26 yo with Chronic Post Tib Tendonitis

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Hi everyone. I'm a 4th year med student who's been suffering from some long lasting PTT. I'm seeing a podiatrist, but I'm curious if anyone had additional thoughts on this.

HPI:

May 2011: Running ~60mpw. No precipitating event, but after a run felt some soreness post/inf to R ankle. After 4 days of continued running, felt 9/10 pain 1 mile into run.

Summer 2011: Tried series of breaks from exercise, between 1 week - 1 month. Pain returned with activity.

August 2011: Saw Sports med MD:
MRI Ankle Aug 2011: There is mild fluid posterior tibialis tenosynovitis.
No midfoot fault or hindfoot valgus.

Put in cam walker boot for 8 weeks, followed by 6 weeks of PT.

Dec 2011: Still have pain with extended ambulation, tried to return to activity with elliptical but continued to have pain after ~30 minutes on elliptical.

Early January 2012: Back in cam walker boot, wearing 24/7 including sleeping.

Repeat MRI in early January 2012:
There is mild posterior tibial tendon tenosynovitis, similar to the
previous study. There is no tibialis posterior tendon tear, as
questioned. There is no talar head uncovering, or hindfoot valgus to
suggest definite posterior tibial tendon dysfunction. There is
minimal flexor digitorum tenosynovitis. The flexor digitorum and
flexor hallucis longus tendons are normal.

I'm currently seeing a podiatrist who prescribed a Ritchey brace which should be coming in later this week. My question is why the PTT hasn't been getting better with the cam walker. Is it because the cam boot doesn't provide enough medial arch support to sufficiently offload the posterior tib from inverting the foot? Secondly, as a 26 year old starting his intern year in June/July, what are the chances that this will progress further into disfunction, and what's the time scale involved? Have you guys ever seen steroid injections being used for something like this? I'm worried about the risk of tendon rupture and it doesn't seem as if it's really been validated from my lit searches in PTT, but at this point I'm honestly willing to try anything. (Platelet injections? Acupuncture? Rain dancing?)

Thanks a ton for any help you guys might have. Going from running marathons to sitting on the couch with all of my free time since last year praying for this to heal is miserable.

 

Sounds like you need a anti-pronation orthosis with more varus correction in the heel and medial arch. In addition, I often will add a large medial arch pad into the cam walker brace since this will help decrease the strain on the posterior tibial tendon. Don't do a cortisone injection due to risk of further weakening of the PT tendon. However I would be doing twice daily icing, 20 minutes per session, in addition to using topical Voltaren gel, TID, over the tendon.

It will be difficult to go back into 60 miles per week running with what you have, but you should be able to run again, assuming that better orthoses are made for you. I have attached an article I wrote on posterior tibial dysfunction over ten years ago that discusses the condition and its treatment so you can gain a better understanding of the biomechanics of your condition.

 

Thanks for the response and article Kevin. Long term the plan is to transition to an orthotic after treatment with the Ritchey. My hope is that I haven't developed actual dysfunction of the tendon yet as on exam I have a normal arch without valgus and 5/5 strength/ able to stand on my toes without issue. Am I wrong in thinking that this means I'm still at the phase of tendonitis (hopefully mild as per MRI), and not of PTTD?

 

You really need to be examined and treated by a podiatrist that is very good at making custom foot orthoses for posterior tibial dysfunction. Give me your location and I will try to come up with some names for you.

 

Find a doctor or podiatrist who does prolotherapy. Glucose injections restart the healing cascade. I have treated dozens of tib post lesions and all have recovered. Google it for more information. Hackett Hemwall foundation and Dr Ross Hauser both have lists of practitioners in North America. Dr Margaret Taylor in Australia.

 

Hi
Where along the tendon is it symptomatic?

I would agree with Kevin that, with your Hx of activity the underlying etiology is most likely biomechanical; as such it should be treated accordingly.

I just have two additional comments; One: Having no tear demonstrated on the MRI does not mean there is no tear. These have a high rate of false negative.

Two: as far as Prolotherapy, the probability of a positive outcome depends on the location (much higher success rates for insertional tendinopathy), what is being injected and what is being treated. This merely increases blood flow secondary to local injury (the act of injecting) - thus possibly allowing the body to "heal" itself.

I do like the rain dance idea. Have you tried it yet?

Steve

 

What is a midfoot fault?

Was the MRI performed weightbearing?

And what shoes were you / are you attempting to run / walk in?

 

I'm a dancing naked around a toadstool at midnight man myself.

 

"Was the MRI performed weightbearing?"

hahahaha
Good one!!!!

 

Just trying to work out how you can judge that "there is no talar head uncovering, or hindfoot valgus" from an MRI and it be relevant unless it is performed weightbearing, Steve?

http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=44952

Since the op wrote:

Even on weightbearing MRI, I'm not sure how these provide a definitive diagnosis though as a spring ligament rupture should probably give lots of talar head exposure. As might a high STJ axis which could also account for a lack of rearfoot eversion.

Anyway, I'm off to find a toadstool... Someone to inject sugar into me (Krispy Kreme vendor)... Or a decent pair of foot orthoses, not decided yet. Hmmmmm, I ponder. Ponder, ponder, ponder...

 

Yep, got it now: a decent pair of foot orthoses and a podiatrist that knows their arse from their elbow when it comes to running related injuries.

 

.....................and a podiatrist that knows their arse from their elbow.

good luck finding one! hahahahaha

 

My experience is that mri's are not always accurate in assessing the posterior tibial tendon. I would surgically explore the tendon and be prepared to to a tenosynovetomy and use topaz on it. If there is any evedence of abnomal pronation and esepecially if there is a tear in the tendon, is to do a medial displacement calaneal osteotomy.

If you want to try a cortizone injection, which I have done only a few times, do not inject the tendon itself, but along side of it.