Transcript Tibialis posterior tendinopathy

Dr F Pato
February 2012
Patient history
 31year old male patient
 Weight 97kg, height 1.79m, BMI 30.27
 Review of a painful right foot and ankle
 Half Iron man
 April
 18months
 40km a day
 Training shoe: Nike Pegasus
 Complains of:
 the knee pain has improved
 foot pain still persisting
Examination
 Tenderness
 medial aspect of right ankle
 posterior to the malleolus
 Tinel test negative
 Knee joint
 Minimal tenderness over the medial joint space and below
 Biomechanichal assessment
 Static and dynamic evaluation
 Core stability assessment
 Gait assessment
 Assessment
 Tibialis posterior tendinopathy
 Tarsal tunnel syndrome
 Plantar fasciitis
 Tibialis posterior tendinopathy
with minor forefoot eversion/
pronation and poor hip
stability.
Management
 Inner foot soles
 Physiotherapy referral
 Biokinetics referral
Aim of management
 Stabilisation
 Proximally: core stability
 Distally: inner foot sole
 Inner foot sole
 Foot arch support
 Muscle support
 Stabilizing of pelvis
 decreases the pressure on the medial leg
 Deloading the medial aspect of the foot
 Core stability training and muscle training and conditioning for
running
 Reduce excessive muscular activity present in high degrees of
overpronation
Discussion
tbp t mx
 Primary dynamic stabiliser of medial longitudinal foot
arch
 High forces act on tendon

Influenced by adverse biomechanics in overpronated foot
 Overuse injury


as a result of excessive walking, running, jumping
overuse injury than acute traumatic injury
 High degrees of subtalar joint overpronation lead to the
development of this problem

Excessive activity of tibialis posterior muscle in ankle
overpronation (subtalar joint)
 Excessive subtalar pronation
 increased eccentric tendon loading during supination for the toeoff phase
 Acute
 direct or indirect trauma
 avulsion fracture
 Inflammatory conditions:
 tenosynovitis secondary to rheumatoid arthritis
 seronegative arthropathies
 Chronic tendinopathy
 rupture of the tendon itself
 collagen disarray
 interstitial tears
 Overuse of the tibialis posterior muscle and long
flexor tendons results in trauma to the periosteum and
bending of the tibia.
 Chronic overloading can also result in fibular stress
fractures.
• Historically
• Two main theories
•
•
Mechanical
Vascular
• Neural theory emerging
• Mechanical theory
• repeated loading causes fatigue and tendon failure
• degenerative in nature
• increases with age
• Vascular theory
• Metabolically active tissue
• Requires vascular supply
• Lack thereof causes degeneration
 Neural theory
 tendons are innervated tissue
 Close association of nerve cell endings and mast cells
within tendon
 Neurally mediated mast cell degranulation
 Chronic overuse
 Excessive neural stimulation and mast cell
degranulation
 Substance P pro-inflammatory
 Glutamamate in Achilles tendinopathy
 Combination of above factors
Anatomy
 The tibialis posterior muscle tendon
 inverts the subtalar joint.
 stabilizes the hindfoot against valgus forces
 provides stability to the plantar foot arch
 Tarsal tunnel
 Anatomical structure on inside of heel bone
 Tendons from calf to toes
 FHL,FD,TP
 Posterior tibial nerve
 Tibialis posterior tendon is palpated from the
posteromedial to the medial malleolus, insertion point is at
the navicular tubercle.
 Macroscopic appearance
 Disorganised tissue
 Mucoid degeneration
 Collagen degeneration
 Fibrosis
 Neovascularisation
 Increased fibroblasts



Increased Prostaglandin E2 production
Leucotriene B4
Degenerative change
Biomechanics of running
 Correct biomechanics result in
 provision of sufficient movement
 reduction of risk of injury.
 Non traumatic sport injuries can potentially be caused by
 abnormal biomechanics.


Static (anatomical)
functional (secondary)
 Static abnormalities cannot be altered
 Secondary effects altered by means of orthoses
 Poor technique and previous injury can result in functional
abnormalities
 Muscle imbalance
 Joint laxity
 The range of motion of the ankle joint
 ±45o plantarflexion
 Neutral when the foot is perpendicular to the leg.
 The minimum range of motion required for movement
 is 10-20o for normal walking
 Excessive pronation results in
 excessive internal rotation of the entire lower limb
during weight bearing,
 thus increasing demands on numerous structures.
 The subtalar joint
 region where pronation occurs
 This leads to
 ground reaction forces being increased on the medial
aspect of the foot.
 the foot therefore becomes unstable.
 The medial longitudinal arch also receives excess loading
causing increased strain on the plantar fascia and
musculature.
 The supporting muscle ends up contracting harder and
longer to decelerate rotation and pronation of the foot.
 Muscles involved is the
 gastrocnemius-soleus complex
 tibialis posterior.
 May result in
 Achilles tendinopathy
 tibialis posterior tendinopathy.
 Excessive pronation results in increased rotation of the
tibia, resulting in :
 Patella being laterally sublaxed
 Quadriceps muscle imbalance

patellofemoral joint dysfunction
 Predisposition to patella tendinopathy
 Tightening of the iliotibial band
 Tibial stress fractures
Clinical picture
 Medial ankle pain
 behind the medial malleolus
 Extending to tendon insertion point
 Swelling is unusual
 There is tenderness along the tendon with occasional
presence of crepitus
 With resisted inversion
 relative weakness compared to the contralateral side
 eliciting of pain
 There is lack of inversion of the hind foot
 difficult to perform a heel raise.
Investigations
 Magnetic resonance imaging (MRI)
 Sensitive and specific for detection of rupture is high
 80% and 90%
 Extent of tendinosis is revealed
 Most useful method of imaging tendons around the ankle
 Ultrasonography
 Less sensitive than MRI
 Inflammation
 Serology and inflammatory markers
 blood
Management
 Conservative versus Surgical
 Conservative
 Pain control where necessary
 Ice if necessary
 Eccentric and concentric tendon loading exercises
 Soft tissue therapy
Manual
 Stretching
Reteaching of balance and proprioception

 Rigid orthoses
 excessive pronation controls
 Symptomatic relief
 Anti-inflammatories
 If caused by inflammatory arthropathies
 Immobilization
 If severe
 Cast used for short term relief of symptoms
 Surgical
 If failed conservative
 ?reconstruction
 Concentric training
 Active shortening of muscle tendon unit
 Eccentric training
 Active lenghtening of muscle tendon unit
 Alfredson’s protocol
 Painful heel drop protocol
 Achilles tendinopathy
 12weeks
 Soft tissue therapy
 Restore pain free range of movement
 Joints
 Muscle
 Tendon
 Nerves
 Explain to patient beforehand
 Massage
 Assess abnormal tension regions
 Trigger points
 Systemic palpation
 Position of treatment
 Target tissue
 Under tension or laxity
 Balance and proprioception retraining
 Digital ischaemic pressure
 Evoke temporary ischaemic reaction


Stimulate tension monitoring receptors
Reduce muscle tone
 Release of pain mediating substances

Analgesic response
 Deactivate symptomatic trigger points
 Sustained myofascial tension
 Application of tensile forces in direction of greatest
fascial restriction or in direction of elongation necessary
for normal function


Aim is to rupture abnormal cross linkages between collagen
fibers
Cross linkages form aro inflammatory response to acute or
overuse injury
 Depth of treatment
 Granter-King scale


Pain grade I – IV
Resistance grade A-C
 Granter- King scale
Pain grade
I
II
III
IV
Resistance grade
A
B
C
Patient’s perception of pain
No pain perceived
Commencement of pain
Moderate level of pain
Severe level of pain
Therapist’s perception of tissue
resistance
No sense of resistance
Onset of tissue resistance
Moderate tissue resistance
 Orthoses
 Correction of mechanics and alignment
 Compensation of structural abnormalities
 Controls excessive subtalar and midtarsal movements
 Placed in the shoe
 Must not be used alone
 Types of orthoses
 Preformed
 casted
 Preformed
 Flexible
 Provides conservative control of foot motion
 establishes tolerance to posture changes
 Determine: control of motion, assist in injury management
 Gives indication if rigid ones will be necessary or helpful to
treat lower limb problems





EVA
cork
rubber
plasterzote
polyurethane
 Catsed
 Polyurethane
 Carbon fibre deposits
 Alter foot mechanics significantly
 Importance is the awareness of the individual’s
tolerance to change inner mechanics.
 Future
 Stem cells ?
Prevention
 Corection of biomechanics
 Two methods of correcting lower limb biomechanics
 Proximal distal correction
 Proximal : correction of poor pelvic mechanisms
 Distal : foot orthoses and footwear
 Muscle weakness or incoordination
 Strengthening and retraining
 Joint stiffness
 Active and passive joint mobilization
 Appropriate shoes
Conclucsion
 A chain is as strong as its weakest link
 Injuries in one part of the kinetic chain result in dysfunction of the whole chain
 Injuries and adaptations in some area of the kinetic chain can result in
problems distant from the affected area.
 compensate for the inadequacy in order to generate adequate force to perform
a specific task.
 Identification and correction of deficits important to prevent further injury
 Proper function of chain
 Performance
 Multi team approach rehab programme
 Well planned
 Well excecuted
 Individualised
Refrences
 Brukner and Khan. Clinical Sports Medicine Revised Third




Edition.2010;40-61, 129-151,600,634-637
Tim Noakes.Lore of running. 4th Edition, 2001
Current concepts in management of tendon disorders.JD
Rees.Rheumatology.May 2006:45(5):508-521
Non surgical management of posterior tibial tendon dysfunction
with orthoses and resistive exercise: A randomized Controlled
Trial. Journal of the American Physical Therapy Association.
Kulig et al.January;89(1):26-37
Does Eccentric Exercise Reduce Pain and Improve Strength in
Physically Active Adults With Symptomatic Lower Extremity
Tendinosis? A Systematic Review.NJ Wasielewski et al. Journal of
Athletic Training. 2007 Jul-Sep;42(3):409-421