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, 2012Alana Gorman
2 What’s Happening for the next 30 mins Review of normal m. & tendonDescription of what PTTD is/involvesDescription of stagesPatient presentationCurrent best evidence for intervention
3 Posterior Tibialis M.ORIGIN: upper 1/3rd of post. tibia, fibula, interosseous membranePATH: tendon distal 1/3rd of tib, passes post. to med. malleolus, sits in shallow groove in distal tib, held in place by flexor retinaculumINSERTION: 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 archMost powerful inverter of the footPlantar flexes and inversion the ankle, adduction of the footGluck et al.
5 PTT DysfunctionRecent literature describes it as a degenerative processPatients suffer pain and fatigue with daily activities, walking & standingRisk factors include trauma, overuse, HTN, Obesity, DMProgression: spring ligament failure >deltoid lig->talocrural lig-> bone breakdownWith a fixed deformity, subtalar jt. is breaking down
6 Secondary Hypotheses Spring Ligament dysfunction Supports medial arch of the footTalocalcanear Interosseus LigamentBinds the talus and calcaneousAccessory navicular boneType 1: ossicle w/in PTTType 2: sits on near tuberosity of navicularType 3: fused to tuberosity of navicularSpring Lig: supports the head of the talus, connects calcaneus-navicularTCI Lig: stability of STJAccessory 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 ITypical 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 IIPresentation 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, swellingLat. 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 & IVPresentation 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 degenerationFixed deformity: loss of inversionPain related to breakdown of deltoid lig med.
10 Stage III & IV Resolution requires surgical intervention Talonavicular arthrodesis/fusionMedializing calcaneal osteotomyFHL, FDL tendon transfer to support the archMore commonly FDLPopelka et. al.
11 Patient Exam for PTTD Signs & Symptoms Pain & Swelling ROM Strength DF w/ knee flexed & extendedSubtalar joint motion; ranges from hyper-hypo mobileIncreased 1st Metatarsal DF suggests midfoot instabilityLoss of medial longitudinal arch heightStrengthPostion: pt. PF, abd & evertedPt. asked to move into PF, add & inversionSingle Heel Rise TestGaitNote forefoot abd, “too many toes”Note heel valgusSL heel raise, walk on toesSTRENGTH:-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 recoveryUnloadActivity modification, foot orthosisReloadEccentric exercisesPreventStop the advancing deformityEd: Tendon recovers slower than boneU: A high arch unloads PTT to decrease pain and increase functionTaping medial arch has shown to reduce demand of TP 45% in stance phase
13 Taping Technique for Medial Arch Support Methods for UnloadingTaping Technique for Medial Arch SupportIncrease 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 liftMedial Arch supportBracingAirLift PTTD brace: clamshell ankle, air midfoot (Neville et. al.)Double Upright AFO (Lin et. al.)Arizona Brace AFO (Augustin et. al.)Shell BracesNeville: Case series, 10 female volunteers w/ PTTD IIarch 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 forefootOne 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 ResearchBowring et. al.Literature review in 2007 showed much discrepancy and limited evidence that supported good outcomes from specific interventionsNo good evidence supporting US, DTM, TFM, Ice therapy, anti-inflammatory medsSupport for rest, orthotics, strengthening exercises for TP & periankle mm., stretching for gastroc-soleus complex, weight loss, and pt. educationCorticosteroids 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 & stretchingOrthoses, stretching & concentric exercisesOrthoses, stretching & eccentric exercisesInclusion Criteria:pain for 3+ monthssymptoms located at the medial ankle or footTenderness to palpation specific to the tibialis posterior tendonfoot flatteningabducted midfootabsence of rigid foot deformityPts 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 groupsStretchingProgressive Resisted ExConcentric (Group II)Eccentric (Group III)Outcome MeasuresFFI5 minute walk testVASCustom fit, all pts agreed to wear orthoses 90% of waking hoursGastroc & soleus stretching 2x/day w/ heel slant. 3x30sHEP w/ TibPost Loader: Horizontal adduction w/ plantar flexion while wearing orthoses & shoes. 2lbWeekly phone interviews, weekly PT visitsConcentric& eccentric: 5s throughout motion, 3x15 BIDKulig et. al.
18 Results Orthoses w/ Concentric Orthoses w/ Eccentric Average resistance lbs13.2% increase in 5MWTSignificant change in VASFFI decrease 10.9 total11.8 pain17.8 disability3.3 activity limitationAverage resistance 12.5 lbs2.6% average increase in 5MWTSignificant change in VASFFI decrease 15 total36.3 pain40.5 disability8 activity limitationNo significant difference between groups w/ VASWeaknessess: 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 programConsidered morphology & vascularization of tendon before/after program. Assessed pain & 6 mo follow-upOM’s: FFI, VAS, 5MWT, Single Heel Raise, PAS, GRSReported pain & function improves much sooner than 10 weeks, but collagen remodeling takes a very long timeInclusion Criteria: current complaints of foot and ankle pain with duration of symptoms lasting at least3 months, symptoms located at the medial ankle or foot, tenderness to palpation at the posterior tibialis tendon behindthe medial malleolus or proximal to the navicular, and weakened posterior tibialis to manual muscle testingLevel IV
20 Results 6 month follow-up: 6M 12 weeks: POST100% 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 program6 month follow-up: 6MNo significant difference between POST & 6M in FFIGRS 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 programMovement 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 monthsNo increase in symptoms occurred w/ eccentric or concentric loading of the tendonGreater 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 painUS may be usefulRadiographs 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 usefulClinical 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 footD: Evidence level 3 or 4; or extrapolated evidence from studies rated as 2+; or evidences from trials classified as (minus) regardless of the level2+: 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 repLow loadProgress as toleratedStretch!!Support!!Thank you!High rep=aerobic manner, endurance mm
25 ReferencesBowring B, Chockalingham N. A clinical guideline for the conservative management of tibialis posterior tendon dysfunction. The Foot. AugustBowring B, Chockalingham. Conservative treatment of tibialis posterior tendon dysfunction-A review. The FootFranettovich 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 :38Rabbito 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, et.al. Acquired adult flat foot due to isolated plantar calcaneonavicular (spring) ligament insufficiency with a normlal tibialis posterior tendon. Foot and Ankle Surg :89-85.