Minimally Invasive Arch Reconstruction

  • Minimally Invasive Heel Shift

  • Sinus Tarsi Implant

  • Gastrocnemius Lengthening


What is the Tibialis Posterior Tendon?

The Tibialis Posterior is a muscle that runs deep in the calf and its tendon inserts onto the arch of the foot. The tendon is one of the key arch supports along with several ligaments (and also the bones whose shape forms the arch of the foot).

When the tibialis posterior tendon fails the arch collapses and the entire foot changes shape. Pain is often the most common reason for an individual to seek a specialist opinion but severe swelling can also occur in the period when the tendon ruptures.

Patients without a normal arch find that their foot feels very inefficient. The failing arch continues to tear the damaged soft tissue which once held the arch in place. The tearing leads to episodes of pain and swelling in the medial ankle and foot.


What are the treatment options?

When the tendons and ligaments which support the arch of the foot have failed there are options:

  1. Insoles and stiff soled shoes such as walking boots or even custom shoes.

  2. Try a steroid injection into the most painful area under Ultrasound guidance. (This will take away inflammation and pain around the injured soft tissues but it will also weaken the tissues and could lead to more rupture. It may be used in certain circumstances - for example in a patient who wants to have surgery but who needs to delay surgery for 6 months)

  3. Release the tight muscle in the back of the legs to allow the insoles to work better.

  4. Rebuild the arch of the foot by key hole surgery to realign the bones of the foot (without putting a new tendon into the place of the failed tibialis posterior tendon).

  5. Rebuild the arch of the foot by putting a new tendon into the place of the failed tibialis posterior tendon, and surgery to realign the bones of the foot.

  6. If the collapse of the arch is longstanding, there may be severe arthritis and the only surgical option might be to rebuild the arch by putting the bones into a better position and then fusing them in place.


Why have the arch rebuilt without having a tendon transfer?

In relative terms surgery on bone heals very quickly and keyhole bony surgery heals even faster. By contrast surgery which requires tendons to heal is very slow. (Tendons are very specialised soft tissue made up largely of dense protein which is super-organised in order to give the tendon strength. Tendons have a poorer blood supply and only a small amount of cells within them. It is the cells which must make the proteins and because their are few cells, little blood supply of nutrients and a complex structure to heal; the end result is slow healing.)


  1. When patients are lower demand their complaint is not of the lack of power that comes from loss of the tendon, their complaint is of pain due to ongoing tearing of the tendon.

  2. Rebuilding the arch of the foot stops the tearing of the tendon. If the tendon has been so damaged that it no longer functions, it will not function again. However the tendon will not be torn because the foot is not able to move into the position which stretches and tears the tendon

Patients have the arch rebuilt in order to have a foot which allows them to manage with shoes and insoles without going through the slow healing process of a tendon transfer

What is a Sinus tarsi Implant?

A sinus tarsi implant is a small metal spacer which sits between the calcaneus and the talus. It holds these bones apart and prevents the arch from collapsing. The implant is also called an arthroereisis screw.

How Long Should a Sinus Tarsi Implant Stay in For?

There are no clear guidelines about how long the implant should stay in for. If the implant causes no pain there is no need to remove it but if there are any symptoms, it can be removed after 6 months. There are reports that the implant produces some changes to how some patients use their arch permanently. If the implant causes no symptoms and allows the patient to resume normal life - it is unlikely that the surgeon and patient will decide to remove it.

What can I expect on the day of surgery?

  • The surgery will normally be under a general anaesthetic.

  • This is can be daycase or overnight stay surgery depending on how mobile a person is.

  • I will numb the ankle with local anaesthetic so that you will be comfortable when you wake.

  • There will be a bulky half plaster cast on your lower leg which you will keep clean and dry.

  • You will be given crutches or a frame and told not to weight bear.

What are the risks and complications?

The vast majority of patients do extremely well. A small group of patients need extra physio due to swelling or stiffness. Complications include infection, blood clots (DVT), nerve damage, non-union, painful screws requiring removal, and some patients may find that they do not have enough power and decide to opt for a tendon transfer at a later stage.

When can I drive?

The best guide that you are safe to return to driving is that you are able to walk well without crutches and without a plaster or a boot. The usual time scale also depends on whether you had surgery on your right or left foot and whether you drive a manual or an automatic

  • Right side and all car types: 6 weeks

  • Left side and manual car: 6 weeks

  • Left side & automatic car: 2 weeks

How long should I take off work?

The time you require off from work depends on what type of job you do. The first two weeks of healing are critical and so you must have this time off work. Many people are able to work from home and so if you can avoid commuting in the first six weeks, you will find that your ankle does better. If your employer can be flexible with your activity at work you may be able to do some lighter duties or reduced hours from 3 weeks onward. If you work on your feet all day, do a manual job, or are required to wear dress shoes you may need 8-12 weeks before you are back at work.

Clear Advice About DVT

A DVT is a Deep Vein Thrombosis or a blood clot in the leg. A blood clot occurs after surgery where patients are placed into plaster or a splint for about 2 in every 100 patients. You can help prevent a blood clot by keeping your knee moving. Keeping yourself hydrated is also helpful to prevent a DVT. Finally elevating your leg to the level of your heart will minimise the amount of swelling you have which will also help to prevent a DVT. You will be given blood thinners for the first two weeks when you at your least active.

We will discuss how best to prevent a DVT and for most patients we opt to use injections of  blood thinners for the first two weeks after surgery. After two weeks the risk is not completely gone however, you will be able to be more active. Most patients would rather stop blood thinners at that stage and monitor their leg for symptoms.


If you were to develop a DVT you would likely have some symptoms and so it is very helpful if know what to look for:

  • The leg (above the dressing/foot) would become hard, heavy, swollen, painful and/or red

  • If you were to have any of the above symptoms you would have to have a scan to look for a blood clot and then be treated with blood thinners

If the blood clot were to move to the lungs you would have a pulmonary embolism which is a medical emergency

  • The symptoms of a pulmonary embolism are breathless & chest pain- Call 911

The Recovery After Minimally Invasive Tendon Reconstruction

Instructions 0-2 weeks

  1. Elevate Leg Above Heart most of the time

  2. Keep dry for two weeks

  3. Low-Molecular-Weight Heparin Injection daily for two weeks

  4. Non weight bearing in air cast boot

  5. Move toes and knee


2 weeks in clinic

  • I will arrange to have your plaster & sutures removed

  • You will then be placed in an aircast boot with your insole and instructed to be partial weight bearing in the boot for the next two weeks

  • Your physio will help you start to do exercises out of the boot

  • You will then be able to wash the ankle

  • You can remove the boot at night and when doing physiotherapy


4 weeks

  • You can progress to full weight bearing in the aircast boot

  • It is essential that you have put your arch support insole into the aircast boot

  • Week on week you should find that you can put more weight through the boot

  • Eventually you will take your weight fully through the boot


6 weeks in clinic

  • I will send you for a X-rays of the ankle and you will be able to weight bear out of the boot for these xrays

  • Provided the X-rays show some early healing you will be allowed to wean out of the Aircast boot


6 weeks- 3 months

  • You will weight bear in boot fully

  • You may start to use a trainer with your insoles first at home and then as you and your physio are happy with your progress you can do so out of the house

  • Discontinue boot after 2 months


 Physiotherapy instructions once able to weightbear and remove the Aircast boot

  • Use the Boot for comfort

  • When your physio and surgeon OK you coming out of the boot you must not be bare foot

  • Instead use a shoe with your insoles

  • Gradually use the boot less and less as comfort allows

  • Use Contrast bathing with bowls of hot and cold water. Place foot for 20 sec in cold and then alternate for 30 sec in hot. Do for 5 min.

  • Your physiotherapist can use other local modalities to reduce swelling

  • You may ice the ankle if this helps

  • Use a compression stocking and elevate the ankle above the heart to help swelling

  • Start to work on strengthening

    • Theraband Resistance

    • Cycling on stationary cycle

    • Swimming and Hydrotherapy

    • Work on developing an even gait

    • Progressing to double heel rises





  • You can go up and down on tiptoes in sets of 3, slowly and 15 reps in each

  • You can stand on a skipping rope and adjust your foot position

  • You can hold a DHR for 15 seconds

  • It can be difficult to progress to the next award level because the ankle will take double the weight when you move to lifting the good leg to lower only on the operated leg.

  • You are better to stay at the bronze award level but to add in a back pack with increasing weight as you feel ready for more

  • When you have done this for some time you will be ready to progress to the silver award level




  • May need to add weight in backpack on DHR to reach silver level

  • You go up on both feet but lift unoperated leg and lower slowly only on operated leg

  • 3 sets, working up to 15 reps in each

  • You can stand both feet on a wobble board

  • You can hold a solid DHR for 20 seconds




  • 3 sets, working up to 15 reps in each

  • You can stand on one foot on wobble board

  • You can hold a solid DHR for 40+ seconds

  • Many patients decide to finish physiotherapy when they have achieved this level



  • Progress to hopping in all directions

  • Double Hops

  • Gentle jogging to reintroduce running