General Rules of Posterior Tibial Tendon Injuries

Posterior Tibial Tendonitis/Dysfunction/Tear (by Richard Blake, DPM)

 

    The posterior tibial tendon is the major tendon to support the main arch of your foot. Damage to the tendon causes arch collapse to a major degree. Any sign that this tendon is having (beginning to have) problems must therefore be over treated to avoid long term issues. It is one of the most common surgeries on my patients because of the disability. I work long and hard on each one of these patients both trying to avoid surgery (usually), or in their post surgical rehabilitation. I encourage you to see my videos on You Tube for posterior tibial tendon problems. On YouTube, type drblakeshealingsole posterior tibial tendon and see what comes up. Rich 

    

The top 10 treatments for tibial tendinitis/dysfunction/tear are:

1.  Understand the biomechanics of the posterior tibial tendon to support the medial longitudinal arch and begin to support the arch as part of all phases of the rehabilitation: Immobilization, Re-Strengthening, and Return to Activity.

2.  Start with OTC and advance to custom orthotic devices with maximal support (this is not an injury to settle with less than optimal support).

3.  Learn several different taping techniques: posterior tibial and circumferential arch.

4.  Ice the area 3 times daily for 15 minutes each.

5.  If possible, get a baseline MRI (may be an important comparison 6 months later).

6.  Most ankle braces hold the ankle pronated which is bad for this injury, consider an Aircast Airlift PTTD brace for times you are not using orthotic devices.

7.  Create an initial pain free environment with below knee removable boot/cam walker, and perhaps a Roll aBout.

8.  If the injury is substantial (Grade 3-4 typically), have a hinged AFO custom made at a brace shop right at the start of the injury (it can take awhile to get fitted)

9.  Begin strengthening the posterior tibial tendon as quickly as possible with at least active range of motion exercises. The Posterior Tibial tendon is strengthened by pointing the ankle first and then moving the foot towards the other foot.

 https://youtu.be/w3FXx4OFqec

10. Definitely have a surgeon as part of the treatment. 

Dr Larry Huppin: Shockwave for Posterior Tibial Tendonosis and Tendon Dysfunction

If you have been suffering from chronic posterior tibial tendon issues, consider the non invasive shockwave therapy presented here from my friend and colleague, Dr. Larry Huppin.

https://youtu.be/lstR-Ls9M5g

Pronated Left Foot: New Orthotic Device to be Made (Posterior Tibial Tendon Dysfunction)

This patient presents with a collapsing left arch for several years. I inherited the patient from my retired partner (Dr. Ronald Valmassy) who kept him going on a 20 year old orthotic device. However the patient has noted a change in the last year with a collapsing left arch and more left arch pain. He has no pain in his right side. He tries to walk 3-4 miles daily, but the last 6 months has been limited to very little walking. 

I am going to start with my highest correction of 35 degrees Inversion for the left foot. I am only making a new left for 3 reasons: only has pain on left, the right orthotic device seems excellent, and he has no insurance and is paying for this himself. 

     This is actually a typical stage 3 PTTD patient. The RCSP (resting heel position) was 17 everted or valgus standing on the orthotic device. The highest correction I do is 35 degrees initially which should push the patient into more varus by 7 degrees (5 to 1 plaster inversion to actual foot change). I will go up from there after he is used to it. I am always hoping for more than the 7 degrees change, but sometimes it will be less with the first correction. 3 months after his new left orthotic device is dispensed, I will either push the orthotic correction 3 or 5 degrees more.      

Podiatry Question #1: What 3 common orthotic RX would help the foot below?

This patient presents to the office with a sudden arch collapse on the right side. Their symptoms are consistent with posterior tibial tendonitis, but really could be any of the symptoms related to pronation. The Rule of 3 of injury teaches us that there are probably 3 or more causes of a weak spot developing in one area. As you evaluate this injury, you find 3 possible causes. These are: 

1. Unilateral pronation placing a strain on the posterior tibial tendon
2. Some inherent weakness in the tendon 
3. A Habit of wearing poor quality non supportive shoes

When we measure the heel bisection at a resting position, the left heel is vertical, but the right is 10 degrees everted. What are six immediate ways, besides placing this patient in a cast for 3 months, or brace them with an AFO, to begin to take the stress off the Tissue combining the Root and Tissue Stress Theories? 

1. An Orthotic Device with some inversion
2. A varus foot wedge external or internal to the shoe
3. A gradual strengthening program of the posterior tibial tendon (may take us 6 months)
4. Stable shoes, stability or motion control, with some heel elevation 
5. Aircast Airlift PTTD brace
6. Posterior Tibial J Strap for Inversion Support

https://youtu.be/w3FXx4OFqec

https://youtu.be/AcSSyBfFocE

It is also important to remember to strengthen the surrounding muscles and other leg muscles which can really help with the functioning of the posterior tibial tendon. These include: 

1. Anterior Tibial Tendon
2. Intrinsic Musculature
3. Peroneus Longus
4. Gastrocnemius and Soleus
5. Sartorius
6. Lateral Hamstrings
7. External Hip Rotators

And now to our question about the type of orthotic device on the market for that right foot. What 4 orthotic devices routinely on the market will help this amount of severe pronation? 

1. Mueller TPD orthotic device
2. Inverted Technique with Kirby Skive
3. Modified Root with Kirby Skive
4. DC Wedge

This is an example that the left side was just stabilized, but the right needed a significant force to balance the pronation. The Inverted Technique gives you 1 degree of heel inversion per 5 degrees of cast modification. So, 35 degrees of inversion within the mold is equivalent to 7 degrees of inversion force, and the 2 mm Kirby Skive (medial heel skive) and a slightly higher medial arch gave me the extra 3 degrees of correction.

What is the modified Root device that should do the same thing? Here is pour the positive cast 6 degrees inverted and apply at 4 mm Kirby medial heel skive. This should work at times. The reasons that I see it have problems are: 

1. Too much correction in the heel fat pad for the body to tolerate
2. Since you are inverting the foot, you could end up with too much correction under the distal medial border of the orthotic device thus blocking first ray function of plantarflexion
3. You modify the Kirby skive, or the medial arch, for comfort losing support in the long run

The Inverted Technique when augmented with the 2 mm Kirby Skive is designed intentionally not to block first ray plantarflexion, should not irritate the medial heel (the skive is carefully molded to remain the shape of the foot), and the support all the way up under the navicular first cuneiform joint gives incredible arch support. 

Hintermann Test or First Metatarsal Raise Test for Recognition of Posterior Tibial Tendon Dysfunction

     Hintermann published a paper in 1996 about a clinical test to help him decide whether a patient needed surgery for posterior tibial tendon dysfunction. It was based on the fact that with the patient standing, when the heel is inverted (or the leg externally rotated), only in the 21 patients that had posterior tibial disease (not necessarily ruptures) was this test positive for leaving the first metatarsal off the ground. It is now known more as the First Metatarsal Raise Test. When I read the article many thoughts crossed my mind, and I need to do this test some, but I need other podiatrists to give me feedback on their successes and failures. So, what bothered me about this test? The things that bother me are:

1. 100% of the patients were positive even though the surgical findings were all over the place (from tendinitis only to complete ruptures)
2. 100% of the patients without post tibial tendon disease were negative, but they do not go into any of these patients (allow they implied the test was being done over 4 years)
3. They made no reference to what type of orthotics were being used preop to avoid surgery and whether the tendon being strengthened thoroughly before (there was no mention about posterior tibial strength at all)
4. They seem to have no knowledge of deformities like rearfoot varus, rear foot valgus, forefoot valgus and forefoot varus. Any of these common deformities would greatly affect this test. 
5. In most of my patients with PTTD, with 10 degrees of heel eversion, and 10 degrees of positional forefoot supinates, when I put the patient into heel varus the first metatarsal is going to be way off of the ground. This does not mean I need to do anything but rehabilitate them. 

http://fai.sagepub.com/content/17/4/236

I am so hopeful that my esteemed colleagues around the world will help decipher the importance of this test. 

Stage ll Posterior Tibial Tendon Dysfunction: Give Conservative Care a Try

Dr. Blake, 

 This is the original post back in March 2018 when the patient contacted me. I referred her eventually to Dr. Matt Werd in Florida. 

http://www.drblakeshealingsole.com/2018/03/posterior-tibial-tendon-dysfunction.html

I wanted to share with you a follow up on my progress with physical therapy. 

I am seeing Dr. Werd and he was very helpful in prescribing PT. Not only that but of all the doctors I have seen for this condition (4 so far), he has by far spent the most time with me analyzing my symptoms and going over the diagnostics and various alternatives. 

I had 5 months of PT. I was very blessed in finding an experienced therapist. I can tell you that it was not easy. It was sometimes painful and discouraging. However, I stuck with it daily, sometimes an hour or more of exercises every day. I had a couple of setbacks but am so thrilled with the results now. I am walking without pain, have full range of motion and full strength. I can easily do 50 single foot heel rises! Although it wasn't easy, I can also say that it was much easier for me to do PT than the alternative of surgery (with the post-op of being non-weight bearing, on painkillers all while trying to take care of my children.) I would have done surgery if absolutely needed but was so glad to have an alternative. 

I'm so thankful to God to lead me to this path. Thank you so much for your help along the way!

Sincerely,

P.S. Do you have any advice for me how to keep my foot healthy (exercises to do? any to avoid?) Dr. Blake's comment: This is your weak spot, but over the next year you will get it stronger and stronger. I pray that you are doing the posterior tibial theraband work level 6 2 sets of 25. Did you go through them? If you did, you need to do twice weekly to maintain the strength and make sure the tendon stays strong. Focus on activities until April that you can do with orthotics like hiking. I would wait another year before starting a walk-run program. Modified Yoga with orthotics on would be wonderful. I hope this gives some direction. You want to keep it strong forever so it will have minimal effects on your overall life. 

https://youtu.be/w3FXx4OFqec

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. 

https://youtu.be/AcSSyBfFocE




https://youtu.be/w3FXx4OFqec

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

Posterior Tibial Tendon Dysfunction with Accessory Navicular: Email Advice

Hi Dr. Blake,

I wanted your advice on my situation. I have been diagnosed with posterior tibial tendon dysfunction - stage II and accessory navicular syndrome. My doctor suggests the following surgical procedures: removal of accessory navicular, FDL tendon transfer and evans flatfoot. I had a recent MRI which showed some wearing of the tendon including a 1 cm tear. 

Dr. Blake's comment: As long as you are in Stage II, where there is no rigid deformity, you can undergo conservative treatment. So, if your arch looks close to normal non-weight bearing, you would be considered stage II, even in the presence of a tear. The tear needs to be treated with removable boot typically for 3 months, then ankle foot orthotics, then foot orthotics with posterior tibial taping or bracing. This should be done at the same time you are strengthening the posterior tibial, anterior tibial, achilles, arch, peroneus longus, and external hip rotators. This is a delicate matter and sometimes it is the inexperience of the health care provider in conservative management that leads to failure. You must find someone that can attempt to rehab this. 

I have been researching these conditions and come across studies which show that wearing an AFO with physical therapy can resolve PTTD. However, it is not clear to me if my accessory navicular or if my tendon tear would be an issue in the success of this protocol. 

Dr. Blake's comment: Definitely they are factors, but as long as your arch collapse is reducible when you are nonweight bearing, I would rehab. 

I would like to avoid surgery if possible but also do not want my PTTD to progress further.

Dr. Blake's comment: That is what is at stake. Surgery is very successful, but Stage II is fixable without surgery if it can be rehabbed. While it is being rehabbed, if the pain can not be controlled, and or the deformity of your arch gets worse, then you should sign up for surgery. I do not do this surgery, I have a wonderful podiatric surgeon as my partner, so I see the patients up to the point of surgery, and then 3 months after the surgery to finish the rehab. Whatever is done initially, if you eventually need surgery, then those same devices and skills can be used in the postoperative period. For example, the same AFO initially, can be used postoperatively until you get strong.  

Some more background: I am 41 years old and have been symptomatic for 4 years. Three years ago I wore a boot for 6 weeks and my symptoms seemed to resolve completely for one year. After that year I had some pain and limitations off and on but nothing that disrupted my life. I had not been wearing inserts until recently which I now realize was a mistake. Now I am in inserts and the air cast boot. 

Dr. Blake's comment: With or without surgery, orthotic devices can be vital, so I am glad you have a good pair. Begin strengthening, and stay in the air cast boot until you have your custom AFO made. Typically they start with a rigid model, and then as you improve, go to a hinged version for more mobility. Good luck!!

Thank you for your advice!

Useful review article: 

https://www.hss.edu/conditions_posterior-tibial-tendon-insufficiency-overview.asp

Good Article Posterior Tibial Tendon Dysfunction (PTTD)

I just recently checked your blog. I had no idea you answered all my questions. I left a quick reply with a  few questions. Besides helping me I am hoping there are others who benefit from my experience and your feedback. I read this article recently. I wanted to share with you

Researchers inch toward understanding of PTTD

Researchers inch toward understanding of PTTD In recent years, studies have elucidated aspects of the biomechanical effects of posterior tibial tendon dysfunc...

THANKS again. Are you a Golden State Warrior fan? I wonder if you have any articles on what the injuries were for Stephen curry, his treatment, and subsequent surgeries. Also, here in NYC, we have the NFL New York Giants. A few receivers had serious injuries. Odell Beckham Jr is the most famous player. I could be mistaken but when NFL and NBA and MLB players get seriously hurt it seems like they get surgery rather fast. It would be a TREAT if you wrote some articles on the more popular and famous athletes and some of their surgeries etc involving the feet.

I look forward to finally meeting and getting that infamous Dr Blake evaluation. THANKS AGAIN