What does current evidence suggest for Physical Therapy intervention in the management of Posterior Tibial Tendon Dysfunction?

March 14, 2012Alana Gorman

What’s Happening for the next 30 mins Review of normal m. & tendon Description of what PTTD is/involves Description of stages

Patient presentation Current best evidence for intervention

Posterior Tibialis M.

Posterior Tibialis…Tibialis Posterior… either way it’s an important muscle!

Dynamic stabilizer of the arch Most powerful inverter of the foot Plantar flexes and inversion the ankle,

adduction of the foot

Gluck et al.

PTT Dysfunction Recent literature describes it as a

degenerative process Patients suffer pain and fatigue with

daily activities, walking & standing Risk factors include trauma, overuse,

HTN, Obesity, DM Progression: spring ligament failure

->deltoid lig->talocrural lig-> bone breakdown

Secondary Hypotheses Spring Ligament dysfunction

Supports medial arch of the foot Talocalcanear Interosseus Ligament

Binds the talus and calcaneous Accessory navicular bone

Type 1: ossicle w/in PTT Type 2: sits on near tuberosity of navicular Type 3: fused to tuberosity of navicular

Stage ITypical Patient : young runners, early onset of condition PresentationStructure: no deformityStrength: mild weakness w/ SL heel raise, mild weakness w/ inversionCC’s: medial pain, edema, tenderness along PTT

Stage IIPresentationStructure: flexible pes planus deformity,“too many toes”, RG’s show lat. talocalcaneal angleStrength: moderate weakness of SL heel raise, inversionCC’s: tenderness, swelling

Stage III & IVPresentationStructure: Fixed deformityStrength: Definite weakness, unable to perform SL heel raiseCC’s: increase in s/s, pain @ calcaneofibular articulation Stage IV PresentationStructure: valgus tilt of talus, lateral tibiotalar degeneration

Stage III & IV Resolution requires surgical intervention

Talonavicular arthrodesis/fusion Medializing calcaneal osteotomy FHL, FDL tendon transfer to support the

arch

Popelka et. al.

Patient Exam for PTTDSigns & Symptoms Pain & Swelling ROM

DF w/ knee flexed & extended Subtalar joint motion; ranges from hyper-hypo mobile Increased 1st Metatarsal DF suggests midfoot instability Loss of medial longitudinal arch height

Strength Postion: pt. PF, abd & everted Pt. asked to move into PF, add & inversion Single Heel Rise Test

Gait Note forefoot abd, “too many toes” Note heel valgus SL heel raise, walk on toes

Treatment-EdUReP Educate

Tendon healing occurs slowly, long recovery

Unload Activity modification, foot orthosis

Reload Eccentric exercises

Prevent Stop the advancing deformity

Methods for Unloading

Taping Technique for Medial Arch Support

Franettovich et. al.

Methods for Unloading Orthotics

Custom made (Kulig et. al.) Medial heel lift Medial Arch support

Bracing AirLift PTTD brace: clamshell ankle, air

bladder@ midfoot (Neville et. al.) Double Upright AFO (Lin et. al.) Arizona Brace AFO (Augustin et. al.) Shell Braces

Research Bowring et. al.

Literature review in 2007 showed much discrepancy and limited evidence that supported good outcomes from specific interventions No good evidence supporting US, DTM, TFM,

Ice therapy, anti-inflammatory meds Support for rest, orthotics, strengthening

exercises for TP & periankle mm., stretching for gastroc-soleus complex, weight loss, and pt. education

Reloading ResearchKulig et. al-Jan 2009, RCT

3 groups, 12 participants each: Orthoses & stretching Orthoses, stretching & concentric exercises Orthoses, stretching & eccentric exercises

Inclusion Criteria: pain for 3+ months symptoms located at the medial ankle or foot Tenderness to palpation specific to the tibialis posterior

tendon foot flattening abducted midfoot absence of rigid foot deformity

Reloading Research Interventions-3 months

Orthoses All groups

Stretching All groups

Progressive Resisted Ex Concentric (Group II) Eccentric (Group III)

Outcome Measures FFI 5 minute walk test VAS

Kulig et. al.

Results

Orthoses w/ Concentric

• Average resistance 3.7 lbs

• 13.2% increase in 5MWT

• Significant change in VAS

• FFI decrease 10.9 total 11.8 pain 17.8 disability 3.3 activity limitation

Orthoses w/ Eccentric

Average resistance 12.5 lbs

2.6% average increase in 5MWT

Significant change in VAS

FFI decrease 15 total• 36.3 pain• 40.5 disability• 8 activity limitation

Kulig et. al.

Reloading Research Kulig, et. al. Sept 2009 : Case Series

10 subjects 2 weeks unloading, 10 weeks of eccentric

exercise program Considered morphology & vascularization

of tendon before/after program. Assessed pain & function @ 6 mo follow-up

OM’s: FFI, VAS, 5MWT, Single Heel Raise, PAS, GRS

Results 12 weeks: POST

100% retention, 77-100% compliance (mean 95%)

Significant increase in # of heel rises (6.3 ± 3.7) to (11.1 ± 4.7)

Significant decrease in FFI (pain & disability) (31.1 ±15.8) to (11.4 ±

9.9) Tendon degeneration

remained present at end of program

6 month follow-up: 6M No significant

difference between POST & 6M in FFI

GRS results achieved MCID in decrease of symptoms (5.2 ± 0.92).

Methods for Reloading

“TibPost Loader”Exercise device (TibPost Loader) designed to provide progressive, constant resistance (2) throughout the range of motion in the transverse plane. The hand lever (3) allows for selective application of the resistance in one direction only. When the foot resists the footplate’s motion towards horizontal abduction, the tibialis posterior is recruited eccentrically. To minimize the activity of the anterior tibialis the patient applies pressure into plantarflexion as indicated by LEDs (1). C, Elastic band provides resistance eccentrically to the tibialis posterior throughout the range of motion. Note the towel under the forefoot to decrease friction and the direction of the elastic band, ∼45 degrees to floor, to resist adduction and plantarflexion.

Kulig et. al.

Take Homes• UNLOAD first: stretch PF, rest, brace & support• Orthoses & stretching alone significantly

reduced self reported pain, disability and activity limitation after 3 months

• No increase in symptoms occurred w/ eccentric or concentric loading of the tendon

• Greater training load achieved w/ eccentric ex (3x as much!)

• Tendon repair/remodeling takes longer than 10 weeks!

Take HomesNational Clearinghouse Guidelines-2007

Special investigations [D] MRI better at differential diagnosis of medial ankle/foot pain US may be useful

Radiographs indicated if unrelieved by 4 weeks of conservative care or in suspected inflammatory arthritis [D] AP, medial oblique, and lateral foot radiographs

Additional views: Weight-bearing ankle series may be useful

So what does the current best evidence say? High rep Low load Progress as tolerated Stretch!! Support!!

Thank you!

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