Orthotics Q & A: Posterior Tibial Tendon Dysfunction

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Welcome back everybody, yet again to Podiatry Today podcast where we continue to bring you the latest in foot and ankle medicine and surgery from leaders in the field. We're honored to yet again have Dr. Nick Romansky with us today as our guest for this Orthotics Q and A. This time we're diving into posterior tibial tendon dysfunction and specific pearls of orthotics excellence in this area. Dr. Romansky is a diplomat of the American Board of Foot and Ankle Surgery. He's fellowship-trained and a team podiatrist for the US Men's and Women's National and World Cup Soccer teams. He's a design consultant for multiple shoe gear companies and a medical consultant to many of Philadelphia's professional sports teams. He's also a podiatrist for the Major League Baseball Umpires Union. So today, Dr. Romansky, thank you again for joining us, but when we're talking about an orthotic for a patient with posterior tibial tendon dysfunction, what do you feel are the most important aspects of the physical and biomechanical exam to assess?

Dr. Romansky:

Again, I think you need to look at the patient, listen to the patient, and feel the patient ultimately with a really good exam of physical exam. Even though you may not know your biomechanical a true no know or uh, feel, you may not know a true biomechanical exam. I think when you looking at a biomechanical exam, you have to see the patient standing, walking in the long hallway like we have in our offices, and look at it from multiple angles to see if you truly see the actual issue that's going on. That may be related to tibialis posterior that actually goes higher up to the knee and the low back and the IT band, quite honestly, their foot is attached to the rest of the body, and, in my opinion, it can affect the low back, SI joint, LS spine, as well.

So I think walking down that hallway, seeing them in the stance position, walk on their heels, walking on their toes, uh, doing the hop test, hopping in place and really seeing how that foot functions sitting, standing and walking with and without shoes on in that long hallway is absolutely critical to get a look of that, putting your hand on that foot and seeing if the subtalar joint is hypermobile, seeing if that foot has got a mild arch in the sitting position that collapses in the stance position and that medial column collapses that heel everts outward, that front of the foot abducts looking at that triplane appearance and motion of the foot that we all learned in first or second years of podiatry school and kind of got lost in the third and fourth year of schooling and certainly in residency, um, and maybe early, early or late into private practice.

So I think putting your hands on and see where it feels, is it a red spot near the navicular tuberosity? Is there a callous somewhere? Is there point tenderness in the sinus tarsi? I think knowing your anatomy here is critical. You know, if you had to go online or go in the back room and look at a book or just kind of look at a model that's on your countertop and show that to the patient, but really seeing where, how much, where and how much deformity they have. Maybe time they're coming in with subtalar joint issues in their sinus tarsi, but you know that tibial is posterior tendon is not working well or you see that tubular swelling on the inside of the, of the ankle. And remember your anatomy that this, in my opinion, the tibialis posterior goes to all 25 out of 26 bones in the foot except the talus.

If I remember my anatomy 101 and first year of podiatry school, I believe that's, still to be true today, that it's a major player in acceleration and most especially in deceleration, that tendon functions extensively except for the mid stance portion, which is between push off and landing. Again, you don't have to think academics here, just think about it. It's milliseconds between push off and landing that that tenant has a break in functioning. That said, one thing does not fit all. And as well as if you're considering the surgical aspect of it, in my opinion, has to be corrected with bone surgery, as well as soft tissue in my opinion. Soft tissue of this, you know, reefing up that tendon, transferring that tendon is not going to work, that you actually need to do some bone and joint surgery as well as soft tissue correction. That said, further pre- and postop orthotic device and tibials posterior dysfunction becomes extremely critical, in my opinion.

Podiatry Today:

So then, what key decisions are there for a clinician to make when they're formulating their prescription for a patient with PTTD that needs an orthotic?

Dr. Romansky:

So going back to the first question again, you know, looking at the physical and biomechanical exam to act to assess this, I think part of the assessment process is, is that you need to get X-rays of both feet. You need to get an X-ray of that affected ankle or rear foot. Uh, my opinion, I do think you need to do, an MRI and a place you feel comfortable that does a good MRI of an ankle and foot, a really thin-sliced one that looks at everything and it has a good interpretation by an appropriate foot and ankle radiologist that reads MRIs of the foot ankle. Very specifically, I also think I lean to the MRI, to help address and see what the internal derangement is of that joint.

They may have an OCD in their ankle and meanwhile it's coming off as a tib posterior dysfunction. They may have a stress fracture in there of the navicular, talus, or calcaneus. So I think that usually ultrasound's not going to get everything, and there's, in my opinion, a skillset set with ultrasound that you really should additionally get an MRI of that, uh, ankle or rearfoot to help formulate the prescription needed for that orthotic. You know, in the past, a lot of braces and, many names have been attached to braces, whether you get it from a orthotic lab, a podiatrist, or an orthotic and prosthetic company. Uh, there's many names out there, many types, but a lot of times they're so bulky that they're very limited with shoes. So this is really, when it comes to prescription orthotic, in my opinion, with tibialis posterior dysfunction of any type, whether zero to four grade, that the shoe absolutely has to be sent.

And that what device you're putting, what device and what shoe you're putting this device in is, is very critical because most braces you are really limited to the shoe you can use. And again, they're all, they're all the names are out there. So that said, when it comes to specific, once you've gotten your complete clinical evaluation supplemented by radiologic studies, some of my thoughts in regard to specifically tibialis posterior dysfunction is, number one is I like to make a deep heel cup, of typically 18 millimeters, depth that again, take sending the shoe that it can actually fit in the shoe to avoid slippage. The next thing I'll do is I'll usually use a medial platform or some form of medial flange that comes up into support, not just the subtalar joint, but extend into the midtarsal joint and even down a little bit to the, to the base of the first metatarsal, I use an extrinsic rearfoot post, intrinsic forefoot post.

And, what I'll also do is I'll also look at the leg, looking for tibial varum and looking up the leg and see how this is doing in regard to the knee. Again, just focusing in that foot and ankle. But really just take a quick glance at that. I'm an east coast guy, and I trained in California, and there's a lot of biomechanics in the west coast. And so there's a technique and there are many techniques, and all labs have different techniques for, addressing tibialis posterior dysfunction.

However, there's one called a Kirby skive, which basically it inverts, the rear foot to an angle, and typically it's 5 degrees, 10 degrees or 15 degrees. And so for every 5degrees you invert, you're actually tilting up that orthotic 25 degrees, 40 to 50 degrees, or if you had to, you know, 60 to 75 degrees. So if you have did that without the Kirby skive technique, think about it, you could be walking on the side of your foot at 45 degrees, which is not, not good, you know, and it would not be comfortable. So it's a factor that actually twists the orthotic, you know, after you get a cast that really helps control the rearfoot and the medial column is what you need for tibs posterior dysfunction that in that medial column, just going through too much motion.

Um, so it's a technique in the lab where you actually shave off some of the mold of along where the medial tubercle is the only issue if you're going to use the skive technique, is that the person cannot have heel pain because you're, you're changing the, the, the load and the direct contact on the heel. So we typically, the only thing that is against the Kirby skive is that it cannot have heel pain with us. If, if it's medial column and anything everywhere else, you're okay. Um, so that's really the main feature - is a deeper heel cup, medial flange, medial column, is more control. Uh, once in a while I'll put a small lateral clip on the rearfoot post that comes up a little bit on the outside to really give them maximum control, in that rearfoot. So those really some basic things that, where I think orthotics fail is they just do not control the subtalar joint enough into the tibialis posterior dysfunction.

Podiatry Today:

Are there any other modifications or materials that you find particularly helpful with this condition other than the ones you've already mentioned?

Dr. Romansky:

Well, I think you have to have the control factor, but they all have to be comfortable as well. So I think the top cover, and the cover underneath the top cover has to be, accommodating, right? Your materials on top should be for shock absorption as well as shear, because there is so much motion going on in that foot that you really have to look at shock and shear and the materials should be appropriate that go on that device. So we don't want it too hard, we don't want it too soft. We want the appropriate top cover and materials underneath the top cover or appropriate depth in the heel cover for control. And, it absolutely has to fit in the shoe because you can make a device that works well, but it can't fit in the shoe like many of the boots do or don't for that matter.

Podiatry Today:

Are there any final pearls that you'd like to share when it comes to orthotic management of posterior tibial tendon dysfunction?

Dr. Romansky:

I think you have to look at the whole patient. Because many times they'll have other issues going on with their back, their knee. I think, you know, like with most patients, you have to see where they really do hurt and have their symptoms. Sometimes I'll mark the foot with then the impression comes on the cast and then we, a lot of times we can accommodate or unload the navicular tuberosity with a punched out area or a buildup area. So they don't have, you know, load management issues, pressure issues because there's a lot of pressure that can go through the heel, the fifth metatarsal base, the navicular tuberosity or medial column. So a lot of times I'll mark the foot with then the impression that comes on the cast and then the lab and I can talk about, you know, balancing as well as controlling this very hypermobile difficult foot.

As in all patients with tib posterior dysfunction, they should go to physical therapy, they can use oral medication, they can use topical medications, they can use picking the right shoe that has a firm high heel counter with the removal insole. Again, the shoe is important as well. With this, I don't need to see a low profile shoe that, does not control or accommodate their foot. So, the shoe type with tib posterior is absolutely critical, not just for the device to fit in, but also to add to additional control around neutral position. One of the things you don't want to do is over control the patient and lock them up with tip posterior dysfunction. Yet again, if you don't do enough of that, you'll, you know, not control it enough and they'll continue to have symptoms. So lab input on that is absolutely critical. You listen to the patient is critical to get that device to work with this very difficult, painful foot. So, remember in the tib, posterior hypermobility or, uh, motion causes pain, motion causes deformity, and that's really true in the diagnosis of tibialis posterior dysfunction. Motion causes pain, motion causes deformity.

Podiatry Today:

Well and being such a common condition that that presents to foot and ankle clinicians, it's absolutely vital to, to master these, these techniques and, and pathways. So thank you so much Dr. Romansky for sharing all of this with us today. We hope that the audience enjoyed as well. As always, this episode and all others are available on PodiatryToday.com and on your favorite podcast platforms like Apple Podcasts, Spotify, and SoundCloud. We hope you'll join us again next time.