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Prognosis for Posterior Tibial Tendonosis

Discussion in 'Biomechanics, Sports and Foot orthoses' started by MarkC78, Dec 18, 2008.

  1. MarkC78

    MarkC78 Active Member


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    Hi All

    I have a patient with posterior tibial tendonosis as confirmed by MRI. The radiologist has confirmed a high grade focal tendinosis with marked thickening of the tendon. Her symptomatic foot has moderate medial talar bulging and a decreased mla height.

    I have put her into a kirby skived device and the patient has recieved great relief, however she still does have some pain with extended periods on her feet. My question is the prognosis with this condition, will the pain reduce with time and will the patient be able to reduce her dependence on her orthotics?

    Thanks

    Mark
     
  2. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    Mark

    IMHO, PTTD is almost always a progressive degenerative condition, and like osteoarthritis, it generally always heads toward gradual worsening.

    This is because the condition weaves from Grade 1 (mild tendonosis), though to Grade 4 (complete ankle valgus and with extensive 2ndry hindfoot DJD) - if the patient lives long enough. Just the same as a mildly arthritic 1st MTPJ pursuing a gradual crusade towards ankylosis.

    I tell my patients that the choice of treatment is loosely related to the symptoms, severity and grading of the condition, with a move from a typical foot orthosis, through to a UCBL device, AFO and surgery a real possibility.

    The challenge is to keep a Stage 1 or 2 PTTD at that level as long as possible to avoid the need for more extensive conservative or surgical treatments.

    I find it a very challenging condition to treat conservatively once the medial column has become rigid and in supinatus. External forefoot varus posting extended to sulcus to accomodate the supinatus seems to be helpful for the more proximal degenerative knee pathology that often accompanies this condition.

    Just my 2 cents. I'm sure our more learned, evidence-based colleagues can add to this.

    LL
     
  3. Adrian Misseri

    Adrian Misseri Active Member

    G'day Mark

    I had a similar patient that was a keen bushwalker with quite pronounced post tib dysfunction with all the associated medial bulging, rearfoot and ankle OA etc. that went with it. I ended up with a mod root style device with a medial heel skive and an extrinsic rearfoot post made out of 400 EVA which extended up to the talonavicular region of the device but was tapered so as to give progressive extrinsic correction. He is now back to doing several hundred kilometer walks with a pack and is pain free whilst with his devices. So the long and short of it is that prognosis is good with the right device, however due to osseous deformity, he needs the devices to be comfortable. He really can't go a day without them.

    Hope that helps!
     
  4. MarkC78

    MarkC78 Active Member

    Thanks for the replies.

    This particular patient works in retail and footwear to fit the orthoses has been an issue. Oh well i shall have to deliver the good news.

    Thanks again.
     
  5. Mark:

    The patient would do well to use a high top hiking boot along with the orthosis to further reduce the pain. She should be doing posterior tibial strengthening exercises daily and continuing to do icing therapy until edema is reduced. She should do no barefoot walking and will likely improve over time. However, she will not likely to be able to reduce her dependence on the proper orthoses and proper shoegear if she wants to keep the pain at a minimum.

    I tell patients that foot orthoses don't change the shape of their foot any more than their eyeglasses change the shape of their eyes. Eyeglasses make their eyes function better with less discomfort, as do orthoses make their feet function better with less discomfort. Removing the functional aid of either eyeglasses or orthoses will likely cause a decrease in function and an increase in discomfort.

    I have attached an article I wrote on the biomechanics, diagnosis and treatment of posterior tibial dysfunction from eight years ago that is still quite current. Hope this helps.
     

    Attached Files:

  6. There are two basic posterior tibial (PT) muscle strengthening exercises I use. The PT tendon can not be specifically "strengthened", but may increase its resistance to elongation under tensile loading forces with long term exercise under physiologic tensile loads.

    First of all, to start strengthening the PT muscle, I use an isometric exercise that involves the patient sitting in a chair with their shoes on and with the heels of the shoes both touching the ground, spaced about 2-3 inches apart. Then I have the patient press both of their medial forefoot areas of their shoe soles together as hard as they can (isometric adduction of the foot on the tibia) for a count of 10, then rest for a count of 10. This should repeated 10 times in one session, with 2-3 sessions per day. It helps, when doing this exercise, to either have the patient put their fist, or a small pillow, between their knees to make sure the proximal tibia is stabilized so that pure foot adduction is occurring, not hip adduction, during the exercise.

    After approximately 2-3 weeks of this exercise, the patient may then be instructed on a concentric/eccentric exercise program which involves again sitting in a chair, but with a Thera-Band or bicycle inner tube wrapped around leg of the chair and the other loop of the Thera-Band/inner tube looped around the medial forefoot of the affected extremity (the chair leg which is lateral to the affected foot is used as the stabilizing point of the elastic loop). Then the patient is instructed to put only their heel on the ground and pivot the foot, on their posterior-plantar heel, into slow adduction against resistance (concentric PT contraction) then slow abduction (eccentric PT contraction) back to the starting position. This exercise should be done about 50-100 reps a day, broken up into 2-3 sessions, again with the proximal tibia stabilized by bracing both knees together with a fist or pillow between the knees.

    I tell patients that they should begin these exercises about 3 weeks after receiving the orthoses once the inflammation has started to subside and continue doing the exercises for about 3 months to try and restrengthen the PT muscle.

    I would be happy to e-mail you the pdf of my article if you contact me via e-mail privately.

    Hope this helps.
     
    Last edited: Dec 23, 2008
  7. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    This recent systematic review may be of help in determining the options for this form of tendinopathy.

    (available via free access)

    LL
     

    Attached Files:

  8. ClintonAbel

    ClintonAbel Active Member

    I like to use the treatment algorithm set down on the National Guideline Clearinghouse website.

    The treatment pathway, allows for a nice classification and handy recommendations of when to bring in a surgical review. Review and monitoring activities over time (as it is usually a progressive condition), are also enhanced.


    http://www.guideline.gov/summary/summary.aspx?doc_id=6827
     
  9. If you choose a low cut shoe, a motion control shoe would be greatly preferable to a neutral shoe. Preferably, however, the most symptomatic relief for posterior tibial dysfunction comes from a well-made foot orthoses in a high top hiking/work boot.
     
  10. drsarbes

    drsarbes Well-Known Member

    Hi Mark:
    Lots of very good advice here.

    I see many more late stage PTTD and can verify that it's a difficult foot to treat.
    Once rigid pes valgus has "set in" either due to DJD/remodeling/peroneal spasms/combination of all the above, there isn't much one can do but a triple arthrodesis. When they are still flexible the previous posting suggestions are all worthwhile.

    Surgically; I've had fairly good outcomes from STJA such as the original MBA implant along with medial arch repair, often repairing the post tib and tenodesing it to the FDL. These depend on STJ ROM and ankle dorsiflexion.

    Your goals (if surgery is not indicated) is to retain ROM in the STJ and ankle as well as isolating the PT for strengthening, as Dr. Kirby recommended. In addition, as LL suggested, you should always remember gravity is working against you.

    One thing you may want to discuss with your patient is to be able to identify peroneal spasms. Once this sets in, if it does, it makes treatment very very difficult.

    Good Luck

    Steve
     
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