PTTD

Question 1

where is the posterior tibial muscle (tendon unit) located?

Answer 1

it runs behind the ankle, medial to the STJ axis. inserting under the midfoot at 9 insertion points.

Question 2

what is the role of the posterior tibialis tendon?

Answer 2

• big internal supinator
• raises the medial longitudinal arch
• weak plantar flexor
• making the rearfoot & midfoot stiffer to gibe stability to the foot going into propulsion.

Question 3

what is the crucial role of the tib post?

Answer 3

resisting external pronation moments and arch flattening moments, created from the GRF in stance

Question 4

what does PTTD stand for?

Answer 4

Posterior tibial tendon dysfunction.

Question 5

what does PTTD initially present with?

Answer 5

• pain around the medial ankle area along the tendon route
• pain within the midfoot at the insertion points.
• swelling along the tendon route.

Question 6

what can be the three stages of PTTD?

Answer 6

1 - adult acquired flatfoot deformity (AAFD)

2 - posterior tibial tendon dysfunction (PTTD)

3 - progressive collapsing foot deformity

Question 7

what factors further increase demand on the tib post?

Answer 7

• med deviated STJ axis
• forefoot abduction
• high supination resistance test
• valugus/everted hind foot
• restriction in ankle dorsiflexion
• spring ligament impairment
• increased mobility in the midfoot joints (flattening of medial longitudinal arch)
• ligament laxity
• soft tissue dysfunction to tibialis posterior muscle tendon unit (gradual over time or trauma)
• muscle weakness

Question 8

explain medial deviated STJ axis

Answer 8

increased lever arm from the GRF to produce an external STJ pronation moment.

larger external pronation moment the larger te internal response by the muscle which controls external STJ pronation (tib post)

Question 9

how does the dysfunction of the tib post effect the rest of the foot?

Answer 9

once the dysfunctions occur in the tendon it then has an impact on the other structures of the foot and ankle which control pronation and midfoot arch collapse (arch flattening)

Question 10

where is the spring ligament located?

Answer 10

it runs on the plantar (bottom) side of the foot, connecting the sustentaculum tail of the calcaneus (heel bone) to the navicular bone.

Question 11

what is the function of the spring ligament?

Answer 11

supports the head of the talus

resists excessive flattening of the arch during weight-bearing.

it is a strong, flat band of ligamentous tissue made of fibrocartilage.

Question 12

what are some associated systemic risk factors for PTTD?

Answer 12

• obesity/ increasing body mass index (BMI)
• inflammatory arthritis
• diabetes mellitus.

Question 13

PTTD is a progressive condition, what can it progress into?

Answer 13

resultant osteoarthritis

Question 14

how is stage one PTTD classified?

Answer 14

• tenosynovitis or degeneration of the tendon.
• pain
• no deformity
• mild weakness (able to complete single heel rise with inversion of hindfoot)

Question 15

how is stage two PTTD classified?

Answer 15

• elongation and degeneration of the tendon
• pain
• flexible pes-planovalgus deformity
• forefoot abduction when weight bearing
• significant weakness (no or limited inversion of hindfoot in single heel rise)

Question 16

how is stage three PTTD classified?

Answer 16

• elongation and degeneration of the tendon
• pain
• fixed pes planovalgus deformity
• forefoot abduction when weight bearing
• inability to perform a single heel rise.

Question 17

how is stage four PTTD classified?

Answer 17

same presentation as stage 3 with inclusion of:

• valgus deformity of the talocrural joint.
• arthritis of the ankle

Question 18

how does PTTD appear clinically?

Answer 18

• increased pronation moments/ arch collapse visually observed during gait
• forefoot abduction

muscle strength test
- plantarflex + supinate foot against resistance
- palpate the tendon area

inability to perform
- single limb heel rise
- double limb heel rise

Question 19

what are the clinical investigations to assess the stage of PTTD?

Answer 19

range of motion assessment of the STJ

X-ray to confirm joint osteoarthritis (OA)
- subtalar joint
- subtalar and ankle joint.

Question 20

what is lateral impingement?

Answer 20

an interosseous compressive force that stops further pronation on the lateral side of the foot and ankle which can cause huge pain for patients.

Question 21

why do joint impingements occur?

Answer 21

as a direct consequence of lack of stability of the joints due to plastic defamation/ laxity or weakness of key muscles in these areas.

Question 22

what is PTTD early stage treatment?

Answer 22

assisting the tib post tendon

• generating supination moments from your device
• resisting arch flattening moments from your device

Question 23

what are the early treatment for stages 3&4 PTTD?

Answer 23

dealing with osteoarthritis (OA) and the goal is to reduce the painful movement

• ankle brace
• AFO to stabilise the Ankle, STJ and MTJ

Question 24

why is it always important to check ankle dorsiflexion range of motion when someone has PTTD?

Answer 24

it is one of the most common missed assessment findings for this condition

• reduced ankle dorsiflexion and reduced stiffness in the midfoot will drive arch flattening moments.
• increasing the load in all the structures that resist arch flattening.

Question 25

how should reductions in ankle joint dorsiflexion be adressed?

Answer 25

- heel lifts - footwear with high heel sole differential - stretching programmes - surgery (if severe)

Question 26

what is the function of tib post during the gait cycle?

Answer 26

generates internal supination moments (by resisting external pronation moments) generates internal arch raising moments (by resisting arch flattening moments)

Question 27

why would a medial rearfoot wedge be used?

Answer 27

it increases the orthotic reaction force into the area of the foot which creates an external supination moment. this will reduce the external pronation moment from GRF.

Question 28

what would generating too much supination moments to the foot and ankle cause additional problems to?

Answer 28

- peroneals - lateral instability lateral ligament complex issues - lateral foot pain - knee pain - any other pain or instability

Question 29

what is the purpose of the manual supination resistance test?

Answer 29

to help determine clinically the summation of STJ pronation and supination moments during relaxed bipedal stance.

Question 30

how do you carry out the manual supination resistance test?

Answer 30

- ask patient to stand in a relaxed normal stance width base - with two fingers under the talonavicular joint - apply a dorsal upwards force to clinically assess how much force it takes to supinate the foot graded as - high - medium - low

Question 31

what are the two treatment options of PTTD?

Answer 31

ankle brace and AFO

Question 32

what are other treatments for PTTD?

Answer 32

physiotherapy to improve dorsiflexion range of motion and strengthen the ankle - tib post strengthening - foot strengthening exercises - calf raises exercise - footwear advice - POLICE (protection, optimal loading, ice, compression, and elevation) - pain medication - immobilise if extremely painful - MRI to assess degree of soft tissue damage surgery i conservative management has failed