RESEARCH: Posterior tibial tendon dysfunction in rheumatoid arthritis.

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Posterior tibial tendon dysfunction in rheumatoid arthritis.

Michelson J, Easley M, Wigley FM, Hellmann D.

Department of Orthopaedic Surgery, s Hopkins Hospital and Medical

Institutions, Baltimore, land, USA.

Although hindfoot pathology in rheumatoid arthritis is a significant

cause of disability for patients, the etiology of the planovalgus

deformity is controversial. The present study surveys 99 patients

with clinically proven rheumatoid arthritis for the presence and

severity of hindfoot pathology. Specific attention was directed at

the function of the posterior tibial tendon, as disruption of this

structure has been implicated by some investigators as a cause of

hindfoot deformity in rheumatoid arthritis. Assessment of posterior

tibial function was by manual testing using two different grading

scales, as well as by examination for several signs associated with

posterior tibial tendon dysfunction. Between 13% and 64% of the study

population could be considered to have posterior tibial tendon

dysfunction, depending upon the specific diagnostic criteria used.

Using the presence of all three of the most stringent criteria for

diagnosis, 11% of patients were believed to have posterior tibial

tendon dysfunction. These criteria were loss of the longitudinal

arch, inability to perform a heel-rise, and lack of a palpable

posterior tibial tendon. This study demonstrates that planovalgus

deformity in rheumatoid arthritis can be due to clinically evident

dysfunction of the posterior tibial muscle-tendon unit. There is a

complex interplay between hindfoot joint disruption due to the

inflammatory process and deformity due to tendinous dysfunction. If

there is primary subtalar joint instability secondary to the

inflammatory process, the posterior tibial tendon is rendered

dysfunctional due to deranged hindfoot mechanics, as with primary

posterior tibial tendon rupture. Since treatment of either condition

(i.e., primary hindfoot instability or primary posterior tibial

tendon rupture) is similar, the distinction is not important clinically

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