Choosing among 3 ankle-foot orthoses for a patient with stage ii posterior tibial tendon dysfunction

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PT, PhD²

Choosing Among 3 Ankle-Foot Orthoses
for a Patient With Stage II
Posterior Tibial Tendon Dysfunction


osterior tibial tendon dysfunction (PTTD) is typically described
as a progressive disorder ranging from stage I to stage IV, with
hallmarks of advancing flatfoot deformity and deteriorating
function. Ultimately,stage IV is identified by the presence
of arthritic changes in the lateral talocrural joint.25 The timeline for
progression of this dysfunction is not clear, though strengthening
programs and the use of orthoses may slow its progression.24,26
Case report.
No head-to-head comparisons
of different orthoses for patients with stage II
posterior tibial tendon dysfunction (PTTD) have
been performedto date. Additionally, the cost of
orthoses varies considerably, thus choosing an
effective orthosis that is affordable to the patient is
largely a trial-and-error process.
A 77-year-old woman
was seen with complaints of abnormal foot
posture (“my foot is out”), minimal medial foot
and ankle pain, and a 3-year history of conservatively managed stage II PTTD. The patient was
not able tocomplete 1 single-limb heel rise on the
involved side, while she could complete 3 on the
uninvolved side. Ankle strength testing revealed
a mild to moderate loss of plantar flexor strength
(20%-31% deficit on the involved side), combined
with a 22% deficit in isometric ankle inversion and
forefoot adduction strength. To assist this patient
in managing her flatfoot posture and PTTD, 3 orthoseswere considered: an off-the-shelf ankle-foot
orthosis (AFO), a custom solid AFO, and a custom
articulated AFO. The patient’s chief complaint was
partly cosmetic (“my foot is out”). As decreasing
flatfoot kinematics may unload the tibialis posterior muscle, thus prevent the progression of foot
deformity, the primary goal of orthotic intervention

was to improve flatfoot kinematics. Given thedifficulties in clinical approaches to evaluating flatfoot
kinematics, a quantitative gait analysis, using a
multisegment foot model, was used.
In the frontal plane, all 3 orthoses
were associated with small changes toward hindfoot
inversion. In the sagittal plane, between 2.7° and
6.1°, greater forefoot plantar flexion (raising the medial longitudinal arch) occurred. There were no differencesamong the orthoses on hindfoot inversion
and forefoot plantar flexion. In the transverse plane,
the off-the-shelf design was associated with forefoot
abduction, the custom solid orthosis was associated
with no change, and the custom articulated orthosis
was associated with forefoot adduction.
Based on gait analysis, the higher-cost custom articulated orthosis was chosen
as optimal for thepatient. This custom articulated
orthosis was associated with the greatest change
in flatfoot deformity, assessed using gait analysis.
The patient felt it produced the greatest correction
in foot deformity. Reducing flatfoot deformity while
allowing ankle movement may limit progression of
stage II PTTD.
Therapy, level 4.
J Orthop Sports Phys Ther 2009;39(11):816-824.
doi:10.2519/jospt.2009.3107biomechanics, PTTD, tendinopathy

Patients’ perception of their pain and
functional limitation can be mild, which
is in stark contrast to the advanced flatfoot deformity and weakness patients
commonly exhibit. The clinical paradox
of mild functional limitation with advanced flatfoot deformity poses a problem when trying to select an appropriate
orthosis. Advanced flatfoot deformity
andweakness support the clinical use of
custom orthoses, which, though expensive, give maximal support to the foot
and theoretically prevent further deformity. Yet minimal functional limitations
and complaints of pain suggest that
custom orthoses, which limit foot and
ankle movement, may be unnecessary.
Furthermore, custom orthoses may lead
to altered gait patterns and contribute to