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Post tibial tendon dysfunction...how long for recovery?

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  #1  
Old 3rd May 2012, 06:46 AM
Gillian Pennington Gillian Pennington is offline
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Default Post tibial tendon dysfunction...how long for recovery?

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I have been treating a patient for several months whom I have diagnosed with post tibial tendon dysfunction. He is a 50 year old postal carrier, with a history of plantar fasciitis. He has been wearing orthotics. From about Novemeber last yaer he developed significantly graeter pain under the medial arch, and into the leg. His greatest pain was walking downstairs. He is unable to stand on tiptoe on this painful right foot. The pain is also on the dorsum of the foot.
I recasted for orthotics, advised RICE, discussed Ritchie ankle brace and orthos, and also advised him to get MRI, and if needed an air cast boot. Other than RICE, orthotics, and trying to do less activity, no other treatment has been done.
My three questions: 1: Is this the right diagnosis? 2: Any other treatment that I could consider, which the patient may respond to and comply with? 3: What is the recovery time for this condition? I intimated 6 - 9 months?
Comments and criticisms welcome.....
Thanks,
Gill
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  #2  
Old 7th May 2012, 02:28 AM
simonf simonf is offline
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Default Re: POST TIBIAL TENDON DYSFUNCTION...HOW LONG FOR RECOVERY?

Gillian,

Hope alls is well with you.

I would expect to see some swelling and tenderness along the course of the pt tendon in addition to the signs you describe. You could get an MSK ultrasound of the area to get an appreciation of the tendon health. (do you know anyone)

As you have said a ritchie brace would be a good option, failing that an aircast pttd brace with decent orthotics and high top runners or trail shoes would be pretty effective. Is your patient able to use NSAID's?

In terms of recovery - how long is a piece of string?

You may through aggressive conservative measures be able to settle this episode, but depending on how the soft tissue are holding up need to look at a longer term strategy. this may involve surgery with a pretty lengthy recovery.

You really need to get an appreciation of the soft tissue health to make an accurate diagnosis and prognosis

Cheers

s
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Old 7th May 2012, 03:53 AM
Gillian Pennington Gillian Pennington is offline
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Default Re: POST TIBIAL TENDON DYSFUNCTION...HOW LONG FOR RECOVERY?

Thankyou s.
There is some swelling, and rubor, but mostly pain.
I'm trying to push this patient back into the system (in Manitoba podiatry is not covered under public health). Truthfully, I do not think the patient appreciated that this condition was going to be painful for months.
Again, thanks for the comments.
Gill
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Old 7th May 2012, 06:36 AM
simonf simonf is offline
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Default Re: POST TIBIAL TENDON DYSFUNCTION...HOW LONG FOR RECOVERY?

Quote:
Originally Posted by Gillian Pennington View Post
Thankyou s.
There is some swelling, and rubor, but mostly pain.
I'm trying to push this patient back into the system (in Manitoba podiatry is not covered under public health). Truthfully, I do not think the patient appreciated that this condition was going to be painful for months.
Again, thanks for the comments.
Gill
I think if you haven't already done so you need to have a good chat with your patient and make sure to outline the potential devastation that untreated pttd can have on the foot. They need to buy in to your treatment plan, and you need to be upfront with them about their potential future issues...

By the way they aren't Diabetic are they?
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Old 7th May 2012, 07:29 AM
efuller efuller is offline
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Default Re: POST TIBIAL TENDON DYSFUNCTION...HOW LONG FOR RECOVERY?

Quote:
Originally Posted by Gillian Pennington View Post
He is a 50 year old postal carrier, with a history of plantar fasciitis. He has been wearing orthotics. From about Novemeber last yaer he developed significantly graeter pain under the medial arch, and into the leg. His greatest pain was walking downstairs. He is unable to stand on tiptoe on this painful right foot. The pain is also on the dorsum of the foot.


I recasted for orthotics, advised RICE, discussed Ritchie ankle brace and orthos, and also advised him to get MRI, and if needed an air cast boot. Other than RICE, orthotics, and trying to do less activity, no other treatment has been done.
My three questions: 1: Is this the right diagnosis? 2: Any other treatment that I could consider, which the patient may respond to and comply with? 3: What is the recovery time for this condition? I intimated 6 - 9 months?
Comments and criticisms welcome.....
Thanks,
Gill
Is he off work? A postal carrier with PT dysfunction is probably not going to get better if he still walking all day long. PT dysfunction usually doesn't hurt on the top of the foot.

Being unable to get up onto the ball of the foot can occur in many conditions other than PT dysfunction. If it hurts, you're not going to want to go up on the ball of your foot. What happens when you test the strength of the PT muscle?

Eric
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Old 7th May 2012, 10:20 AM
Leah Claydon Leah Claydon is offline
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Default Re: POST TIBIAL TENDON DYSFUNCTION...HOW LONG FOR RECOVERY?

Transfrictional rubbing can relieve symptoms and post tib strengthening using a theraband helps to rehabilitate.
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Old 7th May 2012, 06:47 PM
musmed musmed is offline
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Default Re: POST TIBIAL TENDON DYSFUNCTION...HOW LONG FOR RECOVERY?

Dear Gillian
Your patient has the trifecta of heat, swelling and pain. This by definition he has inflammation present.
He needs an ultrasound and X-Ray as a starter. anti inflam drugs for a few days may assist.
Once the ultrasound has been performed and shows inflammatory changes a steroid injection and a walking boot is essential.
As pointed out it will not subside until he changes his ways.
The best way is to scare the hell of him re tendon faliure and 2 years of 24/7 rehab etc.

There are 4 muscles that are linked to this condition.
They are the abductor hallucis, popliteus, tibialis posterior and short head of the biceps femoris.
Tender points or trigger points for others, will be present I have no doubt about that.

These need to be addressed to offload the tendon of post. tibial muscle.
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Old 7th May 2012, 08:49 PM
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Default Re: POST TIBIAL TENDON DYSFUNCTION...HOW LONG FOR RECOVERY?

Musmed,
I don't think that scaring the hell out of the patient is really the best way to achieve a lasting outcome. It is more likely to increase the anxiety the patient has for the problem and instill a sense of doom.

Gillian, why has the patient not taken up any of the other options you have suggested? What are the underlying barriers to this person seeking the treatment you have recommended? How are you going to motivate them to seek treatment? The answer is you can't. That motivation must come from within the patient, there has to be a powerful enough reason for them to overcome the barriers to further treatment. Are the barriers financial (can't afford Tx), emotional, time.

Could you work with the patient to set out - short, medium and long-term goals with a Tx program based around their lifestyle and commitments. Does the employer know of the injury, they may be willing to help with funding, especially if sold to them as a cheaper option than sick pay, loss of employee and recruitment.

We sometimes get so focused on the problem infront of us we forget that there is a person with a life attached to the problem. At the same time the patient must accept responsibility for their own well-being.

Hope that helps a bit.
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Old 7th May 2012, 10:57 PM
musmed musmed is offline
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Default Re: POST TIBIAL TENDON DYSFUNCTION...HOW LONG FOR RECOVERY?

Dear Post Mortem

It is necessary to tell them the truth.
The truth about this surgery should scare the hell out of them.

Paul Conneely
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Old 8th May 2012, 12:54 AM
simonf simonf is offline
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Default Re: POST TIBIAL TENDON DYSFUNCTION...HOW LONG FOR RECOVERY?

Quote:
Originally Posted by musmed View Post
Dear Post Mortem

It is necessary to tell them the truth.
The truth about this surgery should scare the hell out of them.

Paul Conneely
sunset now, just beautiful
www.musmed.com.au
I'm with paul, as I said earlier, Gillian needs to have the full and frank discussion regarding the potential long term issues of PTTD, otherwise the patient will be back in a few years very annoyed that she didn't provide enough information to choose how he managed his problem and it subsequently didn't go well.

Having said that she first needs to make an accurate diagnosis, utilising the appropriate investigations already mentioned.

The waiting time for an Adult MRI in Winnipeg is 8-16 weeks (according to official figures) so perhaps Ultrasound exam would be the best option for a speedy diagnosis......
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Old 8th May 2012, 06:22 AM
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Default Re: POST TIBIAL TENDON DYSFUNCTION...HOW LONG FOR RECOVERY?

Hi Guillian:

I have found PTTD rather straight forward.

If your patient has pain along the course of the PT , swelling along the course and weakness on testing, then it's PTTD.

Treatment is not so straight forward since there are several underlying etiologies for weakness in the PTT as well as several conditions of the tendon itself as the syndrome progresses.

Progression from simple inflammation of the tendon sheath to chronic synovitis to tendon degeneration to tears to ruptures. Along with this are the concomitant conditions of progressive pes valgus, progressive rigid pes valgus and peroneal spasms.

One mistake I feel is often made (me included) is that we get a bit too free with the cortisone injections when there may be a pre rupture condition. Cortisone will allow quick progression to a complete rupture. Although they are fun to repair, no one wants their patient to have a complete rupture.

Surgery all depends on what you're treating. Obviously a simple removal of an accessory ossicle with a PTT debridement is a lot easier and faster healing than a tenodesis with a STJ arthroreisis or a STJ, CCJ or medial column fusion for a rigid pes valgus.

In my own small world I have found that if biomechanical treatment along with aggressive strengthening exercises are not helping then it is not just an inflamed PTT. If the ROM of the STJ is decreasing then surgery sooner rather than later is indicated.

Good luck

Steve
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Old 8th May 2012, 02:55 PM
musmed musmed is offline
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Default Re: POST TIBIAL TENDON DYSFUNCTION...HOW LONG FOR RECOVERY?

Quote:
Originally Posted by simonf View Post
I'm with paul, as I said earlier, Gillian needs to have the full and frank discussion regarding the potential long term issues of PTTD, otherwise the patient will be back in a few years very annoyed that she didn't provide enough information to choose how he managed his problem and it subsequently didn't go well.

Having said that she first needs to make an accurate diagnosis, utilising the appropriate investigations already mentioned.

The waiting time for an Adult MRI in Winnipeg is 8-16 weeks (according to official figures) so perhaps Ultrasound exam would be the best option for a speedy diagnosis......
Hi
In downtown Aus one can get a CT Xray MRI and ultrasound within a day
Great sunny day here
Paul Conneely
www.musmed.com.au
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  #14  
Old 10th May 2012, 06:36 AM
Gillian Pennington Gillian Pennington is offline
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Default Re: Post tibial tendon dysfunction...how long for recovery?

Thank you for all your comments.
It is entirely possible that I have mis diagnosed the condition, (I'm a British trained podiatrist with 5 years experience), so I'll follow on with the patient.
Obviously, this patient is still in pain after six months since I first saw him. He has continued to work (post carrier) albeit on 'light duties', but as he says walking downstairs in an apartment block cariering a 50lb mail bag hurts. Currently he walks for about 1-2 hours, then ices, then continues.
I have been encouraging him to get further testing doneand will do so again.
I will recommend (again) that an air cast boot may be the best treatment plan, to get him to realise the seriousness of the condition.
Thanks again. Great help.
Gill
PS Nice day here too in Manitoba!
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