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Posterior tibial tendon dysfunction

Discussion in 'Biomechanics, Sports and Foot orthoses' started by robcox, May 4, 2008.

  1. robcox

    robcox Active Member


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    Hi all

    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
     
  2. 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.
     
  3. robcox

    robcox Active Member

    hi Kevin

    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?
     
  4. Admin2

    Admin2 Administrator Staff Member

  5. 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.
     
  6. 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! :cool:
     
  7. markjohconley

    markjohconley Well-Known Member

    So little of it and gone forever, really picked me up, thanks simon
     
  8. drsarbes

    drsarbes Well-Known Member

    Hi Robcox:

    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
     
  9. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    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]
     
  10. Steve The Footman

    Steve The Footman Active Member

    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.
     
  11. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    American College of Foot & Ankle Surgeons

    Diagnosis and Treatment of Adult Flatfoot

    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.

    Link to the PDF is here: http://www.acfas.org/pubresearch/cpg/adultff-cpg.htm


    Quite broad and non-specific, but generally good consensus info.

    LL
     
  12. Graham

    Graham RIP

    Rob,

    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
     
  13. efuller

    efuller MVP

    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.

    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.

    Cheers,

    Eric
     
  14. Graham

    Graham RIP

    Thanks Eric,

    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.
     
  15. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Shell Brace for Stage II Posterior Tibial Tendon Insufficiency.
    Krause F, Bosshard A, Lehmann O, Weber M.
    Foot Ankle Int. 2008 Nov;29(11):1095-100
     
  16. Sophe

    Sophe Member

    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
     
  17. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    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.
     
  18. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Association of Tibialis Posterior Tendon Pathology with Other Radiographic Findings in the Foot: A Case-Control Study.
    Shibuya N, Ramanujam CL, Garcia GM.
    Foot Ankle Surg. 2008 November - December;47(6):546-553.
     
  19. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    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
     
  20. Ashley Mahoney

    Ashley Mahoney Welcome New Poster


    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.

    Hope this helps
    Cheers Ashley
     
  21. drsarbes

    drsarbes Well-Known Member

    Hi Sophe:

    " 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
     
  22. Deborah Ferguson

    Deborah Ferguson Active Member

    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
     
  23. DaVinci

    DaVinci Well-Known Member

    I would guess that its 0%
     
  24. pgcarter

    pgcarter Well-Known Member

    Never seen one
     
  25. Bug

    Bug Well-Known Member

    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.
     
  26. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    The prevalence of symptomatic posterior tibialis tendon dysfunction in women over the age of 40 in England
    J. Kohls-Gatzoulisa , B. Woodsb, J.C. Angela and D. Singha
    Foot and Ankle Surgery Volume 15, Issue 2, June 2009, Pages 75-81
     
  27. Berms

    Berms Active Member

    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....

    Adam.
     
  28. drsarbes

    drsarbes Well-Known Member

    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
     
  29. Berms

    Berms Active Member

    Thanks Steve.
     
  30. markleigh

    markleigh Active Member

    Nonsurgical Management of Posterior Tibial Tendon Dysfunction With Orthoses and Resistive Exercise: A Randomized Controlled Trial

    I found this research paper on posterior tibial tendon dysfunction & it's rehabilitation.

    http://physicaltherapyjournal.org/cgi/content/abstract/89/1/26

    I'm wondering if anyone knows the particular eccentric progressive resistive exercises (OE group) they were using in this study?
     
  31. Atlas

    Atlas Well-Known Member

    Re: Nonsurgical Management of Posterior Tibial Tendon Dysfunction With Orthoses and Resistive Exercise: A Randomized Controlled Trial




    The solution to an overworked overloaded structure is to work it more?:craig:


    Ron
    Physiotherapist (Masters) & Podiatrist
     
  32. markleigh

    markleigh Active Member

    Re: Nonsurgical Management of Posterior Tibial Tendon Dysfunction With Orthoses and Resistive Exercise: A Randomized Controlled Trial

    Hi Ron. So where did the improvement come from in the third group when the only difference was the eccentric exercises?
     
  33. admin

    admin Administrator Staff Member

    {THREADS MERGED}
     
  34. Kent

    Kent Active Member

    Re: Nonsurgical Management of Posterior Tibial Tendon Dysfunction With Orthoses and Resistive Exercise: A Randomized Controlled Trial

    Why not? Eccentric loading exercises have been shown to work well in Achilles and patellar tendinopathy.

    Also, how do you know the tendon has been 'overloaded'? An 'underloaded' tendon can also develop tendinopathy can't it???
     
  35. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Extraarticular lateral hindfoot impingement with posterior tibial tendon tear: MRI correlation.
    Donovan A, Rosenberg ZS.
    AJR Am J Roentgenol. 2009 Sep;193(3):672-8.
     
  36. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Effects of foot orthoses on the work of friction of the posterior tibial tendon
    Takaaki Hiranoa, Matthew B.A. McCullougha, Harold B. Kitaokab, Kazuya Ikomaa, Kenton R. Kaufmanb
    Clinical Biomechanics (Articles in Press)
     
  37. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Extraarticular lateral hindfoot impingement with posterior tibial tendon tear: MRI correlation.
    Donovan A, Rosenberg ZS.
    AJR Am J Roentgenol. 2009 Sep;193(3):672-8.
     
  38. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Choosing Among 3 Ankle-Foot Orthoses for a Patient With Stage II Posterior Tibial Tendon Dysfunction.
    Neville C, Houck JR.
    J Orthop Sports Phys Ther. 2009 Nov;39(11):816-24.

     
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