Posterior Tibialis Tendinopathy

posterior tibialis insertion

tarsals and metatarsals (navicular)

what does the posterior tibialis tendon do

-plantarflexor and invertor

-adductor of the forefoot

-primary dynamic stabilizer of the medial longitudinal arch

posterior tibialis tendon and medial longitudinal arch

primary dynamic stabilizer

-works with osteoligamentous structures and spring ligament

-elongation of posterior tibialis tendon by as little as 1 cm can reduce its efficiency as a stabilizer

structures that run by medial malleoli

posterior tibialis tendon's role in gait

-controls rearfoot eversion during LR (eccentric contraction)

-stabilizes transverse tarsal joints during midstance through STJ supination (concentric)

-assists in heel rise and weight shift in late stance

posterior tibialis during midstance

stabilizes transverse tarsal joint through ST supination

-minimal tendon gliding

-midfoto locks

-gastroc complex at a mechanical advantage for propulsion

-assists in maintaining the integrity of the longitudinal arch

posterior tibialis tendon during weight shift

lateral to medial shift of body weight due to balanced activity of posterior tibialis and peroneals

etiology of posterior tibialis tendinopathy

-congenital pes planus (flat foot)

-age related degeneration

-systemic inflammatory diseases (RA, lupus)

-chronic microtrauma/increases mechanical stress

-anatomic anomalies

-increased local mechanical stress from adjacent structures

chronic microtrauma etiology of posterior tibialis tendinopathy

combined repetitive mechanical stress and poor blood supply

anatomical anomalies leading to posterior tibialis tendinopathy

-accessory naviclar bone

-prominent navicular tuberosity

what structure can increase local mechanical stress on posterior tibialis tendon

tight flexor retinaculum leading to tendon constriction posterior to medial malleolus

onset of posterior tibialis tendinopathy

insidious onset is most common

-symptoms can be present for months or years

early symptoms with posterior tibialis tendinopathy

-swelling medially (everywhere)

-pain in medial plantar arch

-heel rise if painful and difficult

-usually unilateral but can be bilateral

-gradual worsening with eventual collapse of medial longitudinal arch

signs of posterior tibialis tendinopathy

-increased heel valgus

-PF of talus

-flattening of medial longitudinal arch

-abduction of forefoot

test/measures for posterior tibialis tendinopathy

-too many toes sign

-first metatarsal rise sign (sensitive at early stage)

-B limb heel rise (assess for inversion of calcaneus)

-single limb heel rise (

first metatarsal rise sign

positive result is first ray rises with tib fib external rotation

imaging for posterior tibialis tendinopathy

MRI is gold standard

-CT is used if MRI is contraindicated

stage 1 PTTD: posterior tib condition

peritendinitis and/or tendon degeneration

stage 1 PTTD: hindfoot

mobile, normal alignment

stage 1 PTTD: pain

medial: focal

-mild to moderate

stage 1 PTTD: too many toes sign

normal

stage 1 PTTD: pathology

synovial proliferation, degeneration

stage 1 PTTD: treatment

conservative

-3 months with synovectomy, tendon debridement, rest

stage 2 PTTD: posterior tib condition

elongation

stage 2 PTTD: hindfoot

mobile

-valgus position

stage 2 PTTD: pain

medial: along posterior tibialis tendon

-moderate

stage 2 PTTD: too many toes sign

positive

stage 2 PTTD: pathology

marked degeneration

stage 2 PTTD: treatment

-conservative

-transfer flexor digitorum longus for posterior tibialis tendon

stage 3 PTTD: posterior tib condition

elongation

stage 3 PTTD: hindfoot

fixed

-valgus position

stage 3 PTTD: pain

medial, possibly lateral

-moderate

stage 3 PTTD: too many toes sign

positive

stage 3 PTTD: pathology

marked degeneration

stage 3 PTTD: treatment

subtalar arthrodesis-> fusion

conservative treatment for posterior tibialis tendinopathy

-elevate medial arch

-orthotic in neutral

-education (shoes)

-reduce swelling

orthotic in stage 3 posterior tibialis tendinopathy

-can give an orthotic to prevent progression but it will not reverse damage because it is fixed

stage 4 posterior tibialis tendinopathy

fixed valgus tilt of the talus in the ankle mortise

-leads to lateral tibiotalar degeneration/arthritis

modalities to NOT use for posterior tibialis tendinopathy

lack of evidence to support the use of US, deep transverse friction massage, massage/mobilization, extracorporeal shock wave therapy

modalities that can be used for posterior tibialis tendinopathy

acute stage can be used to decrease inflammation

-iontophoresis

-cryotherapy

-US

low level laser therapy for posterior tibialis tendinopathy

can reduce pain in chronic tendinopathy

-but not sure exactly for posterior tibialis

non surgical interventions for stage 1 and 2 posterior tibialis tendinopathy

-immobilization for tenosynovitis

-orthosis in neutral

-achilles tendon stretching

-posterior tibialis strengthening

goals of nonsurgical interventions for stage 1 and 2

-elimination of clinical symptoms

-improvement of hindfoot alignment

-prevention of progressive foot deformity

non surgical interventions for stage 3 posterior tibialis tendinopathy

-not passively correctable

-must accommodate deformity

goal of nonsurgical intervention for stage 3 posterior tibialis tendinopathy

-alleviate pain

-slow progression

exercise for conservative posterior tibialis tendinopathy

-gastrocsoleus stretching commonly recommended

-foot adduction in neutral position (orthosis, shoes or taping) more effective

-eccentric strengthening more effective than concentric or orthosis alone

-tendon itself is not getting better (no neovascularization) but pain and function improves

orthotics for posterior tibialis tendinopathy

need to address

-hindfoot eversion

-depressed MLA

-FF abduction

immobilization with posterior tibialis tendinopathy

CAM boots used in highly symptomatic pts

-limit sagittal and frontal plane motion

taping for posterior tibialis tendinopathy

used to assess appropriateness of an orthotic

EdUReP model for tendinopathy

for nonsurgical management of tendinopathy

-Education

-Unloading

-Reloading

-Prevention

education in EdUReP model

-assess

-advise

-agree

-assist

-arrange

unloading in EdUReP model

identification of tendon unloading strategies through behavioral and mechanical methods

-vary general workload tasks

-use of orthoses

-appropriate exercise interventions for surrounding tissues

reloading in EdUReP model

-follows physical stress theory

-12 weeks in duration

-psychoeducational interventions that help modify the volume and technique of an activity

-mechanical loading through orthoses and body weight supported activities

-eccentric reloading at slow speeds and sufficient loads

prevention in EdUReP model

-optimal secondary prevention programs have yet to be determined

-continuation of prior education and unloading/reloading phases

-independence in self-management of residual symptoms and impairments after return to activities