The Effect of Foot Orthotic Treatment in Posterior Tibial Tendon Injuries

https://pubmed.ncbi.nlm.nih.gov/33040609/

Foot orthoses, together with exercise programs, seemed to improve the effect of orthotic treatment. Foot orthoses with personalized internal longitudinal arch support were more effective than flat insoles or standard treatments in reducing pain.

Posterior Tibial Tendon Injury: Email Advice

Good afternoon Dr Blake. I am writing you from New York City. First I want to say THANK YOU for the wonderful blog that you have created. I will be as short and concise with my situation. Like you I have a long history of playing basketball and also running wind sprints. I have sprained my ankle numerous times from basketball. This current injury is different as its the inside side of my left ankle that has PTT (posterior tibial tendon). 

In January I was running wind sprints up a hill in the park on concrete. After my workout, I felt some pain and swelling. I thought it odd that it was the inside side and I don't recall twisting my ankle.  I went to the doctor and he prescribed physical therapy. I went to 5 sessions over 3 weeks and all the pain went away. I did NO home exercises. Fast forward to July and I did the hill workout again. I felt tightness in my calves and some slight swelling but not pain. 2 weeks later I did a sprint workout at a soccer field. After my 4th sprint, my foot locked up on me. I thought it was the dreaded Achilles tendon tear and it hurt and I could barely walk. I elevated a few days, not too much ice. Went back to the doctor. Got a script for physical therapy. I STOPPED all jogging, skipping rope, doing wind sprints.  I went to one clinic 4 times over 2 weeks. I wore no brace. The therapist didn't believe in braces. I took Aleve for 10 days. I switched to another physical therapy clinic. Went there 5 times over 2 weeks. I wasn't getting better. I then went to an orthopaedic surgeon. I believed I needed an MRI. He took Xray and said no stress fracture. He did some manual tests and concluded I had an Unstable Ankle and Posterior Tibialis Tendonitis. He suggested one of the more expensive over the counter Orthotics(hard plastic type). He said I had flat feet but only when standing. He said I might only need the Orthotic for 3-4 weeks. He did not think I needed surgery at all anytime soon. He said 3-4 sessions of physical therapy would be beneficial. 

After 2 weeks of the swelling/inflammation not going down, I went to a new physical therapist. He concluded I didn't have swelling/inflammation and needed heat and home exercises. Things like calf raise (2 sets of 12 twice per day). Theraband for inversion (2 sets x 12 twice per day). The one legged balance for 30" (2 sets x 30" twice per day). Stretch the calves and soleous twice per day for 30". After 2 weeks of still the swelling not going down I went to a podiatrist. He ordered MRI and after the MRI he got me a knee high walking boot. He said to use the boot for 3 weeks (follow-up visit after the 3 weeks

Highlights of MRI:

Chronic postraumatic deformities of the tips of the medial and lateral malleolar are noted 
There is a chronic full-thickness tear of the anterior talofibular ligament 
There is marrow edema within the talar head and neck. Different considerations include a bone contusion or stress reaction. 
There is increased fluid in the posterior tibialis sheath consistent moderate tenosynoviitis with intermediate signal in inframalleolar component of the tendon consistent with mild tendinosis. 
A type 2 accessory navicular is noted with marrow edema within. 

A ganglion is noted with Kager's fat pad measuring 1.9 x 1.1 x 1.4cm 

I have yet to find a physical therapist who actually knows what to do for PTT. Also as nice as the podiatrist was I dont think he fully understands/emphasizes with my frustration as to what to do at home to best heal, strengthen, stretch.

The last physical therapist session was with a new person who suggested to STOP doing calve raises and to stop doing the soleous stretch. To do the theraband in the 2 directions that dont put any strain on the Posterior Tibialis Tendon. I am to return to that therapist in 2-3 weeks. They also said do NOT use heat but to ice 1-2/day. 

I dont know how long to wear the boot. I also dont know what is safe to do strengthening wise. My frustration is not getting the inflammation/swelling completely gone

Have you heard of Tendex Fast surgery?

http://www.tenexfastprocedure.com/medication-adhd-tenex-houston-tx.html

Oh yeah

What specialist would be able to tell if I have muscle weakness or tightness in my hips, thighs, hamstrings, or calves? I think the PTT is the result of some other problem in the chain.

I have placed the Orthotic in my walking boot. I will be watching all of your youtube clips regarding PTT. I wonder if even walking in a boot puts some stress/pressure on the PTT. Currently its is around a portion of the ankle bone where I still feel inflammation/swelling and some pain. The pain flares up when I walk too long. I am wondering if staying at home just reading and watching movies for say a week or two would be truly resting the PTT.

THANK YOU for your time. I appreciate any and all feedback

Dr Blake's comment: Thank you so very much for emailing. I will try to give you my impressions with the info you provided. The MRI was very helpful, and you need another one 6 months from now to check on the edema. I see no place now to consider a surgery. Surgery typically would be a year from now if you are not able to get back. I know it sounds long, but you have to get rid of the underlining talar head and neck bone edema due to impact stresses. It probably is the cause of all your pain with secondary posterior tibial tendon issues. If you rush a talar injury, the stress fracture or stress reaction which is there now could become a full-blown fracture. I have seen fast recoveries from these, but I can not predict. You have to go one month at a time. You want a 9-month course of Exogen bone stim, and a current bone density and Vit D test. You should avoid all impact for 9 months and work on your ankle strength. The ankle sprains could be coming back to haunt you with instability and abnormal stresses. As long as you can avoid painful exercises, do the posterior tibial strengthening program, also Single Leg Balancing, and the peroneus longus and brevis therabands. Do contrasts each evening as a good flush to the superficial and deep bone swelling. 
     The basic routine is to avoid deep ankle flexion as with landing from a jump or deep plie in ballet. Avoid stretching your Achilles for the next month, then one month only with the knee straight, and no negative heel stretching where you drop the heel off the stair. Contrasts each evening, and evaluate bone density for issues. Bone stim for 9 months, and repeat MRI in 6 months. Start a super strengthening program. Stay in the boot 3 months, and then transition to shoes. Monthly evaluations should be done to check progress. I hope this helps. Rich. 

Jay just answered. I read this as a talar injury first and foremost, with secondary PT changes. Keep me in the loop. Rich

Hi Dr Blake

Thanks for reading my email. Do you know of any good podiatrists or Orthopedic foot surgeons in the New York City area?

Dr Blake's comment: In the New York area, I tend to recommend Karen Langone, David Davidson, Tom Conenello, and Joseph D'Amico. I know Joe is in New York City at the podiatry school there. 

I have read quite a bit on your blog regarding Posterior Tibialis Tendonitis. 

Right now I am in a walking boot (for at least 3 weeks). I have Spenco orthotic inserts in the boot. I am icing 2-3 times per day.

What, if anything, would you recommend in terms of healing and recovery? Is the swelling/inflammation from the issue with the PT or the talar?

Dr Blake's comment: I think addressing the talus is the most important right now, although any inflammatory measures will affect both areas. Contrast baths each evening are great for deep swelling. A bone stimulator from Exogen will help with bone flow. I try to get patients doing some form of strengthening of the area, without producing pain, and some sort of both core and cardio work. 

Is there anything I can do for healing the talar? Maybe stay in boot longer than 3 weeks? 

Dr Blake's comment: The talus finding directs healing right now. The boot will be for 3 months with a new MRI to check progress. Can not see past that. One of my blog patients just told me about a good boot. Check out www.vacocast.com. 

If there are any posts on Talar in your blog I can read em too.

Do you take Medicare by any chance? Physical therapy for the Talar issue?

Dr Blake's comment: Yes, I do take Medicare. Physical therapy once a week to help you decide on exercises, cardio, anti-inflammatory is a good idea. 

I will be getting your book. 

Thanks again

Navicular and Posterior Tibial Injury: Email Advice

Hi Dr. Blake: 

 I am a 64-year old woman.  Like many, I have a navicular bone on my right arch which is somehow intertwined with the neighboring tendon.  About 10 years ago, I somehow tweaked the tendon which resulted in a lot of pain.  I was relegated to a boot for 6 weeks and did not have any problems until about one year ago when it started acting up again. 

 It has been intermittent with months of pain free days but recently I had a foot massage and the well-meaning masseuse worked on my feet (much to my delight) only to awaken this pain yet again.  I have gone back into the boot but am not convinced that the boot is doing the best job.   I like being in my new balance tennis shoes with my orthotics because of the arch support from the orthotics which the boot does not have.  I looked on your website today and have also ordered the tape from supporthefoot.com to see if that will help.  There doesn’t seem to be any swelling and I have not had an MRI because the pain is so intermittent.  My concern is that I seem to get better and then fall back time and again… I would like to get this quieted down once and for all.  Any suggestions you can provide on the best course of action will be appreciated. 

Thank you.

Dr Blake's comment: You seem right now to be doing everything right in the short term, but addressing the overall strength of that tendon, and the surrounding tendons/muscles, could be crucial. I typically try to get patients 3 times stronger than you are now. You should also learn the leukotape version of posterior tibial taping. I have a video on that and also the main exercises. You should without pain gradually spend the next year getting stronger. The classic exercises are metatarsal doming, single leg balancing, 2 positional toe raises, and theraband posterior tibial and peroneus longus strengthening. Good luck!

https://youtu.be/AcSSyBfFocE

https://youtu.be/GY-mJjXmeIc



https://youtu.be/-4OB7wcYTJE



https://youtu.be/xjsYz_YFGyY



https://youtu.be/Wa3k5b9kNAM