Tibialis Posterior Recession

Thomas S. Roukis, DPM, PhD, FACFAS1

The equinocavovarus deformity that results from tibialis posterior musculotendinous contracture poses
a treatment challenge that has few reliable conservative or surgical remedies. In this techniques report,
the author describes a tibialis posterior recession procedure that uses the sequential use of topographic
anatomical landmarks, which can be useful in correcting contracture of the tibialis posterior musculoten-
dinous unit. (The Journal of Foot & Ankle Surgery 48(3):402–404, 2009)

Key Words: contracture, deformity, equinocavovarus, musculotendinous imbalance, ulceration

C ontracture of the tibialis posterior musculotendinous unit

represents a significant pathological process that is often
associated with equinocavovarus foot deformity (1–6).
Conservative treatment options, including stretching, splint-
ing, and serial cast application until a rectus alignment is
achieved, are rarely successful (4, 5). Surgical treatment
options, consisting of tendo-Achilles lengthening in isolation
or combined with posterior capsule release and tibialis poste-
rior tendon lengthening in the foot or at the level of the medial
malleolus have also been described (1, 4, 5); however, these
procedures typically require prolonged periods of ankle
immobilization to achieve an adequate degree of tendon heal-
ing. Additionally, placement of incisions about the midfoot
and medial aspect of the ankle can be prone to ischemia
and motion induced wound-healing problems especially,
and this is particularly true in high-risk patients with multiple
comorbidities (6). Laborde (7, 8) described the use of the ti-
bialis posterior ‘‘intra-muscular lengthening’’ for treatment
of plantar fifth metatarsal and cuboid ulcerations in patients
with diabetes, peripheral sensory neuropathy, and structural
deformity (ie, soft tissue ankle equinus and tibialis posterior
contracture). In his detailed description of the technique (8),
Laborde stated the following: ‘‘The incision was medial and
proximal to the ankle. At the musculotendinous junction, the
Address correspondence to: Thomas S. Roukis, DPM, PhD, FACFAS,
Chief, Limb Preservation Service, Vascular/Endovascular Surgery Service,
Department of Surgery, Director Limb Preservation Complex Lower
Extremity Surgery and Research Fellowship, Madigan Army Medical
Center, 9040-A Fitzsimmons Avenue, MCHJ-SV, Tacoma, WA 98431.
E-mail: thomas.s.roukis@us.army.mil.
1
Chief, Limb Preservation Service, Vascular/Endovascular Surgery
Service, Department of Surgery; Director, Limb Preservation Complex,
Lower Extremity Surgery and Research Fellowship, Madigan Army Medical
Center, Tacoma, WA.
Financial Disclosure: None reported.
Conflict of Interest: None reported.
Disclaimer: The opinions or assertions contained herein are the private
view of the author and are not to be construed as official or reflecting the
views of the Department of the Army or the Department of Defense.
Copyright Ó 2009 by the American College of Foot and Ankle Surgeons
1067-2516/09/4803-0021$36.00/0
doi:10.1053/j.jfas.2009.01.003
FIGURE 1 Intraoperative photograph of the medial aspect of the leg
demonstrating the topographic anatomical landmarks used to iden-
tify the proper location for incision placement used to perform tibialis
posterior recession. The medial aspect of the leg is divided into thirds
between the knee joint and the medial malleolus (dotted white lines).
The incision (purple line) is placed at the inferior edge of the junction
between the distal and middle thirds of the leg, just posterior to the
posterior edge of the medial face of the tibia (hashed black line).
Note that proper incision placement for perform of a gastrocnemius
recession (orange line) is proximal and posterior to the incision used
for tibialis posterior recession.
part of the tendon over the muscle was cut so the muscle
would lengthen on full inversion of the foot.’’ Unfortunately,
it is likely that this brief description has not led to widespread
use of Laborde’s procedure, despite the fact that this method
of tibialis posterior recession provides a powerful way to
safely correct even severe deformities caused by contracture
of the tibialis posterior tendon.
The author of this report has used tibialis posterior reces-
sion, as described by Laborde, in combination with superfi-
cial posterior lower leg compartment lengthening (ie,
percutaneous tendo-Achilles lengthening or gastrocnemius
recession) to correct equinocavovarus deformity, plantar
lateral metatarsal head neuropathic ulceration, midfoot defor-
mity related to Charcot neuro-osteoarthropathy, and pedal
imbalance, namely varus deformity, encountered after trans-
metatarsal amputation. This combination of tendon-length-
ening procedures has safely and consistently resulted in
a functional plantigrade foot postoperatively. Additionally,
placement of the incision in the leg, rather than about the
medial ankle or midfoot, appears to reduce the risk of

402 THE JOURNAL OF FOOT & ANKLE SURGERY

FIGURE 2 Cadaveric dissection of the right lower leg demonstrating the proximity of the posteromedial aspect of the distal tibia and the tibialis
posterior musculotendinous unit (A). Intraoperative photograph of the right leg with the incision deepened to the level of the deep fascia (B),
which is incised to expose the posterior aspect of the distal tibia (C). The tibialis posterior musculotendinous unit is exposed and the tibialis
posterior tendon is isolated within the muscle itself (D), where it is transected using the electrosurgical unit (E). The foot is simultaneously dorsi-
flexed and everted until the equinocavovarus deformity is corrected, which completes the tibialis posterior recession (F).

ischemia or motion-induced wound-healing problems. The
purpose of this article is to describe the technique used to
perform tibialis posterior recession, which is based on
specific topographic anatomical landmarks in the leg.
Technique
The patient is positioned supine and the leg is externally
rotated, which can be facilitated with the use of a well-padded
bolster underneath the contralateral buttock. The equinus
contracture is corrected first through a posterior lengthening
procedure consisting of a percutaneous tendo-Achilles
lengthening or a gastrocnemius recession, as previously
described (9). The proper location for the tibialis posterior
recession is determined by means of the sequential identifica-
tion of the following topographic anatomical landmarks on
the medial aspect of the leg. First, the medial aspect of the
knee and the distal edge of the medial malleolus are marked.
Next, the medial aspect of the leg is divided into thirds
between the 2 aforementioned anatomical markers. An inci-
sion is then made just distal to the junction of the middle and
distal thirds of the medial aspect of the leg at the posterior-
most edge of the medial face of the tibia (Figure 1). The tibia-
lis posterior lies directly posterior to the medial-posterior
aspect of the tibia at this level (Figure 2, A). The incision is
then deepened through the subcutaneous tissues and deep
fascia (Figure 2, B), thereby exposing the posterior aspect
of the distal tibia (Figure 2, C), where the tibialis posterior
muscle can be easily identified (Figure 2, D). Thereafter,
the musculotendinous junction of the tibialis posterior is
identified and the tendon is transected within the muscle belly
with the use of the electrosurgical unit (Figure 2, E) while the
foot is simultaneously dorsiflexed and everted until a rectus
alignment is achieved, which completes the recession
(Figure 2, E). Skin and subcutaneous-superficial fascia
closure is then undertaken using a combination of heavy

VOLUME 48, NUMBER 3, MAY/JUNE 2009 403

FIGURE 3 Anteroposterior intrao-
perative photographs of the lower
leg demonstrating an equinocavo-
varus deformity prior to (A) and
immediately following (B) gastroc-
nemius and tibialis posterior reces-
sion as described. Anteroposterior
resting (C) and active dorsiflexion
(D) photographs of the lower leg of
the same patient demonstrating
complete correction of the equino-
cavovarus deformity.
gauge, widely spaced, nonabsorbable sutures in vertical
mattress fashion, interposed by skin staples. The ankle and
leg are then immobilized for an appropriate period of time,
which varies with the concomitant procedures performed;
however, if tibialis posterior recession is performed in isola-
tion or with a gastrocnemius recession, then the patient may
pursue guarded weight bearing in a bulky dressing and post-
operative shoe using a gait aide for balance (10, 11).
Discussion
When combined with a superficial posterior leg compart-
ment lengthening procedure, tibialis posterior recession, as
described in this article, represents a safe, straightforward,
minimally invasive, and reproducible procedure that can
effectively correct even severe equinocavovarus and other
contracture-related deformities (Figure 3). This approach is
advantageous in situations where additional incisions in the
foot, particularly those adjacent to the medial malleolus,
could result in wound-healing problems or excessive length-
ening, which, in turn, may lead to overcorrection of the orig-
inal deformity. Finally, identification of reproducible
topographic anatomical landmarks is an essential part of
the sequential execution of tibialis posterior recession, and
reduces the potential for complications.
404 THE JOURNAL OF FOOT & ANKLE SURGERY
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