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:
What does current evidence suggest for Physical Therapy 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 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 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
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
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
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 PTTD Signs & Symptoms Pain & Swelling ROM DF w/ knee flexed & extended Subtalar joint motion; ranges from hyper-hypo mobile Increased 1 st 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
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 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 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
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 & 6 mo follow-up OM’s: FFI, VAS, 5MWT, Single Heel Raise, PAS, GRS
Results 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).
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 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
So what does the current best evidence say? High rep Low load Progress as tolerated Stretch!! Support!! Thank you!
References 1. 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, 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: 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: 8. 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 : 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, 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.