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

Lower limbs biomechanical deficits associated with stage 1 and 2 posterior tibialis tendon dysfunction during walking

BACKGROUND

Posterior tibialis tendon dysfunction (PTTD) is a chronic degenerative musculoskeletal disorder causing a progressive ankle complex and arch collapse altering lower limb biomechanics. However, biomechanical changes associated with stage 1 and 2 PTTD need to be better characterized during walking to guide clinical recommendations and improve non-operative treatments.

RESEARCH QUESTION

What are the lower limb kinematic and kinetic differences between individuals with stage 1 (PTTD1), individuals with stage 2 PTTD (PTTD2) and healthy counterparts during gait?

METHODS

Sixteen PTTD1, 11 PTTD2 and 20 healthy controls were included in this multicentric case-control study to compare their lower limb gait biomechanics. Kinematic and kinetic data were recorded using a three-dimensional motion capture system and a force plate. One-dimensional statistical parametric mapping was used to compare lower limb joint motion and moments between groups during the stance phase.

RESULTS

PTTD1 had minimal biomechanical differences compared with the control group. In contrast, PTTD2 presented significant differences compared with controls and PTTD1. At the ankle, PTTD2 exhibited greater plantarflexion and eversion angles and midfoot dorsiflexion and inversion angles throughout stance compared with controls and PTTD1. PTTD2 presented lower midfoot abduction moments compared with controls. These changes led PTTD2 to exhibit knee and hip adaptative biomechanical mechanisms in the frontal and transverse planes in late stance. PTTD2 had greater knee internal rotation angles and smaller knee external rotation moments compared to controls. PTTD2 had smaller hip internal rotation angles compared with PTTD1 and smaller hip adduction moments compared with controls.

SIGNIFICANCE

PTTD1 showed minimal biomechanical differences compared to controls and important differences compared to PTTD2. The lower limb biomechanical deficits accentuate as the pathology advances from stage 1 to stage 2. PTTD is a progressive condition needing early clinical management at stage 1 to avoid successive biomechanical changes associated with stage 2.

What's the clinical significance of VAS, AOFAS, and SF-36 in progressive collapsing foot deformity

BACKGROUND

This study aimed to ascertain the minimal clinically important difference (MCID), and substantial clinical benefit (SCB) of the American Orthopedic Foot and Ankle Society (AOFAS) scale, visual analog scale (VAS) for pain, and Short Form-36 Health Survey (SF-36) in progressive collapsing foot deformity (PCFD) surgery.

METHODS

In this retrospective cohort study, a total of 84 patients with PCFD (84 feet) who underwent surgery between July 2015 and April 2021 were included. The study assessed the patients' subjective perception, as well as their VAS, AOFAS, and SF-36 scores at a minimum two-year follow-up, and these data were subjected to statistical analysis. The study utilized Spearman correlation analysis to determine the degree of correlation between patients' subjective perception and their VAS, AOFAS, and SF-36 scores. The minimal detectable change (MDC), MCID, and SCB for VAS, AOFAS, and SF-36 were calculated using both distribution- and anchor-based methods. The classification outcomes obtained from the distribution- and anchor-based methods were assessed using Cohen's kappa.

RESULTS

Based on the subjective perception of the patients, a total of 84 individuals were categorized into three groups, with 7 in the no improvement group, 14 in the minimum improvement group, and 63 in the substantial improvement group. Spearman's correlation analysis indicated that the patients' subjective perception exhibited a moderate to strong association with VAS, AOFAS, SF-36 PCS, and SF-36 MCS, with all coefficients exceeding 0.4. The MCID of VAS, AOFAS, SF-36 PCS, and SF-36 MCS in PCFD surgery were determined to be 0.93, 5.84, 4.15, and 4.10 points using the distribution-based method and 1.50, 10.50, 8.34, and 3.03 points using the anchor-based method. The SCB of VAS, AOFAS, SF-36 PCS, and SF-36 MCS in PCFD surgery were 2.50, 18.50, 11.88, and 6.34 points, respectively. Moreover, the preliminary internal validation efforts have demonstrated the practical application and clinical utility of these findings. With the exception of the distribution-based MCID of SF-36 PCS, which showed fair agreement, all other measures demonstrated moderate to almost perfect agreement.

CONCLUSIONS

The MDC, MCID, and SCB intuitively enhance the interpretation of VAS, AOFAS, and SF-36 in PCFD surgery, assisting all stakeholders to better understand the therapeutic benefits and limitations of clinical care, and thus to make a more rational decision. Each of these parameters has its own emphasis and complements the others. These parameters are recommended for evaluating the clinical relevance of the results, and their promotion should extend to other areas of foot and ankle surgery.

Characterising tibialis posterior tendinopathy using the International Classification of Functioning, Disability and Health: a cross sectional study

BACKGROUND

Tibialis posterior tendinopathy (TPT) is characterised by pain around the medial foot/ankle and difficulties weightbearing.

OBJECTIVE

Compare individuals who have TPT with asymptomatic controls across the International Classification of Functioning, Disability and Health (ICF) domains of body structure and function, activity, participation and personal factors.

METHODS

Twenty-two individuals meeting the selection criteria for TPT (86% female, mean ± SD age:43 ± 13 years; body mass index [BMI]:28 ± 7 kg/m²) were compared to 27 controls (93% female, age:44 ± 16 years, BMI:23 ± 5 kg/m²). Standardised differences (and 95% confidence intervals [CIs]) between groups were estimated for outcomes under each ICF domain using Cliff's delta to allow for comparison of the magnitude of deficits across outcomes (>0.47 considered large).

RESULTS

Impairments in body structure and function in individuals with TPT were accompanied by activity limitations including difficulties due to foot problems (-1.0 (-1.0, -1.0)) and with independent living (-0.8 (-1.0, -0.3)) and greater time to complete stair descent/ascent (-0.6 (-0.8, -0.3)). Considering participation, overall foot-related function (-1.0 (-1.0, -1.0)), ability to participate in activities (-0.7 (-0.08, -0.3)), social restrictions (-0.8 (-1.0, -0.4)) and quality of life (-0.7 (-0.9, -0.5)) were poorer in individuals with TPT.

CONCLUSION

Individuals with TPT have large impairments in body structure and function, activity limitations and participation restrictions, particularly relating to independent living, mental health and pain. Personal factors appear to contribute to a lesser extent to the TPT presentation. Treatment plans should consider activity and participation limitations in addition to body structure and function.

Anatomical Study of Sites and Surface Area of the Attachment Region of Tibial Posterior Tendon Attachment

BACKGROUND

The purpose of this study was not only to examine the attachment site but also to quantify the effect of the tibialis posterior tendon (TPT) on each attachment site by examining the surface area of the attachment region.

METHODS

We examined 100 feet from 50 Japanese cadavers. The TPT attachment to the navicular bone (NB), medial cuneiform bone (MCB), and lateral cuneiform bone (LCB) were set as the main attachment sites (Type I). The attachment seen in Type I with the addition of one additional site of attachment was defined as Type II. Furthermore, surface area was measured using a three-dimensional scanner.

RESULTS

Attachment to the NB, MCB, and LCB was present in all specimens. The TPT attachment to the NB, MCB, and LCB comprised 75.1% of total attachment surface area. The ratio of the NB, MCB, and LCB in each type was about 90% in Types II and III, and 70-80% in Types IV-VII.

CONCLUSION

The quantitative results demonstrated the NB, MCB, and LCB to be the main sites of TPT attachment, although individual differences in attachment sites exist, further developing the findings of previous studies.

Histoarchitecture of the fibrillary matrix of human fetal posterior tibial tendons

Adult tendons are highly differentiated. In mature individuals, tendon healing after an injury occurs through fibrotic tissue formation. Understanding the intrinsic reparative properties of fetal tendons would help to understand the maturation tissue process and tendon tissue repair. The present study evaluated the evolution of histoarchitecture, cellularity and the distribution of collagens I, III and V in the posterior tibial tendon in human fetuses at different gestational ages. Morphological profiles were assessed in nine fresh spontaneously aborted fetuses (Group I: five fetuses aged between 22 and 28 weeks of gestation; Group II: four fetuses aged between 32 and 38 weeks of gestation), characterized by a combination of histology, fluorescence and immunohistochemistry. In Group I, the posterior tibial tendon showed statistically significant greater cellularity and presence of collagen III and V than in Group II tendon, which showed a predominance of collagenous I and a better organization of the extracellular matrix compared with Group I tendons. In addition, a statistically significant higher rate of CD90, a marker of mesenchymal cells, was found in Group I tendons. In fetuses with gestational age between 22 and 28 weeks, the posterior tibialis tendons showed a thin and disorganized fibrillar structure, with an increase in collagen III and V fibers and mesenchymal cells. In the posterior tibialis tendons of fetuses with gestational age between 32 and 38 weeks, the fibrillar structure was thicker with a statistically significant increase in type I collagen and decreased cellularity.

Three-dimensional motion analysis of the hindfoot resulting from simulated contraction of individual lower leg muscles utilizing Thiel-embalmed cadavers

BACKGROUND

Joint movement within the foot is complex involving multiple muscles. We evaluated three-dimensional movement of the hindfoot through simulated traction of extrinsic tendons of the foot.

METHODS

Six Thiel-embalmed cadavers were utilized and thread was sutured to each tendon of the lower leg muscles. Traction of the thread was prescribed and the change of calcaneal position used to quantify foot motion was measured for each increment using a magnetic tracking system.

RESULTS

As the tendon traction length advanced, the angle of the calcaneus with respect to the tibia increased linearly. Eversion and abduction angles due to extensor digitorum longus (EDL) traction were significantly greater than that due to the peroneus longus. Plantarflexion due to Achilles tendon traction was significantly greater than that of other plantarflexors.

CONCLUSIONS

Our results demonstrated three-dimensional characteristics of hindfoot motion by simulated muscle contraction and importance of EDL as an evertor. These information should be applicable for tendon transfer procedures around the ankle and physical therapy for ankle dysfunction such as chronic ankle instability.

A New Anatomical Classification for Tibialis Posterior Tendon Insertion and Its Clinical Implications: A Cadaveric Study

The variations in the tibialis posterior tendon (TPT) could not be defined by previous classification; thus, this study used a larger-scale cadaver with the aim to classify the types of TPT insertion based on the combination of the number and location of TPT insertions. A total of 118 feet from adult formalin-fixed cadavers were dissected (68 males, 50 females). The morphological characteristics and measurements of TPT insertion were evaluated. Four types of TPT insertions were classified, wherein the most common type was type 4 (quadruple insertions, 78 feet, 66.1%), which was divided into four new subtypes that were not defined in the previous classification. The second most common type was type 3 (triple insertions, 25 feet, 21.2%) with three subtypes, including the new subtype. Type 2 was found in 13 feet (11%), and the rarest type was type 1 (2 feet, 1.7%), wherein the main tendon was only attached to the navicular bone and the medial cuneiform bone. We suggest high morphological variability of the TPT in relation to the insertion location, along with the possibility of significant differences according to race and gender. Moreover, this classification will help clinicians understand adult flatfoot deformity-related posterior tibial tendon dysfunction (PTTD).

Biomechanical effects of three types of foot orthoses in individuals with posterior tibial tendon dysfunction

BACKGROUND

Posterior tibial tendon dysfunction (PTTD) is characterized by degeneration of this tendon leading to a flattening of the medial longitudinal arch of the foot. Foot orthoses (FOs) can be used as a treatment option, but their biomechanical effects on individuals with PTTD are not yet fully understood.

RESEARCH QUESTION

The aim of this study was to investigate the effects of three types of FOs on gait biomechanics in individuals with PTTD.

METHODS

Fourteen individuals were recruited with painful stage 1 or 2 PTTD based on Johnson and Strom's classification. Quantitative gait analysis of the affected limb was performed in four conditions: shoes only (Shoe), prefabricated FO (PFO), neutral custom FO (CFO) and custom varus FO (CVFO) with a 5° medial wedge and a 4 mm medial heel skive. A curve analysis, using 1D statistical parametric mapping, was undertaken to assess differences in lower limb joint motion, joint moments and muscle activity over the stance phase of gait across conditions.

RESULTS

Decreased hindfoot eversion angles, decreased ankle inversion moments and increased ankle eversion moments were observed with custom FOs compared to the Shoe and PFO conditions (p < 0.001). CFOs and CVFOs induced an increased knee abduction moment compared to Shoe (p < 0.001). No changes in hip kinematics and kinetics or in EMG activity of tested muscles were observed between conditions.

SIGNIFICANCE

Custom orthoses may be more suitable than PFOs to decrease the pathological biomechanical outcomes observed in PTTD. Decreased ankle inversion moments during the stance phase could explain why custom orthoses are effective at reducing pain in PTTD patients. However, clinicians should be careful when prescribing custom orthoses for PTTD since unwanted collateral biomechanical effects can be observed at the knee.

Injection Techniques for Common Chronic Pain Conditions of the Foot: A Comprehensive Review

Purpose of Review

This is a comprehensive literature review of the available evidence and techniques of foot injections for chronic pain conditions. It briefly describes common foot chronic pain syndromes and then reviews available injection techniques for each of these syndromes, weighing the available evidence and comparing the available approaches.

Recent Findings

Foot and ankle pain affects 20% of the population over 50 and significantly impairs mobility and ability to participate in activities of daily living (ADLs), as well as increases fall risk. It is commonly treated with costly surgery, at times with questionable efficacy. Injection therapy is challenging when the etiology is anatomical or compressive. Morton’s neuroma is a budging of the interdigital nerve. Steroid, alcohol, and capsaicin injections provide some benefit, but it is short lived. Hyaluronic acid (HA) injection provided long-term relief and could prove to be a viable treatment option. Achilles tendinopathy (AT) is most likely secondary to repeat tendon stress—platelet-rich-plasma (PRP) and prolotherapy have been trialed for this condition, but more evidence is required to show efficacy. Similar injections were trials for plantar fasciitis and achieved only short-term relief; however, some evidence suggests that PRP injections reduce the frequency of required therapy. Tarsal tunnel syndrome, a compressive neuropathy carries a risk of permanent neural injury if left untreated. Injection therapy can provide a bridge to surgery; however, surgical decompression remains the definitive therapy. When the etiology is inflammatory, steroid injection is more likely to provide benefit. This has been shown in several studies for gout, as well as osteoarthritis of the foot and ankle and treatment-refractory rheumatoid arthritis. HA showed similar benefit, possibly due to anti-inflammatory effects. Stem cell injections may provide the additional benefit of structure restoration.

Summary

Chronic foot pain is common in the general population and has significant associated morbidity and disability. Traditionally treated with surgery, these are costly and only somewhat effective. Injections provide an effective alternative financially and some evidence exists that they are effective in pain alleviation. However, current evidence is limited and the benefit described from injection therapy has been short-lived in most cases. Further studies in larger populations are required to evaluate the long-term effects of these treatments.

"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.

A proposal for a new classification for the tendon of insertion of tibialis posterior

Although the tendon of the tibialis posterior muscle (TPM) is high morphological variability, its insertion is not well defined in anatomy discussions. The aim of the work is to systematize the classification of tibialis posterior tendon insertion by anatomical dissection. Classical anatomical dissection was performed on 80 lower limbs (40 female, 40 male) fixed in 10% formalin solution. The morphology of the insertion of the tendon was evaluated, and the muscle was subjected to appropriate morphometric measurements. Four types of insertion were observed, the most common being Type III (35 cases - 43.75%): a triple distal attachment where the main tendon inserts to the navicular bone and the medial cuneiform bone, and two accessory bands insert to the medial, lateral, or intermediate cuneiform bone or to the metatarsal bones (II, III, IV, V) depending on subtypes (A-C). The second most common type was Type II (18 cases: 22.5%): a double distal attachment. Type IV (14 cases: 17.5%) was characterized by quadruple distal attachment and was also divided into three subtypes (A-B). The rarest type was Type I (13 cases: 16.25%), which was characterized by a single band: the main tendon inserts to the navicular bone and the medial cuneiform bone. The tendon of the TPM presents high morphological variability. Knowledge of the four particular types of insertions is essential for both clinicians and anatomists. Clin. Anat. 32:557-565, 2019. © 2019 Wiley Periodicals, Inc.