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Stage I and II Posterior Tibial Tendon Dysfunction Treated by a Structured Nonoperative Management Protocol: An Orthosis and Exercise Program.
Foot Ankle Int. 2006 Jan;27(1):2-8

 

The keys to successful treatment of posterior tibial dysfunction (PTD) are appropriately prescribed custom foot orthoses, high top boots/shoes (or braces), icing therapy, gastroc-soleus stretching and gradual progressive strengthening exercises (Kirby KA: Conservative treatment of posterior tibial dysfunction. Podiatry Management, 19:73-82, 2000). 0% of my patients with grade I PTD need surgery and only 10% of my patients with grade II-III PTD are referred for surgery. I see about 10 patients with various stages of PTD every month in my practice.

Understanding the biomechanical concept that foot orthoses may be selectively designed to increase the magnitude of external subtalar joint supination moment during weightbearing activities is critical to proper orthosis prescription for this pathology (Kirby KA: The medial heel skive technique: improving pronation control in foot orthoses. JAPMA, 82: 177-188, 1992; Kirby KA, Green DR: Evaluation and Nonoperative Management of Pes Valgus, pp. 295-327, in DeValentine, S.(ed), Foot and Ankle Disorders in Children. Churchill-Livingstone, New York, 1992).

 

I recently had a heavy set woman come into my office with PTD.After she was put in an AFO,she did get a good result.I agree with Dr.Kirby in that you do not need to do surgery on these patients.

 

Kevin, would you mind sending me this article if its possible.

Regards

Rebecca

 

Kevin et al

Whilst wholeheartedly I agree with you that conservative treatment is the cornerstone of treating PTTD, I often scratch my head about the benefit of any gradual strengthening program for the PT muscle.

I this condition is characterised by degeneration and disorganisation of the PT tendon, would not a strengthening program to the PT muscle be counterproductive? :confused:

If the muscle pulls with greater strength on diseased tendon, won't this just accelerate further disorganisation of the tendon fibres and greater medial column collapse?

The only muscle i target is the posterior calf group - but for stretching only. In essence, I prefer to give up on the PT itself and focus on making the orthotic as aggressive as possible...

Interested in your thoughts,

LL

 

LL et al

I use rehab excerises for PTTD due to the research done on Achilles tendinopathy eccentric re-training Gold standard etc.
In addition, one study showed that eccentric rehab training of the Tib Post muscle reduced thickening and 'normalised' tendon structure.
I agree about the tight posterior structure needing stretching but this has to be done very carefully due to the stress that some stretching routines put on the PTT.

I have had good results so far but patient complinace with the exercises is very difficult to maintain.

Phil

 

Hi Phil,

So what eccentric exercises do you recommend. Are we talking the same as Alfredsons et al for achilles tendinosis? Or rubber band type resistance exercises? How many reps etc - as per alfredsons?

Rebecca

 

Rebecca

I usually use Theraband excersies to start with and once they are performing them correctly - 3 x 15 controlled reps with the strongest bands- I will get them doing a weight bearing version similar to the TA rehab execrsises with the addition of them trying to maintain the arch during loading. You need to chosse your patients carefully before doing this but the sports patients usually do well.


Phil

 

Tony:

If you were to do the strengthening exercises to the posterior tibial (PT) muscle without any other treatment, then you would probably cause more harm than good. However, when PT strengthening is done with other measures that increase external subtalar joint (STJ) supination moment, such as anti-pronation orthoses and/or bracing, the PT strengthening allows the PT muscle to resume a more functional role while the tendon heals.

It must be remembered that without PT muscle strength, the foot has lost its prime STJ supinator so weakness in the PT muscle is never good for the pronated foot. It is also important to note that STJ supination (that is more likely to occur with a strong PT muscle) will cause an increase in the supination moment arm of the PT tendon to the STJ axis that will, in turn, decrease the demand on the PT muscle to cause STJ supination. Increasing the supination moment arm of the PT tendon to the STJ axis will never cause an increase in demand on the PT muscle to cause STJ supination moment, it will only cause a decrease in demand on the PT muscle.

 

Hi everyone:
Well, first, I'd like to comment on the study itself.
There was no mention of a comparison of the criteria for success and the pre-treatment capabilities. Secondly, was there any follow up? Were all the parameters measured and subjective outcomes evaluated immediately at the end of the treatment program? Thirdly, what were the age groups? And finally; Underlying etiology and duration of symptoms.
The reason I raise these questions (and the original study may have dealt with them) is that I try to resist categorizing patients with any post tibial pain as just that....posterior tibial pain. I think the selection of treatment and outcomes of those treatment decisions are, to a very large extent, dependent on the underlying cause of the posterior tibial pain.
Certainly a young athlete with a history of injury and normal mechanics will be treated differently than an overweight, sessile 60 year old with tight tendoachilles and weakness, differently than the 18 year old with accessory naviclular and differently than the patient with chronic pain, early peroneal spasms and a demanding life style.
Are we treating tenosynovitis, tendinitis, microdegeneration of the tendon, tears, tethering, partial rupture? Are these secondary to pathomechanics or is do we have pathomechanics secondary to a weakened Postior Tibial Muscle.

Just food for thought.
Steve

 

Plantar Pressure Analysis in Cadaver Feet After Bony Procedures Commonly Used in the Treatment of Stage II Posterior Tibial Tendon Insufficiency.
Scott AT, Hendry TM, Iaquinto JM, Owen JR, Wayne JS, Adelaar RS.
Foot Ankle Int. 2007 Nov;28(11):1143-53

 

I find that the compliance of patients drops when faced with an AFO. We also use a Cobey X ray view to assess the relationship between the tibia and calcaneum in weight bearing. Often this will explain why foot orthoses won't work with particular patients as the alignment is such that little hindfoot control is possible.

Craig Payne has also published work that demontrate the the orthoses reduce the work load on the PTT as opposed to affecting relative lengthening alone.

 

Just to follow this up - are there any papers that have investigated the true pathology of differing Posterior Tibial tendon pain - perhaps papers similar to that of Khan et al 1999 that looked at Achilles tendon pain and noted lack of inflammatory markers?

I have seen plenty of papers regarding PTTD but non that look at pathomechanics i.e. whether tendinopathy/osis/itis paratenitis.......

Also investigations from the local radiology dept will just note tendinitis.

Any thoughts?

Mark

 

Posterior tibial tendon dysfunction: Imperfect specificity of magnetic resonance imaging
Alex C Lesiak, James D Michelson
Foot Ankle Surg. 2020 Feb;26(2):224-227

 

Evidence-Based Diagnosis and Treatments of Posterior Tibialis Tendinopathy
Carlo Milani, Krina Vyas & George Malik
Current Physical Medicine and Rehabilitation Reports (2022)

 

Characteristics and Future Direction of Tibialis Posterior Tendinopathy Research: A Scoping Review
Hye Chang Rhim et al
Medicina 2022, 58(12), 1858