Posterior Tibial Tendon Dysfunction -Frush Flashcards
main attachment posterior tibial tendon (PTT)
navicular tuberosity
attaches to almost every bone (every tarsal except talus and not 1st and 5th met)
most powerful supinator of foot
posterior tibial
- has weak plantarflexion capabilities
spring ligament =
- superomedial and inferior calcaneal navicular ligament
- PTT passes superficial to ligament and has articulation with it
where is zone of hypovascularity of PTT
1-1.5 cm distal to medial malleolus
* most common area for PTT dysfunction
function of PT in gait
- supporter of longitudinal arch
- decelerates leg internal rotation by eccentric contraction
- during midstance concentric contraction (STJ supination)
what happens biomechanically if PTT dysfunctional?
- can’t prevent excessive pronation
- talar head puts strain on spring ligament causing attenuation
- as arch collapses, deltoid strain can cause ankle valgus
foot types that predispose to degenerative PTT
obesity equinus calcaneal valgus pes planus accessory navicular
typical degenerative PTT pt
over 40, female
s/s PTT dysfunction
- 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
PE PTT dysfunction
- edema along PTT course
- pain with palpation at navicular insertion and hypovascular area
- may have increased warmth if acutely inflamed
“too many toes sign”
pt standing, look from behind and see more toes on affected side
single heel rise test
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
how do you test for posterior tibial m strength
- place foot in plantarflexed and inverted position
- pt holds position against resistance
- evaluate for pain and/or weakness
what type of forefoot position does the pt likely have?
forefoot varus
kite’s angle
talocalcaneal angle (17-21)
cuboid abduction angle
less than 5
talar head uncoverage
percentage of talar head uncovered by navicular
normal is less than 20%
what do you look for on AP ankle
arthritic changes
valgus deformity
normal values and increase or decrease with PTT dysfunction:
calc. inclination
talar declination
meary’s angle (bisection talus and 1st met)t
alocalcaneal
18-21 decrease
21 increase
0-10 increase
15-35 increase
normal rearfoot alignment
0 - 10mm
normal tibial-calcaneal
0-2 valgus
PTTD staging
johnson and strom
johnson and strom I
- 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
johnson and strom II
- elongated tendon
- flexible/valgus rearfoot
- marked heel rise weakness
- positive too many toes
- marked degeneration
- tx with flexor digitorum transfer/ rearfoot arthodesis/ osteotomies
johnson and strom III
- elongated/ complete rupture
- rigid/ valgus rearfoot
- marked weakness with heel rise
- positive too many toes
- marked degeneration/complete rupture
- isolated arthrodesis or triple
johnson and strom IV
- elongated/complete rupture
- rigid/valgus rearfoot and ankle
- marked weakness with heel rise
- positive too many toes
- marked degeneration/complete rupture
- plantar arthrodesis
JFAS Clinical Practice Guideline: Stage 1
- Medial Rearfoot pain
- localized swelling to course of TP
- No positional change in arch
- X-ray: No radiographic angular changes of degenerative changes
- MRI: Tenosynovitis
- US: fluid around tendon
JFAS Clinical Practice Guideline: Stage 2A
- Medial rearfoot pain
- Tendon swelling, warmth, tenderness
- +/- able to do single rise heel test
- Rearfoot valgus, too many toes
- X-ray: peritalar subluxation and increased talar 1st MT angle
- MRI: tenosynovitis, attenuation of tendon, tendinosis
- US: same as MRI
JFAS Clinical Practice Guideline: Stage 2B late
- Same as 2A early but:
- Postional change in arch, rearfoot valgus
- Lateral pain, sinus tarsi, subfibular tenderness
X-ray: same as 2A early but also progressive angular changes on radiographs
MRI: Same as 2A early but also TP rupture, early DJD
US: same as 2A, also tendon rupture
JFAS Clinical Practice Guideline: Stage 3
- Lateral symptoms predominant
- Fixed, non-reduicable deformity
- No heel inversion on double heel test
- Unable to perform single heel raise
X-ray: same as 2A but also degenerative changes in rearfoot complex
MRI: same as 2B late, but DJD
US: same as 2B late
JFAS Clinical Practice Guideline: Stage 4
Same as stage 3 but ankle valgus
MRI, US and X-ray all same as 3
Stage 1 treatment
- Pain predominates
- Cast immobilization 6-8 weeks for acute PT tenosynovitis or patients with chronic fatigue. Weight bearing permitted.
- NSAIDS
- OTC orthotic
- Physical therapy
Stage 2 treatment
Conservative Care:
- Painful flexible deformity
- More hindfoot motion control needed
- Custom functional orthotic (University California at Berkley orthosis)
Surgical Care :
-Soft tissue and osseous procedures
Stage 3 and 4 treatment
Conservative:
- Articulated AFO (stage 3 only)
- Non-articulated AFO (stage 3 and 4)
Surgical:
-Arthrodesis procedures
