This finding is known as the too many toes sign and indicates tibialis posterior tendon (TPT) dysfunction. The patient presents subacutely with nontraumatic, degenerative inflammation of the TPT, which causes pain initially, edema below the medial malleolus, and loss of the medial longitudinal arch. This presentation is commonly seen in patients with acquired flatfoot, resulting in heal valgus and forefoot abduction. As a result, the posterior tibiocalcaneal angle, the angle formed by the heel and the longitudinal axis of the lower leg, is increased. Posterior tibial strength is decreased, so the patient cannot invert her foot effectively nor can she raise her body for the single heel raise test.1
- More toes seen lateral to the heel from a posterior view.
1. Lee MS, Vanore JV, Thomas JL, et al. Diagnosis and treatment of adult flatfoot. J Foot Ankle Surg 2005;44:78-113.
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Seminars in Medical Practice
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