Posterior Tibial Tendinitis, Right Leg (ICD Code: M76.821)

Name of the Condition

• Common Name: Posterior Tibial Tendinitis
• Medical Term: Tibialis posterior tendon dysfunction

Summary

Posterior tibial tendinitis is an inflammation of the tendon that connects the calf muscle to the bones inside the foot. It primarily affects the inner part of the ankle and foot, causing pain and possibly leading to flatfoot deformity if untreated.

Causes

• Overuse or repetitive strain on the tendon
• Acute injury or trauma to the foot or ankle
• Chronic conditions such as inflammatory arthritis

Risk Factors

• Engaging in high-impact sports or activities
• Being overweight, adding strain to the tendon
• Having flat feet or other foot alignment issues

Symptoms

• Pain and swelling around the inside of the ankle
• Pain that worsens with activity or when standing for extended periods
• Flattening of the foot arch over time
• Difficulty or discomfort when walking or running

Diagnosis

• Physical examination focusing on foot and ankle alignment
• Imaging tests, such as X-rays or MRI, to assess tendon damage
• Ultrasound to check for tendon inflammation

Treatment Options

• Rest and activity modification to reduce strain on the tendon
• Anti-inflammatory medications to reduce pain and swelling
• Physical therapy to strengthen the muscles around the tendon
• Orthotic devices to support the foot arch
• In severe cases, surgical intervention may be necessary to repair the tendon

Prognosis and Follow-Up

• With appropriate treatment, many patients experience symptom relief and improved function.
• Follow-up care involves monitoring the condition and ensuring adherence to rehabilitation exercises to prevent recurrence.

Complications

• Uncorrected, it can lead to chronic pain and deformity, such as flatfoot.
• Reduced mobility and an increased risk of developing arthritis in the affected foot

Lifestyle & Prevention

• Maintain a healthy weight to minimize stress on the tendon.
• Incorporate exercises that improve foot strength and flexibility.
• Use proper footwear with adequate arch support.

When to Seek Professional Help

• Persistent pain or swelling around the ankle that does not improve with rest
• Sudden inability to stand on tiptoe
• Noticeable changes in the foot shape or arch

Additional Resources

• American Academy of Orthopaedic Surgeons (AAOS) website: orthoinfo.org
• American Podiatric Medical Association (APMA) website: apma.org

Tips for Medical Coders

• Ensure specificity by noting the leg affected (right leg) in the documentation.
• Double-check for concurrent conditions, like flatfoot, for accurate coding.
• Avoid using undefined codes or missing laterality, as this can lead to inaccuracies in billing and insurance claims.