Title: The predominant radiographic findings shown in figures 85a and 85b are most commonly associated with
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2- The predominant radiographic findings shown in
figures 85a and 85b are most commonly associated
with - Peroneal tendinosis
- Posterior tibial tendon dysfunction
- Charcot-Marie-Tooth disease
- Chronic Achilles tendon rupture
- neurofibromatosis
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4In-Training Questions
- Q3 The predominant radiographic findings shown
in figures 85a and 85b are most commonly
associated with - Peroneal tendinosis
- Posterior tibial tendon dysfunction
- Charcot-Marie-Tooth disease
- Chronic Achilles tendon rupture
- neurofibromatosis
5Selected Foot and Ankle DisordersPosterior
Tibial Tendon Dysfunction
- Leslie Barnes, M.D.
- PGY-IV
- LSU-HSC Dept of Orthopaedic Surgery
6Posterior Tibial Tendon Dysfunction (PTTD)
- AKA posterior tibial tendon insufficiency or
adult-acquired flatfoot deformity - Encompasses wide variety of deformities
- Involves the tendon itself as well as the
ligaments associated with the arch of the foot - A progressive, degenerative process
- Deformity varies in severity, rate of progression
and location along the arch
7Epidemiology/Etiology
- Female gt Male
- Avg age of presentation 50 60 yrs
- Multifactorial etiology
- Pre-exisiting flatfoot deformity is common
- Obesity is common
- Zone of relative hypovascularity exists in the
tendon b/w medial malleolus and navicular
tuberosity - Dysfunction can begin with the ligaments or the
tendon initially, which leads to failure of the
other - Can result from acute rupture of PTT (less common
in older population - More commonly, repetitive microtrauma leads to
slow progression from inflammation to attenuation
to tendon dysfunction
8Anatomy
- Posterior Tibial Tendon (PTT)
- Originates from IO membrane, tibia fibula in
proximal 1/3 of leg - Myotendinous jxn in distal 1/3
- Courses behind medial malleolus at relatively
acute angle held in place by flexor retinaculum
9Anatomy
- Posterior Tibial Tendon (PTT)
- Inserts on navicular tuberosity, but has several
insertion domains - Navicular
- Sustentaculum tali
- Medial, middle lateral cuneiforms
- Cuboid
- Bases of 2nd, 3rd 4th MTs
- Dynamic stabilizer of arch along with intrinsic
musculature of the foot
10Anatomy
- Plantar Ligaments
- Static stabilizers of the arch
- Includes
- Long and short plantar ligaments
- Calcaneonavicular (spring) ligaments
- Bifrucate ligaments
- Calcaneocuboid calcaneonavicular
- Spring composed of the stronger superior medial
ligament and an inferior lateral ligament
11Physiology/Biomechanics
- The PTT passes posterior to the axis of the
tibiotalar joint and medial to the axis of
subtalar joint causing plantarflexion and
inversion of the hindfoot - Its insertions onto midfoot contributes to
adduction and supination of the forefoot
Bifrucate ligaments
12Physiology/Biomechanics
- PTT stabilizes hindfoot against eversion or
valgus forces - It is a stance phase muscle
- During gait, it fires from heel strike to just
after heel lift-off - At heel strike, it contracts eccentrically to
decelerate subtalar pronation - In midstance, it stabilizes the midtarsal joints
- In the push-off phase, it adducts the transverse
tarsal joint, locking it and initiating subtalar
inversion - This in turn allows the G-S complex to maximize
plantar flexion force for push-off
13Physiology/Biomechanics
- The PTT is at rest during the swing phase of gait
- It then allows its primary antagonist, the
peroneus brevis, to function abducting the
midfoot (unlocking the TTJ) and everting the
hindfoot
14 Patient History
- In early stages, pain in posteromedial hindfoot
just distal and inferior to med mall - With progression, the medial pain and tenderness
can resolve though swelling can persist - Patients may complain of gradual flattening of
their arch or weakness - With progression, pain can develop laterally
15Physical Findings
- Examine pt w/ both lower extremities exposed and
knees forward (pts tend to ER affected leg) - Swelling along medial ankle
- Note alignment of foot anatomic vs. mild to
pronounced flatfoot deformity
Stage IIB Forefoot abduction, medial ankle
swelling
16Physical Findings
- Forefoot abduction or too-many-toes sign
- Hindfoot valgus
- Fibular impingement on lateral calcaneus through
valgus hindfoot collapse (severe disease)
17Physical Findings
- Medially
- Talar head prominence possibly with assoc.
plantar callus - Talonavicular and 1st MT-med cuneiform collapse
- Laterally
- Fibular impingement
- Wrinkled skin
18Physical Findings
- Heel rise test (double then single)
- In normal test, should be symmetric hindfoot
inversion - Positive test is inability to elevate heel off
ground or no heel inversion
19Physical Findings
- With PTTD, the heel stays in valgus lateralizing
the achilles-GS - With attempted heel rise, the heel does not
invert and the transverse tarsal joint doesnt
lock - One can cheat on the heel rise if use other
muscles to get onto toes, then GS and plantar
aponeurosis can maintain heel rise position,
bypassing PTT
20Physical Findings
- Seated tests
- G-S tightness w/ knee flexed and extended in
neutral hindfoot position w/ navicular reduced on
talus - PTT function pt resists eversion with foot held
in plantarflexed and inverted position - Forefoot varus
- Relationship of MT heads to neutral hindfoot
- Lat border of foot more plantarflexed if fixed
deformity
21Imaging
- X-rays
- Standing 3-view foot
- Standing 3-view ankle series
- In Stage I, x-rays are normal, but can r/o other
structural problems (tarsal coalition, arthritis,
accessory navicular, old trauma, ex. Lisfranc)
- Findings to look for
- Lat subluxation of TNJ (uncovering of talar head)
- TN joint sag
- 1st MT-medial cuneiform subluxation or arthritis
- Subtalar subluxation
- Ankle arthritis and subfibular impingement
22Minimal TN abduction
Talonavicular joint sag
Min TN sag, but naviculo-cuneiform sag and
possible subtalar subluxation
Significant TN abduction
23Imaging
T2
Fluid in sheath
- MRI
- Detects sheath inflammation fluid around tendon
in tenosynovitis - Assesses integrity of the tendon
- PTT normally 2-3x FDL
- Can be smaller than FDL w/ elongation in Stage II
- Pt position is important
- Axial images most useful
- Pt supine w/ ankle in neutral and slightly
plantarflexed position
PTT w/ longit tear, split tenosynovitis FDS NVB
FHL
T1
24Imaging
- Ultrasound
- Dynamic assessment of tendon function
- More cost effective and faster than MRI
- Examiner dependent
- Tenosynovitis seen as target sign w/
hyperechoic tendon and surrounding hypoechoic
synovial fluid on transverse images - Can evaluate contours of tendon or see empty
tibial groove if ruptured
25Staging
- Stage I
- Degeneration or tear of tendon without
deformity - Tenosynovitis is predominant source of pain
- Length of tendon and motor strength preserved
- Able to do single heel rise, but repetitive rise
worsens pain - No hindfoot valgus, too-many-toes sign or
deformity
26Staging
IIa
- Stage II PTT degeneration with flexible
deformity (passively correctible) - IIa (early)
- Heel valgus w/ mild to mod arch flattening
- Min abdn of TN joint
- lt30 TN uncoverage
- IIb (late)
- Severe arch collapse w/ TN abduction
- gt30 TN uncoverage
IIb
27Staging
- Stage III Fixed deformity involving
triple-joint complex - Cannot reduce TN joint
- Attempt to passively neutralize calcaneus causes
compensatory forefoot supination - Lateral ankle pain (subfibular) develops
- No heel rise
- Pain at rest 2 arthritis
28Staging
- Stage IV Foot deformity with ankle deformity
(lateral talar tilt) - Progressive failure of deltoid ligament
- Has been subclassified with IVa having flexible
foot deformity and IVb with fixed foot
NWB vs. WB views
29Conservative Tx
- Depends on stage at presentation
- Immobilization initially for pain relief
- Stirrup brace or lace-up brace (unloads
inversion) - CAM (controlled-ankle-motion) decreases
sagittal plane motion also, but allows functional
rehab - Cast absolute tendon rest
- NSAIDS
- No injectable or oral steroids
30Therapy
- Modalities
- Iontophoresis w/ steroids
- Cryotherapy or ice massage
- Standard US not recommended b/c heat can
exacerbate inflammation - Pulsed US can reduce tendinopathy w/o heat
31Therapy
- Exercise
- Avoid strengthening until pain is relieved
- Greatest increase in PT muscle activation with
resisted foot adduction w/ Thera-Band
32Conservative Tx
- Bracing decreases strain on PTT by elevating
arch and eliminating pronation - Orthotic w/ medial heel forefoot posting (Stage
I) - University of California Biomechanics Lab (UCBL)
orthosis (Stage II) - Arizona brace (Stage II)
- Articulated ankle AFO (Stage III)
- Solid ankle AFO for pain relief (Stage III or IV)
- When get to Stages III and IV, are not correcting
these fixed deformities, but accommodating them
with goal of decreasing pain.
33Braces
UCBL
Arizona braces
34Surgical Treatment Stage 1
- Tenosynovectomy for refractory inflammatory sx
w/o hindfoot deformity - Pts w/ seroneg spondyloarthropathies, consider
after fail 6 wks conservative tx - In older pts w/ classic sx, can consider after at
least 3 months of non-op tx - Repair of longitudinal split tears of the tendon
- Consider immediate repair for acute rupture
(relatively uncommon)
Inflammed synovial proliferation
35Surgical Treatment Stage 2
- Tendon transfer with FDL to replace or augment
degenerated/elongated or torn tendon (Stage IIA) - Rarely done as isolated procedure
- Criteria for transfer
- Adequate subtalar motion (at least 15 degrees
inversion) to allow FDL to help overcome
hindfoot valgus - Cant invert against fixed deformity
- Supple transverse tarsal joint motion
- At least 10 degrees adduction to lock the joint
- FDL most appropriate for transfer for several
reasons - Origin adjacent to that of PTT
- Similar course/line of pull behind medial mall
- Only has 30 of PTT strength but matches strength
of antagonist peroneus brevis - Both are stance-phase muscles
- FDL is expendable
36Surgical Treatment Stage 2
- Medial calcaneal slide osteotomy
- Can consider in pts w/ flatfoot if do tendon
transfer for Stage I disease - Frequently combined with transfer for Stage II
- Takes strain off transfer to prevent progressive
deformity - Statically improves alignment of arch
- Dynamically improves inversion by medializing
Achilles
37Surgical Treatment Stage 2
FPL
38Surgical Treatment Stage 2
- Spring ligament repair/reconstruction
- Not isolated procedure
- Stronger superomedial calcaneonaviular ligament
- Repair indicated if rupture is visible or laxity
noted intraoperatively - Recon if longstanding rupture w/ degenerated
remaining tissue - Rupture can be seen on MRI
- Cotton osteotomy
- Aka plantar flexion opening wedge medial
cuneiform osteotomy - Another adjuctive procedure
- Indicated in pts w/ forefoot varus where 1st ray
is elevated relative to other MTs
39Surgical Treatment Stage 2
- Lateral column lengthening
- Can be performed using Evans Procedure (calcaneal
neck lengthening) or calcaneocuboid joint
arthrodesis - Used in Stage IIB deformity w/ symptomatic
subfibular impingement and likely irreversible
ligament damage that previous procedures cannot
correct - Contraindicated with fixed deformity (Stage 3)
40Surgical Treatment Stage 3
- Once there is a fixed hindfoot deformity,
surgical options are limited to fusions to
correct deformity and stabilize the foot - Isolated subtalar arthrodesis
- If transverse tarsal joint is still mobile and
correctable and forefoot varus lt10 - Joint fixed in 5 valgus
- Double or triple arthrodesis (Salvage)
- For subtalar transverse tarsal fixed deformity
or significant forefoot varus - Technically challenging
- Must correct deformity (no in situ fusion) then
fuse for plantigrade foot - Subtalar joint in 5 valgus, TTJ in neutral
abd/add, and forefoot varus corrected
41Surgical Treatment Stage 4
- Again, options very limited with foot and ankle
deformity - Correct foot deformity with possible Deltoid
ligament reconstruction for talar tilt - Ankle arthrodesis or total ankle arthroplasty for
severe arthritis in addition to foot deformity
correction
- Note in all stages, if the 1st ray is unstable,
tarsometatarsal fusion is added to the planned
procedures (most common in Stages IIB IV)
42Surgical Treatment
43In-Training Questions
- Q1 Which of the following ligaments is most
likely to be attenuated in a patient with a type
II flatfoot deformity secondary to posterior
tibial tendon dysfunction? - Calcaneonavicular
- Anterior tibiofibular
- Anterior talofibular
- Posterior talofibular
- Deltoid
44In-Training Questions
- Q1 Which of the following ligaments is most
likely to be attenuated in a patient with a type
II flatfoot deformity secondary to posterior
tibial tendon dysfunction? - Calcaneonavicular (Spring Ligament!!!)
- Anterior tibiofibular
- Anterior talofibular
- Posterior talofibular
- Deltoid
45In-Training Questions
- Q2 A 55-year-old woman has a flexible
adult-acquired flatfoot deformity characterized
by a positive too-many-toes sign and medial foot
and ankle swelling. She is unable to perform a
single leg heel raise. These findings are
classified as what stage of posterior tibial
tendon dysfunction? - I
- II
- III
- IV
- V
46In-Training Questions
- Q2 A 55-year-old woman has a flexible
adult-acquired flatfoot deformity characterized
by a positive too-many-toes sign and medial foot
and ankle swelling. She is unable to perform a
single leg heel raise. These findings are
classified as what stage of posterior tibial
tendon dysfunction? - I
- II
- III
- IV
- V
47In-Training Questions
- Q3 The most appropriate orthosis for a patient
with Stage II posterior tibial tendon dysfunction
and fixed forefoot varus would provide a - medial heel lift, longitudinal arch support, and
medial forefoot posting. - medial heel lift, flattened arch, and no forefoot
posting. - medial heel lift, longitudinal arch support, and
a recess for the depressed first metatarsal. - lateral heel lift, longitudinal arch support, and
lateral forefoot posting. - lateral heel lift, longitudinal arch support, and
a recess for the depressed first metatarsal.
48In-Training Questions
- Q3 The most appropriate orthosis for a patient
with Stage II posterior tibial tendon dysfunction
and fixed forefoot varus would provide a - medial heel lift, longitudinal arch support, and
medial forefoot posting. - medial heel lift, flattened arch, and no forefoot
posting. - medial heel lift, longitudinal arch support, and
a recess for the depressed first metatarsal. - lateral heel lift, longitudinal arch support, and
lateral forefoot posting. - lateral heel lift, longitudinal arch support, and
a recess for the depressed first metatarsal.
49In-Training Questions
- Q4 A 72-year-old woman has medial ankle pain and
diffuse hindfoot swelling. Radiographs are shown
in the figures 11a and 11b. What is the most
appropriate surgical treatment for this patient? - Medial displacement calcaneal osteotomy
- Lateral displacement calcaneal osteotomy
- Lateral column lengthening through the anterior
calcaneus - Lateral column lengthening through the
calcaneocuboid joint - Triple arthrodesis
50Imaging
51In-Training Questions
- Q4 A 72-year-old woman has medial ankle pain and
diffuse hindfoot swelling. Radiographs are shown
in the figures 11a and 11b. What is the most
appropriate surgical treatment for this patient? - Medial displacement calcaneal osteotomy
- Lateral displacement calcaneal osteotomy
- Lateral column lengthening through the anterior
calcaneus - Lateral column lengthening through the
calcaneocuboid joint - Triple arthrodesis
52Thank You