Posterior tibial tendon dysfunction: a review

Supination resistance variations in foot and ankle musculoskeletal disorders: implications for diagnosis and customised interventions with wedged insoles

BACKGROUND

Supination resistance is a clinical outcome that estimates the amount of external force required to supinate the foot. A greater supination resistance may indicate greater loads on structures responsible for generating internal supination moments across the subtalar joint during static and dynamic tasks. As such, greater supination resistance may be an expected finding in medial foot and ankle musculoskeletal disorders, such as plantar fasciopathy (PF) and posterior tibial tendon dysfunction (PTTD), whereas reduced supination resistance may be present in lateral ankle disorders, such as chronic ankle instability (CAI). However, no studies have yet investigated the changes in supination resistance across these foot and ankle musculoskeletal disorders. This study aimed to quantify supination resistance in individuals with PF, PTTD and CAI compared to healthy controls. Additionally, this study aimed to explore the changes in supination resistance following the simulation of varus and valgus wedges, which are commonly used interventions for these disorders.

METHODS

Fourteen participants with PF, fourteen with PTTD, fourteen with CAI and fourteen healthy controls were recruited. Supination resistance was quantified on a level surface and on a 10-degree inclined surface with varus and valgus positions.

RESULTS

Supination resistance was lower for the injured foot for CAI (p < 0.001) and greater for PTTD (p < 0.001) compared to the healthy foot. There was no significant between-foot difference observed for PF (p = 0.275) and controls (p = 0.970). In the injured foot, CAI exhibited lower supination resistance compared to controls (p < 0.001), PF (p = 0.012) and PTTD (p = 0.014). Regardless of the groups, supination resistance increased when tested on a surface with valgus inclination (p < 0.001) and decreased when tested on a surface with varus inclination (p < 0.001).

CONCLUSIONS

Varus and valgus inclinations to the surface were effective in modifying supination resistance in PTTD and CAI, respectively. Supination resistance seemed unchanged in PF, and thus inclining the standing surface leads to greater between-feet asymmetries. This study also highlights the potential of wedged insoles as a mean to customise treatments and modify tissue stresses in these disorders. The findings contribute to the understanding of foot and ankle biomechanics and may aid in the development of more effective management and rehabilitation strategies.

Podiatrists' views and experiences of using real time clinical gait analysis in the assessment and treatment of posterior tibial tendon dysfunction

Background

Real time clinical gait analysis (RTCGA) is often incorporated as part of a general or lower limb musculoskeletal (MSK) adult patient assessment. However, it is not known if RTCGA is clinically effective as a useful outcome measure or aids in decision making. Whether there is a clinical worth in conducting RTCGA in adult MSK consultations remains controversial. The aim of this study was to provide unique insights into MSK podiatrists use and opinions of RTCGA, using Posterior Tibial Tendon Dysfunction (PTTD) as an exemplar adult condition.

Methods

A qualitative approach was employed to explore MSK podiatrists’ views and experiences of RTCGA when assessing or treating patients with PTTD. Semi-structured interviews were conducted via Skype video calls which were transcribed using an orthographic transcription method. Thematic analysis was employed to identify key meanings and report patterns within the data.

Results

Twenty nine MSK podiatrists who used RTCGA in the assessment and treatment of PTTD participated in the study. Five themes were identified as 1) RTCGA Method; 2) Working with RTCGA; 3) RTCGA uses; 4) What could aid RTCGA; 5) How RTCGA skills are acquired. This is the first known study to explore this topic of relevance to clinicians and researchers alike. Clinical observations were not only kinematic, but also included patient perceived experiences such as pain and orthotic comfort with normative kinematic reference values not perceived as important to that management goal. The most common barefoot RTCGA observations performed were the rearfoot to leg angle, medial bulge, forefoot abduction and arch integrity. However, a high amount of variation in many gait observations was noted between participants. Documentation methods also varied with a four-point scale system to grade motion and position most often employed and RTCGA was most often learnt through experience. The main barriers to performing RTCGA were clinical time and space restrictions.

Conclusion

Findings from this study have provided a view of how podiatry MSK clinicians utilise RTCGA within their practice. MSK podiatrists use RTCGA as both an outcome measure and as an aid in decision making. This implies a perceived worth in conducting RTCGA, however further work is recommended that focusses on development of a national guideline to RTCGA to be adopted.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13047-021-00482-8.

Posterior Tibial Tendon Integrity Can Be Screened With Plain Anteroposterior Foot Radiography

Posterior tibial tendon integrity is an important consideration when treating adult-acquired flatfoot caused by posterior tibial tendon dysfunction. The condition of this tendon traditionally has been evaluated with ultrasonography or magnetic resonance imaging, but recent advances in radiography have increased the resolution of radiographic soft tissue images. The authors examined whether the posterior tibial tendon could be screened with anteroposterior foot radiographs, based on interobserver agreement and accuracy. The authors retrospectively evaluated consecutive patients who underwent weight-bearing foot radiography and ultrasonography based on suspicion of posterior tibial tendinopathy. The integrity of the posterior tibial tendon was evaluated by 2 orthopedic surgeons with foot radiographs and scored as normal or abnormal. The authors evaluated interobserver agreement and compared the findings of ultrasonography and radiography to evaluate diagnostic accuracy. The study included 21 patients with a mean age of 51.5±15.7 years. Ultrasonography showed that 4 patients had normal tendon integrity, 6 patients had tenosynovitis and no tendinopathy, 8 patients had tendinopathy and tendon continuity, and 3 patients had loss of tendon continuity. The surgeons provided consistent radiographic findings for 81.0% of patients (17 of 21). On the basis of the ultrasonographic findings, the surgeons' accuracy was 76.2% (16 of 21) and 61.9% (13 of 21). The results indicate that weight-bearing anteroposterior foot radiography can be used to evaluate posterior tibial tendon integrity, which may allow orthopedic surgeons to predict the prognosis of patients with posterior tibial tendon dysfunction, determine the extent of surgical treatment, and evaluate tendon integrity postoperatively. [Orthopedics. 2020;43(6):e503-e507.].

Approaching Foot and Ankle Injuries in the Ambulatory Setting

Foot and ankle injuries account for a significant volume of primary care office visits each year. Given the incidence of injury and concern for long-term sequelae, it is imperative that primary care physicians familiarize themselves with commonly encountered foot and ankle injuries. Coupling a sound understanding of key anatomic structures with an appropriately gathered history can help to quickly narrow the differential diagnosis in this clinical presentation. This article focuses on key elements from the history and physical examination as well as provides a concise review of imaging modalities and recommended treatment strategies.

Gait alterations in posterior tibial tendonitis: A systematic review and meta-analysis

BACKGROUND

Posterior tibial tendon dysfunction (PTTD) is a common and debilitating tendinopathy that can lead to a profound decrease in gait function. While the clinical diagnosis and treatment of this disorder are well described, the pathomechanics have not been adequately characterized. The purpose of this systematic review and meta-analysis is to compare foot/ankle kinematics and kinetics in patients with PTTD with healthy controls during gait.

METHODS

Relevant articles were selected thought Medline (Pubmed), Scopus, CINAHL, and Web of Science. Studies focused on foot/ankle kinematics and kinetics in patients with PTTD were involved. Articles were included if they: 1) compared patients with PTTD to healthy controls, 2) utilized kinematics or kinetics as the primary outcome measure, 3) evaluated gait tasks, and 4) were written in English.

RESULTS

Eleven articles were included in this systematic review, and 8 studies were synthesized and analyzed. Our meta-analyses indicated increased dorsiflexion and abduction of the forefoot, as well as increased plantarflexion and eversion of hindfoot for patients with PTTD during stance of walking.

CONCLUSION

Our results from the meta-analysis showed more conclusive changes in the forefoot (increased dorsiflexion and abduction) and hindfoot (increased plantarflexion and eversion) kinematics during stance of walking, which may be associated with a pathological process of PTTD. This review provides an improved understanding of gait function in patients with PTTD and preliminary knowledge for future research.

"I need somebody who knows about feet" a qualitative study investigating the lived experiences of conservative treatment for patients with posterior tibial tendon dysfunction

BACKGROUND

Posterior tibial tendon dysfunction is a disabling, chronic, progressive tendon condition that detrimentally affects foot, ankle and lower limb function. Research suggests that posterior tibial tendon dysfunction is poorly recognised and difficult to treat. When posterior tibial tendon dysfunction is diagnosed, the clinician is faced with a weak evidence base and guidelines for the common conservative treatments.to guide their management. Moreover, there are no current evidence-based guidelines for the conservative management of posterior tibial tendon dysfunction. Emerging research suggests that posterior tibial tendon dysfunction not only has a physical impact on the patient, but it also has psychosocial impact on quality of life.Conservative treatments for posterior tibial tendon dysfunction are generally undertaken during early management. The most common are foot orthoses, exercises, bracing, lifestyle changes and injections. Quantitative evidence supporting conservative treatments for posterior tibial tendon dysfunction in relation to function, pain and patient reported outcome measures are reported in the literature.There is a paucity of qualitative research investigating the psychosocial impact of the common treatments for posterior tibial tendon dysfunction. Interpretative phenomenology is concerned with lived experience which is involves the detailed exploration of experience which is embedded within the social and temporal contexts of the lifeworld of the person. The aim of study research is to investigate the lived experience of conservative treatments for patients who have posterior tibial tendon dysfunction using Interpretative Phenomenological Analysis.

METHODS

Five participants with posterior tibial tendon dysfunction were purposively recruited from a private podiatry practice and semi-structured interviews were conducted to examine their lived experiences of treatment for posterior tibial tendon dysfunction. The data for this study was collected and analysed using Interpretative Phenomenological Analysis.

RESULTS

This research identified three superordinate themes which influenced the lived experience of treatment for these patients (i) adverse experience during the patient journey (ii) treatment burden, and (iii) negative self-concept.

CONCLUSION

This study highlights some of what is anecdotally known about the lived experience of treatment for patients with posterior tibial tendon dysfunction, but has never been studied in a qualitative, methodological manner. This study addresses the gap in the qualitative literature. It reveals novel aspects of the lived experience throughout the patient journey, the detrimental impact of treatment burden, loss and negative self-concept. This evidence is important because it highlights the need for a greater understanding of the psychological and social factors that can influence the lived experience of treatment for this group of patients.

Kinematic risk factors for lower limb tendinopathy in distance runners: A systematic review and meta-analysis

INTRODUCTION

Abnormal kinematics have been implicated as one of the major risk factors for lower limb tendinopathy (LLT).

OBJECTIVE

To systematically review evidence for kinematic risk factors for LLT in runners.

METHODS

Individual electronic searches in PubMed, EMBASE and Web of Science were conducted. Two reviewers screened studies to identify observational studies reporting kinematic risk factors in runners with LLT compared to healthy controls. The Down and Black appraisal scale was applied to assess quality. A meta-analysis was performed provided that at least two studies with similar methodology reported the same factor.

RESULTS

Twenty-eight studies were included: Achilles tendinopathy (AT) (9), iliotibial band syndrome (ITBS) (17), plantar fasciopathy (PF) (2), patellar tendinopathy (PT) (1), posterior tibial tendon dysfunction (PTTD) (1). Eighteen studies were rated high-quality and ten medium-quality. The meta-analyses revealed strong evidence of higher peak knee internal rotation, moderate evidence of lower peak rearfoot eversion and knee flexion at heel strike and greater peak hip adduction in runners with ITBS. Very limited evidence revealed higher peak ankle eversion in runners with PF and PTTD or higher peak hip adduction in PT.

SIGNIFICANCE

Peak rearfoot eversion was the only factor reported in all included LLTs; it is a significant factor in ITBS, PT and PTTD but not in AT and PF. More prospective studies are needed to accurately evaluate the role of kinematic risk factors as a cause of LLT. Taken together, addressing rearfoot kinematic and kinematic chain movements accompanied by peak eversion should be considered in the prevention and management of LLT.

Tendoscopy of Achilles, peroneal and tibialis posterior tendons: An evidence-based update

BACKGROUND

Tendoscopy has been proposed in treating several conditions affecting tendons around the ankle. We reviewed literature to investigate the efficacy of Achilles, peroneal and tibialis posterior tendoscopy.

METHODS

Following the PRISMA checklist, the Medline, Scopus and EMBASE databases were searched, including studies reporting patients affected by disorders of Achilles, peroneal and tibialis posterior tendons and treated by tendoscopy (or tendoscopic-assisted procedures). The tendoscopic technique, rehabilitation protocol, clinical scores, patient satisfaction, success and failure rates and complications were evaluated.

RESULTS

Sixteen studies (319 procedures) dealt with Achilles tendoscopy, nine (108) and six (78) about peroneal and tibialis posterior, respectively. Wound healing, cosmetic results, complication rate, work and sport resumption delay were satisfactory. Clinical scores, classification methods and rehabilitation protocols adopted were heterogeneous.

CONCLUSIONS

The recent scientific evidence suggests that tendoscopy and endoscopic-assisted percutaneous procedures are a safe and effective treatment in chronic and acute disorders of tendons around the ankle.

Role of Tendoscopy in Treating Stage II Posterior Tibial Tendon Dysfunction

BACKGROUND

Stage II tibialis posterior tendon dysfunction (PTTD) resistant to conservative therapies is usually treated with invasive surgery. Posterior tibial tendoscopy is a novel technique being used in the assessment and treatment of posterior tibial pathology. The aims of this study were (1) to clarify the role of posterior tibial tendon tendoscopy in treating stage II PTTD, (2) to arthroscopically classify spring ligament lesions, and (3) to compare the arthroscopic assessment of spring ligament lesions with magnetic resonance imaging (MRI) and ultrasonographic (US) data.

METHODS

We reviewed prospectively collected data on 16 patients affected by stage II PTTD and treated by tendoscopy. We report the reoperation rate and functional outcomes evaluated by comparing pre- and postoperative visual analogic scale for pain (VAS-pain) and the Short-Form Health Survey (SF-36; with its physical [PCS] and mental [MCS] components). Postoperative satisfaction was assessed using a VAS-satisfaction scale. One patient was lost to follow-up. Spring ligament lesions were arthroscopically classified in 3 stages. Discrepancies between preoperative imaging and intraoperative findings were evaluated.

RESULTS

At a mean of 25.6 months' follow-up, VAS-pain ( P < .001), SF-36 PCS ( P = .039), and SF-36 MCS ( P < .001) significantly improved. The mean VAS-satisfaction score was 75.3/100. Patients were relieved from symptoms in 80% of cases, while 3 patients required further surgery. MRI and US were in agreement with intraoperative data in 92% and 67%, respectively, for the tendon assessment and in 78% and 42%, respectively, for the spring ligament.

CONCLUSIONS

Tendoscopy may be considered a valid therapeutic tool in the treatment of stage II PTTD resistant to conservative treatment. It provided objective and subjective encouraging results that could allow continued conservative therapy while avoiding more invasive surgery in most cases. MRI and US were proven more useful in detecting PT lesions than spring ligament tears. Further studies on PT could use this tendoscopic classification to standardize its description.

LEVEL OF EVIDENCE

Level IV, therapeutic study, case series.

Defining excessive, over, or hyper-pronation: A quandary

Abnormal-pronation, excessive-pronation, over-pronation, or hyper-pronation, are terms with a long historical use in both medical and research terminology pertaining to an abnormal movement of the foot. These terms are commonly used as a potential kinematic aetiology to explain the occurrence of multiple lower limb and foot pathologies. Yet despite this widespread use there is no clear definition to explain what the terms abnormal, excess, over, or hyper-pronation, mean. Without a strict definition the use of these terms as a patho-mechanical explanation of injuries, leaves a distinct lack of clarity and is meaningless in regards to being able to distinguish what movement may need clinical intervention. It is unlikely that hyper-pronation can be given a quantitative scale because individual anatomy and activity changes the necessary range of pronation within the foot. This paper attempts to give hyper-pronationa philosophically justifiable definition so that the term may be used in a more precise manner and avoid the confusion that presently exists clinically as well as in research literature.

Assessment and Diagnosis of Posterior Tibial Tendon Dysfunction: Do We Share the Same Opinions and Beliefs?

BACKGROUND

Posterior tibial tendon dysfunction is a disabling pathologic flatfoot disorder. Evidence supports the notion that this condition is poorly diagnosed by health-care professionals. In addition, opinion is divided as to the most appropriate assessment and diagnostic techniques used to reflect the progression or stage of the condition. Hence, this study intended to explore the views and opinions of health-care professionals who may be involved in its assessment and diagnosis.

METHODS

A two-phase sequential mixed methods design was used that combined a questionnaire survey and a focus group interview.

RESULTS

The questionnaire data were analyzed using the Kendall levels of concordance and the Cohen kappa statistic, and the focus group data were analyzed using thematic analysis, which led to three main themes: resource implications, scope of practice, and awareness of the condition.

CONCLUSIONS

This study highlights what may have been suspected previously but that has never been investigated in a structured manner. One approach to the assessment and diagnosis of posterior tibial tendon dysfunction is not necessarily the best, and depending on the clinical teams, different guidance may be required to ensure that patients are receiving the most appropriate and best care.

The effect of polydeoxyribonucleotide prolotherapy on posterior tibial tendon dysfunction after ankle syndesmotic surgery: A case report

RATIONALE

Ankle syndesmotic injuries occasionally require long-term therapy for recovery and can result in tendon injury. Posterior tibial tendon dysfunction (PTTD) is an acquired deformity that can cause flatfoot deformity. The current nonoperative management of PTTD includes nonsteroidal antiinflammatory drugs (NSAIDs), orthopedic devices. Although various treatment options have been attempted, optimal treatments for each stage of the condition are debated. Polydeoxyribonucleotide (PDRN) is effective in healing of chronic wounds associated with tissue damage by attracting tissue growth factors.

PATIENT CONCERNS

A 67-year-old woman who presented at our pain clinic with pain on the inside of ankle. She had a syndesmotic screw fixation 3 years prior. Her ankle pain had persisted after the removal of screws and edema for about 1 month resulting from long-term NSAIDs administration.

DIAGNOSES

The origin of the pain was possibly tibialis posterior muscle and posterior tibial tendon and she was diagnosed as PTTD after syndesmosis surgery.

INTERVENTIONS

Sono guided prolotherapy with PDRN was carried out.

OUTCOMES

Patient showed improvement in the arch of the foot, experienced pain relief, and was able to wear regular shoes without any orthopedic device.

LESSONS

This case report highlights that PDRN prolotherapy is a safe and efficient therapeutic option for the treatment of PTTD.

Posterior tibial tendinopathy: what are the risk factors?

BACKGROUND

Posterior tibial tendinopathy (PTT) is the most common cause of acquired (progressive) flatfoot deformity in adults. To date, PTT research has mainly focused on management rather than on causal mechanisms. The etiology of PTT is likely to be multifactorial because both intrinsic and extrinsic risk factors have been reported. We sought to critically evaluate reported etiologic factors for PTT and consider the concept of genetic risk factors.

METHODS

A detailed review of the literature published after 1936 was undertaken using English-language medical databases.

RESULTS

No clear consensus exists as to the relative importance of the risk factors reported, and neither has any consideration been given to a possible genetic basis for PTT.

CONCLUSIONS

To date, studies have examined various intrinsic and extrinsic risk factors implicated in the etiology of PTT. The interaction of these factors with an individual's genetic background may provide valuable data and help offer a more complete risk profile for PTT. A properly constructed genetic association study to determine the genetic basis of PTT would provide a novel and alternative approach to understanding this condition.

Approach and treatment of the adult acquired flatfoot deformity

Adult acquired flatfoot deformity (AAFD), embraces a wide spectrum of deformities. AAFD is a complex pathology consisting both of posterior tibial tendon insufficiency and failure of the capsular and ligamentous structures of the foot. Each patient presents with characteristic deformities across the involved joints, requiring individualized treatment. Early stages may respond well to aggressive conservative management, yet more severe AAFD necessitates prompt surgical therapy to halt the progression of the disease to stages requiring more complex procedures. We present the most current diagnostic and therapeutic approaches to AAFD, based on the most pertinent literature and our own experience and investigations.

Considerations in footwear and orthotics

This article is based on educating readers and physicians about the use of footwear and orthotics for themselves and their patients, to treat diseases and enhance functionality in sports and daily life.