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