Download Posterior Tibial Tendon Dysfunction

Posterior Tibial Tendon
Dysfunction
Ministry of Health:- Hong Kong
January 2007
Stuart A Baird
Head Division of Podiatric Medicine and Surgery GCU
Tibialis Posterior Muscle
Soleal /
Popliteal
line
Tibialis
Posterior
Flexor Ditorum
Longus
Medial
Cuneaform
Navicular
Insertion
Metatarsal
Insertion
Origin
1 Posterior surface Interosseus Membrane
2 Superior 2/3 med portion posterior
aspect fibula
3 Superior surface posterior tibia lateral to
vertical line
Insertion
Stuart A Baird
Tuberosity of Navicular / Metatarsal Bones
Head Division of Podiatric Medicine and Surgery GCU
Medial Ankle Joint Ligaments
Tibia
Superficial
Posterior
Talotibial Ligt
Anterior
Naviculotibial Ligt
Calcaneotibial
Ligt
Sustentaculum tali
Deltoid Ligament Superficial Structures
Deep anterior talotibial
ligament
Deep
Posterior
talotibial
ligamentt
Sustentaculum tali
Deltoid Ligament Deep Structures
Stuart A Baird
Head Division of Podiatric Medicine and Surgery GCU
Phasic Activity
Posterior Tibial Muscle
Contact Phase
Mid Stance Phase
Decelerates
forward
momentum of
leg
Decelerates
internal leg
rotation
Main decelerator
of Sub talar joint
pronation
Propulsive Phase
Assists in heel
lift
Accelerates
external leg
rotation
Accelerates Sub
talar joint
supination
Contraction Time
Stuart A Baird
Head Division of Podiatric Medicine and Surgery GCU
Sub Talar Joint Position
Normal
Abnormally Pronated
(Root Orien Weed)
Stuart A Baird
Head Division of Podiatric Medicine and Surgery GCU
Posterior Tibial Tendon
Dysfunction
Is Posterior Tibilal Tendon Dysfunction the
main cause of Acquired Adult Flat Foot?
Stuart A Baird
Head Division of Podiatric Medicine and Surgery GCU
What is Posterior Tibial Tendon Dysfunction?
•A condition which is often overlooked and
misdiagnosed in the early stages of development
•Associated loss of function of the posterior tibial
tendon
•Characterised by chronic inflammation within the
tendon sheath
•Degeneration, elongation & interstitial tears within the
tendon
•Possibly rupture of the tendon
•Leads to mal alignment of the rear foot on the mid foot
•Characterised by Calcaneal eversion, plantarflexion of
the talus & subluxcation of the talar navicular joint
•Development of an acquired flat foot
Stuart A Baird
Head Division of Podiatric Medicine and Surgery GCU
Joint Axis of Motion
LMTJ Axis
Sub Talar
Joint Axis
Anterior Tibial
tendon
1st Ray
OMTJ
Ankle
joint
Stuart A Baird
Head Division of Podiatric Medicine and Surgery GCU
Posterior Tibial Muscle action
Soleal /
Popliteal
line
Tibialis
Posterior
Flexor Ditorum
Longus
Mid tarsal
joint axis
Primary actions
Sub Talar
joint axis
1 Supination of the sub talar joint
2 Abduction of the mid tarsal joint around the oblique axis
Prime stabiliser against rear foot eversion and forefoot
adduction
Antagonist against Peroneal Muscles (Peroneus brevis)
Stuart A Baird
Head Division of Podiatric Medicine and Surgery GCU
Etiology of Posterior Tibial Tendon
Dysfunction?
• Abnormal excessive foot pronation
•Structural / Anatomical anomalies
•Accessory navicular
•Shallowness of the Malleolar groove
•Osteophytic proliferation impinging on the Malleolar groove
•Inflammatory Joint disease
•Direct trauma
•Tendon Laceration
•Indirect Trauma
•Eversion Ankle sprain
•Tibialis Posterior tendon dislocation
Stuart A Baird
Head Division of Podiatric Medicine and Surgery GCU
Pathology Associated With Posterior Tibial
Tendon Dysfunction?
Ghormley, Anzel, Kettlelamp and Downey linked Posterior Tibial
tendon dysfunction to Rheumatoid Artheritis
Myerson linked PTTD to seronegative spondyloarthropathy
Other authors disproved any link between collagen disease and
PTTD
Mann & Holmes 1992 found that 52% of patients with PTTD
presented secondary to Diabetes hypertension or obesity
Johnson & Storm 1989 proposed a classification system
comprising 3 stages which were linked to the tendon pathology
and clinical findings
Myerson 1995 added a 4th stage to the classification system
Stuart A Baird
Head Division of Podiatric Medicine and Surgery GCU
Classification of Posterior Tibial Tendon
Dysfunction?
Stage 1
Asymptomatic stage
Assessment may reveal a condition which predisposes to
Posterior Tibial Tendon Dysfunction
Fully compensated rear / fore foot varus
Obesity
Stage 2
Initial Symptomatic Stage
Tibialis Posterior tendonitis (Inflammation of tendon sheath)
Mild weakness Posterior Tibial Muscle (MRC scale)
Stuart A Baird
Head Division of Podiatric Medicine and Surgery GCU
Classification of Posterior Tibial Tendon
Dysfunction?
Stage 3
Marked dysfunction stage
Longitudinal tears within the tendon without complete rupture
Rupture Posterior Tibial Tendon
Avulsion from Navicular insertion
Marked pronation and fore foot abduction
Stage 4
Marked loss of foot function
Rapid progression through stages 1 – 3
Additional pain lateral ankle area
Rigid pronation
Severely restricted mid tarsal join movement
Stuart A Baird
Head Division of Podiatric Medicine and Surgery GCU
Classification of Posterior Tibial Tendon
Dysfunction?
Acute Phase
Presents with diffuse oedema and tenderness medial ankle
Usuall lasts for 2 weeks post onset of symptoms
Tendon pathology may go undiagnosed
May be no associated muscle fatigue
Sub Acute Phase
Lasts form 2 weeks – 6 months
Pain oedema along course of Posterior Tibial tendon
Passive movement of Mid tarsal and sub talar joint pain free
Pain on walking
Appropulsive gait lack of supination at heel strike and toe off
Stuart A Baird
Head Division of Podiatric Medicine and Surgery GCU
Classification of Posterior Tibial Tendon
Dysfunction?
Chronic Phase
Occurs approximately 6 months post onset of symptoms
Patient presents with a unilateral rigid flat foot
Pain associated with medial side of ankle and sinus tarsi
Lateral ankle pain caused by calcaneo-fibula rubbing
periosteal inflammation and peroneal tendinitis
Stuart A Baird
Head Division of Podiatric Medicine and Surgery GCU
Signs & Symptoms Associated with Posterior
Tibial Tendon Dysfunction?
Approximately 50% present with a history of trauma
Forced eversion of the sub talar joint
Usually female
Usually over 40
May present in young athletes
Patients do not seek treatment in stage 1 or the acute
stage of the condition as symptoms are slight
Stuart A Baird
Head Division of Podiatric Medicine and Surgery GCU
Signs & Symptoms Associated with Posterior
Tibial Tendon Dysfunction?
Patients usually present at stage 2 or the sub acute phase
Diffuse swelling
Tenderness
Heat
Single heel raise test:-
difficult / demonstrate instability
Calcaneum fails to supinate and invert as heel lifts from the
ground
Stuart A Baird
Head Division of Podiatric Medicine and Surgery GCU
Signs & Symptoms Associated with Posterior
Tibial Tendon Dysfunction?
Stage 3/4 or Chronic phase
Gradual loss of Medial
longitudinal arch height
Development of unilateral flat
foot
Lower leg fatigue
Excessive abduction of the
forefoot
Too many toes sign
Excessive medial heel wear
on the shoes
Stuart A Baird
Head Division of Podiatric Medicine and Surgery GCU
Diagnosis of Posterior Tibial Dysfunction
Plantar flex and adduct foot
Determine exact site of injury
Direct pressure along the course of the tendon will
cause pain
Partial rupture
Active inversion will against resistance will show
reduced muscle power
If a defect is palpable along the course of the tendon
the probability of a partial tear is high
Complete Rupture
Active inversion against resistance is absent
Tendon cannot be palpated along its normal course
Stuart A Baird
Head Division of Podiatric Medicine and Surgery GCU
Diagnosis of Posterior Tibial Dysfunction
Diagnostic tests
MRI
Bone Scans
Plain Films of little use in early stages (Stage 3)
Stuart A Baird
Head Division of Podiatric Medicine and Surgery GCU
Differential Diagnosis
Bone Anomalies
Accessory Navicular (Os Tibiale Externum)
Navicular Avulsion
Osteochondritis of the Navicular / Head of Talus
Tarsal Coalition
Soft Tissue Anomalies
Deltoid Ligament strain
Flexor Hallucis Longus Strain
Flexor Digitorum Longus Strain
Tarsal Tunnel Syndrome
Stuart A Baird
Head Division of Podiatric Medicine and Surgery GCU
Treatment Posterior Tibial Dysfunction
General principals of treatment are dependant upon:Stage or phase of the condition
Presenting symptoms
Severity of the pain
Treatment should always be:Aggressive
Immediate
Stuart A Baird
Head Division of Podiatric Medicine and Surgery GCU
Treatment Posterior Tibial Dysfunction
Stages 1& 2 + Sub Acute & Acute Phase
This can be for 8 weeks
Reduction of Inflammation:(NSAID), Ultrasound
Joint stabilisation
Strapping / Taping to produce rear foot inversion
Soft orthosis (Valgus filler pad) to produce inversion
Antipronatory orthosis to address foot pathomechanics
Pain control
Exercises to strengthen Posterior Tibial Muscle
Severe case may require immobilisation
Aircast
POP below knee
Steroid injections are not indicated
Stuart A Baird
Head Division of Podiatric Medicine and Surgery GCU
Surgical Treatment Posterior Tibial
Dysfunction
Surgical treatment:Non responsive Stage 2 / sub acute phase
Stage 3 & 4 or chronic phase presentations
Tendon intact
Peritendinous release synovectomy and tendon debridement
Tendon lengthening
Synovectomy Transferof flexor Digitorum Longus
Tendon rupture
Transfer Flexor Digitorum Longus
Shortening of spring Ligament
Tripple athrodesis late sever stage
Stuart A Baird
Head Division of Podiatric Medicine and Surgery GCU
Stuart A Baird
Head Division of Podiatric Medicine and Surgery GCU