33: Posterior Tibial Tendon Dysfunction - Frush

Question 1

main attachment posterior tibial tendon (PTT)

Answer 1

navicular tuberosity

attaches to almost every bone (every tarsal except talus and not 1st and 5th met)

Question 2

most powerful supinator of foot

Answer 2

posterior tibial

- has weak plantarflexion capabilities

Question 3

spring ligament =

Answer 3

• superomedial and inferior calcaneal navicular ligament

- PTT passes superficial to ligament and has articulation with it

Question 4

where is zone of hypovascularity of PTT

Answer 4

1-1.5 cm distal to medial malleolus

* most common area for PTT dysfunction

Question 5

function of PT in gait

Answer 5

• supporter of longitudinal arch
• decelerates leg internal rotation by eccentric contraction
• during midstance concentric contraction (STJ supination)

Question 6

what happens biomechanically if PTT dysfunctional?

Answer 6

• can’t prevent excessive pronation
• talar head puts strain on spring ligament causing attenuation
• as arch collapses, deltoid strain can cause ankle valgus

Question 7

foot types that predispose to degenerative PTT

Answer 7

obesity
equinus
calcaneal valgus
pes planus
accessory navicular

Question 8

typical degenerative PTT pt

Answer 8

over 40 female

Question 9

s/s PTT dysfunction

Answer 9

• pain and swelling in medial ankle/midfoot
• loss of medial arch
• tendency to walk on inner border of foot
• loss of push off/strength
• pain on lateral aspect with impingement b/w lateral ankle and calcaneus

Question 10

PE PTT dysfunction

Answer 10

• edema along PTT course
• pain with palpation at navicular insertion and hypovascular area
• may have increased warmth if acutely inflamed

Question 11

“too many toes sign”

Answer 11

pt standing

look from behind and see more toes on affected side

Question 12

single heel rise test

Answer 12

pt stands on one foot and attempts to rise up on toes

• pain, unable, heel doesn’t invert could indicate PTT dysfunction
• do double heel rise first

Question 13

how do you test for posterior tibial m strength

Answer 13

• place foot in plantarflexed and inverted position
• pt holds position against resistance
• evaluate for pain and/or weakness

Question 14

what type of forefoot position does the pt likely have?

Answer 14

forefoot varus

Question 15

kite’s angle

Answer 15

talocalcaneal angle (17-21)

Question 16

cuboid abduction angle

Answer 16

less than 5

Question 17

talar head uncoverage

Answer 17

percentage of talar head uncovered by navicular

normal is less than 20%

Question 18

what do you look for on AP ankle

Answer 18

arthritic changes

valgus deformity

Question 19

normal values and increase or decrease with PTT dysfunction
calc. inclination
talar declination
meary’s angle (bisection talus and 1st met)
talocalcaneal

Answer 19

18-21 decrease
21 increase
0-10 increase
15-35 increase

Question 20

normal rearfoot alignment

Answer 20

0 - 10mm

Question 21

normal tibial-calcaneal

Answer 21

0-2 valgus

Question 22

PTTD staging

Answer 22

johnson and strom

Question 23

johnson and strom I

Answer 23

• peritendinitis/tenosynovitis
• flexible/normal rearfoot
• mild weakness with heel rise
• too many toes sign negative
• synovial proliferation/ mild degeneration
• conservative tx 3 mo/ tenosynovectomy with tendon debridement if necessary

Question 24

johnson and strom II

Answer 24

• elongated tendon
• flexible/valgus rearfoot
• marked heel rise weakness
• positive too many toes
• marked degeneration
• tx with flexor digitorum transfer/ rearfoot arthodesis/ osteotomies

Question 25

johnson and strom III

Answer 25

• elongated/ complete rupture
• rigid/ valgus rearfoot
• marked weakness with heel rise
• positive too many toes
• marked degeneration/complete rupture
• isolated arthrodesis or triple

Question 26

johnson and strom IV

Answer 26

• elongated/complete rupture
• rigid/valgus rearfoot and ankle
• marked weakness with heel rise
• positive too many toes
• marked degeneration/complete rupture
• plantar arthrodesis