Ankle: Pathologies 2 Flashcards
Posterior tibialis dysfunction: differential dx
- deltoid ligament sprain
- FDL sprain
- FHL injury
- navicular stress fx
- TTS
Posterior tibialis dysfunction: common demographics
Age > 40
Female
Overweight
Posterior tibialis dysfunction: Approximately (%) of cases are seen in females
80%
Posterior tibialis dysfunction: location of pain
along tendon distal to medial malleolus
Posterior tibialis dysfunction: swelling?
Yes - possible
Posterior tibialis dysfunction: atrophy?
May occur proximally
Posterior tibialis dysfunction: presentation
Adult acquired flat foot
Posterior tibialis dysfunction: More than ½ of all patients with a rupture have a history of…
- HTN?
- DM?
- multiple steroid injections
- obesity
Posterior tibialis dysfunction: making the diagnosis…what are the primary characteristics?
- pain or swelling behind the medial malleolus
- change in foot shape
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%
Posterior tibialis dysfunction: pain worse with what activities/movements?
- WB
- inv/PF against resistance
- Single leg toe raise
- ache after walking long distances
Posterior tibialis dysfunction: foot posture observed
- too many toes sign
- lacking normal heel varus when rising on toes
What is the primary stabilizer of the medial longitudinal arch?
Tibialis posterior
Posterior tibialis dysfunction: Often misdiagnosed as…
Medial ankle sprain
Posterior tibialis dysfunction: Can reach a prevalence of 10% in this group
Elderly women
Posterior tibialis dysfunction: Affects nearly (#) people in the US
5 million
Posterior tibialis dysfunction: pathogenesis
- age related tendon degeneration
- fibrotic changes from repeated microtrauma
- abnormal forces from even mild flatfootedness
Posterior tibialis dysfunction: Why is flatfootedness a cause?
Lifelong greater demands on the posterior tibialis than a normal foot
Posterior tibialis dysfunction: How many stages?
4
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
