Randomized Controlled Trial Comparing Orthosis Augmented by Either Stretching or Stretching and Strengthening for Stage II Tibialis Posterior Tendon Dysfunction

Exercise therapy for tendinopathy: a mixed-methods evidence synthesis exploring feasibility, acceptability and effectiveness

Background

Tendinopathy is a common, painful and functionally limiting condition, primarily managed conservatively using exercise therapy.

Review questions

(i) What exercise interventions have been reported in the literature for which tendinopathies? (ii) What outcomes have been reported in studies investigating exercise interventions for tendinopathy? (iii) Which exercise interventions are most effective across all tendinopathies? (iv) Does type/location of tendinopathy or other specific covariates affect which are the most effective exercise therapies? (v) How feasible and acceptable are exercise interventions for tendinopathies?

Methods

A scoping review mapped exercise interventions for tendinopathies and outcomes reported to date (questions i and ii). Thereafter, two contingent systematic review workstreams were conducted. The first investigated a large number of studies and was split into three efficacy reviews that quantified and compared efficacy across different interventions (question iii), and investigated the influence of a range of potential moderators (question iv). The second was a convergent segregated mixed-method review (question v). Searches for studies published from 1998 were conducted in library databases (n = 9), trial registries (n = 6), grey literature databases (n = 5) and Google Scholar. Scoping review searches were completed on 28 April 2020 with efficacy and mixed-method search updates conducted on 19 January 2021 and 29 March 2021.

Results

Scoping review - 555 included studies identified a range of exercise interventions and outcomes across a range of tendinopathies, most commonly Achilles, patellar, lateral elbow and rotator cuff-related shoulder pain. Strengthening exercise was most common, with flexibility exercise used primarily in the upper limb. Disability was the most common outcome measured in Achilles, patellar and rotator cuff-related shoulder pain; physical function capacity was most common in lateral elbow tendinopathy. Efficacy reviews - 204 studies provided evidence that exercise therapy is safe and beneficial, and that patients are generally satisfied with treatment outcome and perceive the improvement to be substantial. In the context of generally low and very low-quality evidence, results identified that: (1) the shoulder may benefit more from flexibility (effect sizeResistance:Flexibility = 0.18 [95% CrI 0.07 to 0.29]) and proprioception (effect sizeResistance:Proprioception = 0.16 [95% CrI -1.8 to 0.32]); (2) when performing strengthening exercise it may be most beneficial to combine concentric and eccentric modes (effect sizeEccentricOnly:Concentric+Eccentric = 0.48 [95% CrI -0.13 to 1.1]; and (3) exercise may be most beneficial when combined with another conservative modality (e.g. injection or electro-therapy increasing effect size by ≈0.1 to 0.3). Mixed-method review - 94 studies (11 qualitative) provided evidence that exercise interventions for tendinopathy can largely be considered feasible and acceptable, and that several important factors should be considered when prescribing exercise for tendinopathy, including an awareness of potential barriers to and facilitators of engaging with exercise, patients' and providers' prior experience and beliefs, and the importance of patient education, self-management and the patient-healthcare professional relationship.

Limitations

Despite a large body of literature on exercise for tendinopathy, there are methodological and reporting limitations that influenced the recommendations that could be made.

Conclusion

The findings provide some support for the use of exercise combined with another conservative modality; flexibility and proprioception exercise for the shoulder; and a combination of eccentric and concentric strengthening exercise across tendinopathies. However, the findings must be interpreted within the context of the quality of the available evidence.

Future work

There is an urgent need for high-quality efficacy, effectiveness, cost-effectiveness and qualitative research that is adequately reported, using common terminology, definitions and outcomes.

Study registration

This project is registered as DOI: 10.11124/JBIES-20-00175 (scoping review); PROSPERO CRD 42020168187 (efficacy reviews); https://osf.io/preprints/sportrxiv/y7sk6/ (efficacy review 1); https://osf.io/preprints/sportrxiv/eyxgk/ (efficacy review 2); https://osf.io/preprints/sportrxiv/mx5pv/ (efficacy review 3); PROSPERO CRD42020164641 (mixed-method review).

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) HTA programme and will be published in full in HTA Journal; Vol. 27, No. 24. See the NIHR Journals Library website for further project information.

Effects of foot intensive rehabilitation (FIRE) on clinical outcomes for patients with chronic ankle instability: a randomized controlled trial protocol

BACKGROUND

Lateral ankle sprains account for a large proportion of musculoskeletal injuries among civilians and military service members, with up to 40% of patients developing chronic ankle instability (CAI). Although foot function is compromised in patients with CAI, these impairments are not routinely addressed by current standard of care (SOC) rehabilitation protocols, potentially limiting their effectiveness. The purpose of this randomized controlled trial is to determine if a Foot Intensive REhabilitation (FIRE) protocol is more effective compared to SOC rehabilitation for patients with CAI.

METHODS

This study will use a three-site, single-blind, randomized controlled trial design with data collected over four data collection points (baseline and post-intervention with 6-, 12-, and 24-month follow-ups) to assess variables related to recurrent injury, sensorimotor function, and self-reported function. A total of 150 CAI patients (50 per site) will be randomly assigned to one of two rehabilitation groups (FIRE or SOC). Rehabilitation will consist of a 6-week intervention composed of supervised and home exercises. Patients assigned to SOC will complete exercises focused on ankle strengthening, balance training, and range of motion, while patients assigned to FIRE will complete a modified SOC program along with additional exercises focused on intrinsic foot muscle activation, dynamic foot stability, and plantar cutaneous stimulation.

DISCUSSION

The overall goal of this trial is to compare the effectiveness of a FIRE program versus a SOC program on near- and long-term functional outcomes in patients with CAI. We hypothesize the FIRE program will reduce the occurrence of future ankle sprains and ankle giving way episodes while creating clinically relevant improvements in sensorimotor function and self-reported disability beyond the SOC program alone. This study will also provide longitudinal outcome findings for both FIRE and SOC for up to two years. Enhancing the current SOC for CAI will improve the ability of rehabilitation to reduce subsequent ankle injuries, diminish CAI-related impairments, and improve patient-oriented measures of health, which are critical for the immediate and long-term health of civilians and service members with this condition. Trial Registration Clinicaltrials.gov Registry: NCT #NCT04493645 (7/29/20).

The Role of Equinus in Flatfoot Deformity

Equinus plays an important role in flatfoot deformity. Proper evaluation and surgical management are critical to comprehensively treat and successfully resolved patients' symptoms. We have discussed the cause, evaluation, and some of the common surgical options. Each procedure has its inherent benefits and risks. It is imperative that the foot and ankle surgeon identify and include these procedures as part of the complete reconstructive surgery.

Characteristics and Future Direction of Tibialis Posterior Tendinopathy Research: A Scoping Review

Background and Objectives: Tibialis posterior tendon pathologies have been traditionally categorized into different stages of posterior tibial tendon dysfunction (PTTD), or adult acquired flatfoot deformity (AAFD), and more recently to progressive collapsing foot deformity (PCFD). The purpose of this scoping review is to synthesize and characterize literature on early stages of PTTD (previously known as Stage I and II), which we will describe as tibialis posterior tendinopathy (TPT). We aim to identify what is known about TPT, identify gaps in knowledge on the topics of TPT, and propose future research direction. Materials and Methods: We included 44 studies and categorized them into epidemiology, diagnosis, evaluation, biomechanics outcome measure, imaging, and nonsurgical treatment. Results: A majority of studies (86.4%, 38 of 44 studies) recruited patients with mean or median ages greater than 40. For studies that reported body mass index (BMI) of the patients, 81.5% had mean or median BMI meeting criteria for being overweight. All but two papers described study populations as predominantly or entirely female gender. Biomechanical studies characterized findings associated with TPT to include increased forefoot abduction and rearfoot eversion during gait cycle, weak hip and ankle performance, and poor balance. Research on non-surgical treatment focused on orthotics with evidence mostly limited to observational studies. The optimal exercise regimen for the management of TPT remains unclear due to the limited number of high-quality studies. Conclusions: More epidemiological studies from diverse patient populations are necessary to better understand prevalence, incidence, and risk factors for TPT. The lack of high-quality studies investigating nonsurgical treatment options is concerning because, regardless of coexisting foot deformity, the initial treatment for TPT is typically conservative. Additional studies comparing various exercise programs may help identify optimal exercise therapy, and investigation into further nonsurgical treatments is needed to optimize the management for TPT.

Physiotherapy treatment of lateral epicondylitis: A systematic review

BACKGROUND

Lateral epicondylitis is a tendinopathy with a prevalence of between 1-3% of the population aged 35-54 years. It is a pathology with a favorable evolution, but with frequent recurrences (which imply an economic extra cost).

OBJECTIVE

The objective of this review was to determine the efficacy of physiotherapy treatment for the treatment of epicondylitis and, if any, to identify the most appropriate techniques.

METHODS

A systematic search was carried out in October 2020 in the databases of PubMed, Cinahl, Scopus, Medline and Web of Science using the search terms: Physical therapy modalities, Physical and rehabilitation medicine, Rehabilitation, Tennis elbow and Elbow tendinopathy.

RESULTS

Nineteen articles were found, of which seven applied shock waves, three applied orthoses, three applied different manual therapy techniques, two applied some kind of bandage, one applied therapeutic exercise, one applied diacutaneous fibrolysis, one applied high intensity laser, and one applied vibration.

CONCLUSIONS

Manual therapy and eccentric strength training are the two physiotherapeutic treatment methods that have the greatest beneficial effects, and, furthermore, their cost-benefit ratio is very favorable. Its complementation with other techniques, such as shock waves, bandages or Kinesio® taping, among others, facilitates the achievement of therapeutic objectives, but entails an added cost.

Assessment of the reporting quality of resistance training interventions in randomised controlled trials for lower limb tendinopathy: A systematic review

OBJECTIVES

1. To describe what exercises and intervention variables are used in resistance training interventions in randomised controlled trials for lower limb tendinopathy 2. To assess completeness of reporting as assessed by the Consensus on Exercise Reporting Template (CERT) and the Toigo and Boutellier framework. 3. To assess the implementation of scientific resistance training principles. 4. To assess therapeutic quality of exercise interventions with the i-CONTENT tool.

DATA SOURCES

We searched MEDLINE, CINAHL, AMED, EMBase, SPORTDiscus, and the Cochrane library databases.

REVIEW METHODS

Systematic review of randomised controlled trials that reported using resistance exercises for lower limb tendinopathies.

RESULTS

We included 109 RCTs. Eccentric heel drops were the most common exercise (43 studies), followed by isotonic heel raises (21), and single leg eccentric decline squats (18). Reporting of exercise descriptor items from the Toigo and Boutellier framework ranged from 0-13, with an average score of 9/13, and only 7 studies achieved a full 13/13. Reporting of items from the CERT ranged from 0-18, with an average score of 14/19. No study achieved a full 19/19, however 5 achieved 18/19. Scoring for resistance training principles ranged from 1-10, with only 11 studies achieving 10/10. Reporting across studies for the i-CONTENT tool ranged from 2-7, with an average score of 5 across included studies. A total of 19 studies achieved a full 7/7 score. Less than 50% of studies achieved an overall low risk of bias, highlighting the methodological concerns throughout studies.

CONCLUSION

The reporting of exercise descriptors and intervention content was generally high across RCTs for lower limb tendinopathy, with most allowing exercise replication. However, reporting for some tendinopathies and content items such as adherence was poor, limiting optimal translation to clinical practice.

Resistance Training Interventions for Lower Limb Tendinopathies: A Scoping Review of Resistance Training Reporting Content, Quality, and Scientific Implementation

The objectives of this scoping review were as follows: (1) to describe what exercises and intervention variables are used in resistance training interventions for lower limb tendinopathy,  (2) to assess the completeness of reporting as assessed by the Consensus on Exercise Reporting Template (CERT) and the Toigo and Boutellier framework, and (3) to assess the implementation of scientific resistance training principles. We searched MEDLINE, CINAHL, AMED, Embase, SPORTDiscus, and Cochrane Library databases. Randomized controlled trials, cohort studies, case series, case reports, and observational studies that reported using resistance exercises for lower limb tendinopathies were considered for inclusion, with 194 studies meeting the inclusion criteria. Completeness of the reporting of exercise descriptors and programme variables was assessed by the CERT and the Toigo and Boutellier framework. Reporting of exercise descriptor items from the Toigo and Boutellier framework ranged from 0 to 13, with an average score of 9/13, with only 9 studies achieving a full 13/13. Reporting of items from the CERT ranged from 0 to 18, with an average score of 13/19. No study achieved a full 19/19; however, 8 achieved 18/19. Scoring for resistance training principles ranged from 1 to 10, with only 14 studies achieving 10/10. Eccentric heel-drops were the most common exercise (75 studies), followed by isotonic heel raises (38), and single-leg eccentric decline squats (27). The reporting of exercise descriptors and intervention content was high across studies, with most allowing exercise replication, particularly for Achilles and patellar tendinopathy. However, reporting for some tendinopathies and content items such as adherence was poor, limiting optimal translation to clinical practice.

Comparison of the effects of low level laser and insoles on pain, functioning, and muscle strength in subjects with stage 2 posterior tibial tendon dysfunction: A randomized study

BACKGROUND

Low level laser therapy (LLLT) is known to be effective in tendinopathies. No study yet investigated the effect of LLLT on posterior tibial tendon dysfunction (PTTD) in comparison to orthotic treatment.

OBJECTIVE

The aim was to compare the effects of LLLT and insole application on pain, function and muscle strength in subjects with stage 2 PTTD.

METHODS

Fifty-two subjects with stage 2 PTTD were randomly assigned to the LLLT and insole groups. The foot pain, function and strength of invertor and evertor muscles of the subjects was evaluated before and after treatment, and after 9 months.

RESULTS

Significant improvement was observed in the foot function and pain (p< 0.05) in both groups after treatment, but in the 9-month follow-up, the insole group had better values. The increase in 180∘.sec-1 concentric invertor muscle strength was found significant after the treatment and in month-9 as compared to the initial values (p< 0.05).

CONCLUSIONS

Both treatments are effective in reducing treating foot pain, as well as improving the function in subjects with stage 2 PTTD. However, at the end of the 9-month follow-up, it was seen that insoles were more effective. Neither method had a clinically important effect on muscle strength.

Foot and ankle functions and deformities focus on posterior tibial tendon dysfunction using magnetic resonance imaging in patients with rheumatoid arthritis

OBJECTIVES

Posterior tibial tendon dysfunction (PTTD) affects the support of the medial longitudinal arch and stability of the hindfoot. The purpose of this study was to assess the relationships of PTTD with foot and ankle functions and foot deformities in patients with rheumatoid arthritis (RA).

METHODS

A total of 129 patients (258 feet) who underwent magnetic plain and contrast-enhanced magnetic resonance imaging were enrolled in this study. Positive magnetic resonance imaging findings were defined as tenosynovitis and incomplete and complete rupture of the posterior tibial tendon. Foot and ankle functions were assessed using the Japanese Society for Surgery of the Foot standard rating system for the RA foot and ankle scale (JSSF-RA) and self-administered foot evaluation questionnaire. Plain radiographs were examined for the hallux valgus angle, first metatarsal and second metatarsal angle, lateral talo-first metatarsal angle, and calcaneal pitch angle.

RESULTS

PTTD was associated with motion in the JSSF-RA (p = .024), activities of daily living in JSSF-RA (p = .017), and pain and pain-related factors in the self-administered foot evaluation questionnaire (p = .001). The calcaneal pitch angle was significantly lower in the feet with PTTD than in those without PTTD (median: 16.2° vs. 18.0°; p = .007).

CONCLUSIONS

The present study shows that PTTD was associated with foot and ankle functions and flatfoot deformity. Thus, a better understanding of PTTD in patients with RA is important for the management of foot and ankle disorders in clinical practice.

The Impact of Foot Orthoses and Exercises on Pain and Navicular Drop for Adult Flatfoot: A Network Meta-Analysis

Background: Adult flatfoot leads to injury and decreased quality of life. The most widely applied noninvasive approaches are wearing foot orthoses or exercising. Both interventions raise controversy about reducing pain and neutralizing foot posture. This study investigated the impact of foot orthoses and exercise on pain and navicular drop (present for foot posture). Methods: Four databases were used: MEDLINE, PubMed, Web of Science, and Cochrane, from the earliest records to November 2020. Randomized controlled studies focused on adult flatfoot that evaluated the effect of exercise and foot orthoses on pain and navicular drop were extracted. We used data analysis to estimate the relative effect of heterogeneity using I² and publication bias using funnel plots. Results: Ten studies were identified through to November 2020. Active interventions (AIs) were exercise and exercise combined with foot orthoses; passive interventions (PIs) were foot orthoses and added stretching. Both AIs and PIs decreased pain significantly (SMD −0.94, 95% CI −1.35, −0.54 and SMD −1.4, 95% CI −1.87, −0.92). The AIs reduced pain level better than PIs. Controversially, no treatment was found to affect navicular drop. Conclusion: Both exercise and foot orthoses can reduce pain but not realign foot posture. Exercise alone or combined with foot orthoses showed a better effect on adult flatfoot than only wearing foot orthoses. Active intervention was shown to have better efficacy in reducing pain than passive intervention.

Nonsurgical Approach in Management of Tibialis Posterior Tendinopathy With Combined Radial Shockwave and Foot Core Exercises: A Case Series

Tibialis posterior tendinopathy is a common debilitating condition seen by foot and ankle providers. Non-operative management is difficult as patients often present in later stages of the disease. This case series evaluated the combination of radial shockwave therapy and a foot core progression exercise regimen on 10 patients who had failed standard conservative treatment techniques. Median follow-up time was 4 months. Clinically important differences in the Foot and Ankle Ability Measure were met in 9 (90%) and 8 (80%) of patients for activities of daily living and sport sub-scores, respectively. No adverse effects were observed.

The implementation of resistance training principles in exercise interventions for lower limb tendinopathy: A systematic review

OBJECTIVES

The primary purpose of this systematic review is to examine the literature on resistance training interventions for lower limb tendinopathy to evaluate the proportion of interventions that implemented key resistance training principles (specificity, progression, overload, individualisation) and reported relevant prescription components (frequency, intensity, sets, repetitions) and reported intervention adherence.

METHODS

Two reviewers performed a systematic review after screening titles and abstracts based on eligibility criteria. Identified papers were obtained in full text, with data extracted regarding the implementation of resistance training principles. Included articles were evaluated by the Cochrane risk of bias tool, with a scoring tool out of 10 used for implementation and reporting of the 5 key principles. Scientific databases were searched in November 2020 and included Medline, CINAHL, AMED, and Sportsdiscus.

RESULTS

52 randomised controlled trials investigating resistance training in five different lower limb tendinopathies were included. Although most studies considered the principles of progression (92%) and individualisation (88%), only 19 studies (37%) appropriately described how this progression in resistance was achieved, and only 18 studies (35%) reported specific instruction on how individualisation was applied. Adherence was considered in 27 studies (52%), with only 17 studies (33%) reporting the levels of adherence. In the scoring criteria, only 5 studies (10%) achieved a total maximum score of 10, with 17 studies (33%) achieving a maximum score of 8 for implementing and reporting the principles of specificity, overload, progression and individualisation.

CONCLUSION

There is meaningful variability and methodological concerns regarding the application and reporting of resistance training principles, particularly progression and individualisation, along with intervention adherence throughout studies. Collectively, these findings have important implications for the prescription of current resistance training interventions, including the design and implementation of future interventions for populations with lower limb tendinopathies.

American College of Foot and Ankle Surgeons Clinical Consensus Statement: Appropriate Clinical Management of Adult-Acquired Flatfoot Deformity

This clinical consensus statement of the American College of Foot and Ankle Surgeons focuses on the highly debated subject of the management of adult flatfoot (AAFD). In developing this statement, the AAFD consensus statement panel attempted to address the most relevant issues facing the foot and ankle surgeon today, using the best evidence-based literature available. The panel created and researched 16 statements and generated opinions on the appropriateness of the statements. The results of the research on this topic and the opinions of the panel are presented here.

Orthotic treatment for stage I and II posterior tibial tendon dysfunction (flat foot): A systematic review

OBJECTIVE

To investigate whether orthotic treatment is effective for the treatment of posterior tibial tendon dysfunction stages I and II (flat foot).

DATA SOURCES

Five databases (PubMed, Scopus, PEDro, SPORTDiscus and The Cochrane Library) were searched for potential RCTs from their inception until August 2020.

REVIEW METHODS

Only randomised controlled trials (RCT) that included subjects diagnosed with posterior tibial dysfunction in the initial stage and treated with orthotic treatments were selected. The outcomes assessed were whatever symptom related to posterior tibial tendon dysfunction stage I and II. Included RCTs were appraised using the Cochrane collaboration risk of bias tool.

RESULTS

Four RCT articles and 186 subjects were included. 75% were at high risk of bias for blinding of participants and personnel. Three different types of conservative treatment were used in the studies: foot/ankle-foot orthoses, footwear and stretching /strengthening exercises. Foot orthoses, together with exercise programmes, seemed to improve the effect of orthotic treatment. Foot orthoses with personalised internal longitudinal arch support were more effective than flat insoles or standard treatments in reducing pain.

CONCLUSIONS

The use of orthotic treatment may be effective in reducing pain in the early stages of posterior tibial tendon dysfunction. Further research is needed into individualised orthotic treatment and high-intensity monitored exercise programmes.

Effects of a 4-Week Short-Foot Exercise Program on Gait Characteristics in Patients With Stage II Posterior Tibial Tendon Dysfunction

CONTEXT

Clinically, it has been suggested that increased activation of intrinsic foot muscles may alter the demand of extrinsic muscle activity surrounding the ankle joint in patients with stage II posterior tibial tendon dysfunction. However, there is limited empirical evidence supporting this notion.

OBJECTIVE

The purpose of this study was to investigate the effects of a 4-week short-foot exercise (SFE) on biomechanical factors in patients with stage II posterior tibial tendon dysfunction.

DESIGN

Single-group pretest-posttest.

SETTING

University laboratory.

PARTICIPANTS

Fifteen subjects (8 males and 7 females) with stage II posterior tibial tendon dysfunction who had pain in posterior tibial tendon, pronated foot deformity (foot posture index ≥+6), and flexible foot deformity (navicular drop ≥10 mm) were voluntarily recruited.

INTERVENTION

All subjects completed a 4-week SFE program (15 repetitions × 5 sets/d and 3 d/wk) of 4 stages (standing with feedback, sitting, double-leg, and one-leg standing position).

MAIN OUTCOME MEASURES

Ankle joint kinematics and kinetics and tibialis anterior and fibularis longus muscle activation (% maximum voluntary isometric contraction) during gait were measured before and after SFE program. Cohen d effect size (ES [95% confidence intervals]) was calculated.

RESULTS

During the first rocker, tibialis anterior activation decreased at peak plantarflexion (ES = 0.75 [0.01 to 1.49]) and inversion (ES = 0.77 [0.03 to 1.51]) angle. During the second rocker, peak dorsiflexion angle (ES = 0.77 [0.03 to 1.51]) and tibialis anterior activation at peak eversion (ES = 1.57 [0.76 to 2.39]) reduced. During the third rocker, the peak abduction angle (ES = 0.80 [0.06 to 1.54]) and tibialis anterior and fibularis longus activation at peak plantarflexion (ES = 1.34 [0.54 to 2.13]; ES = 1.99 [1.11 to 2.86]) and abduction (ES = 1.29 [0.50 to 2.08]; ES = 1.67 [0.84 to 2.50]) decreased.

CONCLUSIONS

Our 4-week SFE program may have positive effects on changing muscle activation patterns for tibialis anterior and fibularis longus muscles, although it could not influence their structural deformity and ankle joint moment. It could produce a potential benefit of decreased tibialis posterior activation.

"I need somebody who knows about feet" a qualitative study investigating the lived experiences of conservative treatment for patients with posterior tibial tendon dysfunction

Background

Posterior tibial tendon dysfunction is a disabling, chronic, progressive tendon condition that detrimentally affects foot, ankle and lower limb function. Research suggests that posterior tibial tendon dysfunction is poorly recognised and difficult to treat. When posterior tibial tendon dysfunction is diagnosed, the clinician is faced with a weak evidence base and guidelines for the common conservative treatments.to guide their management. Moreover, there are no current evidence-based guidelines for the conservative management of posterior tibial tendon dysfunction. Emerging research suggests that posterior tibial tendon dysfunction not only has a physical impact on the patient, but it also has psychosocial impact on quality of life.Conservative treatments for posterior tibial tendon dysfunction are generally undertaken during early management. The most common are foot orthoses, exercises, bracing, lifestyle changes and injections. Quantitative evidence supporting conservative treatments for posterior tibial tendon dysfunction in relation to function, pain and patient reported outcome measures are reported in the literature.There is a paucity of qualitative research investigating the psychosocial impact of the common treatments for posterior tibial tendon dysfunction. Interpretative phenomenology is concerned with lived experience which is involves the detailed exploration of experience which is embedded within the social and temporal contexts of the lifeworld of the person. The aim of study research is to investigate the lived experience of conservative treatments for patients who have posterior tibial tendon dysfunction using Interpretative Phenomenological Analysis.

Methods

Five participants with posterior tibial tendon dysfunction were purposively recruited from a private podiatry practice and semi-structured interviews were conducted to examine their lived experiences of treatment for posterior tibial tendon dysfunction. The data for this study was collected and analysed using Interpretative Phenomenological Analysis.

Results

This research identified three superordinate themes which influenced the lived experience of treatment for these patients (i) adverse experience during the patient journey (ii) treatment burden, and (iii) negative self-concept.

Conclusion

This study highlights some of what is anecdotally known about the lived experience of treatment for patients with posterior tibial tendon dysfunction, but has never been studied in a qualitative, methodological manner. This study addresses the gap in the qualitative literature. It reveals novel aspects of the lived experience throughout the patient journey, the detrimental impact of treatment burden, loss and negative self-concept. This evidence is important because it highlights the need for a greater understanding of the psychological and social factors that can influence the lived experience of treatment for this group of patients.

Evaluation and Treatment of Posterior Tibialis Tendon Insufficiency in the Elderly Patients

Introduction:

Posterior tibialis tendon insufficiency is the most common cause of adult acquired flatfoot deformity in elderly patients. We performed a literature search of primary and secondary journal articles pertaining to posterior tibialis tendon insufficiency in the geriatric population. We examined relevant data from these articles regarding current evaluation in addition to both conservative and advanced treatment approaches that correspond to disease severity.

Significance:

There is a paucity of literature to guide treatment of posterior tibialis tendon insufficiency in the elderly, and this condition may be more prevalent in geriatric patients than previously realized.

Results:

Posterior tibialis tendon insufficiency is an acquired defect that affects 10% of the geriatric population and disproportionately affects women. It is typically caused by degenerative changes. There are four primary stages of posterior tibialis tendon with subcategorizations that range from mild to severe. Conservative treatment with a variety of available ankle braces and non-steroidal anti-inflammatory medications are typically used to treat the first and second stage disease. Surgical repair is warranted for advanced second stage and above posterior tendon insufficiency. A variety of techniques have been proposed, and can include tendon transfer, hindfoot fusion, and even total ankle arthroplasty in extreme cases.

Conclusion:

Posterior tibialis tendon insufficiency causes marked discomfort and alters normal gait biomechanics. Elderly patients typically present with more severe manifestations of the disease. For patients requiring surgery, and especially geriatric patients, the ideal treatment is thought to be a procedure that is minimally invasive in order to maximize positive outcomes for elderly patients. More work is needed to examine clinical and radiographic outcomes of geriatric patients treated for posterior tibialis tendon insufficiency.

Exercise for posterior tibial tendon dysfunction: a systematic review of randomised clinical trials and clinical guidelines

Objective

To systematically review all randomised clinical trials to determine the efficacy of local strengthening exercises compared with other forms of conservative management for adults with posterior tibial tendon dysfunction.

Design

Systematic review.

Data sources

Four electronic databases (Cumulative Index to Nursing and Allied Health Literature, Cochrane, Embase and PubMed) were searched up to June 2018.

Eligibility criteria for selecting studies

The study included randomised clinical trials investigating individuals with posterior tibial tendon dysfunction where local strengthening was compared with other forms of conservative management with respect to pain, function and/or physical impairment outcome measures. Standardised mean differences (SMDs) were used to compare change scores between groups and descriptors of exercise prescription assessed according to the Template for Intervention Description and Replication and the Toigo and Boutellier recommendations.

Results

3 studies (n=93) were eligible for inclusion in the review. Varying strengthening exercises were compared with stretching and foot orthoses (n=2) or no intervention (n=1). Moderate effects (SMD 0.6-1.2) were found for reducing pain and disability with eccentric strengthening in conjunction with stretching and orthoses compared with concentric exercises, stretching and orthoses combined, and stretching and orthoses alone. Evaluation of exercise prescription parameters demonstrated minimal reporting, with the only consistent parameters being the number of sets and repetitions of the exercises, and the duration of the experimental period.

Conclusion

This review demonstrates the paucity of high-quality research for the conservative management of posterior tibial tendon dysfunction, and highlights the lack of exercise prescription parameters reported in clinical trials.

Trial registration number

CRD42017076156.

Self-reported social and activity restrictions accompany local impairments in posterior tibial tendon dysfunction: a systematic review

BACKGROUND

Posterior tibial tendon dysfunction (PTTD) is a painful, progressive tendinopathy that reportedly predominates in middle-age, overweight women. There is no evidence based guidelines that clinicians can use to guide treatment planning, which leaves clinicians to make decisions on the basis of presenting clinical impairments and self-reported pain and disability. The purpose of this systematic review was to quantify clinical impairments, pain and disability in individuals with PTTD compared with controls.

METHODS

Five databases were searched for terms referring to the posterior tibial tendon and flatfoot up to and including 11 March 2018. The systematic review was registered with PROSPERO (CRD: 42016046951). Studies were eligible if they were published in the English language and contained data on clinical impairments, pain or disability compared between participants diagnosed with PTTD and pain-free individuals. Standardised mean differences (SMDs) were calculated where possible and meta-analysis was performed when homogeneity of outcomes allowed.

RESULTS

Ten eligible studies were identified and pooled in the meta-analyses. Strong effects were revealed for poor heel rise endurance (SMD -1.52, 95% CI -2.05 to - 0.99), less forefoot adduction-inversion strength (SMD -1.19, 95% CI -1.68 to - 0.71) and lower arch height (SMD -1.76, 95% CI -2.29 to - 1.23). Compared to controls, individuals with PTTD also had more self-reported stiffness (SMD 1.45, 95% CI 0.91 to 1.99), difficulties caused by foot problems (SMD 1.42, 95% CI 0.52 to 2.33) and social restrictions (SMD1.26, 95% CI 0.25 to 2.27).

CONCLUSION

There is evidence of impaired tibialis posterior capacity and lowered arch height in individuals with PTTD compared to controls. Further to addressing the expected impairments in local tendon function and foot posture, pain, stiffness, functional limitations and social participation restrictions should be considered when managing PTTD.

Role of Tendoscopy in Treating Stage II Posterior Tibial Tendon Dysfunction

BACKGROUND

Stage II tibialis posterior tendon dysfunction (PTTD) resistant to conservative therapies is usually treated with invasive surgery. Posterior tibial tendoscopy is a novel technique being used in the assessment and treatment of posterior tibial pathology. The aims of this study were (1) to clarify the role of posterior tibial tendon tendoscopy in treating stage II PTTD, (2) to arthroscopically classify spring ligament lesions, and (3) to compare the arthroscopic assessment of spring ligament lesions with magnetic resonance imaging (MRI) and ultrasonographic (US) data.

METHODS

We reviewed prospectively collected data on 16 patients affected by stage II PTTD and treated by tendoscopy. We report the reoperation rate and functional outcomes evaluated by comparing pre- and postoperative visual analogic scale for pain (VAS-pain) and the Short-Form Health Survey (SF-36; with its physical [PCS] and mental [MCS] components). Postoperative satisfaction was assessed using a VAS-satisfaction scale. One patient was lost to follow-up. Spring ligament lesions were arthroscopically classified in 3 stages. Discrepancies between preoperative imaging and intraoperative findings were evaluated.

RESULTS

At a mean of 25.6 months' follow-up, VAS-pain ( P < .001), SF-36 PCS ( P = .039), and SF-36 MCS ( P < .001) significantly improved. The mean VAS-satisfaction score was 75.3/100. Patients were relieved from symptoms in 80% of cases, while 3 patients required further surgery. MRI and US were in agreement with intraoperative data in 92% and 67%, respectively, for the tendon assessment and in 78% and 42%, respectively, for the spring ligament.

CONCLUSIONS

Tendoscopy may be considered a valid therapeutic tool in the treatment of stage II PTTD resistant to conservative treatment. It provided objective and subjective encouraging results that could allow continued conservative therapy while avoiding more invasive surgery in most cases. MRI and US were proven more useful in detecting PT lesions than spring ligament tears. Further studies on PT could use this tendoscopic classification to standardize its description.

LEVEL OF EVIDENCE

Level IV, therapeutic study, case series.

Reported selection criteria for adult acquired flatfoot deformity and posterior tibial tendon dysfunction: Are they one and the same? A systematic review

BACKGROUND

Posterior tibial tendon dysfunction (PTTD) and adult acquired flatfoot deformity (AAFD) are used interchangeably, although both suggest quite different pathological processes.

OBJECTIVE

To investigate key differences in selection criteria used for inclusion into research studies.

METHODS

An electronic database search was performed from inception to June 2016. All primary research articles with clear inclusion/diagnostic criteria for PTTD or AAFD were included in the review. All criteria were extracted and synthesised into one aggregate list. Frequencies of recurring criteria were calculated and reported for each stage of the conditions.

RESULTS

Of the potentially eligible papers, 148 (65%) did not specify inclusion/selection criteria for PTTD or AAFD and were excluded. Eligibility criteria were reported 82 times in the 80 included papers, with 69 descriptions for PTTD and 13 for AAFD. After synthesis of criteria from all papers, there were 18 key signs and symptoms. Signs and symptoms were considered to be those relating to tendon pathology and those relating to structural deformity. The total number of individual inclusion/diagnostic criteria ranged from 2 to 9. The majority of articles required signs of both tendon dysfunction and structural deformity (84% for AAFD and 81% for PTTD). Across both groups, the most frequently reported criteria were abduction of the forefoot (11.5% of total criteria used), the presence of a flexible deformity (10.2%) and difficulty performing a single leg heel raise (10.0%). This was largely the case for the PTTD articles, whereas the AAFD articles were more focused on postural issues such as forefoot abduction, medial arch collapse, and hindfoot valgus (each 16.7%).

CONCLUSION

As well as synthesising the available literature and providing reporting recommendations, this review has identified that many papers investigating PTTD/AAFD do not state condition-specific selection criteria and that this limits their clinical applicability. Key signs and symptoms of PTTD and AAFD appear similar, except in early PTTD where no structural deformity is present. We recommend that PTTD is the preferred terminology for the condition associated with signs of local tendon dysfunction with pain and/or swelling along the tendon and difficulty with inversion and/or single leg heel raise characterising stage I and difficulty with single leg heel raise and a flexible flatfoot deformity characterizing stage II PTTD. While AAFD may be useful as an umbrella term for acquired flatfoot deformities, the specific associated aetiology should be reported in studies to aid consolidation and implementation of research into practice.

TRIAL REGISTRATION

Prospero ID: 42016046943.