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I have been searching the literature on the treatment of PTTD. Does anyone have a tretament protocol for this condition, which has been successful for the different stages of this condition?
I have been searching the literature on the treatment of PTTD. Does anyone have a tretament protocol for this condition, which has been successful for the different stages of this condition?
Regards
Rob
Here is a paper that I was invited to write a few years ago on the diagnosis, biomechanics and treatment of posterior tibial dysfunction (Kirby KA: Conservative treatment of posterior tibial dysfunction. Podiatry Management, 19:73-82, 2000).
Hope this helps.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
thanks for this. I have just recieved your precision intricast books from the US. I have found these to be an interesting and informative read. I wish I had purchased these years ago! Can we expect a new book in the near future?
thanks for this. I have just recieved your precision intricast books from the US. I have found these to be an interesting and informative read. I wish I had purchased these years ago! Can we expect a new book in the near future?
Five more years of newsletters have been already written and are ready to be compiled into another book. However, I'm not sure if Precision Intricast is ready to publish the book quite yet.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Five more years of newsletters have been already written and are ready to be compiled into another book. However, I'm not sure if Precision Intricast is ready to publish the book quite yet.
Sed fugit interea fugit irreparabile tempus.
Kevin, did you know when you started writing them what a treasure you would create?
Bring it on Precision!
__________________ Science is the antidote to the poison of enthusiasm and superstition
My approach to PTTD is to first and foremost find a underlying etiology. Some of these are pure biomechanical predisposition, others are not. Acute tears of the Post Tib, talipes equinus, Charcot's, Hip and knee pathology, Tarsal coalitions, STJ arthritis, etc......... can all be causes.
As far as conservative orthotic treatment, I think Kevin has covered this.
In my experience, conservative AND surgical approaches are unrewarding once the peroneal tendons have gone into spasm and a rigid pes valgus results.
Steve
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Green Bay, Wisconsin, USA
Nonsurgical Management of Posterior Tibial Tendon Dysfunction With Orthoses and Resistive Exercise: A Randomized Controlled Trial.
Kulig K, Reischl SF, Pomrantz AB, Burnfield JM, Mais-Requejo S, Thordarson DB, Smith RW. Phys Ther. 2008 Nov 20. [Epub ahead of print]
Quote:
BACKGROUND AND PURPOSE:/b> Tibialis posterior tendinopathy can lead to debilitating dysfunction. This study examined the effectiveness of orthoses and resistance exercise in the early management of tibialis posterior tendinopathy.
SUBJECTS:/b> Thirty-six adults with stage I or II tibialis posterior tendinopathy participated in this study.
METHODS:/b> Participants were randomly assigned to 1 of 3 groups to complete a 12-week program of: (1) orthosis wear and stretching (O group); (2) orthosis wear, stretching, and concentric progressive resistive exercise (OC group); or (3) orthosis wear, stretching, and eccentric progressive resistive exercise (OE group). Preintervention and postintervention data (Foot Functional Index, distance traveled in the 5-Minute Walk Test, and pain immediately after the 5-Minute Walk Test) were collected.
RESULTS: /b> Foot Functional Index scores (total, pain, and disability) decreased in all groups after the intervention. The OE group demonstrated the most improvement in each subcategory, and the O group demonstrated the least improvement. Pain immediately after the 5-Minute Walk Test was significantly reduced across all groups after the intervention.
DISCUSSION AND CONCLUSION:/b> People with early stages of tibialis posterior tendinopathy benefited from a program of orthosis wear and stretching. Eccentric and concentric progressive resistive exercises further reduced pain and improved perceptions of function.
Nonsurgical Management of Posterior Tibial Tendon Dysfunction With Orthoses and Resistive Exercise: A Randomized Controlled Trial.
Kulig K, Reischl SF, Pomrantz AB, Burnfield JM, Mais-Requejo S, Thordarson DB, Smith RW. Phys Ther. 2008 Nov 20. [Epub ahead of print]
This will be an interesting paper to read. It will be especially good to find out the protocols they used for the stretching and eccentric loading. You would think they would be practitioner assisted. I wonder if they used the orthotic protocols that Kevin Kirby published in his paper.
The Diagnosis and Treatment of Adult Flatfoot Clinical Practice Guideline is a 36-page document that includes text, images and pathways. It was published in the March/April 2005 issue of the Journal of Foot & Ankle Surgery.
In early cases I use a device with a kirby skive, usually four or five mm. Forefoot valgus post, 3 0r 4 deg, and a first ray cut away. The device is made with a PTTD profile, deeper heel and ,med flange.
My concern with the term PTTD is that is see these eithe progressing or actually as an aquired adult flat foot (AAFF) deformity which clinically appears to be a spring ligament complex dysfunction.(SLCD) This doesn't hurt so the straucture which is stressed because of this, the PTT, is viewd as the culpruit. (your thaoughts gentleman).
In the more advanced AAFF with SLCD I would use an articulated RICHIE brace with the same sole plate/orthotic RX as above.
Regards
Graham
__________________
Graham Curryer
None of us know what we are doing, but some of us know more about what we are not doing than others!::
In early cases I use a device with a kirby skive, usually four or five mm. Forefoot valgus post, 3 0r 4 deg, and a first ray cut away. The device is made with a PTTD profile, deeper heel and ,med flange.
I wouldn't generically add a forefoot valgus post. Sometimes, with longstanding PTTD you get medial column collapse and this causes the foot to evert to the point that there is no more range of motion to lift the lateral forefoot off of the ground. In this situation a forefoot valgus wedge would tend to increase sinus tarsi pain.
Quote:
Originally Posted by Graham
My concern with the term PTTD is that is see these eithe progressing or actually as an aquired adult flat foot (AAFF) deformity which clinically appears to be a spring ligament complex dysfunction.(SLCD) This doesn't hurt so the straucture which is stressed because of this, the PTT, is viewd as the culpruit. (your thaoughts gentleman).
The PT tendon supinates the STJ. Supinatino of the STJ will shift weight on to the lateral foot. In the absence of force in the PT tendon the foot will evert until something stops it. That something is usually the medial column. With high load on the medial column there will be increased stress on the spring ligament. If the spring ligament tears, the person, to avoid pain, will try to increase force in the PT tendon, which would make the PT dysfunction worse. They are definitely interrelated. High medial loads would also tend to stress the plantar medial cuneiform navicular ligament and medial cuniform first metatarsal plantar ligament. When these tear, you get medial column collapse that I refer to above. Or, with pain in the medial column, you get an extreme reluctance put weight on the forefoot. I believe this is why you see the classic inability to raise the heel off of the ground with PT dysfunction. The PT tendon does not plantar flex the ankle, but it does shift ground reaction force from medial to lateral.
I generally find that if there is reasonable ROM at the first mtpj and the first ray is mobile, without the first ray cut away the shell of the device limits hallux extension over the first mtpj resulting in the need to abductory twist at propulsion therfore further irritating the PTT. The KS and deep heel seat deal with the heel strike to foot flat sequence. Failure of the heel to lift, due to sagittal blockade at the first mtpj will create the abductory twist and pronation into propulson with secondary mid tarsal hinge.
The work by Doug Richie would seem to suggest that the Mid Tarsal complex has more involvement than the STJ, again suggesting that eqaul and oposite forces generated in an "abnormal" propulsion could be the influencing factor in the development of this condition.
__________________
Graham Curryer
None of us know what we are doing, but some of us know more about what we are not doing than others!::
BACKGROUND: The nonoperative treatment of posterior tibial tendon insufficiency (PTTI) can lead to unsatisfactory functional results. Short-term results are available but the impact on the evolution of the deformity is not known. To address these problems, a new brace for the flexible Stage II deformity was developed, and midterm followup was obtained.
MATERIALS AND METHOD: In a prospective case series, eighteen patients (mean age 64.2 years; range, 31 to 82; four male, 14 female) with flexible Stage II PTTI were fitted with the new custom-molded foot orthosis. At latest followup of a mean of 61.4 (range, 20 to 87) months, functional results were assessed with the AOFAS ankle hindfoot score and clinical or radiographic progression was recorded.
RESULTS: The score improved significantly from a mean of 56 points (range, 20 to 64) to a mean of 82 points (range, 64 to 100, p < 0.001). Three patients (3/18, 16%) had a clinical progression to a fixed deformity (Stage III) and a radiographic increase of their deformity. All the other patients were satisfied with the brace's comfort and noted an improvement in their mobility. Complications were seen in three patients (3/18, 16%), and consisted of the development of calluses.
CONCLUSION: The "shell brace" is a valuable option for nonoperative treatment of the flexible Stage II PTTI. Hindfoot flexibility was conserved throughout the observation period in all but three patients. Functional outcome and patient acceptance was above average. Problems were few, and closely associated with a progression to a fixed, Stage III deformity.
For what it's worth, as a health ed professional and a 1 year post triple arthrodesis for PTTD, I would like to offer the following hard earned experience. The foot bone is connected to the leg bone and the leg bone is connected to the back bone. My foot is wonderful, pain free. But I was equally incapacitated with low back pain. I finally went to a physical medicine & rehab doc who ID'd piraformis muscle spasm, facet arthritis, etc. Several injections later I now have a great life.
I am so grateful to my surgeon for his skills in the fusion. The relief from pain is wonderful (I was 2B-3) but it's important to have a backup orthopedist or PM&R doc to help with the realignment issues. ~Sophe
Functional outcome after surgical reconstruction of posterior tibial tendon insufficiency in patients under 50 years.
Tellisi N, Lobo M, O'Malley M, Kennedy JG, Elliott AJ, Deland JT. Foot Ankle Int. 2008 Dec;29(12):1179-83.
Quote:
BACKGROUND: Procedures utilized to address the flatfoot in this study included medializing calcaneal osteotomy, posterior tibial tendon reconstruction with flexor digitorum longus tendon transfer, and in patients with more severe deformity, lateral column lengthening. We evaluated patients age 50 and less at the time of surgery, who underwent surgical reconstruction for Stage 2 posterior tibial tendon dysfunction. Pre- and postoperative activity levels were evaluated to assess the effect of surgical reconstruction in the younger patient.
MATERIALS AND METHOD: Thirty-four feet in 30 patients (11 male, 19 female) with an average age of 41.2 (range, 17 to 50) years had surgery between 1997 and 2004. All feet were examined at an average followup of 44.5 (range, 24 to 65) months and were evaluated with the American-Orthopaedic-Foot and Ankle Society (AOFAS) Hindfoot-Score and SF-36 score.
RESULTS: The average preoperative AOFAS-Score was 53.1 +/- 14.5 points and 83.2 +/- 12.2 points at final postoperative followup. The mean improvement was 29.5. The difference between the preoperative and postoperative AOFAS score was significant (p < 0.0001) using a two-tailed t-test. The difference in the AOFAS pain and alignment subscales was also significant (p < 0.0001). The function subscale improvement was also significant (p = 0.018). The mean physical function component of the postoperative SF-36 score was 79.2. A correlation was found between the SF-36 physical component score and the post operative AOFAS score (r(2) = 0.754).
CONCLUSION: While some lateral discomfort or pain occurred in patients with or without a lateral column lengthening, the posterior tibial tendon reconstruction utilizing medial calcaneal displacement osteotomy with flexor digitorum longus transfer and a lateral column lengthening with more deformity was successful in the higher-functioning, younger patients.
The purpose of this study was to analyze the prevalence of spring ligament pathology and other radiographic changes related to flatfoot deformity in the presence of different degrees of tibialis posterior tendon pathology. A total of 72 patients (24 with tibialis posterior tendon abnormality and 48 sex- and age-matched controls) were evaluated for tibialis posterior tendon pathology, spring ligament pathology, and plain pedal radiographic angles, including cuboid abduction, talar declination, calcaneal inclination, and Meary's angles. The patients with tibialis posterior tendon pathology were subdivided into either minor (Type I) or severe (Type II/III), according to the Conti classification of tibialis posterior tendon pathology on MRI. All the continuous data of radiographic angles were dichotomized into either a flatfoot group or normal/cavus foot group. Associations between these nominal variables were analyzed. There was no association between Type I tibialis posterior tendon pathology and spring ligament pathologies (OR = 0.8, 95% CI = 0.15-4.65). Conversely, every patient with Type II/III tibialis posterior tendon pathology had spring ligament abnormality. Type II/III group also showed statistically significant associations with both increased talar declination angle (OR = 10.4, 95% CI = 1.62-109.22) and Meary's angle (OR = 7.5, 95% CI = 1.35-51.12), while no such associations were found with Type I tibialis posterior tendon pathology (OR = 1.0, 95% CI = 0.18-6.18 with talar declination angle; OR = 3.9, 95% CI = 0.65-27.71 with Meary's angle). In this investigation, only advanced tibialis posterior tendon pathology was statistically significantly associated with adult-acquired flatfoot deformity and spring ligament pathology
Effects of the AirLift PTTD Brace on Foot Kinematics in Subjects With Stage II Posterior Tibial Tendon Dysfunction.
Neville C, Flemister AS, Houck JR. J Orthop Sports Phys Ther. 2009 Mar;39(3):201-9
Quote:
STUDY DESIGN: Experimental laboratory study.
OBJECTIVES: To investigate the effect of inflation of the air bladder component of the AirLift PTTD brace on relative foot kinematics in subjects with stage II posterior tibial tendon dysfunction (PTTD).
BACKGROUND: Orthotic devices are commonly recommended in the conservative management of stage II PTTD to improve foot kinematics.
METHODS AND MEASURES: Ten female subjects with stage II PTTD walked in the laboratory wearing the AirLift PTTD brace during 3 testing conditions (air bladder inflation to 0, 4, and 7 PSI [SI equivalent: 0, 27 579, and 48 263 Pa]). Kinematics were recorded from the tibia, calcaneus (hindfoot), and first metatarsal (forefoot), using an Optotrak motion analysis system. Comparisons were made between air bladder inflation and the 0-PSI condition for each of the dependent kinematic variables (hindfoot eversion, forefoot abduction, and forefoot dorsiflexion).
RESULTS: Greater hindfoot inversion was observed with air bladder inflation during the second rocker (mean, 1.7 degrees ; range, -0.7 degrees to 6.1 degrees ). Less consistent changes in forefoot plantar flexion and forefoot adduction occurred with air bladder inflation. The greatest change toward forefoot plantar flexion was observed during the third rocker (mean, 1.4 degrees ; range, -3.8 degrees to 3.9 degrees ). The greatest change towards adduction was observed during the third rocker (mean, 2.3 degrees ; range, -3.4 degrees to 6.5 degrees ).
CONCLUSIONS: On average, the air bladder component of the AirLift PTTD brace was successful in reducing the amount of hindfoot eversion observed in subjects with stage II PTTD; however, the effect on forefoot motion was more variable. Some subjects tested had marked improvement in foot kinematics, while 2 subjects demonstrated negative results. Specific foot characteristics are hypothesized to explain these varied results
I have been searching the literature on the treatment of PTTD. Does anyone have a tretament protocol for this condition, which has been successful for the different stages of this condition?
Regards
Rob
With respect to rehabilitation of the Posterior Tibialis Tendon,
Over the past 10 years as a private sports clinician practicing at the University of Queensland rehab clinic, I have used many exercises both eccentric and concentric that start from non-weightbearing and progress the client back to full weight-bearing.
I agree with Kevin on the use of orthotics here also. I find myself using many modalities to help clients through this condition (stage 1 and into stage 2).
Sometimes my exercise rehab would include;
Stage 1- Non-weightbearing plantar flexion then Pf with internal rotation
Stage 2 - Non-Weightbearing with theraband resistance bands - plantar flexion then Pf with internal rotation
Stage 3 - Seated Arch lifts,
Stage 4 - Standing Arch lifts
Stage 5 - ArchCOACH eccentric arch strengthening.
" The foot bone is connected to the leg bone and the leg bone is connected to the back bone"
I love that!!!!
Question. You state you had a triple X I year for PTTD. May I ask what was the duration of your symptoms and whether you developed peroneal spasms (i.e. rigid pes valgus) ?
I'm interested in knowing why a triple vs other surgical options.
Thanks
Steve
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Green Bay, Wisconsin, USA
Hi All
Does anyone know what the incidence of PTTD is in children under the age of 14?
I can find very little if anything either on Pub Med or Science Direct.
Thanks in advance
Deborah
Have seen 2, in cousins. Pathology starting in 7-8 and surgical repair by 12 and 10 respectively.
It is only this morning that I had the epiphany of just how rare it was. I originally thought it was tendonopathy however when it was referred off for a surgical opinion after conservative treatment based on Kevin's article (many thanks for back then as I had no idea what to do!!) unfortunately made minimal impact. The surgical letter back to the GP stated that it was PTTD and was surgically repaired and had reference to how unusal it was in that age group. However this is 5+ years ago and they are long lost to the Ortho's/Physio's/Orthotists of the Royal Children's Hospital so I know I will never see them again. I did 2-3 times after the surgical results in the first wasn't a great, the second child did really well according to the first's family.
__________________
Cheers,
Cylie.... in a permanent state of confusion
Background
To investigate the prevalence of posterior tibial tendon dysfunction (PTTD) in women over the age of 40.
Methods
A validated survey was posted to a random sample of 1000 women (over 40 years) from a GP group practice in Hertfordshire, England. Survey positive women were telephoned and when indicated, a detailed examination was performed.
Results
There were 582 usable responses. The majority indicated they had minor forefoot or no problems. Telephone contact was made with 116 women and of those 79 required examination. The diagnosis of symptomatic flatfeet was made in 9 patients, 7 patients had stage I PTTD, 12 patients had stage II PTTD and 9 patients had an adult acquired flatfoot deformity.
Conclusions
This is the first report of the prevalence of stage I and II PTTD in women (over 40 years). The prevalence is 3.3% and all patients were undiagnosed despite characteristic and prolonged symptoms.
In my experience, conservative AND surgical approaches are unrewarding once the peroneal tendons have gone into spasm and a rigid pes valgus results.
Hi Steve, how do you clinically determine the level of Peroneal spasm and pes valgus rigidity that generally will not yield a good result conservatively OR surgically?
The whole PTTD entity is one that confuses me, and admittedly I usually end up treating the mechanical abnormalities to reduce pain and deformity without specifically considering the role/function of the PTT? This is something I need to do a bit more reading on....
Hi Adam:
Pretty simple. Once you have a rigid pes valgus (in these cases due to peroneal spasms from unopposed post tib dysfunction) you are pretty much out of luck.
One can try peroneal tendon lengthenings since normally the spasms subside under general anesthesia, but results are dissapointing. Triple arthrodesis is the procedure of choice (depending on symptoms)
PTTD certainly is quite variable depending on the underlying cause, patient type, duration, etc.....
Some of these are no more than tendinitis, others chronic synovitis, others torn PT and combinations thereof.
In my opinion, true PTTD is chronic (more than 6 months) with clinical weakness of the posterior tibial and unilateral progressive pes planus. These, untreated, are usually progressive to the rigid pes valgus end point.
Hope that helps
Steve
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Green Bay, Wisconsin, USA
In my opinion, true PTTD is chronic (more than 6 months) with clinical weakness of the posterior tibial and unilateral progressive pes planus. These, untreated, are usually progressive to the rigid pes valgus end point.
Posterior tibial tendon dysfunction
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Linear Mode
