A patient, aged 49 years, presented to the office with left foot and ankle pain for approximately two years. The patient noted he had been flat footed for quite some time.
He stated most of his pain seemed to be in the medial and lateral ankle with occasional pain in the mid-foot.
On exam, the patient’s right foot is pes planus alignment and a “too many toes sign” was noted. Significant pain and limited motion was present with subtalar, calcaneal-cuboid, and talonavicular motion.
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The posterior tibial tendon runs posterior to the medial malleolus and the main portion inserts into the tuberosity of the navicular.
The tibialis posterior muscle and tibialis posterior tendon (more commonly called posterior tibial tendon) functions to invert and help plantar flex the foot and ankle. The main function of the posterior tibial tendon is to support the structures of the medial ankle and arch.
The posterior tibial tendon may degenerate over time causing loss of support to the medial arch. As a result, a flatfoot develops.
A typically deformity includes pes planus, hindfoot valgus, and forefoot abduction. When the deformity is viewed from behind the patient a “too many toes sign” may be present, demonstrated in the image above.
- Conti SF, Lalonde KA. AAOS Orthopedic Knowledge Online Journal. 2007; 5 (1).