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 negativeKnee jointMinimal tenderness over the medial joint space and belowBiomechanichal assessmentStatic and dynamic evaluationCore stability assessmentGait assessment
AssessmentTibialis posterior tendinopathyTarsal tunnel syndromePlantar fasciitis
Tibialis posterior tendinopathy with minor forefoot eversion/ pronation and poor hip stability.
Inner foot solesPhysiotherapy referralBiokinetics referral
Aim of managementStabilisation Proximally: core stabilityDistally: inner foot soleInner foot soleFoot arch support Muscle supportStabilizing of pelvis decreases the pressure on the medial legDeloading the medial aspect of the footCore stability training and muscle training and conditioning for runningReduce excessive muscular activity present in high degrees of overpronation
Discussiontbp t mx Primary dynamic stabiliser of medial longitudinal foot archHigh forces act on tendon Influenced by adverse biomechanics in overpronated footOveruse injury as a result of excessive walking, running, jumpingoveruse injury than acute traumatic injuryHigh 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 Acutedirect or indirect trauma avulsion fractureInflammatory conditions: tenosynovitis secondary to rheumatoid arthritis seronegative arthropathiesChronic 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 theoriesMechanical Vascular Neural theory emerging
Mechanical theoryrepeated loading causes fatigue and tendon failure degenerative in natureincreases with ageVascular theoryMetabolically active tissueRequires vascular supplyLack thereof causes degeneration
Neural theorytendons are innervated tissueClose association of nerve cell endings and mast cells within tendonNeurally mediated mast cell degranulationChronic overuse Excessive neural stimulation and mast cell degranulationSubstance P pro-inflammatoryGlutamamate in Achilles tendinopathyCombination of above factors
Anatomy The tibialis posterior muscle tendoninverts the subtalar joint. stabilizes the hindfoot against valgus forcesprovides stability to the plantar foot archTarsal tunnel Anatomical structure on inside of heel boneTendons from calf to toesFHL,FD,TPPosterior tibial nerveTibialis posterior tendon is palpated from the posteromedial to the medial malleolus, insertion point is at the navicular tubercle.
Macroscopic appearanceDisorganised tissueMucoid degenerationCollagen degenerationFibrosisNeovascularisationIncreased fibroblastsIncreased Prostaglandin E2 productionLeucotriene 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 imbalancepatellofemoral joint dysfunctionPredisposition to patella tendinopathyTightening of the iliotibial bandTibial stress fractures
Clinical pictureMedial ankle painbehind the medial malleolusExtending to tendon insertion pointSwelling is unusualThere is tenderness along the tendon with occasional presence of crepitusWith resisted inversionrelative weakness compared to the contralateral sideeliciting 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 ankleUltrasonographyLess sensitive than MRIInflammationSerology and inflammatory markers blood
Management Conservative versus SurgicalConservativePain control where necessaryIce if necessaryEccentric and concentric tendon loading exercisesSoft tissue therapyManual StretchingReteaching of balance and proprioception
Rigid orthoses excessive pronation controlsSymptomatic reliefAnti-inflammatoriesIf caused by inflammatory arthropathiesImmobilizationIf severeCast used for short term relief of symptoms
SurgicalIf failed conservative?reconstruction
Concentric trainingActive shortening of muscle tendon unitEccentric trainingActive lenghtening of muscle tendon unitAlfredsons protocolPainful heel drop protocolAchilles tendinopathy12weeks
Soft tissue therapyRestore pain free range of movementJointsMuscleTendonNervesExplain to patient beforehand
MassageAssess abnormal tension regionsTrigger pointsSystemic palpationPosition of treatmentTarget tissueUnder tension or laxityBalance and proprioception retraining
Digital ischaemic pressureEvoke temporary ischaemic reactionStimulate tension monitoring receptors Reduce muscle toneRelease of pain mediating substancesAnalgesic responseDeactivate symptomatic trigger points
Sustained myofascial tensionApplication of tensile forces in direction of greatest fascial restriction or in direction of elongation necessary for normal functionAim is to rupture abnormal cross linkages between collagen fibersCross linkages form aro inflammatory response to acute or overuse injuryDepth of treatmentGranter-King scalePain grade I IVResistance grade A-C
Granter- King scale
Pain gradePatients perception of painINo pain perceivedIICommencement of painIIIModerate level of painIVSevere level of pain
Resistance gradeTherapists perception of tissue resistanceANo sense of resistanceBOnset of tissue resistanceCModerate tissue resistance
OrthosesCorrection of mechanics and alignmentCompensation of structural abnormalitiesControls excessive subtalar and midtarsal movementsPlaced in the shoeMust not be used aloneTypes of orthosesPreformed 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 problemsEVA corkrubberplasterzotepolyurethane
CatsedPolyurethaneCarbon fibre depositsAlter foot mechanics significantlyImportance is the awareness of the individuals tolerance to change inner mechanics.
FutureStem cells ?
Prevention Corection of biomechanicsTwo methods of correcting lower limb biomechanicsProximal distal correctionProximal : correction of poor pelvic mechanismsDistal : foot orthoses and footwear
Muscle weakness or incoordinationStrengthening and retrainingJoint stiffness Active and passive joint mobilization
ConclucsionA chain is as strong as its weakest linkInjuries 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 injuryProper function of chainPerformance Multi team approach rehab programmeWell plannedWell excecutedIndividualised
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):26-37Does Eccentric Exercise Reduce Pain and Improve Strength in Physically Active Adu