title: Stage I and II posterior tibial tendon dysfunction treated by a structured nonoperative management protocol: an orthosis and exercise program.
abstract: BACKGROUND
  Posterior tibial tendon dysfunction (PTTD) is a relatively common problem of middle-aged adults that usually is treated operatively. The purpose of this study was to identify strength deficits with early stage PTTD and to assess the efficacy of a focused nonoperative treatment protocol.
  
  
  METHODS
  Forty-seven consecutive patients with stage I or II posterior tibial tendon dysfunction were treated by a structured nonoperative protocol. Criteria for inclusion were the presence of a palpable and painful posterior tibial tendon, with or without swelling and 2) movement of the tendon with passive and active nonweightbearing clinical examination. The rehabilitation protocol included the use of a short, articulated ankle foot orthosis or foot orthosis, high-repetition exercises, aggressive plantarflexion activities, and an aggressive high-repetition home exercise program that included gastrocsoleus tendon stretching. Isokinetic evaluations were done before and after therapy to compare inversion, eversion, plantarflexion, and dorsiflexion strength in the involved and uninvolved extremities. Criteria for successful rehabilitation were no more than 10% strength deficit, ability to perform 50 single-support heel rises with minimal or no pain, ability to ambulate 100 feet on the toes with minimal or no pain, and ability to tolerate 200 repetitions of the home exercises for each muscle group.
  
  
  RESULTS
  Before therapy weakness for concentric and eccentric contractures of all muscle groups of the involved ankle was significant (p<0.001). After a median of 10 physical therapy visits over a median period of 4 months, 39 (83%) of the 47 patients had successful subjective and functional outcomes, and 42 patients (89%) were satisfied. Five patients (11%) required surgery after failure of nonoperative treatment.
  
  
  CONCLUSIONS
  This study suggests that many patients with stage I and II posterior tibial tendon dysfunction can be effectively treated nonoperatively with an orthosis and structured exercises.
authors.affiliation: Orthopedics, University of Tennessee College of Medicine, 975 E. Third Street, Hospital Box 287, Chattanooga, TN 37403, USA. Dickankle@aol.com
authors.forename: Richard G
authors.initials: RG
authors.lastname: Alvarez
authors.forename: Andrew
authors.initials: A
authors.lastname: Marini
authors.forename: Coleen
authors.initials: C
authors.lastname: Schmitt
authors.forename: Charles L
authors.initials: CL
authors.lastname: Saltzman
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003131:Combined Modality Therapy; D005081:Exercise Therapy / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009989:Orthotic Devices; D037081:Posterior Tibial Tendon Dysfunction / Q000503:physiopathology / Q000534:rehabilitation / Q000628:therapy*; D011446:Prospective Studies; D016896:Treatment Outcome