Tibialis posterior tendinopathy
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Transcript of Tibialis posterior tendinopathy
Dr F PatoFebruary 2012
Patient history31year old male patientWeight 97kg, height 1.79m, BMI 30.27Review of a painful right foot and ankleHalf Iron manApril 18months40km a dayTraining shoe: Nike Pegasus
Complains of: the knee pain has improvedfoot pain still persisting
Examination Tenderness
medial aspect of right ankleposterior to the malleolus Tinel test negative
Knee jointMinimal tenderness over the medial joint space and
belowBiomechanichal assessment
Static and dynamic evaluationCore stability assessmentGait assessment
AssessmentTibialis posterior
tendinopathyTarsal tunnel syndromePlantar fasciitis
Tibialis posterior tendinopathy with minor forefoot eversion/ pronation and poor hip stability.
Management
Inner foot solesPhysiotherapy referralBiokinetics referral
Aim of managementStabilisation
Proximally: core stabilityDistally: inner foot sole
Inner foot soleFoot arch support Muscle support
Stabilizing of pelvis decreases the pressure on the medial legDeloading 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
Discussiontbp t mx
Primary dynamic stabiliser of medial longitudinal foot arch
High forces act on tendon Influenced by adverse biomechanics in overpronated
footOveruse 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 toe-off phase Acute
direct or indirect trauma avulsion fracture
Inflammatory conditions: tenosynovitis secondary to rheumatoid arthritis seronegative arthropathies
Chronic tendinopathy rupture of the tendon itselfcollagen 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 theorytendons are innervated tissueClose association of nerve cell endings and
mast cells within tendonNeurally mediated mast cell degranulation
Chronic overuse Excessive neural stimulation and mast cell
degranulationSubstance P pro-inflammatoryGlutamamate in Achilles tendinopathy
Combination of above factors
Anatomy The tibialis posterior muscle tendon
inverts the subtalar joint. stabilizes the hindfoot against valgus forcesprovides stability to the plantar foot arch
Tarsal tunnel Anatomical structure on inside of heel boneTendons from calf to toesFHL,FD,TPPosterior tibial nerve
Tibialis posterior tendon is palpated from the posteromedial to the medial malleolus, insertion point is at the navicular tubercle.
Macroscopic appearanceDisorganised tissueMucoid degenerationCollagen degenerationFibrosisNeovascularisationIncreased fibroblasts
Increased Prostaglandin E2 production Leucotriene B4 Degenerative change
Biomechanics of runningCorrect biomechanics result in
provision of sufficient movementreduction of risk of injury.
Non traumatic sport injuries can potentially be caused by abnormal biomechanics.
Static (anatomical) functional (secondary)
Static abnormalities cannot be alteredSecondary effects altered by means of orthoses Poor technique and previous injury can result in
functional abnormalities Muscle imbalanceJoint laxity
The range of motion of the ankle joint ±45o plantarflexionNeutral when the foot is perpendicular to the
leg. The minimum range of motion required for
movementis 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 jointregion 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 sublaxedQuadriceps muscle imbalance
patellofemoral joint dysfunctionPredisposition to patella tendinopathyTightening of the iliotibial bandTibial stress fractures
Clinical pictureMedial ankle pain
behind the medial malleolusExtending to tendon insertion pointSwelling is unusualThere is tenderness along the tendon with
occasional presence of crepitusWith resisted inversion
relative weakness compared to the contralateral side
eliciting of painThere 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 high80% and 90%Extent of tendinosis is revealedMost useful method of imaging tendons around the
ankleUltrasonography
Less sensitive than MRIInflammation
Serology and inflammatory markers blood
Management Conservative versus SurgicalConservativePain control where necessary
Ice if necessaryEccentric and concentric tendon loading
exercisesSoft tissue therapy
Manual StretchingReteaching of balance and proprioception
Rigid orthoses excessive pronation controlsSymptomatic relief
Anti-inflammatoriesIf caused by inflammatory arthropathies
ImmobilizationIf severeCast used for short term relief of symptoms
SurgicalIf failed conservative?reconstruction
Concentric trainingActive shortening of muscle tendon unit
Eccentric trainingActive lenghtening of muscle tendon unit
Alfredson’s protocolPainful heel drop protocolAchilles tendinopathy12weeks
Soft tissue therapyRestore pain free range of movementJointsMuscleTendonNerves
Explain to patient beforehand
MassageAssess abnormal tension regionsTrigger pointsSystemic palpationPosition of treatment
Target tissueUnder tension or laxity
Balance and proprioception retraining
Digital ischaemic pressureEvoke temporary ischaemic reaction
Stimulate tension monitoring receptors Reduce muscle tone
Release of pain mediating substances Analgesic response
Deactivate symptomatic trigger points
Sustained myofascial tensionApplication 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 injuryDepth of treatment
Granter-King scale Pain grade I – IV Resistance grade A-C
Granter- King scale
Pain grade Patient’s perception of pain
I No pain perceivedII Commencement of painIII Moderate level of painIV Severe level of pain
Resistance grade Therapist’s perception of tissue resistance
A No sense of resistanceB Onset of tissue resistanceC Moderate tissue resistance
OrthosesCorrection of mechanics and alignmentCompensation of structural abnormalitiesControls excessive subtalar and midtarsal
movementsPlaced in the shoeMust not be used aloneTypes of orthoses
Preformed casted
PreformedFlexibleProvides conservative control of foot motionestablishes tolerance to posture changesDetermine: control of motion, assist in injury
managementGives indication if rigid ones will be necessary or
helpful to treat lower limb problems EVA cork rubber plasterzote polyurethane
CatsedPolyurethaneCarbon fibre deposits
Alter foot mechanics significantlyImportance is the awareness of the
individual’s tolerance to change inner mechanics.
FutureStem cells ?
Prevention Corection of biomechanics
Two methods of correcting lower limb biomechanics
Proximal distal correctionProximal : correction of poor pelvic mechanismsDistal : foot orthoses and footwear
Muscle weakness or incoordinationStrengthening 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, 129-151,600,634-637Tim Noakes.Lore of running. 4th Edition, 2001Current concepts in management of tendon disorders.JD
Rees.Rheumatology.May 2006:45(5):508-521Non 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