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Hi All,

My first case of PTTD of a youth in acute stage
Any help appreciated.
14 y.o presents with painful navicular. Palpation of navicular and medial head of talus very painful. Xs buldging of navicular. Sent for Xray to rule out accessory bone.
Sent for ultrasound which came back with the findings "tibialis posterior tendon is normal at it's insertion but there is hypoechogenicity in surrounding soft tissues ..... findings most suggestive of early tibialis posterior tendon dysfunction"

I have advised treatment with ice and a rearfoot varus wedge/orthotic. Pt phoned after 2 days as he has been unable to tolerate either ice or orthotic due to pain - so has been using crutches until I see him again (2 days) - but he phoned to say the pain is still intolerable with crutches.

I am at loss to know what path to take next.

As I said - any advice would be appreciated.

SRD

 

Re: Posterior Tibial Dysfunction

Acute inflammatory states like this respond best to immobilisation.

Place the kid in a below-knee CAM walker boot +/- NSAIDs for 4-6 weeks to settle, then bring in footwear/orthoses.

Possible diagnosis; late onset Kohler's disease, Type 3 accessory navicular, or plain old insertional posterior tibial enthesopathy.

PTTD is really a diagnosis of adulthood, once the tendon has true attenutation and degeneration. The kid is possibly heading in this direction.

LL

 

An orthosis with a high medial arch will tend to make the posterior tibial muscle work harder. It can be uncomfortable to lower the arch of your foot onto a hard piece of plastic.

I've had a patient with PT dysfunction who hurt worse with a varus heel wedge orthotic and then remade a device with a lower arch. In one patient the tendon pain resolved with a low arch device. She still had the high arched device and started to use it after the tendon felt better and she liked the high arch devices better when her tendon was pain free.

Cheers,
Eric

 

I'd agree with that.

Sometimes the oft maligned soft and squodgy materials have something to recommend them. I've been known to go higher and softer (as in Poron 92 / poron 4000 soft) with this sort of thing.

The other thing you could try might be strapping.

 

When the patient presents with acute whatever you really must place him/her into the immobilization phase. Golden Rule of Foot: Do whatever it takes to make the patient nonpainful. Once the pain has subsided then you can onsider orthotics, strengthening, etc. So the idea of crutches with a posterior splint for non weight bearing and cool water bath or even room temp water for 30 minutes plus several times a day. Then progress to weight bearing with the cam walker, etc. In my mind, an intolerance to ice means nerve pain, and the post tib nerve is right next to the tendon and easily gets hypersensitive. Rich Blake