What sign is often indicative of posterior tibial tendon dysfunction during a physical examination?

• A. Inability to perform heel raises
• B. 'Too many toes' sign
• C. Medial ankle swelling
• D. Increased inversion strength

Answer: (B)

The "too many toes" sign is a common finding during a physical examination that indicates posterior tibial tendon dysfunction. This sign refers to the observation that, when a patient stands on one leg, the practitioner may notice an excessive number of toes visible when looking from behind the patient. This occurs because the subtalar joint's alignment is affected due to the inability of the posterior tibial tendon to provide sufficient support to the medial arch of the foot. The posterior tibial tendon is crucial for maintaining the arch, and dysfunction leads to the collapse of this arch, resulting in an outward thrust of the forefoot relative to the hindfoot.

The other options mentioned can be related to general foot problems or injuries but are less specific to posterior tibial tendon dysfunction. Inability to perform heel raises is often observed in various conditions affecting the ankle and foot, including muscle weakness or other tendon dysfunctions. Medial ankle swelling can accompany a range of ankle pathologies, not solely limited to posterior tibial tendon issues. Increased inversion strength is not characteristic of posterior tibial tendon dysfunction and could imply other conditions affecting ankle stability or muscle imbalance. Thus, the "too many toes" sign is particularly indicative and directly connected to the mechanics of posterior tibial tendon dysfunction.