2) Posterior Tibial Tendon Dysfunction

Question 1

PTTD always associated with

Answer 1

• Equinus

Question 2

Equinus silverskoid test

Answer 2

1. Test ankle DF with knee extended

2. Flex Knee to release Gastrocnemius

Question 3

Equinus compensation

Answer 3

• Tibialis anterior and digital extensor tendons try to compensate and are overworked

Question 4

Equinus demogrpahics

Answer 4

• Most common cause of adult-acquired flatfoot

- Women- 6th decade

Question 5

Equinus risk factors/associations

Answer 5

• Obesity
• Inflammatory Arthropathy
• Seronegative Spondyloarthropathy

Question 6

Equinus mechanism

Answer 6

• Majority are CHRONIC

- Only 20% are acute injury

Question 7

Equinus pathoanatomy

Answer 7

• Tendon degeneration occurs in the watershed area between the medial malleolus & navicular tuberosity
• Tenosynovitis –> Tendonosis –> Dysfunction

Question 8

Tibialis posterior biomechanics

Answer 8

• Supinator of the STJ
• Supinator Oblique MTJ
• Plantarflexion of the ankle (secondary)
• Antagonist = Peroneus Brevis
• Expect Equinus with TP loss of function

Question 9

Increased STJ pronation

Answer 9

• Stretches the Laciniate Ligament and compresses the Tarsal Tunnel
• Tenosynovitis

Question 10

Tarsal tunnel syndrome associations

Answer 10

• Abnormal subtalar joint pronation
• Low back pain
• Hallux Abducto Valgus
• Hammertoes
• Interdigital Neuroma
• Valgus and internal rotation Knee pain

Question 11

Pronated STJ

Answer 11

• 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

Question 12

As the arch drops due to STJ Pronation, Tibialis Posterior’s Tendon is elongated

Answer 12

• Increases tension/decreasing blood flow

- Intra-substance tears

Question 13

The sum of the deforming forces weaken/elongate Tibialis Posterior leads to

Answer 13

• Loss of STJ & Oblique MTJ supinaton

Question 14

Midtarsal joint NOT locked

Answer 14

• First metatarsal is not stable against the ground

- Elevated first metatarsal limits hallux dorsiflexion

Question 15

An unstable foot at Propulsive phase of the gait leads to

Answer 15

• Arthritic degeneration

- Chronic Medial foot & Sinus Tarsi Pain

Question 16

Loss of support from secondary structures

Answer 16

• Spring Ligament
• Deltoid Ligament
• Other plantar structures

Question 17

4 main components of spring ligament

Answer 17

• Superio Medial CN Ligament (“Ligamentum Neglectum”)
• Tibio Spring Ligament
• Medio Plantar Oblique CN Ligament
• Inferior Plantar CN Ligament (“True Spring Ligament”)

Question 18

3 superficial components of deltoid ligament

Answer 18

• Tibio Navicular Ligament = TNL
• Tibio Spring Ligament = TSL
• Tibio Calcaneal Ligament = TCL

Question 19

2 deep comonents of deltoid ligament

Answer 19

• Anterior Tibio Talar Ligament = ATTL

- Posterior Tibio Talar Ligament = PTTL

Question 20

PTTD classification

Answer 20

• Johnson & Strom (stages 1-4)

Question 21

Johnson & Strom Classification Stage 1

Answer 21

• Tenosynovitis
• No deformity
• (+) Single Heel Leg Rise

Question 22

Johnson & Strom Classification Stage 2

Answer 22

• Flexible Pes Planovalgus deformity
• (-) Can Not Single Heel Leg Rise
• 2A: Rearfoot Valgus
• 2B: Forefoot Abduction “toe many toes signs” >40% TN uncoverage

Question 23

Johnson & Strom Classification Stage 2 Tx options

Answer 23

• 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

Question 24

Koutsagiannis + FDL transfer

Answer 24

• 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

Question 25

All American

Answer 25

• EGR/TAL, Kous, FDL transfer, Evans

Question 26

Koutsagiannis

Answer 26

• Medializing Calcaneal Osteotomy
• Shifts Achilles Tendon medial to STJ axis
• Displace 1cm (10mm)

Question 27

Evans

Answer 27

• Triplanar
• Powerful
• 1-1.5cm proximal to the CC Joint
• 8-10mm in a child
• 6-8mm in an adult

Question 28

Cotton osteotomy

Answer 28

• 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

Question 29

Calcaneal Z osteotomy (Berlett) advantages

Answer 29

• 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!

Question 30

Johnson & Strom Classification Stage 3

Answer 30

• Rigid Pes Planovalgus deformity
• STJ arthritis
• (-) Single Heel Leg Rise

Question 31

Johnson & Strom Classification Stage 3 Tx

Answer 31

• EGR or TAL (release the equinus)
• Medial Double or Triple Arthrodesis
• Cotton/Lapidus/NC fusion/Miller
• Peroneal tendon lengthening

Question 32

Johnson & Strom Classification Stage 4

Answer 32

• Rigid Pes Planovalgus deformity
• Ankle Valgus
• Arthritis
• (-) Single Heel Leg Rise

Question 33

Johnson & Strom Classification Stage 4 Tx

Answer 33

• EGR or TAL (release the equinus)
• Medial Double or Triple arthrodesis.
• Deltoid ligament correction
• Cotton/Lapidus/Miller/NC fusion

Question 34

Johnson & Strom Stage 4 with ankle arthritis Tx

Answer 34

• 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