Conservative Treatment of Posterior Tibial Dysfunction

Kevin Kirby · Oct 19, 2014

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For those who may have never seen this article before, I wrote a paper titled "Conservative Treatment of Posterior Tibial Dysfunction" over 14 years ago for the September 2000 issue of Podiatry Management Magazine (attached below). Reading this article again, now 14 years later, I believe that the concepts are still quite current and should be well understood by any clinician that treats patients with posterior tibial tendon dysfunction.

Admin2 · Oct 20, 2014

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NewsBot · Sep 23, 2015

From LER:
Researchers inch toward understanding of PTTD

NewsBot · Dec 12, 2015

An Ankle Foot Orthosis With a Lateral Extension Reduces Forefoot Abduction in Subjects With Stage II Posterior Tibial Tendon Dysfunction
Christopher Neville, PT, PhD, Mary Bucklin, Nathaniel Ordway, MS, PE, Frederick Lemley, MD
J Orthop Sports Phys Ther, Epub 11 Dec 2015. doi:10.2519/jospt.2016.5618

Study Design
Controlled Laboratory; Repeated Measures.

Background
PTTD is a common musculoskeletal problem that includes tendon degeneration and collapse of the medial arch of the foot (flatfoot deformity). Ankle-foot-orthoses (AFOs) typically are used to correct flatfoot deformity. Correction of flatfoot deformity involves increasing forefoot adduction, forefoot plantar flexion, and hindfoot inversion.

Objectives
To test a foot orthoses with a lateral extension component to determine if it reduces forefoot abduction in patients with Stage II Posterior Tibial Tendon Dysfunction (PTTD) while walking.

Methods
The gait of 15 participants with Stage II PTTD was evaluated under 3 conditions; a standard AFO, an AFO with a lateral extension, and a control shoe-only condition. Kinematic variables of interest were evaluated at designated time points in the gait cycle and included hindfoot inversion/eversion, forefoot plantar flexion/ dorsiflexion, and forefoot abduction/adduction. A 3 x 4 repeated measures ANOVA (brace condition x gait phase) was used to compare variables across conditions.

Results
The AFO with a lateral extension was associated with a significantly greater change in forefoot adduction compared to the standard AFO (2.6 degrees, p=0.02) and shoe-only conditions (4.1 degrees, p<0.01) across all phases of stance. Forefoot plantar flexion was significantly increased when comparing the standard AFO and AFO with a lateral extension to the shoe-only condition. The AFO with the lateral extension component also demonstrated significantly increased hindfoot inversion during the loading response and terminal stance phases.

Conclusions
Off the shelf and standard AFOs have been shown to improve forefoot plantar flexion and hindfoot eversion, but not forefoot adduction. A lateral extension added to a standard AFO along the forefoot significantly improved forefoot adduction in participants with PTTD while walking.
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NewsBot · Feb 14, 2017

Orthotics versus manual therapy in treating patients with posterior tibial tendon dysfunction
Patel, Dipalee, D.P.T.,
Thesis; AZUSA PACIFIC UNIVERSITY, 2016, 32 pages; 10195264

A critical literature search was done to determine whether orthotics or manual therapy techniques were more beneficial in treating patients with posterior tibial tendon dysfunction (PTTD). PubMed, Cochrane Library, and ResearchGate 2005 to March 2015 were searched for relevant articles, and five relevant studies were used in this review. There was no conclusive evidence proving whether orthotics or manual therapy would be more beneficial for treating PTTD. However, there was support for the use of orthoses with stretching exercises, or Graston and active release manual techniques, or orthotics alone. Both orthotics and manual therapy had supporting evidence individually but were not compared in a same study. To strengthen future research in this area, there is a need to directly compare orthotics with manual therapy interventions. Optimal care is always the priority for healthcare professionals when treating patients, and thus determining the most effective treatments for PTTD would be highly beneficial.
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NewsBot · Aug 7, 2019

Conservative Care Principles For Adult-Acquired Flatfoot

NewsBot · May 5, 2020

Nonsurgical Approach in Management of Tibialis Posterior Tendinopathy With Combined Radial Shockwave and Foot Core Exercises: A Case Series
David Robinson et al
Article in Press

Tibialis posterior tendinopathy is a common debilitating condition seen by foot and ankle providers. Non-operative management is difficult as patients often present in later stages of the disease. This case series evaluated the combination of radial shockwave therapy and a foot core progression exercise regimen on 10 patients who had failed standard conservative treatment techniques. Median follow-up time was 4 months. Clinically important differences in the Foot and Ankle Ability Measure were met in 9 (90%) and 8 (80%) of patients for activities of daily living and sport sub-scores, respectively. No adverse effects were observed.
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NewsBot · Oct 18, 2020

Orthotic treatment for stage I and II posterior tibial tendon dysfunction (flat foot): A systematic review
Isabel Gómez-Jurado, José María Juárez-Jiménez, Pedro V Munuera-Martínez
Clinical Rehabilitation October 11, 2020

Objective:
To investigate whether orthotic treatment is effective for the treatment of posterior tibial tendon dysfunction stages I and II (flat foot).

Data Sources:
Five databases (PubMed, Scopus, PEDro, SPORTDiscus and The Cochrane Library) were searched for potential RCTs from their inception until August 2020.

Review Methods:
Only randomised controlled trials (RCT) that included subjects diagnosed with posterior tibial dysfunction in the initial stage and treated with orthotic treatments were selected. The outcomes assessed were whatever symptom related to posterior tibial tendon dysfunction stage I and II. Included RCTs were appraised using the Cochrane collaboration risk of bias tool.

Results:
Four RCT articles and 186 subjects were included. 75% were at high risk of bias for blinding of participants and personnel. Three different types of conservative treatment were used in the studies: foot/ankle-foot orthoses, footwear and stretching /strengthening exercises. Foot orthoses, together with exercise programmes, seemed to improve the effect of orthotic treatment. Foot orthoses with personalised internal longitudinal arch support were more effective than flat insoles or standard treatments in reducing pain.

Conclusions:
The use of orthotic treatment may be effective in reducing pain in the early stages of posterior tibial tendon dysfunction. Further research is needed into individualised orthotic treatment and high-intensity monitored exercise programmes.
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NewsBot · Jan 19, 2022

THE EFFECTIVENESS OF TREATMENT IN CHILDREN WITH RIGID FLATFEET AND DYSFUNCTION OF THE POSTERIOR TIBIAL TENDON
O Danilov et al
Georgian Med News. 2021 Nov;(320):46-52.

The rigid form of longitudinal flatfeet is one of the most common deformities of the foot in children. Dysfunction of the posterior tibial tendon is one of the causes of rigid foot formation with the development of pain syndrome, degenerative-dystrophic changes in the tarsal bones and joints. In most of these cases, conservative treatment is ineffective, prompting the use of surgical methods of foot correction - subtalar arthroereisis. However, currently, the indications for surgical treatment depending on the stage of posterior tibialis tendon dysfunction are poorly studied. The aim of the study was to analyze the clinical and radiological results of treatment of children with rigid flatfeet in the presence of posterior tibialis tendon dysfunction and to develop an algorithm of treatment depending on the stage of dysfunction. The results of treatment of 20 patients (40 cases) with the rigid form of longitudinal flatfeet during 12 months of follow-up were analyzed. In 18 patients (36 cases/90%) degenerative-dystrophic changes of the posterior tibial tendon according to Johnson and Strom classification were diagnosed. Conservative treatment with traditional methods was performed for 12 patients (24 cases), and 8 patients (16 cases) were operated on using subtalar arthroereisis. To analyze the results of treatment, clinical and radiological methods of investigation were performed. The use of conservative methods of treatment made it possible to obtain a positive result in patients with rigid flatfeet of the І severity degree and the absence of posterior tibialis tendon dysfunction. Subtalar arthroereisis was effective in children with II severity degree of rigid flatfeet and stage I of tendon dysfunction. Conservative treatment of rigid flatfeet is effective in the absence of posterior tibialis tendon dysfunction, and the use of subtalar arthroereisis is advisable in stage I of tendon dysfunction.
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