Assessing The Severity Of Posterior Tibial Tendon Dysfunction

When treating a patient with recently arising posterior tibial tendon dysfunction (PTTD), evaluating the severity of the deformity is invaluable to guiding treatment.

Consider a 63-year-old man who is 220 pounds and has PTTD. He says the pain started after doing some low weight leg presses. The pain was not acute but has become progressively worse. Initially, the pain was behind the medial ankle but is now very tender in the front of ankle toward the top of the foot. He estimates the pain at 6/10 on the Visual Analogue Scale. Radiographs show moderate pronation and some foot drop coming from the navicular.

When treating a patient with new onset PTTD, one must confirm the diagnosis and stage the patient at stage I, II, III, or IV. Then the goal is finding a treatment to get the patient into a consistent 0-2 pain level. Typically, these treatments include a controlled ankle motion (CAM) boot, a combination of a CAM boot and PTTD braces, or even crutches if necessary at times. I find patients need various things at different times so it may be appropriate to tape and use orthotics for some activities, employ a Richie Brace for some activities and use a below-knee CAM walker for other activities. Unless the patient has severe stage III or early stage IV and surgery is an option, most patients are walking while they go about life.

In order to advise patients with PTTD, the five common criteria I use to ascertain the severity of PTTD are as follows …

1. What does it take to maintain a 0-2 pain level?
2. What is the tendon’s strength and the patient’s pain when testing the tendon against resistance (manual muscle test in office)?
3. Has the patient noted any subjective increase in pronation or is there an objective increase in pronation as per the clinical evaluation and X-rays?
4. What does the magnetic resonance image (MRI) tell us of the state of the tendon? 
5. Can the patient raise the heel off the ground in single leg support positioning and how much? Does it hurt? 

Editor’s note: This blog originally appeared at https://www.drblakeshealingsole.com/2018/08/posterior-tibial-tendon-dysfunction.html. It is reprinted with permission from the author.