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Sunday, August 5, 2018

Posterior Tibial Tendon Dysfunction: Email Advice

Dr.  Blake:
I'd be glad to pay you for some advice on my recently diagnosed posterior tibial dysfunction or contribute to your blog as you see appropriate.

ME: 63-year-old white male, 220 lbs, HLAB27 positive with possible ankylosing spondylitis (not disabling).  Rt. hip osteoarthritis but able to walk 1-4 miles daily with dogs until about one month ago.   The pain started after doing some low weight leg presses but not acute and has gotten progressively worse.  Initially behind my medial ankle but now very tender in front of ankle towards the top of the foot.  It is possibly coming from the insertion of the tendon into the navicular.  I'd call it a 6.  Intermittent swelling treated with ice and piroxicam.  I did try a short course of oral prednisone.  I have been wearing lace-up figure 8 brace on old orthotics.   I bought a cam walker a few days ago but this was not suggested as needed by the local podiatrist.  He did say stop walking trails on uneven surfaces.  Was hoping to continue some 1/2 mile road walking with the cam boot but that is not going to happen at this point.   Let's just say that the alarm bell is ringing.

 Podiatrist took x-rays and gave laser treatment and has ordered new orthotics with a 7-degree inversion and a skive.  He says x-ray shows moderate pronation and some drop now coming from the navicular I think.     He said a Richie brace might be helpful and have an appt. for casting on Monday.  Just a few questions:

Is the Richie appropriate for trying to calm this down to a pain level 2 and should I be attempting any exercise for the tendon at all until then, including an unweighted range of motion?
Dr. Blake's comment: This is wonderful that you are writing at the same time your injury is relatively new and you are seeing a podiatrist who is talking about inversion and skives. Sounds like everything is good. First, he must confirm the diagnosis of posterior tibial tendon dysfunction and stage you at I, II, III, or IV. This knowledge will help us a lot. Then, you must be good at finding whatever treatment now gets you into 0-2 pain level consistently. Typically these are walking cam boot, or boot and PTTD braces, etc, even crutches if needed at times. I find that patients need various things at different times. So it may be appropriate to tape and orthotic for some activities, other activities with a Richie, and others with a below knee cam walker. Unless they are telling you that you have severe stage 3 or early stage 4 and surgery is being suggested, then most patients are walking and talking whiles they take care of their dogs and get very strong. I will attach the 2 videos on taping and exercises. The exercise will show you how to find the right level for now, and give you advice on how to get very strong. BTW, a 7-degree inversion with skive is very good and protective. 

Do you consider the cam walker imperative for all steps now or can I walk around the house in the figure 8 on the orthotics, perhaps assisted by forearm crutches?
Dr. Blake's comment: The 5 common criteria we use to see the severity to know how to advise you are:

  1. What does it take to maintain a 0-2 pain level
  2. What is the strength found and the pain experienced of the tendon when testing it against resistance (manual muscle test in office)
  3. Has there been any increase in pronation (arch flattening) subjectively by the patient and objectively by the doctor's evaluation and xrays?
  4. What does the MRI tell us of the state of the tendon? 
  5. Can the patient raise their heel off the ground in single leg support positioning, and how much, and does it hurt? 
But, without alot of information, you can still use common sense about maintaining low pain levels, finding your strength difference (comparing right to left), icing 3 times a day for 10 minutes to decrease the local inflammation that hurts. 

Would you recommend a different brace, even an Arizona AFO that stops the dorsi and plantar flection? 
Dr. Blake's comment: The most common brace is the Aircast PTTD Airlift brace, and the taping I linked above with leukotape (strongest tape made). If you can do less then the Richie or Arizona, then the shorty brace from MSI Orthotic Lab looks interesting. I typically use the same type of inversion with a foot orthotic and add the taping even during the first visit. Do not do any resistance bands for strengthening, which can make you worse, if you are not ready for them. Richie is introducing, although I have not tried it yet, and smaller AFO that most labs know about. 

 How about a UCBL or hard shell type brace that controls that motion.  The motion on that plane is indeed painful, but I can manage what I think is a normal gait if taken slowly.   A hard brace around the front top side of the ankle might produce significant pain I would think.
Dr. Blake's comment: I, of course, invented the Inverted Technique for severe pronation which is just the control of the plantar surface of the foot. You can combine the heel inversion with a deep heel cup of 25 mm or so and have a wonderful hybrid orthotic between the inverted technique, the Kirby skive, and the UCBL. 

  I'll mention that I do have intermittent heel pain that I believe is caused by the plantar fascia or perhaps loss of the fat pad so an unpadded orthotic might be an issue. The fascia was surgically released about thirty years ago with good results and I had one cortisone injection there for a flare up about 5 years ago.  I'm not a wealthy man but throwing a couple thousand dollars at this really is something I would like to do to try to keep this from progressing.  I'll hopefully be getting an order for an MRI next week as well.
Dr. Blake's comment: Any orthotic or brace can be padded. Great, I hope you can get an MRI so that they can stage you. 

Do you ever ship out your custom orthotics made from one of the impression kits?   I realize I'd have to get any adjustments made here locally.  Any help or advice on this would be greatly appreciated.
Dr. Blake's comment: I would only work with a local podiatrist if there was trouble getting something accomplished. Start with where you are, get the treatment moving, see what happens. Remember there are 3 Phases of Rehabilitation: Immobilization (where you are, and where braces, AFO, taping, orthotics are working like casts to help rest the injured tissue), Re-Strengthening (which you should be starting now with at least active range of motion exercises, but will be in full force 3 months from now with resistance bands and functional exercises), and finally Return to Activity. Doctors and therapists try to blend all 3 phases all the time, but techniquely for awhile you will be in and out and back into the Immobilization Phase until you get it all calmed down. There is a logic to this rehab, and setting time frames for them is dangerous. For right now, find out by MRI what you have, begin some form of strengthening, find out how to stay in 0-2 with the help of the doctor and other physical therapist. I wish you good luck. Rich

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.