Shell brace for stage II posterior tibial tendon insufficiency

Republication of "Uses of Braces and Orthotics for Conservative Management of Foot and Ankle Disorders"

Nonsurgical management is almost always considered the first-line treatment for the vast majority of foot and ankle pathologies. Foot orthoses, shoe modifications, and therapeutic footwear are considered essential tools for successful conservative management of different foot and ankle disorders. Orthopedic foot and ankle surgeons should have a meticulous understanding of the lower extremity biomechanics as well as the pathoanatomy and the sequelae of diseases affecting the foot and/or ankle. This is essential to the understanding of the desired effects of the different inserts, orthotics, shoe modifications, or braces that may be prescribed for these conditions. In this article, we will summarize the orthoses used for treatment of the most commonly encountered foot and ankle pathologies, with the exclusion of treatment for the diabetic foot because of the unique requirements of that disease process.

Characteristics and Future Direction of Tibialis Posterior Tendinopathy Research: A Scoping Review

Background and Objectives: Tibialis posterior tendon pathologies have been traditionally categorized into different stages of posterior tibial tendon dysfunction (PTTD), or adult acquired flatfoot deformity (AAFD), and more recently to progressive collapsing foot deformity (PCFD). The purpose of this scoping review is to synthesize and characterize literature on early stages of PTTD (previously known as Stage I and II), which we will describe as tibialis posterior tendinopathy (TPT). We aim to identify what is known about TPT, identify gaps in knowledge on the topics of TPT, and propose future research direction. Materials and Methods: We included 44 studies and categorized them into epidemiology, diagnosis, evaluation, biomechanics outcome measure, imaging, and nonsurgical treatment. Results: A majority of studies (86.4%, 38 of 44 studies) recruited patients with mean or median ages greater than 40. For studies that reported body mass index (BMI) of the patients, 81.5% had mean or median BMI meeting criteria for being overweight. All but two papers described study populations as predominantly or entirely female gender. Biomechanical studies characterized findings associated with TPT to include increased forefoot abduction and rearfoot eversion during gait cycle, weak hip and ankle performance, and poor balance. Research on non-surgical treatment focused on orthotics with evidence mostly limited to observational studies. The optimal exercise regimen for the management of TPT remains unclear due to the limited number of high-quality studies. Conclusions: More epidemiological studies from diverse patient populations are necessary to better understand prevalence, incidence, and risk factors for TPT. The lack of high-quality studies investigating nonsurgical treatment options is concerning because, regardless of coexisting foot deformity, the initial treatment for TPT is typically conservative. Additional studies comparing various exercise programs may help identify optimal exercise therapy, and investigation into further nonsurgical treatments is needed to optimize the management for TPT.

Injuries to the Spring Ligament: Nonoperative Treatment

The fibrocartilage within the superomedial calcaneonavicular (spring) ligament is part of an interwoven complex of ligaments that span the ankle, subtalar, and talonavicular joints. Acute isolated rupture of the spring ligament has been reported in association with an eversion ankle sprain. Attenuation and failure of the spring ligament causes complex 3D changes called the progressive collapsing foot deformity (PCFD). This deformity is characterized by hindfoot eversion, forefoot supination, collapse of the medial longitudinal arch, and forefoot abduction. Nonoperative treatment of an isolated spring ligament rupture and PCFD using various designs of orthoses have shown promising results.

Comparison of the effects of low level laser and insoles on pain, functioning, and muscle strength in subjects with stage 2 posterior tibial tendon dysfunction: A randomized study

BACKGROUND

Low level laser therapy (LLLT) is known to be effective in tendinopathies. No study yet investigated the effect of LLLT on posterior tibial tendon dysfunction (PTTD) in comparison to orthotic treatment.

OBJECTIVE

The aim was to compare the effects of LLLT and insole application on pain, function and muscle strength in subjects with stage 2 PTTD.

METHODS

Fifty-two subjects with stage 2 PTTD were randomly assigned to the LLLT and insole groups. The foot pain, function and strength of invertor and evertor muscles of the subjects was evaluated before and after treatment, and after 9 months.

RESULTS

Significant improvement was observed in the foot function and pain (p< 0.05) in both groups after treatment, but in the 9-month follow-up, the insole group had better values. The increase in 180∘.sec-1 concentric invertor muscle strength was found significant after the treatment and in month-9 as compared to the initial values (p< 0.05).

CONCLUSIONS

Both treatments are effective in reducing treating foot pain, as well as improving the function in subjects with stage 2 PTTD. However, at the end of the 9-month follow-up, it was seen that insoles were more effective. Neither method had a clinically important effect on muscle strength.

American College of Foot and Ankle Surgeons Clinical Consensus Statement: Appropriate Clinical Management of Adult-Acquired Flatfoot Deformity

This clinical consensus statement of the American College of Foot and Ankle Surgeons focuses on the highly debated subject of the management of adult flatfoot (AAFD). In developing this statement, the AAFD consensus statement panel attempted to address the most relevant issues facing the foot and ankle surgeon today, using the best evidence-based literature available. The panel created and researched 16 statements and generated opinions on the appropriateness of the statements. The results of the research on this topic and the opinions of the panel are presented here.

Biomechanics and Orthotic Treatment of the Adult Acquired Flatfoot

The adult acquired flatfoot deformity resulting from posterior tibial tendon dysfunction is the result of rupture of the posterior tibial tendon as well as key ligaments of the ankle and hindfoot. Kinematic studies have verified certain levels of deformity causing hindfoot eversion, lowering of the medial longitudinal arch and forefoot abduction. The condition is progressive and left untreated will cause significant disability. Bracing with ankle-foot orthoses has shown promising results in arresting progression of deformity and avoiding debilitating surgery. Various types of ankle-foot orthoses have been studied in terms of effects on gait as well as efficacy in treatment.

Uses of Braces and Orthotics for Conservative Management of Foot and Ankle Disorders

Nonsurgical management is almost always considered the first-line treatment for the vast majority of foot and ankle pathologies. Foot orthoses, shoe modifications, and therapeutic footwear are considered essential tools for successful conservative management of different foot and ankle disorders. Orthopedic foot and ankle surgeons should have a meticulous understanding of the lower extremity biomechanics as well as the pathoanatomy and the sequelae of diseases affecting the foot and/or ankle. This is essential to the understanding of the desired effects of the different inserts, orthotics, shoe modifications, or braces that may be prescribed for these conditions. In this article, we will summarize the orthoses used for treatment of the most commonly encountered foot and ankle pathologies, with the exclusion of treatment for the diabetic foot because of the unique requirements of that disease process.

Reported selection criteria for adult acquired flatfoot deformity and posterior tibial tendon dysfunction: Are they one and the same? A systematic review

BACKGROUND

Posterior tibial tendon dysfunction (PTTD) and adult acquired flatfoot deformity (AAFD) are used interchangeably, although both suggest quite different pathological processes.

OBJECTIVE

To investigate key differences in selection criteria used for inclusion into research studies.

METHODS

An electronic database search was performed from inception to June 2016. All primary research articles with clear inclusion/diagnostic criteria for PTTD or AAFD were included in the review. All criteria were extracted and synthesised into one aggregate list. Frequencies of recurring criteria were calculated and reported for each stage of the conditions.

RESULTS

Of the potentially eligible papers, 148 (65%) did not specify inclusion/selection criteria for PTTD or AAFD and were excluded. Eligibility criteria were reported 82 times in the 80 included papers, with 69 descriptions for PTTD and 13 for AAFD. After synthesis of criteria from all papers, there were 18 key signs and symptoms. Signs and symptoms were considered to be those relating to tendon pathology and those relating to structural deformity. The total number of individual inclusion/diagnostic criteria ranged from 2 to 9. The majority of articles required signs of both tendon dysfunction and structural deformity (84% for AAFD and 81% for PTTD). Across both groups, the most frequently reported criteria were abduction of the forefoot (11.5% of total criteria used), the presence of a flexible deformity (10.2%) and difficulty performing a single leg heel raise (10.0%). This was largely the case for the PTTD articles, whereas the AAFD articles were more focused on postural issues such as forefoot abduction, medial arch collapse, and hindfoot valgus (each 16.7%).

CONCLUSION

As well as synthesising the available literature and providing reporting recommendations, this review has identified that many papers investigating PTTD/AAFD do not state condition-specific selection criteria and that this limits their clinical applicability. Key signs and symptoms of PTTD and AAFD appear similar, except in early PTTD where no structural deformity is present. We recommend that PTTD is the preferred terminology for the condition associated with signs of local tendon dysfunction with pain and/or swelling along the tendon and difficulty with inversion and/or single leg heel raise characterising stage I and difficulty with single leg heel raise and a flexible flatfoot deformity characterizing stage II PTTD. While AAFD may be useful as an umbrella term for acquired flatfoot deformities, the specific associated aetiology should be reported in studies to aid consolidation and implementation of research into practice.

TRIAL REGISTRATION

Prospero ID: 42016046943.

Randomized Controlled Trial Comparing Orthosis Augmented by Either Stretching or Stretching and Strengthening for Stage II Tibialis Posterior Tendon Dysfunction

BACKGROUND

The value of strengthening and stretching exercises combined with orthosis treatment in a home-based program has not been evaluated. The purpose of this study was to compare the effects of augmenting orthosis treatment with either stretching or a combination of stretching and strengthening in participants with stage II tibialis posterior tendon dysfunction (TPTD).

METHODS

Participants included 39 patients with stage II TPTD who were recruited from a medical center and then randomly assigned to a strengthening or stretching treatment group. Excluding 3 dropouts, there were 19 participants in the strengthening group and 17 in the stretching group. The stretching treatment consisted of a prefabricated orthosis used in conjunction with stretching exercises. The strengthening treatment consisted of a prefabricated orthosis used in conjunction with the stretching and strengthening exercises. The main outcome measures were self-report (ie, Foot Function Index and Short Musculoskeletal Function Assessment) and isometric deep posterior compartment strength. Two-way analysis of variance was used to test for differences between groups at 6 and 12 weeks after starting the exercise programs.

RESULTS

Both groups significantly improved in pain and function over the 12-week trial period. The self-report measures showed minimal differences between the treatment groups. There were no differences in isometric deep posterior compartment strength.

CONCLUSIONS

A moderate-intensity, home-based exercise program was minimally effective in augmenting orthosis wear alone in participants with stage II TPTD.

LEVEL OF EVIDENCE

Level I, prospective randomized study.

Nonoperative care for the treatment of adult-acquired flatfoot deformity

Nonoperative therapy for adult-acquired flatfoot is a reasonable treatment option that is likely to be beneficial for most patients. In this article, we describe the results of a retrospective cohort study that focused on nonoperative measures, including bracing, physical therapy, and anti-inflammatory medications, used to treat adult-acquired flatfoot in 64 consecutive patients. The results revealed the incidence of successful nonsurgical treatment to be 87.5% (56 of 64 patients), over the 27-month observation period. Overall, 78.12% of the patients with adult-acquired flatfoot were obese (body mass index [BMI] ≥ 30), and 62.5% of the patients who failed nonsurgical therapy were obese; however, logistic regression failed to show that BMI was statistically significantly associated with the outcome of treatment. The use of any form of bracing was statistically significantly associated with successful nonsurgical treatment (fully adjusted OR = 19.8621, 95% CI 1.8774 to 210.134), whereas the presence of a split-tear of the tibialis posterior on magnetic resonance image scans was statistically significantly associated with failed nonsurgical treatment (fully adjusted OR = 0.016, 95% CI 0.0011 to 0.2347). The results of this investigation indicate that a systematic nonsurgical treatment approach to the treatment of the adult-acquired flatfoot deformity can be successful in most cases.