Different opinions on posterior tibial tendon dysfunction assessment

NewsBot · Jul 23, 2015

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Assessment and Diagnosis of Posterior Tibial Tendon Dysfunction: Do We Share the Same Opinions and Beliefs?
Beverley Durrant, MSc, BSc (Hons) Pod, Nachiappan Chockalingam, Phd, and Christopher Morriss-Roberts, PhD
Journal of the American Podiatric Medical Association In-Press

Background: Posterior tibial tendon dysfunction is a disabling pathologic flatfoot disorder. Evidence supports the notion that this condition is poorly diagnosed by health-care professionals. In addition, opinion is divided as to the most appropriate assessment and diagnostic techniques used to reflect the progression or stage of the condition. Hence, this study intended to explore the views and opinions of health-care professionals who may be involved in its assessment and diagnosis.

Methods: A two-phase sequential mixed methods design was used that combined a questionnaire survey and a focus group interview.

Results: The questionnaire data were analyzed using the Kendall levels of concordance and the Cohen kappa statistic, and the focus group data were analyzed using thematic analysis, which led to three main themes: resource implications, scope of practice, and awareness of the condition.

Conclusions: This study highlights what may have been suspected previously but that has never been investigated in a structured manner. One approach to the assessment and diagnosis of posterior tibial tendon dysfunction is not necessarily the best, and depending on the clinical teams, different guidance may be required to ensure that patients are receiving the most appropriate and best care
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Admin2 · Jul 23, 2015

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NewsBot · Feb 2, 2020

Posterior tibial tendon dysfunction: Imperfect specificity of magnetic resonance imaging
Alex C.LesiakJames D.Michelson
Foot and Ankle Surgery Volume 26, Issue 2, February 2020, Pages 224-227

Highlights
•MRI is useful in diagnosing posterior tibial tendon (PTT) tears.
•Surrounding inflammation can make a normal PTT appear torn.
•MRI for PTT tears should be interpreted cautiously in the presence of other trauma.
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MRI is frequently used in the evaluationand treatment of tibialis posterior tendon (PTT) dysfunction. MRI is reported to have sensitivity up to 95%, with 100% specificity, in the detection of rupture of the PTT. We present three cases where MRI demonstrated complete or partial rupture of the PTT, where subsequent surgery showed an intact PTT with tenosynovitis. In all cases, there was a source of inflammation external to the tendon. It is hypothesized that this exogenous origin of inflammation caused changes in the MRI signal in the PTT that resemble that seen in ruptures. These cases show that in the presence of inflammation near the tibialis posterior tendon, the MRI may falsely indicate a high-grade rupture of the tendon. Recommendations for treatment of suspected PTT rupture in the presence of significant other sources of inflammation are proposed.
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NewsBot · May 24, 2020

Multiplanar Semiautomatic Assessment of Foot and Ankle Offset in Adult Acquired Flatfoot Deformity
Cesar de Cesar Netto et al
Foot Ankle Int. 2020 May 22

Background: Semiautomatic 3-dimensional (3D) biometric weightbearing computed tomography (WBCT) tools have been shown to adequately demonstrate the relationship between the center of the ankle joint and the tripod of the foot. The measurement of the foot and ankle offset (FAO) represents an optimized biomechanical assessment of foot alignment. The objective of this study was to evaluate the correlation between FAO and traditional adult acquired flatfoot deformity (AAFD) markers, measured in different planes. We hypothesized that the FAO would significantly correlate with other radiographic markers of pronounced AAFD.

Methods: In this retrospective comparative study, we included 113 patients with stage II AAFD, 43 men and 70 women, mean age of 53.5 (range, 20-86) years. 3D coordinates (x, y, and z planes) of the foot tripod (most plantar voxel of the first and fifth metatarsal heads, and calcaneal tuberosity) and the center of the ankle joint (most proximal and central voxel of the talar dome) were assessed by 2 blinded and independent fellowship-trained orthopedic foot and ankle surgeons. The FAO was automatically calculated using the 3D coordinates by dedicated software. Multiple WBCT parameters related to the severity of the deformity in the coronal, sagittal, and transverse planes were manually measured.

Results: We found overall good to excellent intra- (range, 0.75-0.99) and interobserver (range, 0.73-0.99) reliability for manual AAFD measurements. FAO semiautomatic measurements demonstrated excellent intra- (0.99) and interobserver (0.99) reliabilities. Hindfoot moment arm (HMA) (P < .00001), subtalar horizontal angle (P < .00001), talonavicular coverage angle (P = .00004), and forefoot arch angle (P = .0001) were the only variables found to significantly influence and correlate with FAO measurements, with an R2 value of 0.79. An HMA value of 19.8 mm was found to be a strong threshold predictor of increased values of FAO, with mean values of FAO of 6.5 when the HMA was lower than 19.8 mm and 14.6 when the HMA was equal to or higher than 19.8 mm.

Conclusion: We found that 3D WBCT semiautomatic measurements of FAO significantly correlated with some traditional markers of pronounced AAFD. Measurements of FAO were also found to be slightly more reliable than the manual measurements. The FAO offers a simple and more complete biomechanical and multiplanar assessment of the AAFD, representing in a single measurement the 3D components of the deformity.
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NewsBot · Jun 16, 2021

Podiatrists’ views and experiences of using real time clinical gait analysis in the assessment and treatment of posterior tibial tendon dysfunction
Paul Harradine, Lucy Gates, Cheryl Metcalf & Catherine Bowen
Journal of Foot and Ankle Research volume 14, Article number: 42 (2021)

Background
Real time clinical gait analysis (RTCGA) is often incorporated as part of a general or lower limb musculoskeletal (MSK) adult patient assessment. However, it is not known if RTCGA is clinically effective as a useful outcome measure or aids in decision making. Whether there is a clinical worth in conducting RTCGA in adult MSK consultations remains controversial. The aim of this study was to provide unique insights into MSK podiatrists use and opinions of RTCGA, using Posterior Tibial Tendon Dysfunction (PTTD) as an exemplar adult condition.

Methods
A qualitative approach was employed to explore MSK podiatrists’ views and experiences of RTCGA when assessing or treating patients with PTTD. Semi-structured interviews were conducted via Skype video calls which were transcribed using an orthographic transcription method. Thematic analysis was employed to identify key meanings and report patterns within the data.

Results
Twenty nine MSK podiatrists who used RTCGA in the assessment and treatment of PTTD participated in the study. Five themes were identified as 1) RTCGA Method; 2) Working with RTCGA; 3) RTCGA uses; 4) What could aid RTCGA; 5) How RTCGA skills are acquired. This is the first known study to explore this topic of relevance to clinicians and researchers alike. Clinical observations were not only kinematic, but also included patient perceived experiences such as pain and orthotic comfort with normative kinematic reference values not perceived as important to that management goal. The most common barefoot RTCGA observations performed were the rearfoot to leg angle, medial bulge, forefoot abduction and arch integrity. However, a high amount of variation in many gait observations was noted between participants. Documentation methods also varied with a four-point scale system to grade motion and position most often employed and RTCGA was most often learnt through experience. The main barriers to performing RTCGA were clinical time and space restrictions.

Conclusion
Findings from this study have provided a view of how podiatry MSK clinicians utilise RTCGA within their practice. MSK podiatrists use RTCGA as both an outcome measure and as an aid in decision making. This implies a perceived worth in conducting RTCGA, however further work is recommended that focusses on development of a national guideline to RTCGA to be adopted.
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NewsBot · Feb 7, 2022

Diagnostic accuracy of measurements in progressive collapsing foot deformity using weight bearing computed tomography: A matched case-control study
FrançoisLintzaAlessioBernasconibShuyuanLicMatthieuLalevéecdCélineFernandoaAlexejBargefKevinDibberncCesarde Cesar Nettoc
Foot and Ankle Surgery; 5 January 2022

Highlights
•The study aimed to investigate diagnostic accuracy of known 2D and 3D measurements for PCFD in WBCT.
•Middle Facet Uncoverage percentage and Foot Ankle Offset were the 2 most accurate diagnostic measurements
•The combination of MF%> 28.7 and FAO> 4.6% yielded 100% sensitivity and 100% specificity for symptomatic PCFD.
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Background
We aimed to investigate the diagnostic accuracy of known two-dimensional (2D) and three-dimensional (3D) measurements for Progressive Collapsing Foot Deformity (PCFD) in weight-bearing computed tomography (WBCT). We hypothesized that 3D biometrics would have better specificity and sensitivity for PCFD diagnosis than 2D measurements.

Methods
This was a retrospective case-control study, including 28 PCFD feet and 28 controls matched for age, sex and Body Mass Index. Two-dimensional measurements included: axial and sagittal talus-first metatarsal angles (TM1A and TM1S), talonavicular coverage angle (TNCA), forefoot arch angle (FFAA), middle facet incongruence angle (MF°) and uncoverage percentage (MF%). The 3D Foot Ankle Offset (FAO) was obtained using dedicated semi-automatic software. Intra and interobserver reliabilities were assessed. Receiver Operating Characteristic (ROC) curves were calculated to determine diagnostic accuracy (Area Under the Curve (AUC)), sensitivity and specificity.

Results
In PCFD, mean MF% and MF° were respectively 47.2% ± 15.4 and 13.3° ± 5.3 compared with 13.5% ± 8.7 and 5.6° ± 2.9 in controls (p < 0.001). The FAO was 8.1% ± 3.8 in PCFD and 1.4% ± 1.7 in controls (p < 0.001). AUCs were 0.99 (95%CI, 0.98–1) for MF%, 0.96 (95%CI, 0.9–1) for FAO, 0.90 (95%CI, 0.81–0.98) for MF°. For MF%, a threshold value equal or greater than 28.7% had a sensitivity of 100% and specificity of 92.8%. Conversely, a FAO value equal or greater than 4.6% had a specificity of 100% and a sensitivity of 89.2%. All other 2D measurements were significantly different in PCFD and controls (p < 0.001).

Conclusions
MF% and FAO were both accurate measurements for PCFD. MF% demonstrated slightly better specificity. FAO better sensitivity. A combination of threshold values of 28.7% for MF% and 4.6% for FAO yielded 100% sensitivity and specificity.
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NewsBot · May 22, 2022

Assessment of Flatfoot Deformity Using Digitally Reconstructed Radiographs: Reliability and Comparison to Conventional Radiographs
Robert M. Fuller, BA, Jaeyoung Kim, MD, Tonya W. An, MD, ...
Foot & Ankle International May 19, 2022

Background:
Digitally reconstructed radiographs (DRRs) generated from weightbearing computed tomography (WBCT) may potentially substitute for weightbearing plain radiographs (XRs) but have not been clinically validated. This study aims to test the reliability of 6 radiographic parameters of progressive collapsing foot deformity (PCFD) as measured on DRR, to investigate whether DRR represents comparably to XR through the same measurements, and to compare agreement of DRR and XR measurements of a standardized arch height parameter with reference measurements made on WBCT.

Methods:
DRR generated from preoperative WBCT of 71 patients (72 feet) treated surgically for PCFD were retrospectively compared with preoperative weight-bearing XR after exclusion criteria were applied. Six radiographic measurements were performed, including Meary angle, calcaneal pitch (CPA), medial cuneiform height (MCH), AP talar–first metatarsal angle (T-1MT), talonavicular coverage (TNCA), and talar incongruency (TIA). Arch height was measured on XR, DRR, and WBCT using a validated, standardized, navicular-based index. Intraclass correlation coefficients assessed DRR intraobserver and interobserver reliability. Paired samples t tests tested differences between XR and DRR. Bland-Altman limits of agreement analysis compared DRR and XR agreement with WBCT measurements.

Results:
Measurements were within standard PCFD ranges on XR and DRR. All measurements demonstrated excellent intrarater reliability and good to excellent interrater agreement, consistent with previous literature on XR. No differences were found for Meary, CPA, or TNCA. Minor differences were observed for MCH, T-1MT, and TIA. DRR measurements demonstrated greater agreement with WBCT than XR measurements.

Conclusion:
DRR from WBCT may be a promising substitute for XR in the clinical evaluation of PCFD. Radiographic measurements made on DRR demonstrated good to excellent reliability. Although small differences were found between XR and DRR for certain measurements, DRR more accurately represented medial arch anatomy compared to gold standard WBCT data than XR. If validated as a clinical substitute, DRR could eventually obviate XR where WBCT is available.
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NewsBot · Jan 12, 2023

Adult Acquired Flatfoot Deformity: A Narrative Review about Imaging Findings
Chiara Polichetti et al
Diagnostics 2023, 13(2), 225; https://doi.org/10.3390/diagnostics13020225

Adult acquired flatfoot deformity (AAFD) is a disorder caused by repetitive overloading, which leads to progressive posterior tibialis tendon (PTT) insufficiency. It mainly affects middle-aged women and occurs with foot pain, malalignment, and loss of function. After clinical examination, imaging plays a key role in the diagnosis and management of this pathology. Imaging allows confirmation of the diagnosis, monitoring of the disorder, outcome assessment and complication identification. Weight-bearing radiography of the foot and ankle are gold standard for the diagnosis of AAFD. Magnetic Resonance Imaging (MRI) is not routinely needed for the diagnosis; however, it can be used to evaluate the spring ligament and the degree of PTT damage which can help to guide surgical plans and management in patients with severe deformity. Ultrasonography (US) can be considered another helpful tool to evaluate the condition of the PTT and other soft-tissue structures. Computed Tomography (CT) provides enhanced, detailed visualization of the hindfoot, and it is useful both in the evaluation of bone abnormalities and in the accurate evaluation of measurements useful for diagnosis and post-surgical follow-up. Other state-of-the-art imaging examinations, like multiplanar weight-bearing imaging, are emerging as techniques for diagnosis and preoperative planning but are not yet standardized and their scope of application is not yet well defined. The aim of this review, performed through Pubmed and Web of Science databases, was to analyze the literature relating to the role of imaging in the diagnosis and treatment of AAFD.
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NewsBot · Jan 23, 2023

Adult Acquired Flatfoot Deformity: A Narrative Review about Imaging Findings
Chiara Polichetti et al
Diagnostics (Basel). 2023 Jan 7;13(2):225

Adult acquired flatfoot deformity (AAFD) is a disorder caused by repetitive overloading, which leads to progressive posterior tibialis tendon (PTT) insufficiency. It mainly affects middle-aged women and occurs with foot pain, malalignment, and loss of function. After clinical examination, imaging plays a key role in the diagnosis and management of this pathology. Imaging allows confirmation of the diagnosis, monitoring of the disorder, outcome assessment and complication identification. Weight-bearing radiography of the foot and ankle are gold standard for the diagnosis of AAFD. Magnetic Resonance Imaging (MRI) is not routinely needed for the diagnosis; however, it can be used to evaluate the spring ligament and the degree of PTT damage which can help to guide surgical plans and management in patients with severe deformity. Ultrasonography (US) can be considered another helpful tool to evaluate the condition of the PTT and other soft-tissue structures. Computed Tomography (CT) provides enhanced, detailed visualization of the hindfoot, and it is useful both in the evaluation of bone abnormalities and in the accurate evaluation of measurements useful for diagnosis and post-surgical follow-up. Other state-of-the-art imaging examinations, like multiplanar weight-bearing imaging, are emerging as techniques for diagnosis and preoperative planning but are not yet standardized and their scope of application is not yet well defined. The aim of this review, performed through Pubmed and Web of Science databases, was to analyze the literature relating to the role of imaging in the diagnosis and treatment of AAFD.
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NewsBot · Jul 17, 2023

Prevalence of Posterior Tibialis Tendon
Dysfunction in Individuals with Flatfeet
Dr. Priyanka Nandkishor Palav1
Veena Kiran Nambiar et al
International Journal for Multidisciplinary Research

Posterior Tibialis Tendon Dysfunction is a condition which is progressive in nature usually associated
with an over pronated foot (flatfoot). PTTD can be caused due to trauma, overuse, obesity, and
degeneration as the age of individual progresses. It can be a debilitating condition in its later chronic
stages severely affecting the ADL’s of an individual if not identified in its earliest stages. The older adult
population with 13.6 % of flatfeet individuals were observed to have 10% prevalence rate of PTTD
whereas the younger population with flatfeet prevalence rate of 11.5% were under assessed for same and
the magnitude or prevalence of dysfunction was not assessed or recorded in literature. This study
therefore was conducted with the objective to identify individuals with PTT dysfunction in its earliest
stages. As an earlier detection may help prevent or halt the progression of PTTD in its advanced severe
stages in younger individuals with age 18 to 25 years with flatfeet. The assessment of the individuals for
PTTD was done using the Johnson and Strom criteria which is a widely used classification for clinical
diagnosis of this dysfunction. The data obtained was analysed using appropriate statistical test. The
results concluded documenting a prevalence rate of 18.54 % which is higher as compared to that
mentioned in literature in older women.
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