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Physical therapy for posterior tibial tendon dysfunction

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Background

Posterior tibial tendon dysfunction (PTTD) is a progressive, painful disorder of the foot that results in an acquired flat foot deformity. It is characterized by a progressive collapse of the medial longitudinal arch, calcaneal valgus, and forefoot abduction.  On histological examination, the collagen of the tendon appears wavy and disorganized, resembling a more degenerative process. PTTD was previously thought to be an inflammatory condition, but recent evidence suggests a degenerative tendinosis condition. 

Stages

Stage

Description

I

Pain in located along the length of the posterior tibial tendon.  There is still normal alignment of the hindfoot and forefoot

II

The tendon becomes enlarged and elongated with poor function.  Foot deformity is present  with pes planus, collapse of medial longitundinal arch, hindfoot valgus, subtalar eversion, and forefoot abduction.  A flexible deformity except for calf tightness.  The hallmark sign is reduction of the talonavicular joint when the ankle is in equinus

III

Same as stage II except that pes planus is a fixed deformity and a laterally subluxed navicular cannot be reduced

*From Current Concepts of Orthopaedic Physical Therapy, 2nd Ed. The Foot and Ankle: Physical Therapy Patient Management Utilizing Current Evidence. APTA, 2006

Management

Management is based on which stage the patient is in. Conservative management is preferred for stages I and II. Stage I treatment usually consists of calf stretching, strengthening the posterior tibial tendon, and foot orthotics. Calf flexibility is important, as inadequate dorsiflexion may promote pronation and further stress to the tendon. Concentric and eccentric strengthening can be performed for the posterior tibial tendon. The tibialis posterior is preferentially recruited during a resisted foot adduction exercise in persons with pes planus; this muscle is selectively activated when flat-footed subjects perform the exercise while wearing arch-supporting orthoses and shoes. Stage II treatment is similar to stage I but the individual may require a more rigid foot orthotic. Stage III individuals usually require surgery due to the deformity being fixed.