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Hi I am trying to find out the different exercise regimes that clinicians use for tib post dysfunction, alonside addressing the biomechanics.

I generally get patients to do eccentric heel raises building up gradually after they have been wearing any insole therapy for 3-4wks, I also get them stretching gastroc/soleus. My results tend to vary but generally positive howevre it does seeem to take a long time to rehab this muscle/tendon. I would like to try and write a 'best practice' pathway for junior podiatrists that come through in rotation

thanks

bartypb

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There was this study: Effect of eccentric exercise program for early tibialis posterior tendinopathy. This showed the benefit of an eccentric program in PTTD.

Keep in mind that the posterior tibial muscle may not actually be weak in PTTD, but just appears weak due to the tendon having a poor lever arm to the the joint axis ... so it may actually be very strong and just feel weak, when in reality its not .... if that is the case, why did the eccentric program in the above study work? ... possibly for a similar reason that Alfredsens protocol in achilles tendonitis works ... the above study used "progressive eccentric tendon loading" in the same way.

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Craig Payne
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Thanks for that craig, just another question I'd like to put out there - is just doing eccentric toe raises enough of an exercise on its own ie using the patient's body weight in a controlled manner. Do you need to have the knee flexed to knock out gastrocs or does this not matter?

regards

Bartypb

I usually get them to do eversion exercises with a theraband.

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Craig Payne
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Do you mean inversion exercises?

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Phil Marshman
Mackay, Queensland Australia

whoops ... yes ... I need to go back on to my medication...

Hi Craig,

Could you direct me to a study on this. I am interested in how they measured muscle strength.

Regards,
Stanley

See this: Muscle strength and posterior tibial tendon dysfunction

There is NO evidence re what I stated above re the short lever arm for the tendon to the joint axis making the muscle appear weaker than it really is. HOWEVER, I have NEVER seen a PTTD in someone without a very medial STJ axis, so the lever arm must be shorter (its just no one has done a study on it yet!).

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Craig Payne
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Dr Doug Richie from the US gave a excerise for PTTD strengthening at his roadshow 2 years ago. Patient does the excerise sitting down with the knee flexed at 90 ,foot flat on floor. Then adduct the foot, knee does not move , then apply a inversion with arch lift movement at the last stage of the adduction movement. Keep fore foot and toes on the ground.
Having been trying it with my patients, to early to say results, but seems to help.
Hope explaination of exercise is clear , hard to describe, and takes patients a while to "get" the excercise and engage right muscle.
Perhaps if interested read his papers for a better explanation.

Hi dsfeet,
Do you have a link for the paper you've mentioned above?
Cheers

Hi sorry for the slow reply, was hunting for my notes from this lecture. Don' t think Dr richie gave a paper with these excerises , think they came from his clinical knowledge. the only papers i wrote down from this lecture are
Imaging of TP Dysfunction 2008 british journal of Radiology By A kong et al
Dysfunction of the TP Tendon 2004 by trinka HJ
Classification of TPPD foot and ankle 1989 Mterson et al
But you could google Richie Brace .com and see what you find.
Sorry this is sketchy but wrote down references in short hand, my style of short hand , which is hard to read. But also assumed i would look at databass to find if doing further reading., and haven't on this topic. the eccentric excerises Craig mentioned were also in his lecture.
Happy searching.

Craig is this correct? The more medial the STJ axis the shorter the lever arm for the PTT to generate a supination moment. couldn't this be the cause as well as the result?

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David G. Wedemeyer, D.C., C.Ped.

The idea that the medially positioned STJ axis creates a smaller lever arm for the PT tendon is a very good story. However, it could be that the medially deviated STJ axis could make the foot much more lateral to the axis and then ground reaction force would have greater leverage to cause pronation. (This is true whether or not the deviation of the axis affects the lever arm of the tendon.) The increased leverage of GRF could be enough by itself to cause the pathology.

Possibly the axis has to follow the talar head. The inferior joint surfaces of the talus will determine the joint axis. So, if the axis exits out of the central portion of the talar head, for all feet, then the distance from the axis to the tendon would tend to be pretty close to the same. I'm more happy with "I don't know" compared to "the leverage of the tendon is less with a medially positioned axis." The increased pronation moment from ground reaction force might be enough to explain the pathology seen.

Eric

Phil, if inversion exercises work the tibialis posterior muscle, which muscles would activate applying eversion exercises?.

I know Eric and I agree with this, but let me put it another way.

As the talar head moves more medially relative to the plantar foot and ground, so too does the subtalar joint (STJ) axis move medially. In addition, the medial rotation/translation of the talar head and STJ axis will decrease the moment arm that the posterior tibial (PT) muscle/tendon has available to cause a STJ supination moment by its actions on the medial navicular (Kirby KA: Conservative treatment of posterior tibial dysfunction. Podiatry Management, 19:73-82, 2000). [See attached paper.]

Therefore, the medial rotation and translation of the talar head also rotates and translates the STJ axis relative to both the plantar foot and to the insertion point of the PT tendon so that a medially deviated STJ axis will cause two main mechanical effects, simultaneously:

1. An increase in external STJ pronation moment from ground reaction force acting more lateral to the STJ axis.

2. A decrease in internal STJ supination moment due to the tension force within the PT tendon having a decreased STJ supination moment arm.

These two effects create the mechanical scenario that leads to the onset of posterior tibial tendon dysfunction and its cascade of events that cause gradual increase in flatfoot deformity and further medial deviation of the STJ axis.

Attached Files

Conservative Treatment of Posterior Tibial Dysfunction.pdf (1.12 MB, 59 views)

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Sincerely,

Kevin

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Kevin A. Kirby, DPM
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Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
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Craig, I apologize. I read that completely wrong.

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"If we all worked on the assumption that what is accepted as true is really true, there would be little hope of advance." - Orville Wright

David G. Wedemeyer, D.C., C.Ped.

I completely agree about the rotation of the axis relative to the plantar surface of the foot. However, I'm not sure about the movement of the axis relative to the effective insertion point of the tendon. Since the tendon sits medial to the talar head, as the talar head internally rotates, it will push the tendon more medially an equal amount to the axis rotation. Even with abduction of the navicular, relative to the talar head, the effective insertion of the tendon is not really changed as it is still sitting medial to the talar head. The talar head will act like a sesamoid bone to increase the lever arm of the pull of the tendon. We cant' tell without experimentation whether or not lever arm of the tendon is changed with talar internal rotation.


Both points are mechanically sound if true. It may be possible to get the damage with only point number one.

Eric

There is an excellent series of research papers addressing ths question by Kornelia Kulig who devised a method of selectively eccentrically activating tibialis posterior in type i and 11 tib post dysfunction in non weightbearing and compared it to activation in wirghtbearing. She also compared the effect of the non weightbearing exercises with and without orthotics. I have had good success with this programme and am about to post a video of the home based version of the exercise on my web site to assit patients.
The 2009 paper summarises herbody of work from 2004:
Kulig K , Reischl S, Pomrantz A, Burnfield JM, Mais-Requejo S, Thordarson D, and Smith R W. Nonsurgical management of Posterior Tibial Tendon Dysfunction with orthoses and resistive exercise: a randomised controlled trial. Physical Therapy , Vol.89 , No.1 pp 26-37 2009

Robyn Gant


reference:

Home-based general versus center-based selective rehabilitation in patients with posterior tibial tendon dysfunction.
Bek N, Simşek IE, Erel S, Yakut Y, Uygur F.
Acta Orthop Traumatol Turc. 2012;46(4):286-92.

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Hi Craig,

Do you know which eccentric exercises were performed in this study?

Thanks,
Robbie