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Stage I and II Posterior Tibial Tendon Dysfunction Treated by a Structured Nonoperative Management Protocol: An Orthosis and Exercise Program. Foot Ankle Int. 2006 Jan;27(1):2-8
Quote:
BACKGROUND: Posterior tibial tendon dysfunction (PTTD) is a relatively common problem of middle-aged adults that usually is treated operatively. The purpose of this study was to identify strength deficits with early stage PTTD and to assess the efficacy of a focused nonoperative treatment protocol.
METHODS: Forty-seven consecutive patients with stage I or II posterior tibial tendon dysfunction were treated by a structured nonoperative protocol. Criteria for inclusion were the presence of a palpable and painful posterior tibial tendon, with or without swelling and 2) movement of the tendon with passive and active nonweightbearing clinical examination. The rehabilitation protocol included the use of a short, articulated ankle foot orthosis or foot orthosis, high-repetition exercises, aggressive plantarflexion activities, and an aggressive high-repetition home exercise program that included gastrocsoleus tendon stretching. Isokinetic evaluations were done before and after therapy to compare inversion, eversion, plantarflexion, and dorsiflexion strength in the involved and uninvolved extremities. Criteria for successful rehabilitation were no more than 10% strength deficit, ability to perform 50 single-support heel rises with minimal or no pain, ability to ambulate 100 feet on the toes with minimal or no pain, and ability to tolerate 200 repetitions of the home exercises for each muscle group.
RESULTS: Before therapy weakness for concentric and eccentric contractures of all muscle groups of the involved ankle was significant (p < 0.001). After a median of 10 physical therapy visits over a median period of 4 months, 39 (83%) of the 47 patients had successful subjective and functional outcomes, and 42 patients (89%) were satisfied. Five patients (11%) required surgery after failure of nonoperative treatment.
CONCLUSION: This study suggests that many patients with stage I and II posterior tibial tendon dysfunction can be effectively treated nonoperatively with an orthosis and structured exercises.
The keys to successful treatment of posterior tibial dysfunction (PTD) are appropriately prescribed custom foot orthoses, high top boots/shoes (or braces), icing therapy, gastroc-soleus stretching and gradual progressive strengthening exercises (Kirby KA: Conservative treatment of posterior tibial dysfunction. Podiatry Management, 19:73-82, 2000). 0% of my patients with grade I PTD need surgery and only 10% of my patients with grade II-III PTD are referred for surgery. I see about 10 patients with various stages of PTD every month in my practice.
Understanding the biomechanical concept that foot orthoses may be selectively designed to increase the magnitude of external subtalar joint supination moment during weightbearing activities is critical to proper orthosis prescription for this pathology (Kirby KA: The medial heel skive technique: improving pronation control in foot orthoses. JAPMA, 82: 177-188, 1992; Kirby KA, Green DR: Evaluation and Nonoperative Management of Pes Valgus, pp. 295-327, in DeValentine, S.(ed), Foot and Ankle Disorders in Children. Churchill-Livingstone, New York, 1992).
__________________
Sincerely,
Kevin
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Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
I recently had a heavy set woman come into my office with PTD.After she was put in an AFO,she did get a good result.I agree with Dr.Kirby in that you do not need to do surgery on these patients.
Whilst wholeheartedly I agree with you that conservative treatment is the cornerstone of treating PTTD, I often scratch my head about the benefit of any gradual strengthening program for the PT muscle.
I this condition is characterised by degeneration and disorganisation of the PT tendon, would not a strengthening program to the PT muscle be counterproductive?
If the muscle pulls with greater strength on diseased tendon, won't this just accelerate further disorganisation of the tendon fibres and greater medial column collapse?
The only muscle i target is the posterior calf group - but for stretching only. In essence, I prefer to give up on the PT itself and focus on making the orthotic as aggressive as possible...
I use rehab excerises for PTTD due to the research done on Achilles tendinopathy eccentric re-training Gold standard etc.
In addition, one study showed that eccentric rehab training of the Tib Post muscle reduced thickening and 'normalised' tendon structure.
I agree about the tight posterior structure needing stretching but this has to be done very carefully due to the stress that some stretching routines put on the PTT.
I have had good results so far but patient complinace with the exercises is very difficult to maintain.
So what eccentric exercises do you recommend. Are we talking the same as Alfredsons et al for achilles tendinosis? Or rubber band type resistance exercises? How many reps etc - as per alfredsons?
I usually use Theraband excersies to start with and once they are performing them correctly - 3 x 15 controlled reps with the strongest bands- I will get them doing a weight bearing version similar to the TA rehab execrsises with the addition of them trying to maintain the arch during loading. You need to chosse your patients carefully before doing this but the sports patients usually do well.
Whilst wholeheartedly I agree with you that conservative treatment is the cornerstone of treating PTTD, I often scratch my head about the benefit of any gradual strengthening program for the PT muscle.
I this condition is characterised by degeneration and disorganisation of the PT tendon, would not a strengthening program to the PT muscle be counterproductive?
If the muscle pulls with greater strength on diseased tendon, won't this just accelerate further disorganisation of the tendon fibres and greater medial column collapse?
The only muscle i target is the posterior calf group - but for stretching only. In essence, I prefer to give up on the PT itself and focus on making the orthotic as aggressive as possible...
Interested in your thoughts,
LL
Tony:
If you were to do the strengthening exercises to the posterior tibial (PT) muscle without any other treatment, then you would probably cause more harm than good. However, when PT strengthening is done with other measures that increase external subtalar joint (STJ) supination moment, such as anti-pronation orthoses and/or bracing, the PT strengthening allows the PT muscle to resume a more functional role while the tendon heals.
It must be remembered that without PT muscle strength, the foot has lost its prime STJ supinator so weakness in the PT muscle is never good for the pronated foot. It is also important to note that STJ supination (that is more likely to occur with a strong PT muscle) will cause an increase in the supination moment arm of the PT tendon to the STJ axis that will, in turn, decrease the demand on the PT muscle to cause STJ supination. Increasing the supination moment arm of the PT tendon to the STJ axis will never cause an increase in demand on the PT muscle to cause STJ supination moment, it will only cause a decrease in demand on the PT muscle.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Hi everyone:
Well, first, I'd like to comment on the study itself.
There was no mention of a comparison of the criteria for success and the pre-treatment capabilities. Secondly, was there any follow up? Were all the parameters measured and subjective outcomes evaluated immediately at the end of the treatment program? Thirdly, what were the age groups? And finally; Underlying etiology and duration of symptoms.
The reason I raise these questions (and the original study may have dealt with them) is that I try to resist categorizing patients with any post tibial pain as just that....posterior tibial pain. I think the selection of treatment and outcomes of those treatment decisions are, to a very large extent, dependent on the underlying cause of the posterior tibial pain.
Certainly a young athlete with a history of injury and normal mechanics will be treated differently than an overweight, sessile 60 year old with tight tendoachilles and weakness, differently than the 18 year old with accessory naviclular and differently than the patient with chronic pain, early peroneal spasms and a demanding life style.
Are we treating tenosynovitis, tendinitis, microdegeneration of the tendon, tears, tethering, partial rupture? Are these secondary to pathomechanics or is do we have pathomechanics secondary to a weakened Postior Tibial Muscle.
Just food for thought.
Steve
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Green Bay, Wisconsin, USA
The Following User Says Thank You to drsarbes For This Useful Post:
Plantar Pressure Analysis in Cadaver Feet After Bony Procedures Commonly Used in the Treatment of Stage II Posterior Tibial Tendon Insufficiency.
Scott AT, Hendry TM, Iaquinto JM, Owen JR, Wayne JS, Adelaar RS. Foot Ankle Int. 2007 Nov;28(11):1143-53
Quote:
BACKGROUND: Bony procedures play an essential role in the operative treatment of stage II posterior tibial tendon insufficiency and often substantially alter the loading characteristics of the foot.
METHODS: Eight matched pairs of cadaver lower extremities were axially loaded onto a TekScan HR Mat. (TekScan, Inc., South Boston, MA) After intact testing, each specimen had a lateral column lengthening (either a calcaneocuboid distraction arthrodesis [CCDA] or Evans procedure), a medializing calcaneal osteotomy (MCO), and a plantarflexion (Cotton) osteotomy of the medial cuneiform. The measured plantar pressures were divided into three forefoot regions, two midfoot regions, and two hindfoot regions. For each region, average pressure, peak pressure, and contact area data were collected.
RESULTS: Despite the fact that both lateral column lengthening procedures resulted in increased lateral forefoot pressures, no significant differences were noted between the CCDA and the Evans procedure. The addition of a MCO did not significantly alter the plantar pressures measured after the lateral column lengthening alone. Although the Cotton osteotomy resulted in increased average pressures within the medial forefoot, a compensatory significant decrease in lateral forefoot pressures was not observed.
CONCLUSIONS: The present study demonstrated increased lateral forefoot pressures after a combined lateral column lengthening and MCO and does not support the idea that a Cotton osteotomy significantly reduces loading of the lateral forefoot.
CLINICAL RELEVANCE: The incidence of lateral forefoot pain and fifth metatarsal stress fractures subsequent to either lateral column lengthening procedure may not significantly decline after a Cotton osteotomy.
I find that the compliance of patients drops when faced with an AFO. We also use a Cobey X ray view to assess the relationship between the tibia and calcaneum in weight bearing. Often this will explain why foot orthoses won't work with particular patients as the alignment is such that little hindfoot control is possible.
Craig Payne has also published work that demontrate the the orthoses reduce the work load on the PTT as opposed to affecting relative lengthening alone.
Hi everyone:
Well, first, I'd like to comment on the study itself.
There was no mention of a comparison of the criteria for success and the pre-treatment capabilities. Secondly, was there any follow up? Were all the parameters measured and subjective outcomes evaluated immediately at the end of the treatment program? Thirdly, what were the age groups? And finally; Underlying etiology and duration of symptoms.
The reason I raise these questions (and the original study may have dealt with them) is that I try to resist categorizing patients with any post tibial pain as just that....posterior tibial pain. I think the selection of treatment and outcomes of those treatment decisions are, to a very large extent, dependent on the underlying cause of the posterior tibial pain.
Certainly a young athlete with a history of injury and normal mechanics will be treated differently than an overweight, sessile 60 year old with tight tendoachilles and weakness, differently than the 18 year old with accessory naviclular and differently than the patient with chronic pain, early peroneal spasms and a demanding life style.
Are we treating tenosynovitis, tendinitis, microdegeneration of the tendon, tears, tethering, partial rupture? Are these secondary to pathomechanics or is do we have pathomechanics secondary to a weakened Postior Tibial muscle
Just to follow this up - are there any papers that have investigated the true pathology of differing Posterior Tibial tendon pain - perhaps papers similar to that of Khan et al 1999 that looked at Achilles tendon pain and noted lack of inflammatory markers?
I have seen plenty of papers regarding PTTD but non that look at pathomechanics i.e. whether tendinopathy/osis/itis paratenitis.......
Also investigations from the local radiology dept will just note tendinitis.
Any thoughts?
Mark
Last edited by Cooking Pod : 9th January 2008 at 06:53 AM.
Reason: forgot to add a bit
Posterior tibial tendon dysfunction
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