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Snapped Posterior Tibialis-Treatment?

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Podiatry777, Jan 11, 2007.

  1. Podiatry777

    Podiatry777 Active Member

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    :confused: An elderly lady didn't feel the snap as literature backs up. Lots of pain prior, GP didn't do a thing. I'm placing her in orthotics shortly as B/F severly pronated with abduction. Do we need to surgically reatach the P.T. insertion now moved 3 cm proximal? I recommended she see good orthopod for advice as I only imagine tendon not on stretch shrinking further. Any one has some thoughts? Remember no more pain-but swelling-Yes.
  2. DrPod

    DrPod Active Member

  3. Craig Payne

    Craig Payne Moderator

    If it was end stage PTTD, then there are very few alternatives to surgery. If it wasn't end stage PTTD, then treat it as such --> sugery
  4. Admin2

    Admin2 Administrator Staff Member

  5. Podiatry777

    Podiatry777 Active Member


    Thanks for straight answerers from Dr Pod and Mark Payne. Next step for me as a clinitian is to ask what pros and cons are there. I'd say it was very chronic and end stage due to other foot almost identical yet asymptomatic. Pain level very high on affected foot prioir to snap.

    Dr. Pod are you a Pod surgeon or what is your familiarity with Pod surgery outcomes on P.T. Snapped in USA? Should you care to go further on this thread.

    Mark Payne if you know great reference to an article you can suggest as reading, would like to hear some more. I love researches to back up treatment for us clinitians.

    I got on this morning thinking its wise to brows the surgery section shortly, but think clinitian point of view is extremelly important also as they see these patients longterm once they have their surgery.

    That week I got another lady similar age with what I'd say is earlier stage of samething-she's getting physio strengthening-is sore but we are watching this.
  6. Yeh Mark Payne, tell us all about it ;) Podiatry777, I guess reading isn't a strong point. :cool:
  7. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    Podiatry 777

    Do a Medline search and you will come across literally hundreds of references for surgical options in PTTD in the orthopaedic and podiatric literature.

    Stage 3/4 PTTD is typically managed with triple arthrodeses when the tendon has failed and there is degenerative change in the medial column and STJ. Surgical repair of the tendon is usually unsuccessful, as is tendon transfer, so primary fusion is usually the most appropriate course of action to stabilise the foot. Left alone the ankle may go into valgus, neccessitating additional ankle fusion.

    Otherwise AFO + brace + boot may assist if not fit for surgery.

    Big surgery, long recovery, swelling and discomfort for up to 12 months+.

  8. Podiatry777

    Podiatry777 Active Member


    Thanks for the practical summary sounds like you did some reading/ and seen a few cases? I did do general reading -wondered about Flexor Digitorum Longus Tendon transfer if it was worth it. Thanks for the ankle fusion update-hope orthotics compliance can avoid the secondary issue. Yes there is plenty of joints degeneration present.

    Question: a/What outcomes to the loose tendon->shrinks more? Cause any further problems of adhesion to soft tissues?? Can it get trapped somewhere?? b/Swelling- should it go now since infalmmation dispersing due to snap??

    I know that's alot, but would love to pick your brain on these or hear anyone else's respone.

  9. Podiatry777

    Podiatry777 Active Member

    Admin 2,

    Thanks for quick references-I'll get to the 'primacy' one shortly.
  10. Podiatry777

    Podiatry777 Active Member

    Admin 2,

    Just read it. I think I'm happy to treat this far gone condition with soft EVA for accommodation of deformity (as I already prescribed) and consider footwear modifications or boot to increase ankle stability. patient compliance to boot won't happen-she's not very realistic unfortunatelly, but ensuring firm sole at least will help. Other patients ie one withot the snap I should be a bit more prepared for now.

    Surgical options from Lisfranc also helpful-it may encourage her to better comply with conservative treatment. :D

    Must say stil wondering if strengthening is more 'weakening' in more advaned cases.
  11. DaVinci

    DaVinci Well-Known Member

    I have heard him called a few things before, but never "mark".
  12. My tibiliailis posterior tendon was repaired successfully 7 years ago, nine years after it ruptured. It was repaired using my flexor digitorum longus tendon. Tendon repair can be successful if done correctly on the right patient. :) :)
  13. musmed

    musmed Active Member

    Dear All

    The big picture has been missed.

    The history is: an elderly lady....


    Red Flags?

    ? diabetes
    ? BP
    ? Old smoker
    ? renal disease
    ? lives alone
    ? osteoporosis
    ? Who in the hell will look after her?
    does she have 18 months to live so that when she is fully rehabed she will reap the benefits of surgery?

    Let's be real and KISS.

    Local treatments and most likely a nursing home of sorts or home assistance etc. this is reality, I know I look after such people.

  14. Podiatry777

    Podiatry777 Active Member

    Hello Musmed,

    As you have practically stated, the old lady won't benefit with such a complex surgery and lengthy recovery. She said to me when I fitted the orthotics a few days ago, 'I don't want any surgery-I don't know how long I'll live." She's 80yrs old.-very consistent with what one would expect.

    Any one out there know what happens to that floating tendon?

    I'd like to know if some physical therapy is needed to prevent adhesions etc...

    Many Thanks,

  15. Podiatry777

    Podiatry777 Active Member

    Thanks for sharing your success, Annette, its great to hear how the younger body heals well. With agood attitude the immune system does the rest. ;)

  16. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    If the tendon has truly "snapped", then it will recoil up into the leg within the tendon sheath.

    I would suggest there is no local physical therapy needed, other than addressing the inevitable muscle imbalance and peroneus brevis dominance.

    AFO, Richie brace or similar will be needed if too frail for surgery.

  17. I have treated a few of these patients (i.e. elderly with PT ruptures) so that they can walk nearly pain free with high top hiking boots and anti-pronation (e.g. medial heel skive) foot orthoses. AFOs and Richie braces are not necessarily the best nonsurgical treatments for all individuals with this condition.

    Finally, I don't believe that the problem with these patients is "peroneus brevis dominance" as Mr. LisFranc states. Rather, the mechanical problem is a loss of the STJ supination moment from the PT muscle due to rupture of the PT tendon which, in turn, causes medial deviation of the STJ axis. The medially deviated STJ axis then greatly increases the magnitudes of STJ pronation moments from the actions of ground reaction force, and especially during the late midstance phase of gait.
  18. Tend to agree with Kevin's analysis. However, Gray and Basmajian noted that: "Peroneus longus is most active at mid-stance and heel-off and generally more active in flatfooted persons."
  19. Podiatry777

    Podiatry777 Active Member

    Why not poor STJ alignment + evertors still acting but main invertor is gone (Post Tib). Muscle imbalance with foot joints ready for more damage= Trouble for the foot stability, joint deterioration (Osteoarthritis @ least) and strain on the rest of the lower limb structures-biomechanical causes.
  20. Podiatry777

    Podiatry777 Active Member

    Thanks LL,

    Patient likes boots in colder months-So I'll consider AFO, which I gave her as a better treatment option. Summer may be an issue. Appreciate the input on that elusive tendon, very much.


  21. LuckyLisfranc

    LuckyLisfranc Well-Known Member


    I agree enitrely with you that the inevitable march of the STJ axis to a much greater medial position is the main cause of the chronic medial column and STJ (and ankle) pathologies that Stage 3 and 4 PTTD patients suffer.

    Once PT has "gone" completely (ie late Stage 3, and 4), and there is some degree of ankle valgus creeping in, I have personally observed a tendency toward peroneus brevis shortening - akin to peroneal spastic flatfoot. I find it hard to dismiss this as at least a small contributory factor in the progression of STJ axis position more medially.

    Either way, I feel that agressive management of these patients in the early (Stage 1,2) stages by the methods you describe is about the only way to slow the progression of this condition and delay the multitude of pathologies caused by the failure of PT to do its "job". By rupture time though, I personally find at least 50% of these will fail with a foot orthosis/high top boot, and need an AFO.


  22. I would tend to agree that the long STJ moment arm of the peroneus brevis tendon that results from medial STJ axis deviation will contribute to the increased STJ pronation moments experienced by patients with PTTD. I also agree that an AFO, especially a Arizona style lace-up ankle gauntlet brace works well or, even better for controlling pronation, a double steel upright hinged ankle brace with a medial T-strap attached to an oxford style shoe. However, if I can get a patient relatively pain-free and functioning with a high top boot and good foot orthosis, they most commonly seem to have little desire to wear a brace or have corrective surgery.
  23. Podiatry777

    Podiatry777 Active Member

    Just briefly,

    So a reasonable deduction would be that severity of Subtalarjoint pronation initially seen at the clinic, and some follow up would help to determine next course of treatment- AFO or otherwise. I have booked my three Post Tib cases to a 6 months review, all treated with orthotics, stretches and ultrasound originally for the non snapped feet. I'll be implementing a record on STJ pronation angle or rearfoot valgus-will think some more 1st, from now on to help monitor Pos Tib dysfunction progression. Should help in monitoring what works and when. What says though?

  24. METaylor

    METaylor Active Member

    If the tendon hasn't ruptured but is strained or tearing but the tendon has not withdrawn into the tendon sheath, prolotherapy is the ideal treatment. It should certainly prevent Post Tib dysfunction progression. A small injection (0.5cc) of a mixture of glucose and a local anaesthetic eg lignocaine (perhaps 4cc 25% glucose and 1cc 1% lignocaine, OR 2cc 50% glucose and 2cc 0.5% lignocaine) will release cytokines which initiate the healing cascade releasing growth factors and causing the formation of new collagen within and around the existing fibres of the tendon. The correct place is the enthesis (attachment of ligament to bone) and is easily found by where the tenderness to palpation is. You may need to do several of the insertions of Tibialis Posterior. Several treatments are usually necessary except in the young and very fit, when 1 may be enough.
    My website has collapsed but you can read more at www.podprol.org
    My next workshop for podiatrists is in Adelaide, South Australia on Sunday April 1 (...no its not a joke!). There were 15 or so at the Sydney one in August 2006 and they are getting some good results with the technique. email me at taylorme@internode.on.net if you are interested.
    Incidentally there is a fascinating report of repair of a completely ruptured Achilles tendon in a 26 yo, using prolotherapy, by a DO, Marc Lazzara, from California, in J of Orthopaedic Medicine 2005;27[3]:128.
  25. Podiatry777

    Podiatry777 Active Member


    I took the time to read through your brief website 'podprol'. As a brief input on your new treatment modality-

    An injection is an (mildly) invasive procedure, which sounds interesting and makes Pods look like they have more alternatives- True. However I can't help wondering that the issue is "how do we increase circulation to the area to allow immune processes to do self healing of the body".

    Therefore an ultrasound increasing circulation and mechanical tissue movement for breakdown of scar tissue sounds Less Invasive in my conservativism attitude to patient care.

    You mentioned injections ("you can use many substances") to induce inflammation-> body goes to work to heal it-> increase circulation-> increase self healing.

    My question to you is- " do we need to irritate the body further just to wake it to self heal. We already have inflammation process daily due to stress of ambulation to effected tissues.

    I certainly agree with collagen predominating the affected sight and increased circulation is needful.

  26. Podiatry777

    Podiatry777 Active Member

    I am stil hoping more practitioners who use ultrasound with both caution and enthusiasm will speak up. Studies are not enough to convince me- too theoretical- they rarely fully describe methods so we can pick it apart properly. :)

    However, if Craig Payne can produce a good one from his evidence= I'll take a look. Otherwise I may need to go to Physio sites to see what the go is on this one?


  27. Podiatry777

    Podiatry777 Active Member

    I meant to post the last one to ultrasound redirected thread- I'm a little lost, Admin2?
  28. Craig Payne

    Craig Payne Moderator

  29. METaylor

    METaylor Active Member

    Yes we do need to "irritate the body further" to initiate the healing cascade as the inflammatory process has become arrested for some reason which has puzzled me for a long time. Podiatrist Martin Harvey, the author of the www.podprol.org website, hypothesises that it is because dense connective tissue like tendons and ligaments have very few cells to release the cytokines necessary for the initiation (and continuation?) of the inflammatory process. Anyway, research has shown that collagen strained beyond 4-5% of its length undergoes a 'plastic' change and loses its normal mechanical properties, and henceforth is more easily stretched (stimulating pain nerve endings) and torn (nb the increased frequency of subsequent injury after strains). Yes I agree that ultrasound and (painful) massage are probably also ways of setting off the inflammatory cascade, but just increasing circulation is not always enough (otherwise a nice hot pack would heal everything). Having used this needling technique for 17 years now, I know that most patients are happy to put up with a brief hurt in order to heal something that has been bothering them. As healers we have to overcome our natural powerful instincts to avoid hurting people and express compassion as we treat the injury. They give us permission to do so and are very grateful for the result.
    The treatment may be new to podiatry but it has been used by doctors in USA since the 1940s and is slowly becoming widespread as patients are demanding alternatives to steroids. A pod I taught in August who mainly concentrates on biomechanics, with orthotics, acupuncture and and foot mobilisation, says "Prolo fits very well in what I do and the results are amazing."

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