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The predominant radiographic findings shown in figures 85a and 85b are most commonly associated with

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The predominant radiographic findings shown in figures 85a and 85b are most commonly associated with – PowerPoint PPT presentation

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Title: The predominant radiographic findings shown in figures 85a and 85b are most commonly associated with


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  • 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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4
In-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

5
Selected Foot and Ankle DisordersPosterior
Tibial Tendon Dysfunction
  • Leslie Barnes, M.D.
  • PGY-IV
  • LSU-HSC Dept of Orthopaedic Surgery

6
Posterior 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

7
Epidemiology/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

8
Anatomy
  • 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

9
Anatomy
  • 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

10
Anatomy
  • 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

11
Physiology/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
12
Physiology/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

13
Physiology/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

15
Physical 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
16
Physical Findings
  • Forefoot abduction or too-many-toes sign
  • Hindfoot valgus
  • Fibular impingement on lateral calcaneus through
    valgus hindfoot collapse (severe disease)

17
Physical Findings
  • Medially
  • Talar head prominence possibly with assoc.
    plantar callus
  • Talonavicular and 1st MT-med cuneiform collapse
  • Laterally
  • Fibular impingement
  • Wrinkled skin

18
Physical 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

19
Physical 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

20
Physical 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

21
Imaging
  • 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

22
Minimal TN abduction
Talonavicular joint sag
Min TN sag, but naviculo-cuneiform sag and
possible subtalar subluxation
Significant TN abduction
23
Imaging
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
24
Imaging
  • 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

25
Staging
  • 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

26
Staging
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
27
Staging
  • 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

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Staging
  • 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
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Conservative 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

30
Therapy
  • 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

31
Therapy
  • Exercise
  • Avoid strengthening until pain is relieved
  • Greatest increase in PT muscle activation with
    resisted foot adduction w/ Thera-Band

32
Conservative 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.

33
Braces
UCBL
Arizona braces
34
Surgical 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
35
Surgical 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

36
Surgical 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

37
Surgical Treatment Stage 2
FPL
38
Surgical 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

39
Surgical 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)

40
Surgical 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

41
Surgical 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)

42
Surgical Treatment
43
In-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

44
In-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

45
In-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

46
In-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

47
In-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.

48
In-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.

49
In-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

50
Imaging
51
In-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

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