The Tibialis Posterior Tendon Transfer for Foot Drop procedure is a surgical solution for patients suffering from foot drop, a condition where there is a loss of dorsiflexion, leading to difficulty in lifting the foot during walking. This condition can occur due to several reasons, including nerve injuries (such as peroneal nerve damage), neurological disorders, and trauma. Foot drop can severely affect gait, leading to high stepping, foot slapping, and difficulty in clearing the foot during the swing phase of walking. This article provides a detailed overview of the procedure, its indications, planning, surgical steps, and post-operative recovery.
How Common It Is and Who Gets It? (Epidemiology)
Foot drop is a common condition resulting from nerve injury or neurological conditions, such as peroneal nerve damage, cerebral palsy, multiple sclerosis, and stroke. It affects individuals of all ages but is more common in older adults due to the prevalence of nerve injuries and neuropathies.
Why It Happens – Causes (Etiology and Pathophysiology)
Foot drop occurs when there is a loss of dorsiflexion due to dysfunction in the peroneal nerve, tibialis anterior muscle, or other structures responsible for foot movement. Nerve injuries, compartment syndrome, and neuromuscular diseases are the most common causes of foot drop. It can lead to a high-stepping gait and difficulty with normal walking patterns.
How the Body Part Normally Works? (Relevant Anatomy)
The tibialis posterior tendon plays a critical role in controlling ankle movement and supporting the arch of the foot. In foot drop, the tibialis anterior tendon is usually compromised, preventing proper dorsiflexion. Tibialis posterior tendon transfer helps compensate for this loss by rerouting the tendon to improve foot movement.
What You Might Feel – Symptoms (Clinical Presentation)
Symptoms of foot drop include difficulty lifting the foot, especially when walking or during the swing phase. This leads to a high-stepping gait, foot slap, and an inability to clear the ground with the foot. These symptoms can cause tripping, instability, and difficulty walking for extended periods.
How Doctors Find the Problem? (Diagnosis and Imaging)
Foot drop is diagnosed through clinical examination, including testing gait, foot position, and strength. Imaging studies such as X-rays or MRI scans are used to rule out other conditions, such as fractures or arthritis, and confirm the underlying cause of the foot drop, particularly nerve damage.
Classification
Foot drop is classified by its etiology, including nerve injuries, neurological diseases, and trauma. In some cases, the condition can be categorized by its severity, from mild cases with slight dorsiflexion weakness to more severe cases where there is complete inability to lift the foot.
Other Problems That Can Feel Similar (Differential Diagnosis)
Conditions such as drop foot due to peroneal nerve palsy, hemiplegia, or certain forms of neuropathy can present with similar symptoms. The key to an accurate diagnosis is identifying the underlying cause of foot drop, which will guide appropriate treatment.
Treatment Options
Non-Surgical Care:
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Bracing: A foot drop brace (AFO) helps support the foot and improve gait.
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Physical Therapy: Strengthening exercises for the foot and ankle can help compensate for weakness.
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Orthotics: Custom shoes or insoles may be used to improve foot alignment and reduce discomfort.
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Surgical Care:
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Tibialis posterior tendon transfer is the primary surgical treatment for foot drop when nerve recovery is not expected, rerouting the tendon to improve dorsiflexion.
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Recovery and What to Expect After Treatment
Following tibialis posterior tendon transfer surgery, patients are placed in a non-weight-bearing cast for several weeks. Gradual weight-bearing is allowed after this period, and physical therapy is initiated to restore function. Full recovery can take several months, depending on individual healing progress.
Possible Risks or Side Effects (Complications)
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General Risks: Infection, scarring, nerve injury, and blood clots are common risks with any surgical procedure.
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Specific Risks: Failure of the tendon transfer, further surgery, or complications like compartment syndrome.
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Postoperative Rehabilitation: Avoiding passive plantarflexion during rehabilitation is essential to prevent tendon detachment or stretching.
Long-Term Outlook (Prognosis)
The prognosis for tibialis posterior tendon transfer is generally excellent, with many patients experiencing significant improvement in foot function and gait. The success of the procedure depends on factors such as preoperative muscle strength, rehabilitation adherence, and the underlying cause of foot drop.
Out-of-Pocket Cost
Medicare
CPT Code 27691 – Tibialis Posterior Tendon Transfer: $175.25
Medicare Part B generally covers 80% of the approved cost for this procedure once your annual deductible has been met, leaving you responsible for the remaining 20%. Supplemental Insurance plans such as Medigap, AARP, or Blue Cross Blue Shield typically cover the remaining 20%, significantly reducing or eliminating out-of-pocket expenses for Medicare-approved procedures. These plans work alongside Medicare to fill the coverage gap and reduce patient costs.
If you have Secondary Insurance, such as TRICARE, an Employer-Based Plan, or Veterans Health Administration coverage, it acts as a secondary payer. These plans generally cover any remaining coinsurance or small deductibles, which typically range from $100 to $300, depending on your plan and provider network.
Workers’ Compensation
If your tibialis posterior tendon transfer is required due to a work-related injury or overuse condition, Workers’ Compensation will cover all associated medical expenses, including surgery, rehabilitation, and follow-up care. You will not have any out-of-pocket expenses, as the employer’s insurance carrier directly pays for all approved treatments.
No-Fault Insurance
If your tendon transfer surgery is related to an automobile accident, No-Fault Insurance will generally cover the full cost of treatment, including surgery and postoperative care. The only potential out-of-pocket cost may be a small deductible or co-payment depending on your insurance policy.
Example
Emma Johnson had chronic posterior tibial tendon dysfunction and underwent a tibialis posterior tendon transfer (CPT 27691) to restore foot function. Her estimated Medicare out-of-pocket cost was $175.25. Since Emma had supplemental insurance through Blue Cross Blue Shield, her remaining balance was fully covered, leaving her with no out-of-pocket expenses for the surgery.
Frequently Asked Questions (FAQ)
Q. What is Tibialis Posterior Tendon Transfer?
A. Tibialis posterior tendon transfer is a surgical procedure used to treat foot drop by rerouting the tibialis posterior tendon to restore dorsiflexion and improve walking ability, particularly when the nerve recovery is not expected.
Q. What are the indications for Tibialis Posterior Tendon Transfer?
A. This procedure is indicated for patients with foot drop due to peroneal nerve injury, neuromuscular conditions, or trauma, especially when other treatments like bracing have failed.
Q. How is the Tibialis Posterior Tendon Transfer performed?
A. The tibialis posterior tendon is harvested from the foot and re-routed through the interosseous membrane to a new location on the foot to improve dorsiflexion and restore normal gait.
Q. What is the recovery process after Tibialis Posterior Tendon Transfer?
A. Recovery involves immobilization in a cast, followed by physiotherapy to re-educate the tendon and improve foot movement. Full recovery can take several months.
Q. What are the risks associated with Tibialis Posterior Tendon Transfer?
A. Risks include infection, nerve injury, tendon failure, and the possibility of the tendon not achieving the desired dorsiflexion function.
Q. How long does the Tibialis Posterior Tendon Transfer procedure take?
A. The procedure typically takes about 2 to 3 hours, depending on the complexity of the case and whether additional procedures are needed.
Q. Can Tibialis Posterior Tendon Transfer be performed on both feet at the same time?
A. While it is possible, it is generally recommended to perform the procedure on one foot at a time to allow for proper healing and rehabilitation.
Q. Will I be able to return to sports after Tibialis Posterior Tendon Transfer?
A. High-impact activities should be avoided for 6 to 12 months after surgery, but most patients can return to light activities once the tendon has healed and normal foot movement is restored.
Q. How effective is Tibialis Posterior Tendon Transfer for restoring foot function?
A. The procedure is highly effective, with many patients experiencing significant improvement in foot function, including better dorsiflexion, walking ability, and reduced foot drop, allowing for normal or near-normal gait.
Q. Is physical therapy necessary after Tibialis Posterior Tendon Transfer surgery?
A. Yes, physical therapy is essential to help restore strength, flexibility, and mobility in the foot and ankle. It also aids in re-training the foot to use the new tendon pathway effectively.
Q. Will I experience any pain after Tibialis Posterior Tendon Transfer?
A. Some discomfort and swelling are expected during the recovery process, but pain is generally manageable with prescribed medications. Most patients report significant pain relief once the tendon has healed.
Q. Can Tibialis Posterior Tendon Transfer correct severe foot deformities?
A. While it is primarily used to address foot drop, Tibialis Posterior Tendon Transfer can also improve alignment and function in patients with moderate foot deformities related to nerve damage or tendon dysfunction.
Q. How soon can I walk after Tibialis Posterior Tendon Transfer?
A. You will be non-weight bearing for the first several weeks after surgery, typically using crutches or a walking boot. Gradual weight-bearing is introduced once healing begins, usually after 6 weeks.
Q. Are there any long-term complications associated with Tibialis Posterior Tendon Transfer?
A. While complications are rare, some potential long-term issues include tendon failure, recurrence of foot drop, or development of other foot deformities. Proper rehabilitation and follow-up care reduce the risk of these complications.
Q. How long will the results of Tibialis Posterior Tendon Transfer last?
A. The results are generally long-lasting, with most patients maintaining improved foot function and gait for years. However, the longevity of the results depends on factors such as rehabilitation, activity level, and any underlying conditions.
Summary and Takeaway
Tibialis posterior tendon transfer is a highly effective solution for foot drop caused by nerve damage, trauma, or neuromuscular conditions when nerve recovery is not expected. This surgical intervention restores dorsiflexion, improves gait, and enhances overall foot function. With a high success rate and low complication risk, tibialis posterior tendon transfer significantly improves patients’ mobility and quality of life. Comprehensive post-operative care, including physical therapy, is crucial for achieving optimal results and preventing complications.
Clinical Insight & Recent Findings
A recent study published in the World Journal of Orthopedics examined outcomes of tibialis posterior tendon transfer in patients with foot drop caused primarily by peroneal nerve injury. Conducted over seven years in Pakistan, the study followed 37 patients (mean age 22 years), most of whom developed foot drop after road traffic accidents.
The procedure—performed through the circumtibial route—proved highly effective, with 76% of patients achieving good to excellent results after one year. Complications were minimal, limited to a few wound infections and hypertrophic scars.
The authors concluded that this tendon transfer is a technically straightforward, reliable, and affordable option for restoring ankle dorsiflexion and improving gait in patients with irreversible nerve damage. (“Study on tibialis posterior tendon transfer for foot drop – see PubMed.”)
Who Performs This Treatment? (Specialists and Team Involved)
Orthopedic surgeons, particularly those specializing in foot and ankle surgery, typically perform tibialis posterior tendon transfer. In some cases, a multidisciplinary team, including physical therapists and rehabilitation specialists, may be involved in the post-operative care.
When to See a Specialist?
If you are experiencing difficulty lifting your foot while walking or tripping frequently due to foot drop, it’s essential to consult with a specialist who can evaluate the condition and recommend appropriate treatments, including tibialis posterior tendon transfer.
When to Go to the Emergency Room?
Seek emergency care if you experience severe pain, swelling, or a sudden inability to move your foot, as this could indicate a serious injury or condition requiring immediate intervention.
What Recovery Really Looks Like?
Recovery from tibialis posterior tendon transfer requires several months of rehabilitation. Initially, non-weight-bearing is recommended, followed by gradual weight-bearing and physical therapy to restore foot function. Full recovery typically takes 6 to 12 months.
What Happens If You Ignore It?
Ignoring foot drop can lead to persistent gait abnormalities, increased risk of falls, and deterioration in foot function. Early surgical intervention can significantly improve mobility and prevent further complications.
How to Prevent It?
Preventing foot drop typically involves managing underlying conditions like nerve damage or neuromuscular diseases early. Regular check-ups and early intervention can prevent the progression of the condition.
Nutrition and Bone or Joint Health
Maintaining a healthy diet rich in calcium and vitamin D helps support bone and joint health, which is essential for recovery after surgery. Proper nutrition also aids in muscle function and healing.
Activity and Lifestyle Modifications
After surgery, it is important to avoid high-impact activities until fully healed. Low-impact activities such as swimming or cycling can help maintain fitness while minimizing stress on the foot during recovery.
Dr. Mo Athar
