Results of Non-Surgical Treatment of Stage II Posterior Tibial Tendon Dysfunction

NewsBot · Aug 30, 2008

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Results of Non-Surgical Treatment of Stage II Posterior Tibial Tendon Dysfunction: A 7- to 10-Year Followup.
Lin JL, Balbas J, Richardson EG.
Foot Ankle Int. 2008 Aug;29(8):781-6.

BACKGROUND: There are few long-term studies on the non-operative treatment of Stage II Posterior Tibial Tendon Dysfunction (PTTD). The purpose of this study is to describe the natural history and determine the efficacy of non-operative treatment of Stage II PTTD using clinical outcome scores.

MATERIALS AND METHODS: Patients with Stage II PTTD treated with a Double Upright Ankle Foot Orthosis (DUAFO) with a minimum followup of 7 years were identified retrospectively. Patients were evaluated with the AOFAS Ankle/Hindfoot Score, SF-36, Foot Function Index (FFI), Visual Analog Scale (VAS) for pain, and a custom questionnaire in addition to a comprehensive physical examination.

RESULTS: Thirty-three feet in 32 patients were included with an average followup of 8.6 years. Success defined as being brace-free and avoiding surgery was 69.7%. Five patients (15.2%) were unable to completely wean from a brace. Five patients went on to surgery. The mean AOFAS and FFI score was 78.4 and 18.4, respectively. Compared to national norms, SF-36 subscores for each age sub-category showed no significant difference in any of the age groups (p < 0.05). Average VAS pain scale score was 1.9. Satisfaction was rated as "satisfied" in 20 patients (60.6%), "satisfied with minor reservations" in 11 patients (33.3%), partially satisfied in one (3.0%), and "unsatisfied" in one (3.0%). None of the patients rated as "satisfied with major reservations".

CONCLUSION: Treatment of Stage II PTTD with a DUAFO has been shown to be a viable alternative to surgery with a high likelihood of adequate function, avoidance of surgery, and being brace-free at 7- to 10-year followup.
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NewsBot · Apr 1, 2011

Nonoperative Care for the Treatment of Adult-acquired Flatfoot Deformity
Matthew D. Nielsen, et al
Journal of Foot and Ankle Surgery (in press)

Nonoperative therapy for adult-acquired flatfoot is a reasonable treatment option that is likely to be beneficial for most patients. In this article, we describe the results of a retrospective cohort study that focused on nonoperative measures, including bracing, physical therapy, and anti-inflammatory medications, used to treat adult-acquired flatfoot in 64 consecutive patients. The results revealed the incidence of successful nonsurgical treatment to be 87.5% (56 of 64 patients), over the 27-month observation period. Overall, 78.12% of the patients with adult-acquired flatfoot were obese (body mass index [BMI] ≥ 30), and 62.5% of the patients who failed nonsurgical therapy were obese; however, logistic regression failed to show that BMI was statistically significantly associated with the outcome of treatment. The use of any form of bracing was statistically significantly associated with successful nonsurgical treatment (fully adjusted OR = 19.8621, 95% CI 1.8774 to 210.134), whereas the presence of a split-tear of the tibialis posterior on magnetic resonance image scans was statistically significantly associated with failed nonsurgical treatment (fully adjusted OR = 0.016, 95% CI 0.0011 to 0.2347). The results of this investigation indicate that a systematic nonsurgical treatment approach to the treatment of the adult-acquired flatfoot deformity can be successful in most cases.
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NewsBot · Apr 10, 2015

Randomized Controlled Trial Comparing Orthosis Augmented by Either Stretching or Stretching and Strengthening for Stage II Tibialis Posterior Tendon Dysfunction
Jeff Houck, Christopher Neville, Josh Tome, Adolph Flemister
Foot & Ankle International April 9, 2015

Background: The value of strengthening and stretching exercises combined with orthosis treatment in a home-based program has not been evaluated. The purpose of this study was to compare the effects of augmenting orthosis treatment with either stretching or a combination of stretching and strengthening in participants with stage II tibialis posterior tendon dysfunction (TPTD).
Methods: Participants included 39 patients with stage II TPTD who were recruited from a medical center and then randomly assigned to a strengthening or stretching treatment group. Excluding 3 dropouts, there were 19 participants in the strengthening group and 17 in the stretching group. The stretching treatment consisted of a prefabricated orthosis used in conjunction with stretching exercises. The strengthening treatment consisted of a prefabricated orthosis used in conjunction with the stretching and strengthening exercises. The main outcome measures were self-report (ie, Foot Function Index and Short Musculoskeletal Function Assessment) and isometric deep posterior compartment strength. Two-way analysis of variance was used to test for differences between groups at 6 and 12 weeks after starting the exercise programs.
Results: Both groups significantly improved in pain and function over the 12-week trial period. The self-report measures showed minimal differences between the treatment groups. There were no differences in isometric deep posterior compartment strength.
Conclusions: A moderate-intensity, home-based exercise program was minimally effective in augmenting orthosis wear alone in participants with stage II TPTD.
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NewsBot · Aug 12, 2015

Conservative Management of Stage I and II Posterior Tibial Tendon Dysfunction
Holly Phimister, Elaine Figgins
Prosthet Orthot Int June 2015 vol. 39 no. 1 suppl 2-608 (abstract 425)

Background (approx 70 words)
The posterior tibial tendon primarily maintains the medial longitudinal arch of the foot, damage results in posterior tibial tendon dysfunction (PTTD). PTTD is the commonest cause of acquired adult flatfoot deformity and largely affects middle-aged women of increased body weight. There is a lack of evidence with regard to the most effective conservative treatment of PTTD.
Objectives:
This literature review aims to assess the level of evidence in relation to stage I and II Posterior Tibial Tendon Dysfunction (PTTD) and conclude on the most effective treatment.
Aim: (approx. 30 words)
The literature surrounding PTTD focuses largely on surgical intervention and there is little available on orthotic management. The aim of this project is to produce a literature review to determine the most effective conservative treatment method of stage I and II PTTD within the adult population. This review may be used by clinicians to aid clinical judgement and encourage evidence-based practice within the field of Orthotics.
Method: (approx 100 words)
A literature review was systematically carried out and studies were assessed for level of evidence, utilising the databases Medline, Embase, Cochrane database, CINAHL and ASSIA. Generally, there was a lack of high quality of evidence with only one randomised control trial.
Results: (approx 130 words, or less if you paste an image or insert a table )
Ten studies were included in this review, all relating to conservative treatment methods of stage I and II PTTD. Study and population characteristics, interventions and outcome measures were evaluated. Although no restriction was put on the paper search with regard to date, all of the studies used were conducted within the last fifteen years. The Scottish Intercollegiate Guideline Network (SIGN) was used to appraise the literature. There were some cases of bias in the papers, as some of the orthotic devices were provided by companies and this must be taken into account. The mean number of participants was n=27.3 and the median number is 27.5, with a range of 1-64. The sex of the participants is uneven with a total of 218 females as compared to only 54 males. Most of the studies observed the use of an ankle-foot (AFO) or supra-malleolar (SMO) orthotic device. These orthoses are classed as such because they incorporate the talo-crural joint as well as both the subtalar and midtarsal joints. The majority of the orthoses were manufactured from polypropylene thermoplastic. The study with the highest level of evidence used a foot orthoses in combination with an exercise programme. Exercise or stretching as a treatment method was subdivided into either isokinetic, concentric or eccentric exercise. Several of the studies utilised other various forms of treatment including initial immobilisation, rest and ice therapy.
Discussion & Conclusion (approx 70)
Evidence suggested that the most effective treatment for the treatment of stage I and II PTTD is a custom-made polypropylene foot orthosis in conjunction with an exercise programme consisting of stretches and eccentric strengthening. The most common outcome measure used in the studies was the AOFAS (American Orthopaedic Foot and Ankle Society) ankle/hindfoot scale .This scale measures subjective pain, activity limitations, walking distance, walking distance, walking aids and ability to walk on different surfaces. A full-length semi-rigid foot orthosis with a medial heel wedge and forefoot posting is a suitable prescription for the treatment of stage I and II PTTD. A UCBL is also a suitable treatment method when the deformity is still flexible. Custom-made orthotic devices are most effective at correcting the foot deformity. All the studies used in this review agreed that the use of orthoses in the early stages of PTTD decreased the need for surgery and prevented progression.
Further work includes more studies of a higher level of evidence, specifically in Europe with more comparison between orthotic devices and conservative treatment methods.
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NewsBot · Dec 22, 2016

The effect of polydeoxyribonucleotide prolotherapy on posterior tibial tendon dysfunction after ankle syndesmotic surgery: A case report.
Lim TH, Cho HR, Kang KN, Rhyu CJ, Chon SW, Lim YS, Yoo JI, Kim JW, Kim YU.
Medicine (Baltimore). 2016 Dec;95(51):e5346.

RATIONALE:
Ankle syndesmotic injuries occasionally require long-term therapy for recovery and can result in tendon injury. Posterior tibial tendon dysfunction (PTTD) is an acquired deformity that can cause flatfoot deformity. The current nonoperative management of PTTD includes nonsteroidal antiinflammatory drugs (NSAIDs), orthopedic devices. Although various treatment options have been attempted, optimal treatments for each stage of the condition are debated. Polydeoxyribonucleotide (PDRN) is effective in healing of chronic wounds associated with tissue damage by attracting tissue growth factors.
PATIENT CONCERNS:
A 67-year-old woman who presented at our pain clinic with pain on the inside of ankle. She had a syndesmotic screw fixation 3 years prior. Her ankle pain had persisted after the removal of screws and edema for about 1 month resulting from long-term NSAIDs administration.
DIAGNOSES:
The origin of the pain was possibly tibialis posterior muscle and posterior tibial tendon and she was diagnosed as PTTD after syndesmosis surgery.
INTERVENTIONS:
Sono guided prolotherapy with PDRN was carried out.
OUTCOMES:
Patient showed improvement in the arch of the foot, experienced pain relief, and was able to wear regular shoes without any orthopedic device.
LESSONS:
This case report highlights that PDRN prolotherapy is a safe and efficient therapeutic option for the treatment of PTTD.
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NewsBot · Mar 8, 2020

ACFAS Clinical Consensus Statement
American College of Foot and Ankle Surgeons Clinical Consensus Statement: Appropriate Clinical Management of Adult-Acquired Flatfoot Deformity
Jason A.PirainoDPM, MS, FACFAS(Chair)Michael H.TheodoulouDPM, FACFAS, CochairJulioOrtizDPM, FACFASKylePetersonDPM, FACFASAndrewLundquistDPM, FACFASShaneHollawellDPM, FACFASRyan T.ScottDPM, FACFASRobertJosephDPM, FACFASKieran T.MahanDPM, FACFASPhilip J.BresnahanDPM, FACFASDanielle N.ButtoDPM, AACFASJarrett D.CainDPM, MS, FACFASTimothy C.FordDPM, FACFASJessica MarieKnightDPM, AACFASGarrett M.WobstDPM, FACFAS
Adult-Acquired Flatfoot Deformity Clinical Consensus Statement Panel of the American College of Foot and Ankle Surgeons, Chicago, IL
24 February 2020.

This clinical consensus statement of the American College of Foot and Ankle Surgeons focuses on the highly debated subject of the management of adult flatfoot (AAFD). In developing this statement, the AAFD consensus statement panel attempted to address the most relevant issues facing the foot and ankle surgeon today, using the best evidence-based literature available. The panel created and researched 16 statements and generated opinions on the appropriateness of the statements. The results of the research on this topic and the opinions of the panel are presented here.
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