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Friday, August 12, 2011

Posterior Tibial Tendon Dysfunction: Gait and Mechanical Treatment

The three videos to follow represent a patient with posterior tibial tendon dysfunction left worse than right, even with attempted posterior tibial tendon reconstruction on the left with subtalar arthroesis.

When I first met with Ruth she had the following gait pattern reflecting a resting heel position of 12 degrees everted on the right and 17 degrees everted on the left.

What was the treatment? I felt with the Inverted Orthotic Technique and Varus Shoe Wedging that I have touched upon in other posts I could get her to the ideal heel vertical position. On physical examination, she had the range of motion to get to heel vertical which was a crucial finding. The Inverted Technique gives a 5 to 1 approx heel correction (ie 25 degree cant equals 5 degrees inversion force). 35 degree Inverted cant (giving 7 degrees of actual heel change) is normally my highest initial correction. It is my starter orthotic to see how the patient responds.

After the 35 degree orthotic gave its 7 degree correction, with the patient still painfully pronating into the orthotic device, I changed to 50 degrees (10 degree change predicted) with 4mm Kirby Skive (2-3 degree change predicted) and a 1/4 inch varus shoe wedge (2-4 degree change predicted). The following video is with this orthotic and shoe combo.

I apologize in the video that I switch the right for the left. The right side (12 degree everted heel) is easily centered to vertical with the combination of inversion forces (cant, Kirby skive, varus wedge), but the left (17 degree everted heel) still is not great. This weekend I am increasing the inversion to 60 with slight more Kirby Skive and higher varus cant (up to 3/8 inch) keeping it all the way out to the toes. I hope you can appreciate that with orthotics and shoe modifications, as long as you can physically get the patient to a vertical heel position, you should be able to accomplish that in gait.

Symptoms related to the poor mechanics, in general, should resolve once the patient is in a vertical heel position.

Here is the latest left orthotic device with 60 degrees Inversion force and 3/8th inch varus midsole wedege. There was no change to the right. Hopefully, the almost complete correction of the left is noted.

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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.