Tibialis Anterior Tendinitis / FO

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Good Evening! Have been browsing all day and haven't really found what I'm looking for which is possible foot orthotic treatment for anterior tibial tendinitis / tendinopathy.

Patient is Female, 43 y.o., 120 lb. active walker, yoga, outdoors etc.
Pain is focused on the dorsal-medial aspect of right foot only along the area of the navicular / medial cuneiform.
Pain is elicited when she everts / abducts the foot not wt bearing. Resisted eversion / inversion does not make it worse. Resisted dorsi - plantar flexion does not elicit pain.
One particular yoga pose causes it to flare: imagine starting with your back to the wall feet shoulder width apart. now slide down the wall until you are basically in a baseball catchers crouch but flat footed (not on the toes). It's supposed to be done free standing but she can't balance without the wall behind her.
This position, every time, causes it to flare up.

MRI results showed some signal alteration around the anterior tib. tend. adjacent to the navicular and medial cun. but an intact tendon.
Some signal alteration around the peroneals but saggital sequence did not confirm.
Some signal alteration within the pasterior tibiofibular and deltoid lig.'s.
all others normal.
Impressions were tendinopathy / tenosynovitis distal anterior tibial tend.
possible tear in one of the peroneals
possible grade 1 strain of ptf and delt ligs.

I put her into a device with a medial heel skive, medial flange and a first ray accomodation (she looked to have a plantarflexed 1st MTH).

I'm wondering if I went a wrong direction with the insert and am looking for some additional guidance as she is not worse but is no better either.

Any thoughts would be welcome and if I can provide any further information please let me know.

Thanks!!

Stephen

 

Hi Stephen.

here my 2 cents

Is there large Navicular drop or drift or both?
If the pain is focus arounds the tendon of the Tibialis anterior (Tib Ant)then you need to take load from that tissue. I also assume that the patient has a medial deviated axis? correct me if I´m wrong.

So you will want to reduce the pronation moment of the Subtalar joint ( STJ) which your medial skive will do, you will want to also stop movement of the navicular ie drift and drop if there is any. You can do this by increased arch height of the device and very stabile shoe which fit well around the Navicular area. Sometime when the medial skive is used the arch height is reduced in the manufactor process.

You may want to add a lateral Forefoot wedge - FF Valgus post to your device which should also help the windlass mechanism- which we hope will lead to increase arch height as the heel starts to leave the group also reducing the load on the Tib Ant.

Is the patient resting ? are they Icing 1-2 a day for 20-25 mins? is the patient on Anti-inflams? Also I would stop her from doing that Yoga position-if it hurts the body is talking the patient must learn to listen.

Hope that helps

 

It's difficult to know what to do if we are unsure of the mechanism of injury.

Was it insidious onset or after one session of yoga?
Any changes in footwear?
How tight does she do her shoes up? (simple but could be)
If she has a functional hallux limitus style gait the injury could be due to an extensor substitution in which case your insoles should definitely help.
What is her gait pattern like?

Michael is right with the icing/NSAID's definitely should help.

Happy saturday!

Sam

 

Thanks so much for the replies!


Some additional info from my notes to answer some response questions:
Michael:
Navicular drop? I did not note an excessive amount.
Is the pt. resting? I believe not - although the recommendation has been made.
Iceing? Unsure
Anti-inflams? yes
The insert indeed has a valgus FF wedge - sorry i left that off the original post.
I did advise against any activity - yoga or otherwise- that elicits the pain.

Sam:
It's mare insidious. The particular pose in question is just putting stresses just right to make it act up on que - which in some ways is nice. I hate not being able to reproduce a symptom I'm trying to treat.
I do think she exhibits a gait pattern indicating FHL.

Now a couple additional questions:
Would it be worthwhile to add to the heel elevation in case of a tight gastroc?
Would the combination of the medial support / 1st ray drop on the insert combined with a strong medial support shoe (think Brooks Beastish) be too much? Or do you think more is better?

I've a follow up early next week and will reevaluate several items to see if I missed something.

Have a Great Weekend!
Taking the kids fishing in the morning - should be a blast!

Stephen

 

Well, I think herein lies a big part of the problem after discussion in the follow up today.
Resting? Yes; when she's not doing things. So - no, or not enough. (the Ortho put her into a walking boot (she's wearing the insert in the boot) for 2-3 weeks. so maybe that will 'encourage' rest.)
Icing? 1 x / day. Not seeing this as a wholly worthwhile endeavor - so no follow through.
(I told her she really needs to do this 2x / day. I know it's boring - but really can be helpful).
Anti-inflams? Yes. Alleve. But not following the Ortho's dosage rec's b/c of worry over difference of Dr. Rx'd dose v. on bottle dose instructions. (I told her to call the doc and discuss)

Her running shoes are Saucony and her daily shoes are Keen.

I'm hoping the boot et. al will get it calmed down enough that the insert can keep it stable. I'll have to see.

If you have any other ideas - please feel free!!



Stephen

 

Stephen,
the boot sounds like a good idea, Rest is key at the moment is sounds like.


You may have to try to scare the patient into resting and following orders. The other major thing to discuss now with the patient is that after the boot comes off she must slowly build up her stress on the foot, not just jump back into the same level of activity.

Also have you checked the arch height of the device, as I said before the medial skive can reduce the arch height-you may have to put a D pad on the arch of the device to lift more under the Navicular. This maybe able to reduce in height as the Tendon problems improve.
thats my 4 cents worth.

 

Hi Stephen,

Maybe soft tissue release/treatment on her tib ant would be benificial? There maybe some musculofascial restrictions or trigger points in the muscle belly negating the effect of your orthotic. Possibly release of the posterior compartment would help reduce the load on the tib ant as well.

Cheers
Patrick