PTTD Pes Planus

1. PTTD
- Dr Darshan Kapoor

2. 1. INTRODUCTION
2. ANATOMY OF TIBIALIS POSTERIOR
3. CAUSES
4. PATHOMECHANICS
5. CLINICAL FEATURES
6. CLASSIFICATION
7. INVESTIGATIONS
8. TREATMENT

3. ANATOMY
1. LOCATION - COMPARTMENT
2. ORIGIN
3. INSERTION
4. ACTION
5. NERVE SUPPLY
6. BLOOD SUPPLY

4. 1. COMPARTMENT

5. JUNCTION AT DISTAL THIRD CALF

6. 1. TUBERCLE OF NAVICULAR BONE
2. CUNIEFORMS
3. BASE OF 2, 3 , 4 TH METATARSALS
4. TALONAVICULAR JOINT CAPSULE – MEDIAL
AND PLANTAR ASPECTS

8. UNIQUE FEATURES OF THIS TENDON :
LENGTH – 12 – 15 CMS
CROSS SECTION DIA - 12 – 6 MM
GLIDING TENDON
FIBROCARTILAGE –
METAPLASIA ?
PHYSILOGICAL COMPONENT ?

9. NERVE SUPPLY - POSTERIOR TIBIAL NERVE
L 4 - 5

10. BLOOD – MAJOR – POSTERIOR TIBIAL ARTERY
WATERSHED AREA OF TENDON – ABOUT 2.5 - 3 CMS PROXIMAL TO MEDIAL MALLEOLUS
RELATIVE HYPOVASCULAR AREA – PRONE FOR DEGENERATION, POOR HEALING AND TEAR
DEGENERATION – PRIOR TO CLINICAL SYMPTOMS

11. FUNCTIONS
1. PRIMARY DYNAMIC STABILISER OF MEDIAL LONGITUDINAL ARCH
2. MAIN – INVERTER OF SUBTALAR JOINT – MAX at STANCE – gives mechanical advantage to TA.
( The Dynamic stability is complemented by static stability – bony and soft tissues – spring,
talonavicular capsule, plantar fascia and deltoid ligament)
3. ASSISTS PLANTAR FLEXION – ANKLE

12. PTTD- Posterior tibial tendon dysfunction

13. Synonym - Adult Acquired Flatfoot Deformity
• 1950’S Distinct entity
• Historical treatment background – late surgical arthrodesis
• Now, early diagnosis and limiting progress , to preserve ROM and function.

14. CAUSES –
1. Multifactorial
2. Over use
3. Age related degeneration
4. Traumatic
5. Congenital Pes Planus – greater stresses as patients age, predisposed.
6. Co- morbidities – Obesity, Systemic steroids, DM, Fluoroquinolones, RA, SSA
PATHOLOGY –
1. After tendon injury, local inflammatory
cascade increases local metallo-proteinase
activity and leads to further tendon injury.

15. CLINICAL FEATURES
1. PAIN
2. FATIGUE
3. FLAT FOOT
4. FLAT FOOT
5. TOE MANY TOE SIGN
6. HEEL VALGUS
7. INABILITY TO DO STANCE PHASE
8. ABSENCE OF HEEL INVERSION DURING TOE OFF
9. TENDERNESS, SWELLING , WARMTH
10. PALPABLE DEFECTS IN CONTINUITY
11. SUBTALAR IMPINGEMENT
12. ANKLE AND MIDFOOT ARTHRITIS – JOINTLINE
TENDERNESS
13. MOTOR POWER OF TENDON
14. FINGOMETER
COMAPRE WITH OPPOSITE SIDE !

17. CLASSIFICATION :
1. JOHNSON AND STROM - 2 STAGES –
I. PERITENDINITIS
II. TENDON ELONGATES – SUPPLE FLAT FOOT
III. RIGID FLATFOOT DEFORMITY
2. In 1996, Myerson – added 4 th stage - tilting of ankle joint.
3. Bluman , 2007 , updated – descriptive including treatment recommendations of each stage.
4. Richter , 2013 - only evaluated function of tendon – independently from stiffness of joints

20. INVESTIGATIONS –
1. X-rays
2. USG
3. MRI scan

22. TREATMENT
STAGE 1 :-
• CONSERVATIVE
• BRACE - 6 WEEKS
• CAM – WALKING BOOT – CONTROLLED ANKLE MOTION
• PTTD BRACE
• MEDIAL ARCH INSOLES
• NO INJECTABLE STEROIDS !!! - PREDISPOSES TENDON RUPTURES.
• Physiotherapy – local modalities, gastrocnemius stretches, muscle strengthening, BM – aspirate injection.
• Refractory – tenosynovectomy , arthroaresis.

23. STAGE 2 :
• Stage 1 + surgical modalities.
1. MDCO – medial displacement calcaneal osteotomy. –
• Shifts the TA pull medially , biomechanical advantages .
• About 1 cm medial translation and step plate fixation.
• “Crushplasty” – prominence –lateral cortical wall.
2. FDL Transfer – in phase muscle, similar lines of pull .
• Usually with MDCO. Fixed with interference screw / navicular bone tunnel.
• Transfer tensioned before fixing – 15 ◦ plantar flexion and 15 ◦ inversion.
• Existing tendon is augmented.
3. Lateral Column Lengthening – usually in combination, especially for severe forefoot
abduction.
4. Cotton Osteotomy-
• Dorsal opening wedge osteotomy of medial cuneiform.
• Without violating plantar cortex.
• Wedge graft inserted.
5. Arthroaresis –
• Prevents and blocks – limits eversion and blocks talus rotating medially.

25. Stage 3 and 4
• Arthrodesis –
• Triple arthrodesis – compare with contra lateral hindfoot position.
• Corrective osteotomies , Ankle arthroplasty / fusion.

26. 40/F , H/O RIGHT FOOT PROGRESSIVE - PAIN ON EXERSION AND
WEIGHT BEARING SINCE 2 YEARS.

28. SUMMARISE
ANATOMY
MECHANISM
CAUSES
CLASSIFICATION
TREAMENT

29. THANK YOU