid Ligament Failure Medial Malleolus and Flexor Retinaculum Changes, and Findings
Associated with Os Naviculare
The deltoid ligament is a medial static constraint of the longi-
tudinal arch of the foot and is not usually affected until late in the In chronic tears of the PTT, the repetitive friction of the tendon over
course of PTT dysfunction. The tibiospring ligament, the superficial the posteromedial aspect of the medial malleolus leads to reactive
 A. Chhabra et al. / The Journal of Foot & Ankle Surgery 50 (2011) 320–328 327

Fig. 9. A 53-year-old woman with posterior tibial tendon dysfunction surgically treated with flexor digitorum longus (FDL) tendon transfer and calcaneal osteotomy. In a preoperative
axial T2-weighted image (A) a type I os naviculare (arrow) is apparent. From a postoperative MRI examination performed 1 year after the operation, presented are axial proton density–
weighted (B), coronal fat-suppressed proton density–weighted (C), and sagittal fat-suppressed T2-weighted (D) images, which demonstrate tear and proximal retraction of the FDL tendon
from the navicular tuberosity (arrow in B and C), thickening of the superomedial bundle of the spring ligament (arrowhead in C), as well as calcaneal postsurgical changes with thickening
of the proximal plantar fascia (arrowhead in D).

bone marrow edema, periostitis, and eventually bony changes Hindfoot Planovalgus Deformity
(18, 32). Similarly, the overlying anterior portion of the flexor reti-
naculum demonstrates associated thickening (9). In patients with When the PTT and subsequently spring ligament fail, the antago-
a type II or III os naviculare, other findings may include stress-related nistic action of the peroneus brevis tendon becomes unopposed. This
edematous, cystic, or sclerotic changes across the synchondrosis; leads to medial longitudinal arch collapse, and ultimately to a plano-
insertional tendinosis or tears, and paratendonitis, as well as adven- valgus deformity of the hindfoot. On MRI, a tibiocalcaneal angle of
titial bursa formation (Figure 7) (14, 33). greater than 6 degrees accurately characterizes this abnormality
328 A. Chhabra et al. / The Journal of Foot & Ankle Surgery 50 (2011) 320–328

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