Hi all
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I have been searching the literature on the treatment of PTTD. Does anyone have a tretament protocol for this condition, which has been successful for the different stages of this condition?
Regards
Rob
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Foot orthoses reduce internal supination moment- how?
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Help and advice needed for patient with forefoot pain
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Hope this helps. -
hi Kevin
thanks for this. I have just recieved your precision intricast books from the US. I have found these to be an interesting and informative read. I wish I had purchased these years ago! Can we expect a new book in the near future? -
Related:
Threads tagged with Posterior tibial tendon dysfunction -
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Kevin, did you know when you started writing them what a treasure you would create?
Bring it on Precision! :cool: -
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Hi Robcox:
My approach to PTTD is to first and foremost find a underlying etiology. Some of these are pure biomechanical predisposition, others are not. Acute tears of the Post Tib, talipes equinus, Charcot's, Hip and knee pathology, Tarsal coalitions, STJ arthritis, etc......... can all be causes.
As far as conservative orthotic treatment, I think Kevin has covered this.
In my experience, conservative AND surgical approaches are unrewarding once the peroneal tendons have gone into spasm and a rigid pes valgus results.
Steve -
Nonsurgical Management of Posterior Tibial Tendon Dysfunction With Orthoses and Resistive Exercise: A Randomized Controlled Trial.
Kulig K, Reischl SF, Pomrantz AB, Burnfield JM, Mais-Requejo S, Thordarson DB, Smith RW.
Phys Ther. 2008 Nov 20. [Epub ahead of print]
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American College of Foot & Ankle Surgeons
Diagnosis and Treatment of Adult Flatfoot
The Diagnosis and Treatment of Adult Flatfoot Clinical Practice Guideline is a 36-page document that includes text, images and pathways. It was published in the March/April 2005 issue of the Journal of Foot & Ankle Surgery.
Link to the PDF is here: http://www.acfas.org/pubresearch/cpg/adultff-cpg.htm
Quite broad and non-specific, but generally good consensus info.
LL -
Rob,
In early cases I use a device with a kirby skive, usually four or five mm. Forefoot valgus post, 3 0r 4 deg, and a first ray cut away. The device is made with a PTTD profile, deeper heel and ,med flange.
My concern with the term PTTD is that is see these eithe progressing or actually as an aquired adult flat foot (AAFF) deformity which clinically appears to be a spring ligament complex dysfunction.(SLCD) This doesn't hurt so the straucture which is stressed because of this, the PTT, is viewd as the culpruit. (your thaoughts gentleman).
In the more advanced AAFF with SLCD I would use an articulated RICHIE brace with the same sole plate/orthotic RX as above.
Regards
Graham -
Cheers,
Eric -
Thanks Eric,
I generally find that if there is reasonable ROM at the first mtpj and the first ray is mobile, without the first ray cut away the shell of the device limits hallux extension over the first mtpj resulting in the need to abductory twist at propulsion therfore further irritating the PTT. The KS and deep heel seat deal with the heel strike to foot flat sequence. Failure of the heel to lift, due to sagittal blockade at the first mtpj will create the abductory twist and pronation into propulson with secondary mid tarsal hinge.
The work by Doug Richie would seem to suggest that the Mid Tarsal complex has more involvement than the STJ, again suggesting that eqaul and oposite forces generated in an "abnormal" propulsion could be the influencing factor in the development of this condition. -
Shell Brace for Stage II Posterior Tibial Tendon Insufficiency.
Krause F, Bosshard A, Lehmann O, Weber M.
Foot Ankle Int. 2008 Nov;29(11):1095-100
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For what it's worth, as a health ed professional and a 1 year post triple arthrodesis for PTTD, I would like to offer the following hard earned experience. The foot bone is connected to the leg bone and the leg bone is connected to the back bone. My foot is wonderful, pain free. But I was equally incapacitated with low back pain. I finally went to a physical medicine & rehab doc who ID'd piraformis muscle spasm, facet arthritis, etc. Several injections later I now have a great life.
I am so grateful to my surgeon for his skills in the fusion. The relief from pain is wonderful (I was 2B-3) but it's important to have a backup orthopedist or PM&R doc to help with the realignment issues. ~Sophe -
Functional outcome after surgical reconstruction of posterior tibial tendon insufficiency in patients under 50 years.
Tellisi N, Lobo M, O'Malley M, Kennedy JG, Elliott AJ, Deland JT.
Foot Ankle Int. 2008 Dec;29(12):1179-83.
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Association of Tibialis Posterior Tendon Pathology with Other Radiographic Findings in the Foot: A Case-Control Study.
Shibuya N, Ramanujam CL, Garcia GM.
Foot Ankle Surg. 2008 November - December;47(6):546-553.
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Effects of the AirLift PTTD Brace on Foot Kinematics in Subjects With Stage II Posterior Tibial Tendon Dysfunction.
Neville C, Flemister AS, Houck JR.
J Orthop Sports Phys Ther. 2009 Mar;39(3):201-9
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With respect to rehabilitation of the Posterior Tibialis Tendon,
Over the past 10 years as a private sports clinician practicing at the University of Queensland rehab clinic, I have used many exercises both eccentric and concentric that start from non-weightbearing and progress the client back to full weight-bearing.
I agree with Kevin on the use of orthotics here also. I find myself using many modalities to help clients through this condition (stage 1 and into stage 2).
Sometimes my exercise rehab would include;
Stage 1- Non-weightbearing plantar flexion then Pf with internal rotation
Stage 2 - Non-Weightbearing with theraband resistance bands - plantar flexion then Pf with internal rotation
Stage 3 - Seated Arch lifts,
Stage 4 - Standing Arch lifts
Stage 5 - ArchCOACH eccentric arch strengthening.
Hope this helps
Cheers Ashley -
Hi Sophe:
" The foot bone is connected to the leg bone and the leg bone is connected to the back bone"
I love that!!!!
Question. You state you had a triple X I year for PTTD. May I ask what was the duration of your symptoms and whether you developed peroneal spasms (i.e. rigid pes valgus) ?
I'm interested in knowing why a triple vs other surgical options.
Thanks
Steve -
Hi All
Does anyone know what the incidence of PTTD is in children under the age of 14?
I can find very little if anything either on Pub Med or Science Direct.
Thanks in advance
Deborah -
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Never seen one
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Have seen 2, in cousins. Pathology starting in 7-8 and surgical repair by 12 and 10 respectively.
It is only this morning that I had the epiphany of just how rare it was. I originally thought it was tendonopathy however when it was referred off for a surgical opinion after conservative treatment based on Kevin's article (many thanks for back then as I had no idea what to do!!) unfortunately made minimal impact. The surgical letter back to the GP stated that it was PTTD and was surgically repaired and had reference to how unusal it was in that age group. However this is 5+ years ago and they are long lost to the Ortho's/Physio's/Orthotists of the Royal Children's Hospital so I know I will never see them again. I did 2-3 times after the surgical results in the first wasn't a great, the second child did really well according to the first's family. -
The prevalence of symptomatic posterior tibialis tendon dysfunction in women over the age of 40 in England
J. Kohls-Gatzoulisa , B. Woodsb, J.C. Angela and D. Singha
Foot and Ankle Surgery Volume 15, Issue 2, June 2009, Pages 75-81 -
The whole PTTD entity is one that confuses me, and admittedly I usually end up treating the mechanical abnormalities to reduce pain and deformity without specifically considering the role/function of the PTT? This is something I need to do a bit more reading on....
Adam. -
Hi Adam:
Pretty simple. Once you have a rigid pes valgus (in these cases due to peroneal spasms from unopposed post tib dysfunction) you are pretty much out of luck.
One can try peroneal tendon lengthenings since normally the spasms subside under general anesthesia, but results are dissapointing. Triple arthrodesis is the procedure of choice (depending on symptoms)
PTTD certainly is quite variable depending on the underlying cause, patient type, duration, etc.....
Some of these are no more than tendinitis, others chronic synovitis, others torn PT and combinations thereof.
In my opinion, true PTTD is chronic (more than 6 months) with clinical weakness of the posterior tibial and unilateral progressive pes planus. These, untreated, are usually progressive to the rigid pes valgus end point.
Hope that helps
Steve -
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Nonsurgical Management of Posterior Tibial Tendon Dysfunction With Orthoses and Resistive Exercise: A Randomized Controlled Trial
I found this research paper on posterior tibial tendon dysfunction & it's rehabilitation.
http://physicaltherapyjournal.org/cgi/content/abstract/89/1/26
I'm wondering if anyone knows the particular eccentric progressive resistive exercises (OE group) they were using in this study? -
Re: Nonsurgical Management of Posterior Tibial Tendon Dysfunction With Orthoses and Resistive Exercise: A Randomized Controlled Trial
The solution to an overworked overloaded structure is to work it more?:craig:
Ron
Physiotherapist (Masters) & Podiatrist -
Re: Nonsurgical Management of Posterior Tibial Tendon Dysfunction With Orthoses and Resistive Exercise: A Randomized Controlled Trial
Hi Ron. So where did the improvement come from in the third group when the only difference was the eccentric exercises? -
{THREADS MERGED}
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Re: Nonsurgical Management of Posterior Tibial Tendon Dysfunction With Orthoses and Resistive Exercise: A Randomized Controlled Trial
Also, how do you know the tendon has been 'overloaded'? An 'underloaded' tendon can also develop tendinopathy can't it??? -
Extraarticular lateral hindfoot impingement with posterior tibial tendon tear: MRI correlation.
Donovan A, Rosenberg ZS.
AJR Am J Roentgenol. 2009 Sep;193(3):672-8.
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Effects of foot orthoses on the work of friction of the posterior tibial tendon
Takaaki Hiranoa, Matthew B.A. McCullougha, Harold B. Kitaokab, Kazuya Ikomaa, Kenton R. Kaufmanb
Clinical Biomechanics (Articles in Press)
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Extraarticular lateral hindfoot impingement with posterior tibial tendon tear: MRI correlation.
Donovan A, Rosenberg ZS.
AJR Am J Roentgenol. 2009 Sep;193(3):672-8.
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Choosing Among 3 Ankle-Foot Orthoses for a Patient With Stage II Posterior Tibial Tendon Dysfunction.
Neville C, Houck JR.
J Orthop Sports Phys Ther. 2009 Nov;39(11):816-24.
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Foot orthoses reduce internal supination moment- how?
|
Help and advice needed for patient with forefoot pain
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