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Case #5: Reagan Buie Parrish Amie Lehman Haracz

1) This case involves a 47-year-old female with a history of flat feet for several years and tenderness in her left medial ankle for 6 months. 2) Her physical exam reveals pes planus more pronounced on the left, pain along the navicular bone and below the medial malleolus on the left. X-rays show signs consistent with stage 2 posterior tibial tendon dysfunction. 3) The working diagnosis is stage 2 posterior tibial tendon dysfunction. Treatment options at this stage include orthoses, bracing, and physical therapy.

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122 views

Case #5: Reagan Buie Parrish Amie Lehman Haracz

1) This case involves a 47-year-old female with a history of flat feet for several years and tenderness in her left medial ankle for 6 months. 2) Her physical exam reveals pes planus more pronounced on the left, pain along the navicular bone and below the medial malleolus on the left. X-rays show signs consistent with stage 2 posterior tibial tendon dysfunction. 3) The working diagnosis is stage 2 posterior tibial tendon dysfunction. Treatment options at this stage include orthoses, bracing, and physical therapy.

Uploaded by

bao
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Case #5

Reagan Buie Parrish


Amie Lehman Haracz
History
47 y/o Female
CC - Flat Feet several years
Tenderness medial left ankle
6 months duration
Worse at end of day & after aerobics
Changed shoe gear, takes Advil as prn
Any trauma? Ankle sprain?
PMH

HTN, Type 2 diabetes (how long?)


Meds- Norvasc 5mg (Amplodipine: Ca2+
channel blocker), Glucovance (Metformin &
Glyburide)
Surgeries – removal of fibroid cyst, 1996
Para? Gravida?
Social History
Lawyer
Teaches aerobics 2x/wk (how long has
she been teaching it for?)
Non-smoker
Social drinker: 3 glasses of wine/wk
Married? Kids?
Family History
Mother, alive, Rheumatoid arthritis
Father, deceased, Heart attack

ROS
Non-contributory
Physical Exam
Vitals: WNL Neurology: WNL
 Weight?
 Height?

Vascular
DP & PT 2/4 B/L
Positive digital hair
Edema? Erythema?
Musculoskeletal
Palpable pain along
navicular and inferior to
medial malleolus
Pes planus L>R
FF abduction L
Muscle Testing: 5/5 all
muscles except PT 4/5, www.myfootshop.com/SearchResults.asp?Method=A...

Left
Contracted digits 5th B/L
Inversion against
resistance
Heel Raise Test

www.blackburnfeet.org.uk/hyperbook/hist_exam.htm

normal abnormal

Flexible flatfoot Rigid flatfoot


Hubscher Maneuver

The Hubscher
maneuver will detect
loss of ligamentous
integrity. Activation
windlass
of the
effect causes no
movement transfer
to the tibia.
Hinterman Test
•fully weightbearing

•invert the heel or externally


rotate tibia

•When there is a
dysfunction of the posterior
tibial tendon, you will see
the first metatarsal rise off www.podiatrytoday.com/article/305

the ground
Differential Diagnoses

PTTD STJ coalition


Medial ankle sprain Equinus
Arthritic changes Ankle fracture
Flat feet Iatrogenic
Bone tumor Charcot
Medial ankle Navicular stress fracture
capsulitis/synovitis
Tarsal tunnel syndrome
Imaging
X-rays
Diagnostic Ultrasound
MRI

www.uphs.upenn.edu
X- Rays
X-Rays Cont
Working Diagnosis
Posterior Tibial Tendon Dysfunction – Stage 2

www.blackburnfeet.org.uk/hyperbook/hist_exam.htm
Stage I
(Johnson and Strom)

Normal Tendon Length


Mild degeneration
Medial foot and ankle pain and swelling
Mild weakness
No deformity
Pt. can perform heel rise without difficulty
Stage I
Goal: reduce pronation

Treatment:
Functional orthoses – no deformity or changes in
flexibility
UCBL – decrease in flexibility
Walking boot
Shoe modifications
Bracing
Taping (“J” strapping)
Physical Therapy (ultrasound)
NSAIDs
Stage 2
Attenuation of tendon
Increased pronation
 Calcaneal eversion
 Forefoot abduction

 Increased forefoot supinatus

Decreased muscle strength of posterior


tibial tendon
Stage 2
Goal: return foot to normal position/prevent
residual deformity

Treatment:
 Functional (cast in neutral or rectus)
 UCBL orthoses (cast rectus if possible)
 Shoe modifications
 Braces
 Immobilization cast
 Physical Therapy (ultrasound)
 NSAIDs
Stage 3
Severe pronatory deformity becomes
rigid with associated rearfoot arthritis
Fixed valgus position of calcaneus
Fixed forefoot supinatus deformity
Stage 3
Goal: support deformity and minimize
compensatory changes proximal and distal to
deformity
Treatment:
 Accommodative orthoses (more rigid; cast off
weight bearing pronated or partial weight-bearing,
pocket for plantar prominences)
 Shaffer plate (cast weight-bearing pronated or
partial weight-bearing)
 Shoe modifications
 Bracing
Stage 4
In addition to fixed valgus deformity at
STJ, the ankle functions in valgus
position
Stage 4
Goal: allow for a stable foot/ankle for
ambulation
Treatment:
 Don’t use foot orthoses alone!
 Orthoses may be incorporated into a more
proximal brace
 Shoe modifications
 Braces
Other classifications of
PTTD
According to Hutchinson and O’Rourke (1995) and Landorf
(1997), the various stages in the pathological development of TPD
can be categorized. They are as follows:

 Stage 1 primarily an asymptomatic stage. Generally there is an underlying


biomechanical fault that may predispose any symptomatology.
 Stage 2 - this is the initial symptomatic stage. At this stage posterior tibial
tendonitis is the major symptom. Only a mild weakness is present.
 Stage 3 during this stage there is significant dysfunction of the tendon. This
can be the result of a tear, attenuation or partial rupturing of the tendon.
Patients are generally presenting with mid foot pronating and the forefoot
abducting.
 Stage 4 this is the end stage of development of the disorder. There is a rapid
progression of the above mentioned symptoms. Movement is severely
restricted due to the rigidity of the condition.

Cath Emeades. Posterior Tibial Tendon Dysfunction. Website: http://podiatry.curtin.edu.au/encyclopedia/pt/


MRI Classification
Chronic rupture of the posterior tibial tendon was surgically graded by
Jahss . Conti described an MRI classification scheme. Both schemes
categorize chronic rupture of the posterior tibial tendon into three major
groups:

 Type 1: The posterior tibial tendon is partially torn and focally enlarged. It
contains multiple longitudinal splits that reach the tendon surface. Usually
patients are symptomatic for less than one year.
 Type 2: The posterior tibial tendon is partially torn and focally attenuated.
Distal to the tear, the degenerated tendon is often enlarged over a short
segment. The tendon lengthens and there is progressive hindfoot valgus.
Patients are usually symptomatic between one and two years.
 Type 3: The posterior tibial tendon is completely torn and no intact fibers
bridge the torn ends. Peritendinous inflammatory changes may initially tether
the torn ends to the tenosynovium, limiting tendon retraction. Peritalar
subluxation and arthritis are progressive. Patients are usually symptomatic for
more than two years.

Claudia Sadro, M.D. and Murray Dalinka, M.D. Magnetic Resonance Imaging of the Tendons of the Ankle and Foot .
UPOJ. Volume 13 Spring 2000 pages 1-9. http://www.uphs.upenn.edu/ortho/oj/2000/html/oj13sp00p1.html
Orthotic Modifications
Stages 1 and 2

High medial 1st ray cut out


flange Arch fill
Lateral clip Wide width
Deep heel seat Kirby skive
Medial heel post Blake inverted pour
flare Heel lift (equinus)
Extended medial Undercut lateral
heel post heel post
Richie Brace

Functional orthoses
incorporated into
AFO
Stages 1-3

www.sololabs.com/product_disp.php?detail=11
Arizona Brace

Stages 1 & 2
Cast partial weight-
bearing

www.durrettsoandp.com/.../belowkneepage.htm
Marzano Brace
UCBL incorporated into AFO
Stages 1-3
Airlift Brace
integrated aircells
When inflated, they
accommodate various
arch shapes and
heights, lifting the arch
to achieve a more
natural foot position,
according to the
company. www.podiatrytoday.com/article/5168
Surgical Considerations
**to be considered only after conservative treatment fails**

Stage 1 – debridement of posterior tibial tendon


Stage 2 – tendon transfer with corrective osteotomy; lateral
column lengthening
Stage 3 – arthrodesis of one or more joints of rearfoot
Stage 4 – pantalar arthrodesis
References
Dr. Jarrett’s biomechanics notes. “Orthoses, Braces, and Shoe Modifications for
Posterior Tibial Tendon Dysfunction.”
Cath Emeades. Posterior Tibial Tendon Dysfunction. Website:
http://podiatry.curtin.edu.au/encyclopedia/pt/
Claudia Sadro, M.D. and Murray Dalinka, M.D. Magnetic Resonance Imaging of the
Tendons of the Ankle and Foot. UPOJ. vol. 13. Spring 2000.
Hockenbury, R Todd, MD. “Acquired Flatfoot.” emedicine. June 1, 2005
Kohls-Gatzoulis, Julie; Angel, John C; Singh, Dishan; Haddad, Fares; Livingstone,
Julian; Berry, Greg “Tibialis posterior dysfunction: a common and treatable cause of
adult acquired flatfoot.” BMJ 2004;329:1328-1333 (4 December).
Richie, Douglas A, DPM. “A New Approach to Adult Acquired Flatfoot.” Podiatry
Today. Volume 17 - Issue 5 - May 2004 - Pages: 32 - 46
Richie, Douglas H., DPM. “Current Concepts in Treating Posterior Tibial
Dysfunction.” www.richiebrace.com.

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