Ankle: Pathologies 2

Question 1

Posterior tibialis dysfunction: differential dx

Answer 1

• deltoid ligament sprain
• FDL sprain
• FHL injury
• navicular stress fx
• TTS

Question 2

Posterior tibialis dysfunction: common demographics

Answer 2

Age > 40
Female
Overweight

Question 3

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

Answer 3

80%

Question 4

Posterior tibialis dysfunction: location of pain

Answer 4

along tendon distal to medial malleolus

Question 5

Posterior tibialis dysfunction: swelling?

Answer 5

Yes - possible

Question 6

Posterior tibialis dysfunction: atrophy?

Answer 6

May occur proximally

Question 7

Posterior tibialis dysfunction: presentation

Answer 7

Adult acquired flat foot

Question 8

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

Answer 8

• HTN?
• DM?
• multiple steroid injections
• obesity

Question 9

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

Answer 9

• pain or swelling behind the medial malleolus

- change in foot shape

Question 10

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

Answer 10

100%

Question 11

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

Answer 11

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

Question 12

Posterior tibialis dysfunction: foot posture observed

Answer 12

• too many toes sign

- lacking normal heel varus when rising on toes

Question 13

What is the primary stabilizer of the medial longitudinal arch?

Answer 13

Tibialis posterior

Question 14

Posterior tibialis dysfunction: Often misdiagnosed as…

Answer 14

Medial ankle sprain

Question 15

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

Answer 15

Elderly women

Question 16

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

Answer 16

5 million

Question 17

Posterior tibialis dysfunction: pathogenesis

Answer 17

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

Question 18

Posterior tibialis dysfunction: Why is flatfootedness a cause?

Answer 18

Lifelong greater demands on the posterior tibialis than a normal foot

Question 19

Posterior tibialis dysfunction: How many stages?

Answer 19

4

Question 20

Posterior tibialis dysfunction: Stage 1 symptoms

Answer 20

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

Question 21

Posterior tibialis dysfunction: Stage 1

Appearance

Answer 21

Normal appearing tendon

Question 22

Posterior tibialis dysfunction: Stage I

Surgical treatment?

Answer 22

• mostly conservative

- tendon debridement with osteotomy

Question 23

Posterior tibialis dysfunction: Stage 2-4

Symptoms

Answer 23

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

Question 24

Posterior tibialis dysfunction: Presentation

Answer 24

• elongated posterior tib tendon
• advanced degeneration
• longitudinal tears
• flexible planovalgus foot

Question 25

Posterior tibialis dysfunction: Stage 2 | Surgery

Answer 25

Tendon transfer and corrective osteotomy

Question 26

Posterior tibialis dysfunction: Stage 3 presentation

Answer 26

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

Question 27

Posterior tibialis dysfunction: Stage 3 | Surgery

Answer 27

triple arthrodesis of subtalar, calcaneocuboid, and talonavicular joints

Question 28

Posterior tibialis dysfunction: Stage 4 | Presentation

Answer 28

Same as stage 3 but with valgus tilt of talus

Question 29

Posterior tibialis dysfunction: Stage 4 | Surgery

Answer 29

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

Question 30

Posterior tibialis dysfunction: Stage 1 | Assumed underlying pathology

Answer 30

Tendon pathology with or without synovitis

Question 31

Posterior tibialis dysfunction: Stage 2 assumed underlying pathology

Answer 31

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

Question 32

Posterior tibialis dysfunction: Stage 3 and 4 assumed underlying pathology

Answer 32

- 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

Question 33

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

Answer 33

fracture boot

Question 34

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

Answer 34

Surgery OR | Long term care with custom AFO

Question 35

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

Answer 35

AFO off the shelf | Exercise

Question 36

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

Answer 36

Surgical candidate

Question 37

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

Answer 37

Custom AFO | Exercise

Question 38

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

Answer 38

Surgery

Question 39

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

Answer 39

Off the shelf foot orthosis | Exercise

Question 40

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

Answer 40

Fracture boot

Question 41

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

Answer 41

Custom AFO

Question 42

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

Answer 42

Surgery

Question 43

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

Answer 43

- manipulate TCJ/STJ | - manipulate cuboid

Question 44

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

Answer 44

Restore dorsiflexion

Question 45

Posterior tibialis dysfunction: Why do a cuboid manipulation?

Answer 45

Due to plantar drop

Question 46

Posterior tibialis dysfunction: Important to restore strength of

Answer 46

- Posterior tibialis | - foot intrinsic strength

Question 47

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

Answer 47

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

Question 48

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

Answer 48

OTC arch supports

Question 49

Posterior tibialis dysfunction: Grades 1-2 treatment | Stretching

Answer 49

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