Tibialis Posterior Reconstruction

What is Tibialis Posterior Insufficiency and how is it caused?

Tibialis Posterior Insufficiency (TPI) is the most common cause of a flat foot or “dropped arches” in adults, and typically affects women in their 40s or 50s. In this condition, the Tibialis Posterior tendon, which acts as a “guy rope” to hold up the arch of the foot, suffers wear and tear damage, and stretches or ruptures. This allows the arch of the foot to drop further, and also causes inflammation and pain in the tendon.

What are the symptoms?

The arch of the foot drops.

Swelling and pain on the inner ankle / inside of foot.

Pain with standing or walking for long periods.

Difficulty with footwear.

What treatments are available?

The initial treatment is usually insoles or shoe modifications along with observation, to ensure significant stiffness does not develop. Anti-inflammatory painkillers, weight loss, modification of activities and change of footwear may also help. If non-operative measures fail, then surgery may be necessary, to reconstruct the shape of the foot.

What does the operation involve?

The operation is carried out under general anaesthesia, often supplemented with a local anaesthetic block for pain relief. The most common type involves an osteotomy (cutting and moving sideways) of the heel bone, a tendon transfer and ligament reconstruction. A small implant may also be placed just below the ankle, which is removed again about 6 months later. The surgery is major, and will be discussed with you in detail by your surgeon.

What about pain?

Whilst you are in hospital you will be monitored and the medical staff will give you painkillers as required and prescribed. You will be given painkillers and instructions on management of the pain by the nursing staff before you leave hospital.

How long does recovery take?

Most patients remain in hospital for 1–2 days after the operation. You will have a temporary cast below the knee, and will be required to non-weight bear with crutches initially.

Your temporary cast and wound dressings will be changed and stitches removed (if applicable) at the clinic during your follow-up appointment, which is usually about 10 days after the operation.

Swelling is quite common after foot and ankle surgery and this is best managed by elevating the foot at regular intervals. You are advised to elevate the operated foot/ankle on a pillow every night and during the day on three separate occasions, e.g. 11am, 3pm and 6pm for about one hour each time. The above measures will help to reduce swelling of the ankle. These instructions should be followed for at least 10-14 days.

After 10-14 days, you will be placed in a definitive below-knee cast, but will not be allowed to weight-bear at that stage. You must keep this cast dry. The length of time until weight-bearing is permitted varies with the operative technique used, and you should ask your surgeon about this before the operation. After 6 weeks, you will be allowed “protected weight-bearing” in a special removable walker-boot. The usual length of time until unprotected weight-bearing is 10 – 12 weeks.

Patients having had the left ankle operated on will be able to drive an automatic car within 2-3 weeks (short distances only to avoid swelling). Those who have had an operation on the right side will be able to drive after about 12 weeks.

You are advised not to fly after surgery for about six weeks.

If you have a desk job and are able to get to work, you should be able to return to work with your foot up in the boot or plaster after 2-4 weeks. If on the other hand you do manual work, you will need at least 12 weeks off work.

After Tibialis Posterior reconstruction the ankle is stiff, but often patients are very stiff prior to surgery and loss of movement is seldom noticed. Golf, walking and even running short distances are all possible after a successful reconstruction.

What can go wrong?

All operations have an in-built risk and complication rate. The risks for Tibialis Posterior reconstruction are as follows:


Prolonged swelling.

Nerve or blood vessel injury.

Stiffness of the ankle.

Deep vein thrombosis (clot in vein).

Pulmonary embolus (clot in lung).

Delayed union or Non-union (failure of bone to join).

Malunion (bone joins in imperfect position).

Post-operative pain (including complex regional pain syndrome).

Residual or recurrent deformity.

Over-correction of deformity (pes cavus).

The above complications are rare but can occur.