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Changes in gait associated with acute stage II posterior tibial tendon dysfunction
S.I. Ringle, S.J. Kavros, B.R. Kotajarvi, D.K. Hansen, H.B. Kitaoka and K.R. Kaufman
The purpose of this study was to examine differences in gait mechanics between patients with acute stage II PTTD and healthy volunteers. Hindfoot and midfoot kinematics, plantar foot pressures and electromyographic (EMG) activity of the posterior tibialis, gastrocnemius, anterior tibialis and the peroneals were measured in five patients with acute stage II PTTD. Kinematics and kinetics were compared to a database of 20 healthy volunteers. EMG and plantar pressure data were obtained from five healthy volunteers. Hindfoot moments and powers were also calculated. The center of pressure excursion index (CPEI) was calculated from the plantar pressures. Significant differences were observed between the two groups, which confirmed clinical observations. Limited hindfoot eversion and increased midfoot external rotation occurred during the first and third rockers. The EMG data suggested that tendon dysfunction in the posterior tibialis is associated with compensatory activity, not only in its antagonists (the peroneals), but also in the anterior tibialis and the gastrocnemius. These data suggest that non-operative treatment of patients with PTTD should consider minimizing the activity of the posterior tibialis as well as the peroneals, the anterior tibialis and the gastrocnemius.
STUDY DESIGN: A 2 x 4 mixed-design ANOVA with a fixed factor of group (posterior tibialis tendon dysfunction [PTTD] and asymptomatic controls), and a repeated factor of phase of stance (loading response, midstance, terminal stance, and preswing).
OBJECTIVE: To compare 3-dimensional stance period kinematics (rearfoot eversion/inversion, medial longitudinal arch [MLA] angle, and forefoot abduction) of subjects with stage II PTTD to asymptomatic controls.
BACKGROUND: Abnormal foot postures in subjects with stage II PTTD are clinical indicators of disease progression, yet dynamic investigations of forefoot, midfoot, and rearfoot kinematic deviations in this population are lacking.
METHODS: Fourteen subjects with stage II PTTD were compared to 10 control subjects with normal arch index values. Subjects were matched for age, gender, and body mass index. A 5-segment, kinematic model of the leg and foot was tracked using an Optotrak Motion Analysis System. The dependent kinematic variables were rearfoot inversion/eversion, forefoot abduction/adduction, and the MLA angle. An ANOVA model was used to compare kinematic variables between groups across 4 phases of stance.
RESULTS: Subjects with PTTD demonstrated significantly greater rearfoot eversion (P = .042), MLA angle (P = .008) and forefoot abduction angles (P < .005) during specific phases of stance. Subjects with PTTD demonstrated significantly greater rearfoot eversion (P<.004) and MLA angles (P < .009) by 6.2 degrees and 8.0 degrees, respectively, during loading response when compared to controls. During preswing, the subjects with PTTD demonstrated a significantly greater MLA angle (P < .002) and a forefoot abduction angle (P<.001) which exceeded that of the controls by 10.0 degrees.
CONCLUSIONS: The abnormal kinematics observed at the rearfoot, midfoot, and forefoot across all phases of stance implicate a failure of compensatory muscle and secondary ligamentous support to control foot kinematics in subjects with stage II PTTD.
Re: Gait changes with tibialis posterior dysfunction
Comparison of Changes in Posterior Tibialis Muscle Length Between Subjects With Posterior Tibial Tendon Dysfunction and Healthy Controls During Walking.
Neville C, Flemister A, Tome J, Houck JR. J Orthop Sports Phys Ther. 2007;37(11):661-669.
STUDY DESIGN: Case control study. OBJECTIVE: To compare posterior tibialis (PT) length between subjects with stage II posterior tibial tendon dysfunction (PTTD) and healthy controls during the stance phase of gait. BACKGROUND: The abnormal kinematics demonstrated by subjects with stage II PTTD are presumed to be associated with a lengthened PT musculotendon, but this relationship has not been fully explored.
METHODS AND MEASURES: Seventeen subjects with stage II PTTD and 10 healthy controls volunteered for this study. Subject-specific foot kinematics were collected using 3-D motion analysis techniques for input into a general model of PT musculotendon length (PTLength). The kinematic inputs included hindfoot eversion/inversion (HF Ev/Inv), forefoot abduction/adduction (FF Ab/Add), forefoot plantar flexion/dorsiflexion (FF Pf/Df), and ankle plantar flexion/dorsiflexion (Ankle Pf/Df). To estimate the change in PTLength from neutral the following was used: PTLength = 0.401(HF Ev/Inv) + 0.270(FF Ab/Add) + 0.137(FF Pf/Df) + 0.057(Ankle Pf/Df). Positive values indicated lengthening from the subtalar neutral (STN) position, while negative values indicated shortening relative to the STN position. A 2-way analysis of variance (ANOVA) model was used to compare PTLength between groups across the stance phases of walking (loading response, midstance, terminal stance, and preswing). Also, a 2-way ANOVA was used to assess the foot kinematics that contributed to alterations in PTLength. The Short Musculoskeletal Functional Assessment Index and Mobility subscale were used to compare function and mobility.
RESULTS: PTLength was significantly greater (lengthened) relative to the STN position in the PTTD group compared to the control group across all phases of stance, with the greatest between-group difference in PTLength occurring during preswing. The greater PTLength in subjects with PTTD compared to controls was principally attributed to significantly greater HF Ev/Inv during loading response (P=.014) and midstance (P=.015). During terminal stance and preswing, each kinematic input to estimate PTLength contributed to lengthening (main effect, P=.03 and P=.01, respectively). Subjects with PTTD with abnormally greater PTLength reported significantly lower function (P = .04) and mobility (P = .03) compared to subjects with PTTD with normal PTLength during walking.
CONCLUSIONS: The greater PTLength, as determined from foot kinematics, suggests the PT musculotendon is lengthened in subjects with stage II PTTD, compared to healthy controls. The amount of lengthening is not dependent on the phase of gait; however, different foot kinematics contribute to PTLength across the stance phase. Targeting these foot kinematics may limit lengthening of the PT musculotendon. Subjects with excessive PT lengthening experience a decrease in function
The purpose of this study is to provide a quantitative characterization of gait in patients with posterior tibial tendon dysfunction (PTTD), including temporal-spatial and kinematic parameters, and to compare these results to those of a Normal population. Our hypothesis was that segmental foot kinematics were significantly different in multiple segments across multiple planes. A 15 camera motion analysis system and weight-bearing radiographs were employed to evaluate 3D foot and ankle motion in a population of 34 patients with PTTD (30 females, 4 males) and 25 normal subjects (12 females, 13 males). The four-segment Milwaukee Foot Model (MFM) with radiographic indexing was used to analyze foot and ankle motion and provided kinematic data in the sagittal, coronal and transverse planes as well as temporal-spatial information. The temporal-spatial parameters revealed statistically significant deviations in all four metrics for the PTTD population. Stride length, cadence and walking speed were all significantly diminished, while stance duration was significantly prolonged (p < 0.0125). Significant kinematic differences were noted between the groups (p < 0.002), including: (1) diminished dorsiflexion and increased eversion of the hindfoot; (2) decreased plantarflexion of the forefoot, as well as abduction shift and loss of the varus thrust in the forefoot; and (3) decreased range of motion (ROM) with diminished dorsiflexion of the hallux. The study provides an impetus for improved orthotic and bracing designs to aid in the care of distal foot segments during the treatment of PTTD. It also provides the basis for future evaluation of surgical efficacy. The course of this investigation may ultimately lead to improved treatment planning methods, including orthotic and operative interventions.
BACKGROUND: Subjects with stage II posterior tibial tendon dysfunction (PTTD) exhibit abnormal foot kinematics; however, how individual segment kinematics (hindfoot (HF) or first metatarsal (first MET) segments) influence global foot kinematics is unclear. The purpose of this study was to compare foot and ankle kinematics and sagittal plane HF and first MET segment kinematics between stage II PTTD and controls.
MATERIALS AND METHODS: Thirty patients with stage II PTTD and 15 healthy controls were evaluated. Kinematic data from the tibia, calcaneus, and first MET were collected during walking using three dimensional motion analysis techniques. A three-segment foot model (HF, calcaneus; first MET, first metatarsal, and tibia) was used to calculate relative angles (ankle, HF relative to tibia; midfoot, first MET relative to HF) and segment angles (HF and first MET relative to the global). A mixed effect ANOVA model was utilized to compare angles between groups for each variable.
RESULTS: Patients with PTTD showed greater ankle plantarflexion (p = 0.02) by 6.8 degrees to 8.4 degrees prior to or at 74% of stance; greater HF eversion (p < 0.01) across stance (mean difference = 4.5 degrees); and greater first MET dorsiflexion (p < 0.01) across stance (mean difference = 8.8 degrees). HF and first MET segment angles revealed greater HF dorsiflexion (p = 0.01) during early stance and greater first MET dorsiflexion (p = 0.001) across stance.
CONCLUSION: Abnormal HF and first MET segment kinematics separately influence both ankle and midfoot movement during walking in subjects with stage II PTTD.
CLINICAL RELEVANCE: These abnormal kinematics may serve as another measure of response to clinical treatment and/or guide for clinical strategies (exercise, orthotics, and surgery) seeking to improve foot kinematics
BACKGROUND: Adult acquired flatfoot is often associated with Achilles tendon contracture and may be associated with isolated spring ligament insufficiency without Achilles tendon contracture. We have studied the hypothesis that standing valgus hindfoot alignment moment arm is increased in adult acquired flatfoot with Achilles tendon contracture when compared to adult acquired flatfoot without Achilles tendon contracture.
MATERIALS AND METHODS: The standing hindfoot alignment, standing lateral tibial-calcaneal angle, lateral talo-first metatarsal angle, lateral medial cuneiform arch height, and anteroposterior talonavicular coverage angle were measured in 22 patients with a clinical diagnosis of adult acquired flatfoot with one foot with clinical Achilles tendon contracture and one without that diagnosis. We compared the adult acquired flatfoot group to a control group of 15 patients with no foot or ankle deformities or previous foot or ankle surgeries.
RESULTS: In patients with flatfoot and Achilles tendon contracture, there was a significantly increased valgus hindfoot alignment, talo-first metatarsal angle, talonavicular coverage angle, tibiocalcaneal angle and a decreased arch height when compared to the control group. In all flatfeet, we found an increased tibiocalcaneal angle. In both flatfoot groups, an increasing tibiocalcaneal angle and an increasing talo-first metatarsal angle was correlated to a decreasing arch height. In adult acquired flatfoot without Achilles tendon contracture diagnosed by clinical exam, an increasing talonavicular coverage angle was correlated to an increasing talo-first metatarsal angle and a decreasing arch height.
CONCLUSION: Adults with flatfoot and Achilles tendon contracture have a significantly increased standing hindfoot valgus alignment moment arm and other associated deformities.
BACKGROUND: Stage II flatfoot secondary to posterior tibial tendon insufficiency may be subclassified into mild (IIa) and severe (IIb) deformity based on the degree of talonavicular abduction. Current assessment of this abduction is difficult. We hypothesized that two new anteroposterior radiographic parameters, the lateral talonavicular incongruency angle (IA) and incongruency distance (ID) would demonstrate good reliability, correlate with current abduction parameters, and differ in IIb deformity, IIa deformity, and controls.
MATERIALS AND METHODS: Preoperative radiographs for consecutive patients undergoing flatfoot reconstruction were reviewed and subdivided into those with a Stage IIb (n = 32) or Stage IIa (n = 8) deformity. A third group of patients without flatfoot served as control (n = 30). Radiographs were measured blindly by two investigators. Reliability was assessed with intraclass correlation coefficients (ICC), correlation with existing parameters with Pearson coefficients, and comparison between groups with analysis of variance.
RESULTS: The mean intrarater and interrater ICC's for the IA (0.88 and 0.81, respectively) were high. The IA correlated well with the coverage angle (r = 0.86) and uncoverage percent (r = 0.76). The IA was higher in the IIb versus IIa patients (p = 0.007) and in the IIb group versus control (p < 0.001). The ID demonstrated excellent reliability (ICC's of 0.83 and 0.83), but correlated poorly with the two other abduction parameters (r = -0.59 and -0.49) and failed to differentiate between the three groups (p = 0.0528).
CONCLUSION: This data suggests that the IA is reliable and may help subclassify Stage II flatfoot deformity.
To investigate differences in arch height, ankle muscle strength, and biomechanical factors in individuals with stage I posterior tibial tendon dysfunction (PTTD) in comparison to healthy individuals.
PTTD is a progressive condition, so early recognition and treatment are essential to help delay or reverse the progression. However, no previous studies have investigated stage I PTTD and no single study has measured static anatomical structure, muscle strength, and gait mechanics in this population.
Twelve individuals with stage I PTTD and 12 healthy, age, and gender matched, control subjects, engaged in running-related activities, participated in this study. Measurements of arch height index (AHI), maximum voluntary ankle invertor muscle strength, and 3-dimensional rearfoot and medial longitudinal arch (MLA) kinematics during walking were obtained.
The runners with PTTD demonstrated significantly lower seated AHI (p = 0.02) and greater (p = 0.03) and prolonged (p = 0.05) peak rearfoot eversion angle during gait when compared to the healthy runners. No differences were found in standing AHI values (p=0.28), arch rigidity index (p=0.06), ankle invertor strength (p = 0.49), or peak MLA values (p = 0.49) between groups.
The increased foot pronation is hypothesized to place greater strain on the posterior tibialis muscle, which may partially explain the progressive nature of this condition
Re: Gait changes with tibialis posterior dysfunction
Women With Posterior Tibial Tendon Dysfunction Have Diminished Ankle and Hip Muscle Performance
Kornelia Kulig, John M. Popovich, Lisa M. Noceti-Dewit, Stephen F. Reischl, Dong Kim J Orthop Sports Phys Ther 2011;41(9):687-694
STUDY DESIGN: Controlled laboratory study using a cross-sectional design.
OBJECTIVES: To characterize ankle and hip muscle performance in women with posterior tibial tendon dysfunction (PTTD) and compare them to matched controls. We hypothesized that ankle plantar flexor strength, and hip extensor and abductor strength and endurance, would be diminished in women with PTTD and this impairment would be on the side of dysfunction.
BACKGROUND: Individuals with PTTD demonstrate impaired walking abilities. Walking gait is strongly dependent on the performance of calf and hip musculature.
METHODS: Thirty-four middle-aged women (17 with PTTD) participated. Ankle plantar flexor strength was assessed with the single-leg heel raise test. Hip muscle performance, including strength and endurance, were dynamometrically measured. Differences between groups and sides were assessed with a mixed-model analysis of variance.
RESULTS: Females with PTTD performed significantly fewer single-leg heel raises and repeated sagittal and frontal plane non–weight-bearing leg lifts, and also had lower hip extensor and abductor torques than age-matched controls. There were no differences between sides for hip strength and endurance measures for either group, but differences between sides in ankle strength measures were noted in both groups.
CONCLUSION: Women with PTTD demonstrated decreased ankle and hip muscle performance bilaterally.
Re: Gait changes with tibialis posterior dysfunction
Total and Distributed Plantar Loading in Subjects With Stage II Tibialis Posterior Tendon Dysfunction During Terminal Stance.
Neville C, Flemister AS, Houck J. Foot Ankle Int. 2013 Jan;34(1):131-9.
Background: In subjects with stage II tibialis posterior tendon dysfunction (TPTD), the function of the tibialis posterior muscle is altered and may be associated with a change in total and distributed loading.
Methods: Thirty subjects with a diagnosis of stage II TPTD and 15 matched control subjects volunteered to participate in a study to examine the total and distributed plantar loading under the foot during the terminal stance phase of gait. Plantar loading, measured as the subject walked barefoot, was assessed using instrumented flexible insoles. A secondary analysis was done to explore the contribution of flatfoot kinematics to plantar loading patterns.
Results: Overall, there was reduced total plantar loading in subjects with stage II TPTD compared with controls. Accounting for differences in total loading, the presence of clinically measured weakness in subjects with TPTD was associated with reduced lateral forefoot loading. Medial longitudinal arch height was significantly correlated with loading patterns but explained only 21% of the variance in observed loading patterns.
Conclusion: Subjects with TPTD who are strong exhibited loading patterns similar to controls. Changes in total and distributed loading during terminal stance suggest there are altered ankle mechanics at push-off during the functional task of gait.
Clinical Relevance: Strength, in the presence of TPTD, may be important to stabilize the midfoot during gait and might be important in rehabilitation protocols.
Re: Gait changes with tibialis posterior dysfunction
An in vivo study of hindfoot 3D kinetics in stage II posterior tibial tendon dysfunction (PTTD) flatfoot based on weight-bearing CT scan.
Zhang Y, Xu J, Wang X, Huang J, Zhang C, Chen L, Wang C, Ma X. Bone Joint Res. 2013 Dec 9;2(12):255-263.
The objective of this study was to evaluate the rotation and translation of each joint in the hindfoot and compare the load response in healthy feet with that in stage II posterior tibial tendon dysfunction (PTTD) flatfoot by analysing the reconstructive three-dimensional (3D) computed tomography (CT) image data during simulated weight-bearing.
CT scans of 15 healthy feet and 15 feet with stage II PTTD flatfoot were taken first in a non-weight-bearing condition, followed by a simulated full-body weight-bearing condition. The images of the hindfoot bones were reconstructed into 3D models. The 'twice registration' method in three planes was used to calculate the position of the talus relative to the calcaneus in the talocalcaneal joint, the navicular relative to the talus in talonavicular joint, and the cuboid relative to the calcaneus in the calcaneocuboid joint.
From non- to full-body-weight-bearing condition, the difference in the talus position relative to the calcaneus in the talocalcaneal joint was 0.6° more dorsiflexed (p = 0.032), 1.4° more everted (p = 0.026), 0.9 mm more anterior (p = 0.031) and 1.0 mm more proximal (p = 0.004) in stage II PTTD flatfoot compared with that in a healthy foot. The navicular position difference relative to the talus in the talonavicular joint was 3° more everted (p = 0.012), 1.3 mm more lateral (p = 0.024), 0.8 mm more anterior (p = 0.037) and 2.1 mm more proximal (p = 0.017). The cuboid position difference relative to the calcaneus in the calcaneocuboid joint did not change significantly in rotation and translation (all p ≥ 0.08).
Referring to a previous study regarding both the cadaveric foot and the live foot, joint instability occurred in the hindfoot in simulated weight-bearing condition in patients with stage II PTTD flatfoot. The method used in this study might be applied to clinical analysis of the aetiology and evolution of PTTD flatfoot, and may inform biomechanical analyses of the effects of foot surgery in the future