Posterior Tibial Tendon Dysfunction, Achilles Tendinopathy and Posterior Ankle Pain EXAM 3

generally good (more support for stages I and II) and may require some level of management over time; less known for those that opt for surgery

What is the general prognosis for Posterior Tibial Tendon Dysfunction (PTTD)

stage 1 of Posterior Tibial Tendon Dysfunction (PTTD)

- Tenderness to palpation/swelling of PTT

- Abnormal morphology of tendon

- Pain with heel raise testing

- Tendon pathology with or without synovitis

stage 2 of Posterior Tibial Tendon Dysfunction (PTTD)

- Flexible flatfoot posture (forefoot abduction, lower medial longitudinal arch, rearfoot eversion)

- Tendon pathology with or without synovitis;

- damage to spring ligament and soft tissue structures of foot

stage 3 of Posterior Tibial Tendon Dysfunction (PTTD)

- Rigid flatfoot posture

- Tendon pathology; spring, deltoid ligament and/or soft tissue structure damage; joint contracture development

stage 4 of Posterior Tibial Tendon Dysfunction (PTTD)

- Ankle OA

- Longstanding PTT rupture and medial ligament complex insufficiency

- Medial aspect of ankle/arch pain along posterior tibialis tendon

- Typically of an insidious onset

- Increased pain typically with WB-based tasks (stand, ambulation, stairs, transfers, work)

- May be due to rapid increase in loading the joint for more acute cases

- More commonly: chronic progressive symptoms over time +/- associated loss in activity/change in foot function

- May have previously tried orthotics/bracing

What does a patient history for Posterior Tibial Tendon Dysfunction (PTTD) look like

- Tenderness and/or swelling along PTT

- Pain/weakness with ankle PF+INV

- Posture (MLA height, arch height index, navicular height, 'too many toes' sign)

- Talocrural, subtalar, and midfoot mobility/ROM

- During single leg heel raise the calcaneus remains in a more neutral or everted position

What are typical exam findings for Posterior Tibial Tendon Dysfunction (PTTD)

calcaneus

with looking at Posterior Tibial Tendon Dysfunction, doing a single leg stance lets the ______ remain more neutral/elevated

plantar flexion

inversion

with Posterior Tibial Tendon Dysfunction, there is pain/weakness with ankle ____ and ____

Single leg heel raise

What is an important test to observe for patients with Posterior Tibial Tendon Dysfunction (PTTD)

- Patient education (training, weight loss, activity modification)

- Strengthening / Progressive reloading of tissue (Importance of eccentrics vs. restoration of general leg and foot muscle function)

- Bracing/orthotics/taping

- Manual therapy, cross friction massage, gastroc-soleus stretching

What does management of Posterior Tibial Tendon Dysfunction (PTTD) entail

- Studies have demonstrated positive outcomes using initial bracing to unload tendon with transition to custom or OTC orthotic (Alvarez et al, 2006; O'Connor et al, 2010)

- In-shoe custom or OTC orthotic typically utilized for Stage I or II PTTD, whereas rigid boot orthoses, AFOs, or surgery recommended for Stage III or IV → more support needed to guide management

What are key points about bracing and orthotics for the management of Posterior Tibial Tendon Dysfunction (PTTD)

Retrocalcaneal Bursitis

Irritation of bursa between calcaneus and Achilles tendon

Retrocalcaneal Bursitis

- Can occur with or without Achilles tendinopathy (AT)

- Common in athletes and those who wear heels often

- Risk: tight, poorly fitting shoes

- May develop Haglund's deformity - 'pump bump'

- Pain in posterior heel, particularly with running/jumping/standing on tiptoes

- Tenderness to insertion of Achilles

- Swelling at the back of heel

- Increase in pain with activities that load/stretch gastroc-soleus complex

What are examination findings for Retrocalcaneal Bursitis

- We often do not see patients at this stage, but:

- Education on shoe ware, exercise

- Modalities

- Trial heel lift, orthotics, taping

- Progressive load of Achilles tendon

What types of treatments or interventions are used for Retrocalcaneal Bursitis

- Through arc of available motion

- Eccentric, HSR

What is the loading strategy used for management of mid-portion Achilles Tendinopathy

Insertional Achilles Tendinopathy

- 0-2 cm

- More rare

- More challenging prognosis

Neutral ROM loading (due to compressive and tensile load effects at insertion site)

What is the loading strategy used for management of insertional Achilles Tendinopathy

mid-portion or insertion of the Achilles tendon that limits functional activity

In cases of Achilles tendinopathy, where is pain likely to present

- Multifactorial that consists of internal and external factors

- Prior lower limb tendinopathy or fracture

- Use of quinolone/ofloxacin antibiotics

- Moderate alcohol use

- Ankle PF strength

- Obesity

- Male

- Older age

What are risk factors associated with Achilles Tendinopathy

generally good for individuals

What is the general prognosis for Achilles Tendinopathy

spans brief period of weeks to months

How long does the recovery process for Achilles Tendinopathy typically take

- Repetitive overloading / training error re: duration and intensity

- Pain often related to loading exercise / activity

- May report stiffness with initial WB and beginning activity

- Consider risk factors

What are common history findings for Achilles tendinopathy

- Point tenderness over Achilles or insertion

- Pain provoked by tendon loading activities

- Tightness or decreased flexibility of gastroc/soleus

- Hypomobility of TC, STJ and/or other joints

- Arc sign/Royal London Hospital Test

What are common examination findings for Achilles tendinopathy

- redness, warmth, and swelling

- high levels of pain limiting low level activity

What are diagnostic indicators of low load tolerance in patients with Achilles tendinopathy

- no redness, warmth, and swelling

- pain after the onset of or after completing higher level activity

What are diagnostic indicators of high load tolerance in patients with Achilles tendinopathy

- Exercise (Grade A)

- Patient Education (Grade B)

- Multimodal (Grade C)

- Heel lifts to limit DF (Grade C)

- Manual therapy (Grade F)

- Taping (Grade E)

- Orthoses (Grade D)

- LLLT and US not recommended (Grade C)

What does management for Achilles Tendinopathy entail

- Tendon loading exercise with loads as high as tolerated who do not have presumed frailty of tendon; at least 3x/wk

- Volume and intensity adherence linked to better pain and outcome

What are key points about exercise interventions for Achilles Tendinopathy

- Heavy slow resistance program

- Silbernagel program

- Eccentric program

What included in the protocol for mid-portion Achilles Tendinopathy strengthening

- Don't need to sprint to eccentric loading right away!

- Use if it meets the functional demands of the patient

- Educate the patient on what to expect: They will be very sore & they will work through the pain

Key points about using Alfredson / Eccentric Loading for Achilles Tendinopathy

- Weeks 1-2

- Patient Status: pain and difficulty with all activities, difficulty performing ten single leg toe raises

- Goal: start to exercise, gain understanding of their injury and of pain-monitoring model

- Treatment program: Perform exercises daily

What are the key points about phase 1 of the Silbernagel Program

- Weeks 2-5

- Patient status: Pain with exercise, morning stiffness, pain when performing toe raises

- Goal: Start strengthening

- Treatment program: Perform exercises every day

What are the key points about phase 2 of the Silbernagel Program

- Weeks 3-12 (longer if needed)

- Patient status: Handled the phase 2 exercise program, no pain distally in tendon insertion, possibly decreased or increased morning stiffness

- Goal: Heavier strength training, increase or start running and/or jumping activity

- Treatment program: Perform exercises every day and with heavier load 2-3 times/week

What are the key points about phase 3 of the Silbernagel Program

- Week 12-6 months (longer if needed)

- Patient status: Minimal symptoms, morning stiffness not every day, can participate in sports without difficulty

- Goal: Maintenance exercise, no symptoms

- Treatment program: Perform exercises 2-3 times/week

What are the key points about phase 4 of the Silbernagel Program

- 3x/week

- 3-4 sets with rest breaks between

- 3 secs for conc and ecc

What are the training recommendations for Heavy Slow Resistance Training for Achilles Tendinopathy

eccentric exercise

For Achilles Tendinopathy, _____ exercise is shown to outperform other loading types

- Local steroids

- Quinolone antibiotics

- Chronic tendon inflammation

- Spring season

- Diabetes

- Renal failure

- Regular participation in athletic activity

- Prior contralateral Achilles rupture

- Genetic factors (presence of COL5A1 gene)

What are risk factors associated with Achilles Ruptures

- Palpable and/or visible defect in tendon

- Altered gait pattern - unable to push off

- Swelling and ecchymosis

- Ability to PF with secondary muscles, but significantly weaker than normal

- Positive Thompson test

What are exam findings for Achilles Ruptures

Thompson’s Test: Squeeze calf to cause plantarflexion, if no movement it is torn

What is a poor test to use to determine Achilles Ruptures

- In a boot, NWB to PWB for up to 6 weeks

- Heel lifts/cushion, gradually removed in segments over time

- Gentle progressive ROM (Usually DF is most restricted and omitted in early care)

- Scar, soft tissue and joint mobilizations (Based on impairments)

- Gentle progressive stretching (as tolerated to the calf)

- Progressive strengthening from isometrics to Theraband to weight bearing to function

- Proprioceptive and functional retraining

What does post-surgical treatment for Achilles Ruptures entail

- Usually functional around 3 months

- Sports or higher level activities around 6 -12 months

- Average RTS-activities 22-26 wk recommended by expert panel (Saxena et al, 2021)

- Typically takes a long time--need to educate

What is the general prognosis for Achilles Rupture