Acquired Flat-foot Pathway(Medial Ankle Pain Pathway/ Tibialis Posterior Dysfunction (TPD))

Clinical signs and symptoms

Patient Will

• complain of pain around medial malleolus which is often spontaneous at onset.

• struggle to perform a single leg heel raise

Patient May

• have simultaneous change in foot shape.• have obvious hindfoot valgus (deviation of Achilles Tendon towards midline)

and “too many toes” sign at lateral border of foot. • be locally swollen posterior/inferior to medial malleolus and tender on

palpation of tibialis posterior tendon.

Clinical Test – Heel raise

Ask patient to perform a heel raise on each leg - try for 8 to10 repetitions.

A patient without TPD should be able to do this without pain. A patient with TPD will struggle.

References/ Further reading

Kohls-Gazoulis J et al Tibialis posterior Dysfunction: a common and treatable cause of adult acquired flatfoot BMJ 2004; 329: 1328-33

Kulig K et al Nonsurgical management of Posterior Tibial Tendon Dysfunction with Orthoses and Resistive Exercise: A Randomised Controlled Trial Physical Therapy 2009; 89: 26-37

 When to refer to Sheffield MSK?

If you have a patient with both…

• spontaneous onset of medial ankle pain• who struggles to perform a single leg calf raise for up

to 8 to 10 repetitions