03/13/2024    Jeff Root

Recalcitrant Case of Posterior Tibial Tendonitis (PM News Subscriber)

Regarding the query about the treatment of
recalcitrant "posterior tibial tendonitis", or what
many would call posterior tibial tendon dysfunction
(PTTD), I would like to share a few of my thoughts.
The PM News subscriber stated that the patient
wears "HOKA shoes and custom orthotics". The term
"custom orthotics" simply implies that the devices
were not prefabricated. In some cases, the lines
between custom and prefabricated shoe inserts have
been intentionally and unintentionally blurred. In
addition, the term "custom orthotics" tells us
little to nothing about the nature (i.e. design and
properties) of the orthoses because there are
hundreds if not thousands of types of custom
orthotics and orthotic designs.

For example, what was the position of the joints of
the foot, including the STJ, MTJ and 1st ray when
the foot was casted or scanned? What were the
specifications of the orthotic prescription? What
lab techniques were used in creating the corrected
mold, or in some cases, the orthoses directly via
direct orthotic shell milling or 3D printing? What
material or materials was the device produced from?
There are so many variables, the term "custom
orthotics" has become virtually meaningless.

Some of the specific options that I would consider
when prescribing and manufacturing an orthosis for
PTTD include casting the foot with the STJ in the
neutral position (in a minority of cases in a
supinated or pronated position), with the MTJ in a
fully pronated position and possibly plantarflexing
the 1st ray. I would consider whether the cast
should be corrected with the heel in an inverted,
vertical or everted position. In most cases of PTTD
I would recommend correcting the heel (calcaneal
bisection) in either a vertical or inverted
position in order to resist STJ pronation/STJ
pronation moments. I would consider whether the
patient may benefit from a higher medial arched
device, a medial heel skive, a Blake Inverted
Orthosis or even an AFO.

What is the patient's foot type? Is the symptomatic
side more pronated and does it have a lower medial
arch than the contralateral side? Does the medial
cuneiform or navicular and the medial cuneiform
area need to be accommodated in order to locally
reduce pressure while simultaneously increasing
pressure and support in the surrounding area to
resist STJ pronation? Custom foot orthotic
prescription specifications should be based on an
appropriate biomechanical examination of the
individual patient, a well thought out orthotic
prescription and good laboratory technique. As a
result, the custom foot orthotic device may vary
from one patient with PTTD to another.

Jeff Root, President, KevinRoot Medical

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