Non-surgical treatment of pain associated with posterior tibial tendon dysfunction: study protocol for a randomised clinical trial.
BACKGROUND
Symptoms associated with pes planovalgus or flatfeet occur frequently, even though some people with a flatfoot deformity remain asymptomatic. Pes planovalgus is proposed to be associated with foot/ankle pain and poor function. Concurrently, the multifactorial weakness of the tibialis posterior muscle and its tendon can lead to a flattening of the longitudinal arch of the foot. Those affected can experience functional impairment and pain. Less severe cases at an early stage are eligible for non-surgical treatment and foot orthoses are considered to be the first line approach. Furthermore, strengthening of arch and ankle stabilising muscles are thought to contribute to active compensation of the deformity leading to stress relief of soft tissue structures. There is only limited evidence concerning the numerous therapy approaches, and so far, no data are available showing functional benefits that accompany these interventions.


METHODS
After clinical diagnosis and clarification of inclusion criteria (e.g., age 40-70, current complaint of foot and ankle pain more than three months, posterior tibial tendon dysfunction stage I & II, longitudinal arch flattening verified by radiography), sixty participants with posterior tibial tendon dysfunction associated complaints will be included in the study and will be randomly assigned to one of three different intervention groups: (i) foot orthoses only (FOO), (ii) foot orthoses and eccentric exercise (FOE), or (iii) sham foot orthoses only (FOS). Participants in the FOO and FOE groups will be allocated individualised foot orthoses, the latter combined with eccentric exercise for ankle stabilisation and strengthening of the tibialis posterior muscle. Participants in the FOS group will be allocated sham foot orthoses only. During the intervention period of 12 weeks, all participants will be encouraged to follow an educational program for dosed foot load management (e.g., to stop activity if they experience increasing pain). Functional impairment will be evaluated pre- and post-intervention by the Foot Function Index. Further outcome measures include the Pain Disability Index, Visual Analogue Scale for pain, SF-12, kinematic data from 3D-movement analysis and neuromuscular activity during level and downstairs walking. Measuring outcomes pre- and post-intervention will allow the calculation of intervention effects by 3×3 Analysis of Variance (ANOVA) with repeated measures.


CONCLUSIONS
The purpose of this randomised trial is to evaluate the therapeutic benefit of three different non-surgical treatment regimens in participants with posterior tibial tendon dysfunction and accompanying pes planovalgus. Furthermore, the analysis of changes in gait mechanics and neuromuscular control will contribute to an enhanced understanding of functional changes and eventually optimise conservative management strategies for these patients.


BACKGROUND
ClinicalTrials.gov Protocol Registration System: ClinicalTrials.gov ID NCT01839669.
Bern University of Applied Sciences, Health, Physiotherapy, Murtenstrasse 10, 3008 Bern, Switzerland.
Angela
A
Blasimann
Bern University of Applied Sciences, Health, Physiotherapy, Murtenstrasse 10, 3008 Bern, Switzerland.
Patric
P
Eichelberger
Bern University of Applied Sciences, Health, Physiotherapy, Murtenstrasse 10, 3008 Bern, Switzerland.
Yvonne
Y
Brülhart
Salem-Spital, Foot Surgery, Schänzlistrasse 39, 3013 Bern, Switzerland.
Isam
I
El-Masri
Sonnenhofspital, Foot Surgery, Buchserstrasse 30, 3006 Bern, Switzerland.
Gerhard
G
Flückiger
Spital STS AG, Orthopaedics & Traumatology, Krankenhausstrasse 12, 3600 Thun, Switzerland.
Lars
L
Frauchiger
Outpatient Clinic for Foot Surgery Bern, Schänzlistrasse 33, 3013 Bern, Switzerland.
Martin
M
Huber
Siloah, Clinic for Orthopaedics and Traumatology, Worbstrasse 316, 3073 Gümligen bei Bern, Switzerland.
Martin
M
Weber
Department of Orthopaedic Surgery, University of Bern, Inselspital, Freiburgstrasse, 3010 Bern, Switzerland.
Fabian G
FG
Krause
Bern University of Applied Sciences, Health, Physiotherapy, Murtenstrasse 10, 3008 Bern, Switzerland.
Heiner
H
Baur
Exercise therapy; Flat foot; Flatfeet; Foot orthoses; Gait; Pes planus; Resistance training