Complex distal insertions of the tibialis posterior tendon: detailed anatomic and MR imaging investigation in cadavers

The purpose of this report was to demonstrate the normal complex insertional anatomy of the tibialis posterior tendon (TPT) in cadavers using magnetic resonance (MR) imaging with anatomic and histologic correlation.

Ten cadaveric ankles were used according to institutional guidelines. MR T1-weighted spin echo imaging was performed to demonstrate aspects of the complex anatomic distal insertions of the TPT in cadaveric specimens. Findings on MR imaging were correlated with those derived from anatomic and histologic study.

Generally, the TPT revealed a low signal in all MR images, except near the level of the medial malleolus, where the TPT suddenly changed direction and “magic angle” artifact could be observed. In five out of ten specimens (50%), a type I accessory navicular bone was found in the TPT. In all cases with a type I accessory navicular bone, the TPT had an altered signal in this area. Axial and coronal planes on MR imaging were the best in identifying the distal insertions of the TPT. A normal division of the TPT was observed just proximal to the insertion into the navicular bone in five specimens (100%) occurring at a maximum proximal distance from its attachment to the navicular bone of approximately 1.5 to 2 cm. In the other five specimens, in which a type I accessory navicular bone was present, the TPT directly inserted into the accessory bone and a slip less than 1.5 mm in thickness could be observed attaching to the medial aspect of the navicular bone (100%). Anatomic inspection confirmed the sites of the distal insertions of the components of the TPT.

MR imaging enabled detailed analysis of the complex distal insertions of the TPT as well as a better understanding of those features of its insertion that can simulate a lesion.