Posterior Tibial Tendon Dysfunction The Role of Extra-Osseous TaloTarsal Stabilization Michael E. Graham, D.P.M., F.A.C.F.A.S. Inventor, HyProCure Founder: GraMedica, Graham International Implant Institute Private Practice: Shelby Township, Michigan, USA
Why?• We need to take a critical look at this very common condition.• We need to take action to prevent the progression of the disease progression.• Why does PTTD occur?• What are the best viable treatment options.
Patient presents with symptoms or concerns due to excessive rearfoot motion. Is this normal or is this pathologic? This foot has a mechanical disadvantage.
This excessive pronatory motion has beennamed as the most common etiology of the majority of foot & ankle conditions.
This patient was not born with her foot looking like this. This is the result of years of “conservative” treatment. Her specialists thought that they were “doing no harm” in reality they have caused great harm.
What should we do with this patient’s foot?
If we do nothing (conservative care) it will most likely end up like this.
Getting back to basics It all begins with a stable osseous foundation. The average person takes between 6,000 to 10,000 steps a day, depending on their activity level.
Normal TaloCalcaneal Position
Osseous alignment determines how/where the transfer of the weight from the body above transfers through the foot to the ground below.This is how the osseous foot structuresshould be aligned.
It all begins with theTaloTarsal Mechanism
Normal TaloTarsal Alignment • Talus is sitting on top of the calcaneus. • The articular facets are aligned. • The two bones are balanced. • Sinus tarsi is in its natural open position.
TaloTarsal Mechanism Talus acting on the articulations with the calcaneus and navicular Talus Navicular Facet Calcaneus Posterior FacetMiddle & Anterior Facet
TaloTarsal Motion: You cannot talk about the motion of the subtalar joint withoutalso discussing the talonavicular joint as even though there are 4 separate anatomical joints they function as one.
The articulations of the talus on the tarsal mechanism With the TTM inNEUTRAL POSITION www.hyprocure.com
Malposition of the posterior articulation results in malposition ofthe middle/anterior facets and also talonavicular joint. www.hyprocure.com
Ligament Support • Ligaments function as a supportive tissue to assist in the alignment of the osseous structures. • The alignment of the talotarsal mechanism is so important that there is a major complex of supporting ligament attachments.
Remember • The talus is the only “foot” bone that does not have a tendon attachment. • Its motion is dependent on the articular facets of the tarsal mechanism, capsular and ligament tissues.
Ligament Contains mechanicoreceptors to send a signal to the CNS which in response sends a signal to the muscle to contract to provide support to the joint.
Tibialis Posterior Muscle/Tendon Complex • Functions to supinate the foot. • Strongest supinator of the mid-foot • Has to over-come pronatory forces to lift the foot for toe- off.
Additional Important SupportiveStructures to Tibialis Posterior Function• Tendon sheath- helps the tendon glide behind the medial malleolus and within the flexor retinaculum.• Flexor retinaculum- keeps the tendon aligned for optimum function.
Tibialis Posterior Tendon Insertions Primary insertion in the navicular tuberosity and secondary insertions plantar aspects of the medial column of the foot.
THIS IS VERY IMPORTANT Tibialis posterior inserts into themedial/plantar aspect of the mid-footto supinate the medial column at late mid-stance to toe off.
Tibialis Posterior Tendon Dysfunction Why do good tendons go bad?
Every “effect” has its “cause”
There is an underlying etiology to every symptom.The goal is not to solely treat the symptom but to eliminate the cause.
People are not born with pathologic tendons. At birth our tendons are very healthy.
However, if the talotarsalmechanism is not properly alignedas a child a good healthy posteriortibial tendon will slowly but surely continue to become diseased.
Let’s take a closer look at thetalotarsal mechanism and how it can significantly implant the function of tibial posterior
Normal TTMRemember- talus is sitting on top ofthe calcaneus, sinus tarsi is open, andthere is a normal cyma.The articular facets of the talus areperfectly aligned with the articularfacets of the calcaneus and navicular.
Abnormal TTMThe talus slid off its normal positionoff of the calcaneus. The articularfacets are not aligned. Sinus tarsi ispartially collapsed. The talus isplantarflexing on tarsal mechanism.Excessive abnormal forces are actingon the medial column of the foot.
The problem isn’t with the calcaneus or the bottom of the foot. Its talar position on the tarsal mechanism. RCSP NCSP
Due to abnormal talar motion on thetarsal mechanism excessive strain is placed on the medial column.
Abnormal TTM • This is not just a sagittal plane deformity but also transverse. • Excessive motion in one plane of the talotarsal mechanism results in excessive motion in all 3 cardinal planes.
Navicular Drop-Normal TTM Abnormal TTM
Navicular DropResting BalancedStance TaloTarsal JointThe navicular is forced out of position due to the excessive abnormalforces from the talar displacement. This is a dynamic deformity occurringwith every step taken.
Navicular Drop• Imagine that during the walking cycle with no weight on the talotarsal mechanism- it is in alignment. At heel strike the talus quickly displaces on the tarsal mechanism, it partially dislocates anteriomedially to push the navicular down which is forced to “drop”.
Navicular Drop • Not only is the navicular pushed forward it is also forced plantar. • The talus is responsible to transfer the entire weight of the body from the leg above to the foot below.
Use your imagination.Do you think will have a negative effective on the posterior tibial tendon? Withevery step excessive abnormal forces are acting on the posterior tibial tendon.
Effect of navicular drop to the tibialis posterior tendon
Posterior Tibial Tendon Strain
Posterior Tibial Tendon Strain
Ill-effects of Excessive Strain to a tendon. • There is an entrapment of the tendon within the flexor retinaculum just like there is with entrapment of the tibial posterior nerve.
Posterior Tibial Tendon Compression • Flexor retinaculum turns from a friend to an enemy when the talus slips off its normal alignment on the tarsal mechanism.
Normal Cylindrical Shaped Tendon
Abnormally Shaped Tendon due to compression
Tendon StrainNormal Abnormal
Effect of navicular drop on tibialis posterior.The poor tendon doesn’t have a chance, think about the damage being inflictedthousands of times a day, day after day, week after week, month after month, yearafter year, decade after decade.
Talus slips off the calcaneus resulting in partial dislocation of the talotarsal mechanism. This forces the navicular to eventually “drop”. Tibialis posterior tendon is immediatelystrain/elongated which decreases blood flow within the tendon.The strain is continually placed on the tendon until more and more damage ensues.
What are the treatment options for these patients? • Nothing? • Orthotics? • Injections? • Oral meds.? • External braces? • Calcaneal osteotomy? • Talonavicular Arthrodesis? • Triple Arthrodesis?
Foot Orthotics• Cannot stabilize the talus• Cannot prevent the excessive talar motion• Have to be used in shoes• Have to find shoes to fit the device• Not covered by most insurance companies• Gives a false sense of correction• Provides only minimal support• The list goes on …..
Medial Displacement Osteotomy? Just doesnt make a lot of sense.There isn’t a deformity within thecalcaneus its above…the partialdisplacement of the talus on theTarsal mechanism-remember.
Extra-Osseous, Extra-Articular TaloTarsal Stabilization DevicesTalus Type I Type II Laterally anchored HyProCure Medially Anchored
Anatomically ShapedBiomechanically Functional
“Lifted” Navicular = Decreased strain on Tib. Posterior
Closer look- repositioned talotarsal mechanism.
Right foot isolated E.O.T.T.S.procedure with HyProCure. BEFORE Not Yet AFTER
3 days post op- Right foot Before After
Extra-Osseous TaloTarsal Stabilization Why Not?• It addresses the deformity• Completely reversible• Not dependent on external factors-shoes• Can be performed on a wide age-range of patients• Fast recovery, dependable results
The goal• Early ambulation• Effective correction• Least amount of down time• Least amount of complications• Return to normal function• Do no harm• Why wait until they need a major rearfoot reconstructive procedure?
Fix the cause,don’t ameliorate the symptom(s).
What would YOU rather have done to your foot?
HyProCure®• FDA 510(k) Sept 2004, CE 2006• Routinely used in pediatrics, adults, geriatrics.• Can be a stand alone or used in conjunction with other surgical procedures (depending on secondary deformities)• Thousands have been successfully placed globally• Placed in athletes of almost every sport
Extra-Osseous TaloTarsal Stabilization• When orthotics don’t give enough correction• Prior to more radical rearfoot surgery• Think• E.O.T.T.S.• There are limitations…foot must be flexible.
HyProCure Please visit:www.hyprocure.com For further information