Effects of a 4-Week Short-Foot Exercise Program on Gait Characteristics in Patients With Stage II Posterior Tibial Tendon Dysfunction.

CONTEXT: Clinically, it has been suggested that increased activation of intrinsic foot muscles may alter the demand of extrinsic muscle activity surrounding the ankle joint in patients with stage II posterior tibial tendon dysfunction. However, there is limited empirical evidence supporting this notion. OBJECTIVE: The purpose of this study was to investigate the effects of a 4-week short-foot exercise (SFE) on biomechanical factors in patients with stage II posterior tibial tendon dysfunction. DESIGN: Single-group pretest-posttest. SETTING: University laboratory. PARTICIPANTS: Fifteen subjects (8 males and 7 females) with stage II posterior tibial tendon dysfunction who had pain in posterior tibial tendon, pronated foot deformity (foot posture index ≥+6), and flexible foot deformity (navicular drop ≥10 mm) were voluntarily recruited. INTERVENTION: All subjects completed a 4-week SFE program (15 repetitions × 5 sets/d and 3 d/wk) of 4 stages (standing with feedback, sitting, double-leg, and one-leg standing position). MAIN OUTCOME MEASURES: Ankle joint kinematics and kinetics and tibialis anterior and fibularis longus muscle activation (% maximum voluntary isometric contraction) during gait were measured before and after SFE program. Cohen d effect size (ES [95% confidence intervals]) was calculated. RESULTS: During the first rocker, tibialis anterior activation decreased at peak plantarflexion (ES = 0.75 [0.01 to 1.49]) and inversion (ES = 0.77 [0.03 to 1.51]) angle. During the second rocker, peak dorsiflexion angle (ES = 0.77 [0.03 to 1.51]) and tibialis anterior activation at peak eversion (ES = 1.57 [0.76 to 2.39]) reduced. During the third rocker, the peak abduction angle (ES = 0.80 [0.06 to 1.54]) and tibialis anterior and fibularis longus activation at peak plantarflexion (ES = 1.34 [0.54 to 2.13]; ES = 1.99 [1.11 to 2.86]) and abduction (ES = 1.29 [0.50 to 2.08]; ES = 1.67 [0.84 to 2.50]) decreased. CONCLUSIONS: Our 4-week SFE program may have positive effects on changing muscle activation patterns for tibialis anterior and fibularis longus muscles, although it could not influence their structural deformity and ankle joint moment. It could produce a potential benefit of decreased tibialis posterior activation.

[Degeneration of the posterior tibial tendon : Established and new concepts]. / Degeneration der Tibialis­posterior-Sehne : Bewährtes und Neues.

BACKGROUND: The most common cause of degeneration of the posterior tibial tendon is a congenital valgus deformity of the calcaneus. Other associated pathologies are forefoot supination, forefoot abduction and shortening of the gastrocnemius muscle. DIAGNOSTICS: Loaded x­rays of the foot in three planes as well as the hindfoot alignment view enable evaluation of the axis of the foot under static loading conditions. The posterior tibial tendon can be imaged with ultrasound and magnetic resonance imaging (MRI). The fatty degeneration of the posterior tibial muscle can be identified in MRI. CONSERVATIVE THERAPY: Unloading of the posterior tibial tendon can be achieved by orthotics with medial support or braces. SURGICAL THERAPY: The surgical therapy of the posterior tibial tendon alone has not been proven to be successful. The key element is the correction of the hindfoot valgus by medializing calcaneal osteotomy. Depending on the deformity, an additional lateral lengthening osteotomy of the calcaneus, as well as a dorsal open wedge osteotomy of the medial cuneiform bone (Cotton osteotomy) can additionally be indicated. The transposition of the tendon of the flexor digitorum longus muscle to the navicular bone is used to augment the posterior tibial tendon. Ruptures of the plantar calcaneonavicular ligament are sutured, in addition a sinus tarsi spacer can be implanted to protect medial soft tissues. A shortening of the gastrocnemius muscle is addressed by release of the aponeurosis. First results are published on use of biologically active substances, such as platelet rich plasma. RESULTS: The correction of the hindfoot deformity as well as the subsequent treatment of the different components of the pathology lead to a significant improvement in foot function. Pre-existing degenerative alterations are limiting factors.

An Ankle-Foot Orthosis With a Lateral Extension Reduces Forefoot Abduction in Subjects With Stage II Posterior Tibial Tendon Dysfunction.

STUDY DESIGN: Controlled laboratory, repeated measures. BACKGROUND: Posterior tibial tendon dysfunction is a common musculoskeletal problem that includes tendon degeneration and collapse of the medial arch of the foot (flatfoot deformity). Ankle-foot orthoses (AFOs) typically are used to correct flatfoot deformity. Correction of flatfoot deformity involves increasing forefoot adduction, forefoot plantar flexion, and hindfoot inversion. OBJECTIVES: To test whether a foot orthosis with a lateral extension reduces forefoot abduction in patients with stage II posterior tibial tendon dysfunction while walking. METHODS: The gait of 15 participants with stage II posterior tibial tendon dysfunction was evaluated under 3 conditions: a standard AFO, an AFO with a lateral extension, and a shoe-only control condition. Kinematic variables of interest were evaluated at designated time points in the gait cycle and included hindfoot inversion/eversion, forefoot plantar flexion/dorsiflexion, and forefoot abduction/adduction. A 3-by-4, repeated-measures analysis of variance (brace condition by gait phase) was used to compare variables across conditions. RESULTS: The AFO with a lateral extension resulted in a significantly greater change in forefoot adduction compared to the standard AFO (2.6°, P = .02) and shoe-only conditions (4.1°, P<.01) across all phases of stance. Forefoot plantar flexion was significantly increased when comparing the standard AFO and AFO with a lateral extension to the shoe-only condition. The AFO with the lateral extension also demonstrated significantly increased hindfoot inversion during the loading response and terminal stance phases. CONCLUSION: Off-the-shelf and standard AFOs have been shown to improve forefoot plantar flexion and hindfoot eversion, but not forefoot adduction. A lateral extension added to a standard AFO along the forefoot significantly improved forefoot adduction in participants with posterior tibial tendon dysfunction while walking.

Posterior Tibialis Tendon Dysfunction: Overview of Evaluation and Management.

EDUCATIONAL OBJECTIVES As a result of reading this article, physicians should be able to: 1. Recognize posterior tibialis tendon dysfunction and begin to include it in differential diagnoses. 2. Recall the basic anatomy and pathology of the posterior tibialis tendon. 3. Assess a patient for posterior tibialis tendon dysfunction with the appropriate investigations and stratify the severity of the condition. 4. Develop and formulate a treatment plan for a patient with posterior tibialis tendon dysfunction. The posterior tibialis is a muscle in the deep posterior compartment of the calf that plays several key roles in the ankle and foot. Posterior tibialis tendon dysfunction is a complex but common and debilitating condition. Degenerative, inflammatory, functional, and traumatic etiologies have all been proposed. Despite being the leading cause of acquired flatfoot, it is often not recognized early enough. Knowledge of the anatomical considerations and etiology of posterior tibialis tendon dysfunction, as well as key concepts in its evaluation and management, will allow health care professionals to develop appropriate intervention strategies to prevent further development of flatfoot deformities.

Home-based general versus center-based selective rehabilitation in patients with posterior tibial tendon dysfunction.

OBJECTIVE: The aim of this study was to compare the effect of home-based and supervised center-based selective rehabilitation in patients with Grade 1 to 3 posterior tibial tendon dysfunction (PTTD). METHODS: The study included 49 subjects diagnosed with PTTD and referred to physiotherapy by an orthopedic surgeon. Subjects were randomly assigned into a home-based rehabilitation (21 cases; mean age: 33.56 ± 17.59) group or center-based rehabilitation (28 cases; mean age: 28.57 ± 14.74 years). The patients in the home-based rehabilitation group followed a home program of cold application, strengthening exercises for the posterior tibial and intrinsic muscles, and stretching in the subtalar neutral position. The patients in the center-based rehabilitation group followed a selective, supervised treatment consisting of the home protocol plus re-education of the non-functional tibialis posterior, proprioceptive neuromuscular facilitation methods, electrical stimulation, joint mobilization and taping techniques. Both groups received appropriate orthotics. All subjects were assessed before and after treatment for pain, muscle strength, foot function index (FFI) scores and specific tests for PTTD. RESULTS: Statistical analysis showed significant differences between pre- and post-treatment results for pain, first metatarsophalangeal angle, forefoot abduction angle, FFI scores and foot and ankle muscle strengths in the center-based group and for the tibialis posterior muscle strength in the home-based group (p<0.05). Intergroup comparison, however, showed no differences between the groups at the end of the treatment program with the exception of posterior tibial muscle strength (p<0.05). CONCLUSION: Home- and center-based forms of rehabilitation seem to be equally effective in relieving pain and improving functional outcome in patients with Grade 1 to 3 PTTD. A patient-selective, supervised program may provide a better improvement in tibialis posterior strength than home-based rehabilitation.

Efectos del tratamiento con Kinesio tape en el pie plano / Effects of treatment with Kinesio tape for flat feet

El objetivo principal de este estudio era evaluar los cambios producidos en el dolor posterior de la pierna y en el valgo del retropié mediante la aplicación del Kinesio tape (KT) sobre el musculo tibial posterior en sujetos con pies planos pronados. Para ello, se realizaron mediciones pre/post-intervencion (a las 24 h) del dolor percibido mediante la escala visual analogica (EVA) y de los grados de pronacion del retropie con la regla de Perthes, en 15 sujetos (13 mujeres, 2 hombres). Los resultados mostraron que los sujetos experimentales percibieron una disminucion estadisticamente significativa de su dolor tras la intervencion (p < 0,05). Sin embargo, no reflejaron un cambio estadisticamente significativo en la pronacion del retropie (p ≥ 0,05). Asi mismo, no se observaron diferencias estadisticamente significativas entre sexos o grados de obesidad en los valores preintervencion y post-intervencion del dolor percibido ni en los grados de pronacion del retropie. En conclusion, los resultados obtenidos de este trabajo parecen indicar que un KT aplicado 24 h sobre el musculo tibial posterior en sujetos con pies pronados puede producir una disminucion de la sintomatologia dolorosa de la zona, pero no del grado de pronacion del retropie (AU)

Abstract The main purpose of this study was to investigate changes in pain in the back of leg and hindfoot valgus with Kinesio tape application over tibialis posterior muscle in subjects with flat feet. We made pre-post-intervention measurements (24hours) of perceived pain with visual analogue scale (VAS) and degrees of pronation rear foot with Perthes Ruler in 15 subjects (13 women, 2 men). The results showed that the subjects perceived a statistically significant decrease in their pain after treatment (P<0.05). However, a statistically significant change was not observed in rearfoot pronation (P≥0.05). Similarly, no statistically significant differences were observed between gender or degrees of obesity in pre-post intervention measures of perceived pain and the degree of pronation rearfoot. In conclusion, the results obtained in this study suggest that Kinesio tape application for 24hours over tibialis posterior muscle in subjects with flat feet can decrease pain in the area but not the degrees of rearfoot pronation

Eficacia del tratamiento con férula tipo INMOYBA en niños con torsión tibial interna y externa / Efficacy of treatment with INMOYBA type splint in children with internal and external tibial torsion

Introducción. Los problemas rotacionales de los miembros inferiores son una de las causas más frecuentes de consulta de ortopedia pediátrica. Existe una gran controversia en cuanto al tratamiento conservador. El objetivo de nuestro estudio es valorar la eficacia de la férula tipo INMOYBA para el tratamiento de la torsión tibial. Material y método. Estudio descriptivo retrospectivo donde hemos evaluado a los pacientes remitidos a nuestra Unidad de Rehabilitación Infantil, con diagnóstico de torsión tibial patológica, tratados con férula tipo INMOYBA de uso nocturno. Recogimos variables sociodemográficas y perfil rotacional. Las medidas se realizaron justo antes de comenzar el tratamiento con la férula y seis meses después de su retirada. El ángulo muslo-pie (AMP) también fue recogido en el momento de retirada de la ortesis. Resultados. La corrección producida en el AMP inicial con respecto al de la retirada fue de media 14,38° en el izquierdo y de 13,08° en el derecho siendo esto estadísticamente significativo. Al comparar el AMP de la retirada con el valor final, la corrección aumentó aún más. Al correlacionar las rotaciones interna y externa de cadera previa y posterior al tratamiento así como la flexión dorsal y plantar se obtuvo una disminución de las mismas, siendo esta última estadísticamente significativa. Conclusión. El uso de la férula tipo INMOYBA nocturna parece eficaz para el tratamiento tanto de la torsión tibial interna como externa. Sería recomendable dilucidar si la disminución producida en la flexión plantar se debe al empleo de este tipo de ortesis o si va vinculado a la evolución natural (AU)

Introduction. Rotational problems of the lower limbs are one of the most common causes of pediatric orthopedics consultation. There is considerable controversy regarding conservative treatment. The aim of our study is to assess the effectiveness of the INMOYBA type brace for the treatment of tibial torsion. Material and methods. A retrospective descriptive study was performed including the patients referred to our Child Rehabilitation Unit who were diagnosed with pathological tibial torsion and treated with INMOYBA type splint for nighttime use. We collected sociodemographic variables and rotational profile. Measurements were made just before starting treatment with the splint and six months after its removal. Thigh-foot angle (TFA) was also obtained on removal of the splint. Results. The correction produced in the initial TFA compared to the removal one was 14.38° on the left and 13.08° on the right, this being statistically significant. When the removal TFA was compared with the final value, correction was even greater. A reduction was obtained when the internal and external rotation of the hip was correlated before and after treatment as well as dorsal and plantar flexion. The latter was statistically significant. Conclusion. The use of INMOYBA-type night splint appears to be effective for the treatment of both internal and external tibial torsion. It would be advisable to ascertain whether the decrease in plantar flexion produced is due to the use of this type of brace or if it is associated to the natural evolution (AU)

Disfunción del tibial posterior / No disponible

La disfunción del tibial posterior es una patología adquirida en el adulto de carácter progresivo que cursa con sintomatología dolorosa y el desarrollo de un pie plano valgo o plano. Es uno de los músculos del pié sobre el que recae más patología siendo muy frecuente además la lesión en su estructura tendinosa. En el trabajo expuesto hablaremos de la etiología, diagnostico y clínica. Realizamos la confección de un tratamiento ortopodológico mediante soportes plantares de Rovalfoam para corregir algunas de las patologías asociadas a este trastorno(AU)

Tibialis Posterior dysfunction is a adquired disease mainly in adulthood producing progressive pain symptoms, leading to a valgus flat foot. Tibialis Posterior is an extrinsic muscle of the foot that undergoes so much injuries, often affecting the muscle/tendon unit. We’ll also discuss a clinical case suggesting a conservative treatment by foot orthoses made with Rovalfoam, in order to correct or improve some of the pathologies associated with this dysfunction(AU)

Stage I and II posterior tibial tendon dysfunction treated by a structured nonoperative management protocol: an orthosis and exercise program.

BACKGROUND: Posterior tibial tendon dysfunction (PTTD) is a relatively common problem of middle-aged adults that usually is treated operatively. The purpose of this study was to identify strength deficits with early stage PTTD and to assess the efficacy of a focused nonoperative treatment protocol. METHODS: Forty-seven consecutive patients with stage I or II posterior tibial tendon dysfunction were treated by a structured nonoperative protocol. Criteria for inclusion were the presence of a palpable and painful posterior tibial tendon, with or without swelling and 2) movement of the tendon with passive and active nonweightbearing clinical examination. The rehabilitation protocol included the use of a short, articulated ankle foot orthosis or foot orthosis, high-repetition exercises, aggressive plantarflexion activities, and an aggressive high-repetition home exercise program that included gastrocsoleus tendon stretching. Isokinetic evaluations were done before and after therapy to compare inversion, eversion, plantarflexion, and dorsiflexion strength in the involved and uninvolved extremities. Criteria for successful rehabilitation were no more than 10% strength deficit, ability to perform 50 single-support heel rises with minimal or no pain, ability to ambulate 100 feet on the toes with minimal or no pain, and ability to tolerate 200 repetitions of the home exercises for each muscle group. RESULTS: Before therapy weakness for concentric and eccentric contractures of all muscle groups of the involved ankle was significant (p<0.001). After a median of 10 physical therapy visits over a median period of 4 months, 39 (83%) of the 47 patients had successful subjective and functional outcomes, and 42 patients (89%) were satisfied. Five patients (11%) required surgery after failure of nonoperative treatment. CONCLUSION: This study suggests that many patients with stage I and II posterior tibial tendon dysfunction can be effectively treated nonoperatively with an orthosis and structured exercises.

Recovery of the posterior tibial muscle after late reconstruction following tendon rupture.

The purpose of this study was to determine the recovery potential of the posterior tibial muscle after late reconstruction following tendon rupture in stage II of posterior tibial tendon dysfunction. Fourteen patients (18 women, 6 men; mean age 59.8 years) were investigated 47 months (range, 24-76 months) after surgical reconstruction of a completely ruptured posterior tibial tendon (end-to-end anastomosis, side-to-side augmentation with the flexor digitorum longus tendon) in combination with a distal calcaneal osteotomy with a tricortical iliac crest bone graft for lengthening of the lateral column. At follow-up, clinical and radiological investigations were performed, including strength measurement and qualitative and quantitative MRI investigation. The overall clinical results were graded excellent in 12 patients, good in one, fair in one, and poor in none. The average ankle-hindfoot score (American Orthopaedic Foot and Ankle Society) improved from preoperatively 49.1 (range, 32-60) to 93.1 (range, 76-100) at follow-up. The functional result correlated with patient's satisfaction and sports activities (p <.05). All patients showed a significant strength of the posterior tibial muscle on the affected side, but it was smaller than on non-affected side (p <.05). The mean posterior tibial muscle strength was 75.1 N on affected and 104.9 N on nonaffected side, corresponding to a ratio of 0.73 between the two legs. The mean area of the posterior tibial muscle was 1.89 cm(2) on affected side, and 3.48 cm(2) on nonaffected side, corresponding to a ratio of 0.55 between the two legs. While fatty degeneration for the posterior tibial muscle was found in all patients, it was found to decrease with increasing strength of the posterior tibial muscle (p <.05) and muscular size (p <.05). On postoperative MRI, the posterior tibial tendon could be found to be intact in all patients. The recovery potential of the posterior tibial muscle was shown to be significant even after delayed repair of its ruptured tendon. A ruptured and/or diseased posterior tibial tendon should not be transected as it excludes any recovery possibilities of the posterior tibial muscle.