Ankle: Pathologies 2 Flashcards by Suzanne Maggioni

Posterior tibialis dysfunction: differential dx

deltoid ligament sprain
FDL sprain
FHL injury
navicular stress fx
TTS

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Posterior tibialis dysfunction: common demographics

Age > 40
Female
Overweight

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Posterior tibialis dysfunction: Approximately (%) of cases are seen in females

80%

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Posterior tibialis dysfunction: location of pain

along tendon distal to medial malleolus

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Posterior tibialis dysfunction: swelling?

Yes - possible

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Posterior tibialis dysfunction: atrophy?

May occur proximally

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Posterior tibialis dysfunction: presentation

Adult acquired flat foot

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Posterior tibialis dysfunction: More than ½ of all patients with a rupture have a history of…

HTN?
DM?
multiple steroid injections
obesity

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Posterior tibialis dysfunction: making the diagnosis…what are the primary characteristics?

pain or swelling behind the medial malleolus

- change in foot shape

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If the patient has pain or swelling behind the medial malleolus AND a change in foot shape, there is a sensitivity of (%) for diagnosis of posterior tibialis dysfunction

100%

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Posterior tibialis dysfunction: pain worse with what activities/movements?

WB
inv/PF against resistance
Single leg toe raise
ache after walking long distances

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Posterior tibialis dysfunction: foot posture observed

too many toes sign

- lacking normal heel varus when rising on toes

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What is the primary stabilizer of the medial longitudinal arch?

Tibialis posterior

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Posterior tibialis dysfunction: Often misdiagnosed as…

Medial ankle sprain

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Posterior tibialis dysfunction: Can reach a prevalence of 10% in this group

Elderly women

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Posterior tibialis dysfunction: Affects nearly (#) people in the US

5 million

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Posterior tibialis dysfunction: pathogenesis

age related tendon degeneration
fibrotic changes from repeated microtrauma
abnormal forces from even mild flatfootedness

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Posterior tibialis dysfunction: Why is flatfootedness a cause?

Lifelong greater demands on the posterior tibialis than a normal foot

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Posterior tibialis dysfunction: How many stages?

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Posterior tibialis dysfunction: Stage 1 symptoms

pain and swelling along posterior tib tendon
normal, painful heel raise
myofascial restrictions

Posterior tibialis dysfunction: Stage 1

Appearance

Normal appearing tendon

Posterior tibialis dysfunction: Stage I

Surgical treatment?

mostly conservative

- tendon debridement with osteotomy

Posterior tibialis dysfunction: Stage 2-4

Symptoms

pain/swelling
too many toes sign
UA to perform heel raise

Posterior tibialis dysfunction: Presentation

elongated posterior tib tendon
advanced degeneration
longitudinal tears
flexible planovalgus foot

Posterior tibialis dysfunction: Stage 2 | Surgery

Tendon transfer and corrective osteotomy

Posterior tibialis dysfunction: Stage 3 presentation

Same as stage 2, but with - rigid, more severe planovalgus foot - radiographic degenerative changes

Posterior tibialis dysfunction: Stage 3 | Surgery

triple arthrodesis of subtalar, calcaneocuboid, and talonavicular joints

Posterior tibialis dysfunction: Stage 4 | Presentation

Same as stage 3 but with valgus tilt of talus

Posterior tibialis dysfunction: Stage 4 | Surgery

Pantalar arthrodesis of joints: - talocrural - subtalar - calcaneocuboid - talonavicular

Posterior tibialis dysfunction: Stage 1 | Assumed underlying pathology

Tendon pathology with or without synovitis

Posterior tibialis dysfunction: Stage 2 assumed underlying pathology

- Tendon pathology with or without synovitis | - damage to spring ligament and other soft tissue supports

Posterior tibialis dysfunction: Stage 3 and 4 assumed underlying pathology

- tendon pathology without synovitis - damage to spring ligament in most cases - may also include deltoid ligament and other soft tissue supports - development of joint contractures

Posterior tibialis dysfunction: decision making | Stage II or less, UA to walk 15 feet

fracture boot

Posterior tibialis dysfunction: decision making | Stage II or less, unable to walk 15 feet. Likely a candidate for

Surgery OR | Long term care with custom AFO

Posterior tibialis dysfunction: decision making Stage II or less, able to ambulate > 15 feet Mild deformity

AFO off the shelf | Exercise

Posterior tibialis dysfunction: decision making Stage II or less, able to ambulate > 15 feet Mild deformity If off the shelf AFO + exercise is not successful, what is the response

Surgical candidate

Posterior tibialis dysfunction: decision making Stage II or less, able to ambulate > 15 feet Severe deformity

Custom AFO | Exercise

Posterior tibialis dysfunction: decision making Stage II or less, able to ambulate > 15 feet Mild deformity If custom AFO + exercise fails...

Surgery

Posterior tibialis dysfunction: decision making Stage II or less, able to ambulate > 15 feet Mild deformity Custom AFO + exercise - if successful...

Off the shelf foot orthosis | Exercise

``` Posterior tibialis dysfunction: decision making Severe deformity (stage III/IV) ``` First step

Fracture boot

``` Posterior tibialis dysfunction: decision making Severe deformity (stage III/IV) ``` If fracture boot is successful, what’s next?

Custom AFO

``` Posterior tibialis dysfunction: decision making Severe deformity (stage III/IV) ``` If fracture boot and/or custom AFO are unsuccessful...

Surgery

Posterior tibialis dysfunction: for grade 1-2, what are the preferred manual therapy interventions?

- manipulate TCJ/STJ | - manipulate cuboid

Posterior tibialis dysfunction: Manipulate TC/ST joints for...

Restore dorsiflexion

Posterior tibialis dysfunction: Why do a cuboid manipulation?

Due to plantar drop

Posterior tibialis dysfunction: Important to restore strength of

- Posterior tibialis | - foot intrinsic strength

Posterior tibialis dysfunction: For grade 1-2, what are good exercises for restoring posterior tibialis strength?

- TB and/or inversion on towel | - progress to standing calf raise with ball between heels to bias inversion

Posterior tibialis dysfunction: Grades 1-2 injuries | May prescribe what if needed?

OTC arch supports

Posterior tibialis dysfunction: Grades 1-2 treatment | Stretching

May need to address gastroc/soleus flexibility | ONLY with foot in neutral or supination to protect arch