2) Posterior Tibial Tendon Dysfunction Flashcards
PTTD always associated with
- Equinus
Equinus silverskoid test
- Test ankle DF with knee extended
2. Flex Knee to release Gastrocnemius
Equinus compensation
- Tibialis anterior and digital extensor tendons try to compensate and are overworked
Equinus demogrpahics
- Most common cause of adult-acquired flatfoot
- Women- 6th decade
Equinus risk factors/associations
- Obesity
- Inflammatory Arthropathy
- Seronegative Spondyloarthropathy
Equinus mechanism
- Majority are CHRONIC
- Only 20% are acute injury
Equinus pathoanatomy
- Tendon degeneration occurs in the watershed area between the medial malleolus & navicular tuberosity
- Tenosynovitis –> Tendonosis –> Dysfunction
Tibialis posterior biomechanics
- Supinator of the STJ
- Supinator Oblique MTJ
- Plantarflexion of the ankle (secondary)
- Antagonist = Peroneus Brevis
- Expect Equinus with TP loss of function
Increased STJ pronation
- Stretches the Laciniate Ligament and compresses the Tarsal Tunnel
- Tenosynovitis
Tarsal tunnel syndrome associations
- Abnormal subtalar joint pronation
- Low back pain
- Hallux Abducto Valgus
- Hammertoes
- Interdigital Neuroma
- Valgus and internal rotation Knee pain
Pronated STJ
- Tendo Achilles moves lateral to STJ axis
- Tibialis Anterior moves lateral to STJ axis
- The valgus position of the rearfoot shifts the axis of the Achilles Tendon from medial to lateral
- Converts secondary inverter to everter of STJ
As the arch drops due to STJ Pronation, Tibialis Posterior’s Tendon is elongated
- Increases tension/decreasing blood flow
- Intra-substance tears
The sum of the deforming forces weaken/elongate Tibialis Posterior leads to
- Loss of STJ & Oblique MTJ supinaton
Midtarsal joint NOT locked
- First metatarsal is not stable against the ground
- Elevated first metatarsal limits hallux dorsiflexion
An unstable foot at Propulsive phase of the gait leads to
- Arthritic degeneration
- Chronic Medial foot & Sinus Tarsi Pain
Loss of support from secondary structures
- Spring Ligament
- Deltoid Ligament
- Other plantar structures
4 main components of spring ligament
- Superio Medial CN Ligament (“Ligamentum Neglectum”)
- Tibio Spring Ligament
- Medio Plantar Oblique CN Ligament
- Inferior Plantar CN Ligament (“True Spring Ligament”)
3 superficial components of deltoid ligament
- Tibio Navicular Ligament = TNL
- Tibio Spring Ligament = TSL
- Tibio Calcaneal Ligament = TCL
2 deep comonents of deltoid ligament
- Anterior Tibio Talar Ligament = ATTL
- Posterior Tibio Talar Ligament = PTTL
PTTD classification
- Johnson & Strom (stages 1-4)
Johnson & Strom Classification Stage 1
- Tenosynovitis
- No deformity
- (+) Single Heel Leg Rise
Johnson & Strom Classification Stage 2
- Flexible Pes Planovalgus deformity
- (-) Can Not Single Heel Leg Rise
- 2A: Rearfoot Valgus
- 2B: Forefoot Abduction “toe many toes signs” >40% TN uncoverage
Johnson & Strom Classification Stage 2 Tx options
- EGR or TAL (release the equinus)
- Koutsagiannis + FDL transfer
- “All American”
- Calcaneal Z Osteotomy (Berlett)
- Koutsagiannis, Evans, Cotton
- Koutsagiannis, Kidner, Cotton
- Isolated TN fusion & PTT repair
- STJ Arthroeresis
Koutsagiannis + FDL transfer
- Boney reconstruction via calcaneal slide osteotomy
- Optimizes the dynamic forces of FDL which is only 1/3 the strength of Tibialis Posterior
- Reducing the counterforce required to overcome the powerful evertors
All American
- EGR/TAL, Kous, FDL transfer, Evans
Koutsagiannis
- Medializing Calcaneal Osteotomy
- Shifts Achilles Tendon medial to STJ axis
- Displace 1cm (10mm)
Evans
- Triplanar
- Powerful
- 1-1.5cm proximal to the CC Joint
- 8-10mm in a child
- 6-8mm in an adult
Cotton osteotomy
- Dorsally based, opening wedge osteotomy performed in the medial cuneiform
- Goal = Remove the residual Forefoot
- Supinatus
- 1st cut: Parallel to the 1st TMT, depth = approx. 30 mm, wedge = 6mm
Calcaneal Z osteotomy (Berlett) advantages
- 3-Diminsional Correction of the entire foot via Translation + Rotation)
- Provides reproducible correction
- With a Broad Base of Bone with a rich vascular supply allows for inherent stability and early consolidation via the Transverse arm (union by 6-8 weeks)
- Eliminates the need to perform the Evans + Koutsagiannis osteotomy’s together!
Johnson & Strom Classification Stage 3
- Rigid Pes Planovalgus deformity
- STJ arthritis
- (-) Single Heel Leg Rise
Johnson & Strom Classification Stage 3 Tx
- EGR or TAL (release the equinus)
- Medial Double or Triple Arthrodesis
- Cotton/Lapidus/NC fusion/Miller
- Peroneal tendon lengthening
Johnson & Strom Classification Stage 4
- Rigid Pes Planovalgus deformity
- Ankle Valgus
- Arthritis
- (-) Single Heel Leg Rise
Johnson & Strom Classification Stage 4 Tx
- EGR or TAL (release the equinus)
- Medial Double or Triple arthrodesis.
- Deltoid ligament correction
- Cotton/Lapidus/Miller/NC fusion
Johnson & Strom Stage 4 with ankle arthritis Tx
- Add ankle arthrodesis to other procedures
- EGR or TAL (release the equinus)
- Medial Double or Triple arthrodesis.
- Deltoid ligament correction
- Cotton/Lapidus/Miller/NC fusion
