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March 14, 2012 Alana Gorman

What does current evidence suggest for Physical T herapy intervention in the management of Posterior Tibial Tendon Dysfunction?. March 14, 2012 Alana Gorman. What’s Happening for the next 30 mins. Review of normal m. & tendon Description of what PTTD is/involves Description of stages

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March 14, 2012 Alana Gorman

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  1. What does current evidence suggest for Physical Therapy intervention in the management of Posterior Tibial Tendon Dysfunction? March 14, 2012 Alana Gorman

  2. 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

  3. Posterior Tibialis M.

  4. 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.

  5. 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->talocrurallig-> bone breakdown

  6. Secondary Hypotheses • Spring Ligament dysfunction • Supports medial arch of the foot • TalocalcanearInterosseus 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

  7. Stage I Typical Patient : young runners, early onset of condition Presentation Structure: no deformity Strength: mild weakness w/ SL heel raise, mild weakness w/ inversion CC’s: medial pain, edema, tenderness along PTT

  8. Stage II Presentation Structure: flexible pesplanus deformity, “too many toes”, RG’s show lat. talocalcaneal angle Strength: moderate weakness of SL heel raise, inversion CC’s: tenderness, swelling

  9. Stage III & IV Presentation Structure: Fixed deformity Strength: Definite weakness, unable to perform SL heel raise CC’s: increase in s/s, pain @ calcaneofibular articulation Stage IV Presentation Structure: valgus tilt of talus, lateral tibiotalar degeneration

  10. Stage III & IV • Resolution requires surgical intervention • Talonavicular arthrodesis/fusion • Medializing calcaneal osteotomy • FHL, FDL tendon transfer to support the arch Popelka et. al.

  11. Patient Exam for PTTD Signs & 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

  12. Treatment-EdUReP • Educate • Tendon healing occurs slowly, long recovery • Unload • Activity modification, foot orthosis • Reload • Eccentric exercises • Prevent • Stop the advancing deformity

  13. Methods for Unloading Taping Technique for Medial Arch Support Franettovich et. al.

  14. Methods for Unloading • Orthotics • Custom made (Kulig et. al.) • Medial heel lift • Medial Arch support • Bracing • AirLiftPTTD brace: clamshell ankle, air bladder@ midfoot(Neville et. al.) • Double Upright AFO (Lin et. al.) • Arizona Brace AFO (Augustin et. al.) • Shell Braces

  15. 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

  16. Reloading Research Kulig 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 tibialisposterior tendon • foot flattening • abducted midfoot • absence of rigid foot deformity

  17. 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 Kuliget. al.

  18. Results Orthoses w/ Concentric 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 • 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 Kuliget. al.

  19. 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

  20. 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).

  21. 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 plantarflexionas 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. Kuliget. al.

  22. 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!

  23. Take Homes National 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 radiographsAdditional views: Weight-bearing ankle series may be useful

  24. So what does the current best evidence say? • High rep • Low load • Progress as tolerated • Stretch!! • Support!! • Thank you!

  25. References • Bowring B, Chockalingham N. A clinical guideline for the conservative management of tibialis posterior tendon dysfunction. The Foot. August 2009. 211-217. • Bowring B, Chockalingham. Conservative treatment of tibialis posterior tendon dysfunction-A review. The Foot. 2010. 18-26. • Franettovich M, Chapman A, Vicenzino B. Tape that increases medial longitudinal arch height also reduces leg muscle activity: a preliminary study. Med Sci Sports Exerc. 40(4):593 – 600, 2008. • Gluck GS, Heckman DS, Parekh SG. Tendon Disorders of the Foot and Ankle, Part 3: The Posterior Tibial Tendon. Am J Sports Med. 2010. 38: 2133-2144. • Kulig K, Reischl SF, Pomrantz AB, Burnfield JM, et. Al. Nonsurcical Management of PoseriorTibial Tendon Dysfunction With Orthoses and Resistive Exercise: A Randomized Controlled Trial. PHYS THER. 2009; 89:26-37. • Kulig K, Lederhaous ES, Reischl S, Aryia S, et al. Effect of Eccentric Exercise Program for Early Tibialis Posterior Tendonopathy. Foot and Ankle International. September 2009. 30;9:877-885. • National Clearinghouse Guidelines: Accessed on March 11,2012: http://www.guideline.gov/content.aspx?id=13007&search=posterior+tibial+tendon+dysfunction. • Neville C, Flemister AS, Houck J. Effects of the AirLift PTTD Brace on Foot Kinematics in Subjects With Stage II Posterior Tibial Tendon Dysfunction. JOSPT. March 2009; 39;3: 202-209. • Neville C, Houck J. Choosing Amung 3 Ankle-Foot Orthoses for a Patient With Stage II Posterior Tibial Tendon Dysfunction. J Orthop Sports PhysTher. November 2009; 39 (11):816-824. • Neville C, Flemister AS, Houck JR. Deep Posterior Compartment Strength and Foot Kinematics in Subjects With Stage II Posterior Tibial Tendon Dysfunction. Foot Ankle Int. April 2010; 31(4): 320-328. • Parsons S, Naim S, Richards PJ, McBride D. Correnction and Prevention of Deformity inType II tibialis Posterior Dysfunction. ClinOrthopRelat Res. October 2009. 468:1025-1032. • Pisani G. Peritalardestabilisation syndrome (adult flatfoot with degenerative glenopathy). Foot and Ankle Surg. 2010:183-188. • Popelka S, Hromadka R, Vavrik P, Stursa P, et. Al. Isolated talonavicular arthrodesis in patients with rheumatoid arthritis of the foot and tibialis posterior tendon dysfunction. BMC Muskloskeletal Disorders. 2010. 11:38 • Rabbito M, Pohl MB, Humble N, Ferber R. Biomechanical and Clinical Factors Related to Stage I Posterior Tibial Tendon Dysfunction. JOSPT October 2011. 41; 10: 776-784. • Tryfonidis M, Jackson W, Mansour R, Cooke PH, et.al. Acquired adult flat foot due to isolated plantar calcaneonavicular (spring) ligament insufficiency with a normlaltibialis posterior tendon. Foot and Ankle Surg. 2008. 14:89-85.

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