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Also known as tibialis posterior dysfunction, posterior tibial dysfunction and adult acquired flatfoot deformity
PTTD Staging
Johnson KA, Strom DE: Tibialis posterior tendon dysfunction. Clinical Ortho., 239:196-206, 1989. Myerson MS: Adult acquired flatfoot deformity: treatment of dysfunction of the posterior tibial tendon. JBJS, 78:780-792, 1996.
Multiple staging systems proposed by various authors to classify the clinical severity of PTTD Most commonly used staging system is that proposed by Johnson and Strom in 1989 that was later modified by Myerson in 1996
Research with Penn State Biomechanics Lab involves using motion-based method to determine STJ axis location in both cadaver and live subjects without drilling pins into talus
Lewis GS, Kirby KA, Piazza SJ: Determination of subtalar joint axis location by restriction of talocrural joint motion. Gait and Posture. 25:63-69, 2007.
Lewis GS, Cohen TL, Seisler AR, Kirby KA, Sheehan FT, Piazza SJ: In vivo tests of an improved method for functional location of the subtalar joint axis. J Biomechanics, 42:146-151, 2009.
Kirby KA: Methods for determination of positional variations in the subtalar joint axis. JAPMA, 77: 228-234, 1987.
Points of No Rotation
Severely Medially Deviated STJ Axis in Patient with PTTD (Right Foot)
STJ Axis
Kirby KA: Conservative treatment of posterior tibial dysfunction, Podiatry Management, Vol 19, No 7, pp. 73-82, 2000.
Shortened PT tendon supination moment arm creates need for increased PT muscle contractile force to produce a given magnitude of STJ supination moment Increased tensile stress on PT tendon results that may cause tendon injury of PT tendinitis/PTTD
Stress
Ultimate Stress Yield Point Elastic Limit Rupture Point Proportional Limit
Linear Region
Toe Region
Strain
Increased STJ axis medial deviation also increases medial distance from forefoot to STJ axis which increases STJ pronation moment from GRF STJ pronation moments are, therefore, greatest in late midstance when forefoot GRF is greatest
http://www.footankleinstitute.co m/TendonInjury.html
Feet with PTTD Have Reduced Plantar Area Medial to STJ Axis
As STJ axis becomes medially deviated, foot orthosis has decreased surface area medial to STJ axis by which to generate STJ supination moments
Synergy of Medial Heel Skive and Increased Orthosis Medial Arch Height
Medial heel skive without increased medial arch height causes too little medial longitudinal arch force from orthosis to optimize pronation control Increased medial arch height without medial heel skive causes excessive medial arch force from orthosis Combination of both medial heel skive and increased medial longitudinal arch height in orthosis will result in optimum synergistic STJ supination effect from orthosis
Areas of increased medial arch and medial heel pressure from medial heel skive orthosis
High Top Boots/Shoes are Needed Along With Foot Orthoses for PTTD
Very important that patient wear orthoses in high top hiking boots or high top shoes to increase orthosis efficacy
Medial T-Strap
Kirby KA: Subtalar joint axis location and rotational equilibrium theory of foot function. JAPMA, 91:465-488, 2001.
1. Posterior calcaneal displacement osteotomy causes medial shift in plantar calcaneus relative to STJ axis which increases STJ supination moment when GRF acts plantar to calcaneus
2. Posterior calcaneal displacement osteotomy also causes a medial shift in Achilles tendon force relative to STJ axis which increases supination moment during late midstance and propulsion, when Achilles tendon tensile forces are greatest
Kirby KA, Loendorf AJ, Gregorio R: Anterior axial projection of the foot. JAPMA, 78: 159-170, 1988.
Anterior axial projection allows reproducible method of obtaining frontal plane image of relative positions of plantar rearfoot, forefoot and ankle mortise while the patient stands in angle and base of gait
Clark JR, Gerbert J, Jenkin WM: The Kirby view: A radiographic view for flatfoot evaluation. JFAS, 43:436-439, 2004.
Positioning device
X-ray tube
Photo courtesy of J. Gerbert, DPM
Patient is positioned on device with center of second digit and center of plantar calcaneus resting on longitudinal bisection line Patient is positioned in angle and base of gait with opposite foot resting on surface of same height as positioning device
Anterior axial projection readily demonstrates plantar contours of calcaneus and its position relative to ankle mortise Plantar contours of medial and lateral calcaneal tubercles are well visualized relative to horizontal reference marker and relative to ankle mortise
Normal
Pes Planus
Pes Cavus
Anterior axial projection is used to document relative changes in calcaneal position with posterior displacement calcaneal osteotomies which are commonly used for surgical treatment of PTTD