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

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Presentation on theme: "What does current evidence suggest for Physical Therapy intervention in the management of Posterior Tibial Tendon Dysfunction? March 14, 2012 Alana Gorman."— Presentation transcript:

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. ORIGIN: upper 1/3rd of post. tibia, fibula, interosseous membrane PATH: tendon distal 1/3rd of tib, passes post. to med. malleolus, sits in shallow groove in distal tib, held in place by flexor retinaculum INSERTION: tendon splits! -navicular tuberosity, inf. capsule of med. naviculocuneiform jt, & inf. surface of med cuneiform -plantar surface of cuboid, middle & lat cuneiforms, bases of 2nd, 3rd, 4th mets.

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->talocrural lig-> bone breakdown With a fixed deformity, subtalar jt. is breaking down

6 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 Spring Lig: supports the head of the talus, connects calcaneus-navicular TCI Lig: stability of STJ Accessory Navicular: -pressure relief w/ shoeing, medial heel wedge, orthotics/bracing, surgery?? -present in women >men, unilateral or bilateral -pts. Complain of medial foot pain w/ walking & WB, narrow shoes, strenuous activity

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 pes planus deformity, “too many toes”, RG’s show lat. talocalcaneal angle Strength: moderate weakness of SL heel raise, inversion CC’s: tenderness, swelling Lat. Talocalcaneal pitch angle: The lateral talocalcaneal angle is the angle formed by the intersection of the line bisecting the talus with the line along the axis of the calcaneus on lateral weight-bearing views. A line is drawn at the plantar border of the calcaneus (or a line can be drawn bisecting the long axis of the calcaneus).The other line is drawn through two midpoints in the talus, one at the body and one at the neck. (1st-2nd rocker) Heel strike-Single limb support=excessive hind foot eversion (3rd rocker) Double limb-toe off=increased forefoot abduction & DF…The third rocker is also a time when high loads are being transmitted through the forefoot after the heel is off the floor, making controlling forefoot motion with orthotic devices potentially challenging.

9 Stage III & IV Presentation Structure: Fixed deformity Strength: Definite weakness, unable to perform SL heel raise CC’s: increase in s/s, calcaneofibular articulation Stage IV Presentation Structure: valgus tilt of talus, lateral tibiotalar degeneration Fixed deformity: loss of inversion Pain related to breakdown of deltoid lig med.

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

11 Patient Exam for PTTD Signs & Symptoms Pain & Swelling ROM Strength
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 STRENGTH: -strength deficits apparent (20-30%) w/ Stage II -if STJ is not inverted w/ heel rise, suggests PT weakness -just because they can do the Heel test, doesn’t mean the form is right, doesn’t mean negative PTTD!! GAIT: -heel valgus >normal 5-10 degrees can cause achilles tendon contracture/shortening -pain, discomfort, instability w/ SL heel raise/walking on toes highly indicative of PTTD

12 Treatment-EdUReP Educate Unload Reload Prevent
Tendon healing occurs slowly, long recovery Unload Activity modification, foot orthosis Reload Eccentric exercises Prevent Stop the advancing deformity Ed: Tendon recovers slower than bone U: A high arch unloads PTT to decrease pain and increase function Taping medial arch has shown to reduce demand of TP 45% in stance phase

13 Taping Technique for Medial Arch Support
Methods for Unloading Taping Technique for Medial Arch Support Increase in arch height, alteration of TP, TA activation. Increased m. efficiency, research has shown that flat-footed posture =increase in extrensic mm=higher demand=more succeptibal to overuse? *Preliminary evidence, case series (5 individuals-asymptomatic) Franettovich et. al.

14 Methods for Unloading Orthotics Bracing Custom made (Kulig et. al.)
Medial heel lift Medial Arch support Bracing AirLift PTTD brace: clamshell ankle, air midfoot (Neville et. al.) Double Upright AFO (Lin et. al.) Arizona Brace AFO (Augustin et. al.) Shell Braces Neville: Case series, 10 female volunteers w/ PTTD II arch height index: the ratio of dorsum height at 50%of the foot length, divided by the foot length from the heel to the base of the distal first metatarsal head. *no difference between 4PSI and 7PSI, more effect on hindfoot than forefoot One study by Lin et al demonstrated a 70% success rate at a 7- to 10-year follow-up for nonoperative treatment of stage 2 PTTD using a double upright AFO for an average bracing period of 14 months

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 Corticosteroids are not typically used by MD’s in treating this due to increased risk of tendon rupture. Conclusion is anti-inflammatory drugs could be helpful (ionto, NSAID’s) but need more research

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 tibialis posterior tendon foot flattening abducted midfoot absence of rigid foot deformity Pts recruited by referral from Department of Orthopedics at the University of Southern California and Long Beach Memorial Medical Center between 2002 and 2006.

17 Reloading Research Interventions-3 months Outcome Measures Orthoses
All groups Stretching Progressive Resisted Ex Concentric (Group II) Eccentric (Group III) Outcome Measures FFI 5 minute walk test VAS Custom fit, all pts agreed to wear orthoses 90% of waking hours Gastroc & soleus stretching 2x/day w/ heel slant. 3x30s HEP w/ TibPost Loader: Horizontal adduction w/ plantar flexion while wearing orthoses & shoes. 2lb Weekly phone interviews, weekly PT visits Concentric& eccentric: 5s throughout motion, 3x15 BID Kulig et. al.

18 Results Orthoses w/ Concentric Orthoses w/ Eccentric
Average resistance 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 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 No significant difference between groups w/ VAS Weaknessess: OE group had increased deficits at start of study. More studies needed with more equal baseline. Control group (just stretching & bracing) also had benefits: Kulig et. 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 & 6 mo follow-up OM’s: FFI, VAS, 5MWT, Single Heel Raise, PAS, GRS Reported pain & function improves much sooner than 10 weeks, but collagen remodeling takes a very long time Inclusion Criteria: current complaints of foot and ankle pain with duration of symptoms lasting at least 3 months, symptoms located at the medial ankle or foot, tenderness to palpation at the posterior tibialis tendon behind the medial malleolus or proximal to the navicular, and weakened posterior tibialis to manual muscle testing Level IV

20 Results 6 month follow-up: 6M
12 weeks: POST 100% retention, % 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). 12 weeks: decrease of symptoms retained after 6 months with no tx

21 Methods for Reloading Kulig et. al.
“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. Based on eccentrics, proved to achieve increased training load at end of program Movement of the tibialis posterior tendon through the unique pulley system as it abruptly wraps around the medial malleolus has been implicated as a possible mechanism of injury to the tendon.38 This suggestion has led to concerns in the clinical setting about whether it is safe to load the tendon in association with non-isometric contractions. Our findings suggest that both concentric training and eccentric training, when performed within the limits of a patient’s pain tolerance, are safe methods for loading the tendon. Kulig et. 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 radiographs Additional views: Weight-bearing ankle series may be useful Clinical features: -Medial ankle/foot pain initially -May lead to disabling weight bearing symptoms -Talonavicular subluxation -Difficulty or inability to perform single-limb heel rise -Weak resisted inversion of fully flexed foot D: Evidence level 3 or 4; or extrapolated evidence from studies rated as 2+; or evidences from trials classified as (minus) regardless of the level 2+: Well-conducted case-control or cohort studies with small CI and/or small alpha and beta

24 So what does the current best evidence say?
High rep Low load Progress as tolerated Stretch!! Support!! Thank you! High rep=aerobic manner, endurance mm

25 References Bowring B, Chockalingham N. A clinical guideline for the conservative management of tibialis posterior tendon dysfunction. The Foot. August Bowring B, Chockalingham. Conservative treatment of tibialis posterior tendon dysfunction-A review. The Foot 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 : Kulig K, Reischl SF, Pomrantz AB, Burnfield JM, et. Al. Nonsurcical Management of Poserior Tibial 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 ;9: National Clearinghouse Guidelines: Accessed on March 11,2012: 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: Neville C, Houck J. Choosing Amung 3 Ankle-Foot Orthoses for a Patient With Stage II Posterior Tibial Tendon Dysfunction. J Orthop Sports Phys Ther. November 2009; 39 (11): 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): Parsons S, Naim S, Richards PJ, McBride D. Correnction and Prevention of Deformity inType II tibialis Posterior Dysfunction. Clin Orthop Relat Res. October : Pisani G. Peritalar destabilisation syndrome (adult flatfoot with degenerative glenopathy). Foot and Ankle Surg. 2010: 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 :38 Rabbito M, Pohl MB, Humble N, Ferber R. Biomechanical and Clinical Factors Related to Stage I Posterior Tibial Tendon Dysfunction. JOSPT October ; 10: Tryfonidis M, Jackson W, Mansour R, Cooke PH, Acquired adult flat foot due to isolated plantar calcaneonavicular (spring) ligament insufficiency with a normlal tibialis posterior tendon. Foot and Ankle Surg :89-85.

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