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Assistance with unusual PTTD presentation

Discussion in 'Biomechanics, Sports and Foot orthoses' started by David Smith, Oct 11, 2010.

  1. David Smith

    David Smith Well-Known Member

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    Hi all

    12 days ago I was referred a lady, 45yrs old 163cm tall 66kg, from orthopaedic an consultant. She is not an highly physically active but leads a busy life. The Diagnosis was Posterior tibial tendon dysfunction (PTTD) right foot. Initial onset about 1 year ago but recently got worse i.e. examined by medics various and x rayed in Jan 2010 and July 2010. Since she was referred to me I guess that the consultant considered surgery was unnecessary at this juncture.

    The presentation was unusual in that there was almost no Post tib pain and no swelling allong its track, the PT function was very strong and she could do a very high single leg heel raise and invert the heel. The swelling and pain was entirely over the medial malleolus and the pain focused on the origin of the anterior deltoid and talotibial ligament at the medial anterior inferior aspect of the medial malleolus. No lateral pain from sinus tarsi impingement.

    Pressure applied to the origin of the anterior deltoid ligament (tibial calcaneal ligament) and the anterior tibio-talar ligament elicits the most pain

    The lady reported that she had always had ankles that roll in a lot but recently it had become worse and a few weeks ago she had a fall at work when she slipped on a hard floor and twisted her left ankle. She could not remember how the foot twisted. The ankle was swollen and tender before this though.

    The foot posture was max pronated STJ, plantargrade foot with abducted fore foot and the talocrural joint a little medially displaced.

    Anterior Talar drawer test was clinically positive but inversion stress test inconclusive.

    I viewed ankle x rays taken in Jan 2010 and July 2010 and ankle mortice joint space seemed wider in the latter.

    I requested ankle stress test xrays but the local hospitals could not do them as they have a policy that only an orthopaedic specialist must stress the ankle?? I referred her to a private hospital and the report was normal ankle joint.??? Strange I thought I don't believe that. My patient has just 10 minutes ago phoned to say she is a little angry because they just took plain films with no stress applied even tho she queried the procedure. Ahh I didn't think that report looked right:confused:

    I have fitted as as temporary measure a neoprene ankle support and a polyprop milled orthosis with medial posting and medial skive. She reports today, 12 days later, that the ankle is significantly less painful. I thinking of going to a AFO (Ritchie Brace) to stabilise the ankle and reduce medial stress. This may not be well tolerated by the lady on cosmetic grounds and might be a bit on the expensive side but we'll see.

    So my question is: do you think that long term plastic deformation of the Post tib tendon can take place to that extent without any other pathology i.e. pain and swelling and loss of strength? Do you think this is really an unstable ankle joint and not PTTD? Do you think the medial anterior ligaments could have become traumatised and the joint become unstable as a progression of 'non pathological' PTTD? or do you think something else? Your help much appreciated please.

    I'm keen to establish whether surgery would be a better or necessary option or at least to strengthen my case for using an AFO. I think the ankle could risk serious damage if not treated appropriately.

    Regards Dave Smith

    extract from referral x ray request letter

    My assessment (clinical notes below) indicates that this is not classic PTTD, although the post tib clearly does not efficiently support the integrity of the medial longitudinal arch as is its purpose. The pronated plantargrade foot and painful, swollen medial aspect of the ankle at first suggest PTTD. However, the Post tib is strong and almost pain free, the pain and swelling is on the anterior superior aspect of the medial maleolus. Pressure applied to the origin of the anterior deltoid ligament (tibial calcaneal ligament) and the anterior tibio-talar ligament elicits the most pain. Anterior talar drawer test is clinically positive the frontal plane talar stress inversion test is inconclusive. I have reviewed recent talocrural joint x rays and compared them to earlier ones and there appears to be an increase in joint spacing. My conclusion is ankle joint instability due to ligament trauma i.e. acute tearing or chronic plastic deformation. Both may have happened as Ms A reports that the ankle joint complex has always be lax and pronated. She also reports having a fall at work where she twisted the right ankle but she cannot remember exactly how.

    I have referred Ms A back to you and would ask if you could refer her for specialist x- rays i.e. lateral projection anterior talar drawer and frontal plane (AP) inversion talar stress radiographs to establish if there is significant ankle instability. I can then determine what the next step is in her treatment plan and rehabilitation therapy. I wonder if you could be so kind as to forward a copy of her recent MRI scan report to me please when it is available.
    Last edited: Oct 11, 2010
  2. Dave:

    Sounds like a deltoid ligament sprain to me, not posterior tibial tendon dysfunction. I would treat initially with custom foot orthoses, high top boots, icing 20 minutes/per application-twice daily. Physical therapy is often helpful in these patients along with cortisone injections into the anterior deltoid ligament, careful to avoid the PT tendon.

    I wouldn't bother with plain film radiographs in this case since they will likely be negative. MRI scan would be the best choice. There is a good prognosis for healing with non-surgical care if the PT muscle is strong and you can restore more normal gait function with an anti-pronation orthosis and more supportive shoes/bracing.

    Hope this helps.
  3. RobinP

    RobinP Well-Known Member

    Based on a very recent similar case, I would agree with Kevin. It does sound like deltoid ligament sprain. With an acute injury, however, I was under the impression that avulsion would likely involve some bony fragment detachment which is why in the case I have just seen, I started looking down other avenues.

    Prescription wise, the chap was prescribed custom foot orthosis and advised to wear walking boots. Worked very well over a 6-8 week period. Now pain free although patient continues to wear foot orthosis as it is more comfortable.

    Thanks for bringing your case up - will be interested to hear MRI findings

    Last edited: Oct 13, 2010

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