Exercise for Posterior Tibial Tendon Dysfunction Case Summary

CC: Left foot and left heel painHPI: patient is a type 2 diabetic female who presents to the clinic with left foot and heel pain that
has been going on for the past 6 months. She says the pain is typically a constant dull pain but
recently it has been a sharp pain. She rates the pain at a 4/10 but at times can progress to a 5
or 6/10. When she’s standing and walking the pain gets worse, and the pain also worsens after
her weekly aerobics’ classes. She has tried taking Advil and changing her shoes but nothing
has been helping the pain. She works as a lawyer and wears high heels but also wears tennis
shoes for other daily activities. She states that the pain has been gradual progression.
:Last Hgb A1C was 6.7 which was taken 1 month ago. Fasting blood glucose is unknown.
:PMHx: Type 2 diabetes mellitus w/o neuropathy
:PSHx: Uterine fibroids removed at age 40
:Medications: Metformin 500 mg, Amlodipine 5 mg.
:Allergies: NKDA
:Social hx: No tobacco, drink 1 glass of wine per week.
:Family hx: Dad died of a heart attack 65, mom had RA.
Objective:
Vitals: 78 HR, BP 145/88, 18 RR, 98.6 F. 160 lbs, 5’7”
Vascular: Dorsalis Pedis and Posterior Tibial pulses 2/4 bilaterally, CFT: < 3 seconds Derm: There is no edema present, skin is warm and intact bilaterally. Skin turgor intact bilaterally Neuro: SWMF 10/10 bilaterally. MSK: There is pain at the medial calcaneal tuberosity as well as at the medial arch of the left foot. Pain is located along the left posterior tibial tendon. Muscle strength is 4/5 for the posterior and medial muscle compartments of the left foot and 5/5 for all other muscle groups crossing the ankle joint of the right and left. When asked to do the single heel rise test, the patient is unable to perform it because of pain on the left foot. When asked to do the double heel raise test pain is present on the left foot and there is less inversion on the left foot, however there are normal findings of the right foot. Jack Test shows supination of the rearfoot and external rotation of the tibia more prominent on the right than on the left. Ankle ROM is limited with the knee extended and normal with the knee flexed. MPJ ROM is limited unloaded and normal loaded. There is increased abduction of the forefoot on the rearfoot bilaterally in stance and gait, with increased eversion on the left. BMX: Fully compensated structural limb length deformity of the right leg, increased base of gait noted on the left, increased tibial torsion of 14 degrees externally rotated on the right limb, gastrocnemius equinus notes bilaterally, increased degree of pronation noted on the left STJ, forefoot deformity noted on the left foot, reduced 1st MPJ ROM noted on the left compared to the right 1st MPJ but both are within normal limits. X-Ray Interpretation: Quality: Bilateral weight bearing AP projection with adequate exposure and collimation Soft tissue:Normal soft tissue density and contour. No foreign bodies, calcification, or emphysema seen. Bone: Normal integrity and morphology of all osseous Joint and joint spaces: No narrowing of the joint spaces and no coalitions. Biomechanical evaluation: Decreased Calcaneal Inclination angle, increased talar declination angle, anterior deviated cyma line, pseudo sinus tarsi Quality: Bilateral weight bearing AP projection with adequate exposure and collimation. Soft tissue: Normal soft tissue density and contour. No foreign bodies, calcification, or emphysema seen. Bone: Enlarged navicular tuberosity, OTE type 3, and rule of halves is followed. Joint and joint spaces: No narrowing of the joint spaces and no coalitions. Biomechanical evaluation: Angles within normal limits. Assessment: 1. Posterior Tibial Tendon Dysfunction stage 2B Johnson and Strom ❖ Graded at a 2B because of too many toes’ signs ❖ Flexible, so remains under a stage 3 2. Flexible Pes Planus ❖ When performing the Jack’s test, dorsiflexion of hallux introduced the arch which indicates a flexible deformity. Plan: 1. 2. 3. 4. 5. 6. Educate patient on avoiding heels X-rays & Ultrasound of left foot ordered. K-Taping the left foot to support the failing arch Functional Orthoses with heel lift on right prescribed Physical therapy for PTTD Stretching exercises Orthotic Rx: For the Left: Type: Functional Casted: Neutral Shell Material: Polypropylene Posting: Post the rearfoot to NCSP Modification: Deep heel seat, arch fill, EVA Topcover with Reverse Morton’s extension For the Right: Type: Functional Casted: Neutral Shell Material: Polypropylene Posting: as sits Modification: .5 cm heel lift Orthopedics Capstone Journal Club Find a recent journal article (within the last 10 years) with high level of evidence (level I or II evidence preferred) that pertains and relates to the case that you worked up in Ortho PBL #1. Write a 1-2 page summary that includes information the type of study, methods, and results of the study. Discuss the strengths and weaknesses of the study and explain how this particular study relates to the case that you worked up in Ortho PBL #1. You will present your summary in journal club (Ortho PBL #2) in 3 minutes or less. We will then discuss the study with your cohorts and faculty. You will be graded on the content, your communication/presentation skills, and your involvement overall in the journal club (participation in discussion) Ortho PBL Case: 1 2 3 4 5 6 Article topic/title: ________________________________ 3 Summary (type of Described all 3 study/method/results) appropriately Strength/Weaknesses Application Discussion Presentation/ Communication skills 2 Described 2/3 appropriately Described both strengths and weaknesses appropriately Clinical application is appropriate Student participated throughout journal club Student knows article content well and presents it confidently. Kept audience engaged. Student appears to know content well and presents somewhat confidently. Kept audience fairly engaged. 1 Described 1/3 appropriately Description of either strengths or weaknesses appropriate Some lack of understanding of clinical application Student participated occasionally during journal club Student shows weak knowledge of content material and does not appear too confident. Audience confused/not too engaged 0 Did not describe any appropriately No description of strengths or weaknesses of article Clinical application inappropriate, lacking Student did not participate during journal club Student does not understand the content material and is not confident when presenting. Audience not engaged. Student will lose points if: Journal not appropriate (not within last 10 years, Low level of evidence for topic) (-1) ____ Oral review not within time limit of 3 min (-1) _____ Notes: Total (12) ____ Review Exercise for posterior tibial tendon dysfunction: a systematic review of randomised clinical trials and clinical guidelines Megan H Ross, Michelle D Smith, Rebecca Mellor, Bill Vicenzino To cite: Ross MH, Smith MD, Mellor R, et al. Exercise for posterior tibial tendon dysfunction: a systematic review of randomised clinical trials and clinical guidelines. BMJ Open Sport & Exercise Medicine 2018;4:e000430. doi:10.1136/ bmjsem-2018-000430 ►► Additional material is published online only. To view please visit the journal online (http://​dx.​doi.​org/​10.​1136/​ bmjsem-​2018-​000430). Accepted 13 August 2018 © Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ. Department of Physiotherapy, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia Correspondence to Professor Bill Vicenzino; ​b.​ vicenzino@u​ q.​edu.​au Abstract Objective To systematically review all randomised clinical trials to determine the efficacy of local strengthening exercises compared with other forms of conservative management for adults with posterior tibial tendon dysfunction. Design Systematic review. Data sources Four electronic databases (Cumulative Index to Nursing and Allied Health Literature, Cochrane, Embase and PubMed) were searched up to June 2018. Eligibility criteria for selecting studies The study included randomised clinical trials investigating individuals with posterior tibial tendon dysfunction where local strengthening was compared with other forms of conservative management with respect to pain, function and/or physical impairment outcome measures. Standardised mean differences (SMDs) were used to compare change scores between groups and descriptors of exercise prescription assessed according to the Template for Intervention Description and Replication and the Toigo and Boutellier recommendations. Results 3 studies (n=93) were eligible for inclusion in the review. Varying strengthening exercises were compared with stretching and foot orthoses (n=2) or no intervention (n=1). Moderate effects (SMD 0.6–1.2) were found for reducing pain and disability with eccentric strengthening in conjunction with stretching and orthoses compared with concentric exercises, stretching and orthoses combined, and stretching and orthoses alone. Evaluation of exercise prescription parameters demonstrated minimal reporting, with the only consistent parameters being the number of sets and repetitions of the exercises, and the duration of the experimental period. Conclusion This review demonstrates the paucity of high-quality research for the conservative management of posterior tibial tendon dysfunction, and highlights the lack of exercise prescription parameters reported in clinical trials. Trial registration number CRD42017076156. Introduction Posterior tibial tendon dysfunction (PTTD) is prevalent, with estimates of prevalence ranging between 3.3% and 10%,1 but suspected to be much higher, as the condition What is already known? ►► Posterior tibial tendon dysfunction is a progressive condition occurring along a continuum from tendon pain and dysfunction to acquired flatfoot deformity. ►► Management in the early stages is typically conservative, focusing on local strengthening exercises and arch-supporting devices. What are the new findings? ►► High-quality clinical trials for the efficacy of exercise management in posterior tibial tendon dysfunction are lacking. ►► Exercise prescription parameters are poorly reported in the literature. ►► Preliminary evidence suggests exercise is beneficial in reducing pain and disability. is often not formally diagnosed until the later stages.1 PTTD is progressive and disabling, characterised by impaired mobility,2 poor function,3 4 and often a range of comorbidities including hypertension and diabetes and higher body mass index (BMI).3 5 6 Decisions regarding management vary according to the stage of the pathology,7 with reports of surgery predominating, probably due to the condition more commonly presenting in later and more severe stages.8 Surgery aims to correct deformity in the later stages of the condition (ie, stages III and IV)9–11 and, relatively recently, to prevent soft tissue and joint destructions in earlier stages (I–II) that do not respond to conservative management.12–18 Conservative management is used in earlier stages (I–II) with a focus on local strengthening exercises for the tibialis posterior musculotendinous unit and use of an orthosis to brace the foot.19–21 The level of evidence in support of this approach is currently unevaluated and is the basis of this systematic review. Ross MH, et al. BMJ Open Sport Exerc Med 2018;4:e000430. doi:10.1136/bmjsem-2018-000430 1 BMJ Open Sport Exerc Med: first published as 10.1136/bmjsem-2018-000430 on 19 September 2018. Downloaded from http://bmjopensem.bmj.com/ on November 14, 2023 by guest. Protected by copyright. Open access In evaluating the level of evidence, it is important to also evaluate the quality of reporting of the exercise prescription parameters due to the potential influence variations in these parameters may have on the effectiveness of the treatment22 and on clinical practice. The aims of this systematic review of randomised clinical trials (RCTs) were to provide estimates of treatment effects of local strengthening exercises compared with other forms of conservative management for adults with PTTD on outcomes relating to the international classification of functioning, disability and health (ICF) framework (impairments, activity limitations and participation restrictions), and to evaluate the completeness of exercise prescription descriptors. Methods This systematic review was performed using a predetermined protocol in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.23 It was registered with PROSPERO (trial registration number CRD42017076156) and is available at http://www.​crd.​york.​ac.​uk/​PROSPERO/​display_​ record.​php?​ID=​CRD42017076156. Search strategy and data sources To answer the research question about the treatment effects of local strengthening exercises for PTTD, four electronic databases (Cumulative Index to Nursing and Allied Health Literature, Cochrane, Embase and PubMed) were searched from inception to June 2018 for full-text papers published in peer-reviewed journals. A comprehensive search strategy was developed to capture variations in terminology used in the literature for PTTD and key conservative interventions (online supplementary table 1). No further limits were applied to the initial search strategy. Reference list checks and author searches were also performed to ensure all relevant literature was identified. Eligibility criteria Eligibility criteria were determined prospectively using the patient, intervention, comparator and outcome (PICO) framework.24 Trials were eligible for inclusion if they investigated individuals with PTTD or adult-acquired flatfoot deformity due to PTTD, if they were randomised, and if local strengthening was compared with other forms of conservative management with respect to pain, function and/or physical impairment outcome measures. A diagnosis of PTTD was required to be made based on a minimal list of diagnostic criteria,25 with two or more of the following: tenderness on palpation of the posterior tibial tendon, pain and/or swelling along the posterior tibial tendon, medial foot pain, difficulty and/or pain with single leg heel raise, and inability to invert the calcaneus on double leg heel raise. Flatfoot deformity was not considered as a selection criterion and as such all stages of PTTD were included. 2 Trials were excluded if they compared surgical interventions for PTTD, did not include a comparator group and combined data for individuals diagnosed with conditions other than PTTD. Reviews, case studies and trials for paediatric flatfoot, asymptomatic flatfoot, neurological conditions and rheumatoid arthritis were also excluded. Study selection The lead reviewer (MHR) performed the search and exported all retrieved records into EndNote V.X7 (Thompson Reuters, Carlsbad, California, USA). Duplicates were removed and titles and abstracts were screened independently by two reviewers (MHR and RM), based on established eligibility criteria. Full texts were retrieved for all potentially eligible papers and reviewed for inclusion and exclusion criteria. Where there were uncertainties, at least one additional author (MDS or BV) was consulted to determine final eligibility. Data extraction Data extraction for each included trial was completed by two investigators (MHR and RM) using a predetermined spreadsheet. Where reference was made to protocol papers or supplementary materials, these sources were obtained and used for data extraction. For each trial, study design, sample size, participant characteristics/ demographics, diagnostic criteria, methods, intervention details (type, frequency, duration), outcomes, follow-up and results (means and SDs) for each time point were extracted. As reporting of parameters of exercise prescription is essential for the implementation of research findings in exercise therapy, these data were also extracted. The ‘Template for Intervention Description and Replication’ (TIDieR) checklist26 (developed to facilitate reporting and replication of intervention studies) and the guidelines developed by Toigo and Boutellier27 specifically for resistance exercise prescription provide a framework appropriate for the appraisal of exercise prescription in intervention studies for musculoskeletal conditions.28 As such, specific parameters (% repetition maximum, repetitions, time under tension and so on) were extracted to allow for analysis of mechanobiological descriptors of exercise prescription.27 Data for the 12-item TIDieR checklist26 were also independently extracted by two reviewers, and the completeness of reporting was evaluated by allocating 1 point for complete items (clear, unambiguous descriptions allowing replication) and 0 for incomplete items (partial or no description) as per Holden et al.28 The total scores were calculated for each checklist and two authors (MDS and BV) verified all extracted data for accuracy. Risk of bias Risk of bias was assessed as recommended by The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials.24 The tool assesses six potential sources of bias under five domains (selection bias, Ross MH, et al. BMJ Open Sport Exerc Med 2018;4:e000430. doi:10.1136/bmjsem-2018-000430 BMJ Open Sport Exerc Med: first published as 10.1136/bmjsem-2018-000430 on 19 September 2018. Downloaded from http://bmjopensem.bmj.com/ on November 14, 2023 by guest. Protected by copyright. Open access performance bias, detection bias, attrition bias and reporting bias) and considers each as being either ‘low risk’, ‘high risk’ or ‘unclear risk’ of bias. Two independent reviewers (MHR and RM) rated included trials and the results were collated and examined for discrepancies. Inter-rater disagreements were discussed and where a consensus could not be met were taken to a third party (BV or MDS). Statistical analyses/data synthesis Analyses were performed in Review Manager (RevMan) V.5.3 (Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration). For continuous measures of pain, function and/or physical impairment, individual study effect sizes were expressed as standardised mean differences (SMDs) using means and SDs. The mean change scores from preintervention to postintervention were compared between two independent participant groups (ie, strengthening vs no strengthening; type of strengthening comparison). Change scores (mean and SD) for each group were calculated as postscore minus prescore with within-group correlation assumed to be 0.524 and were used to estimate the SD of the mean change using t-distributions. The difference between each group was considered significant where 95% CIs did not contain 0. For pain and self-reported outcome measures, higher scores indicated worse outcomes, and as such the inverse of effect size was reported so that positive effect sizes indicated a beneficial effect for the intervention group. Improvements in strength and function measures were indicated by higher scores and positive effect sizes. The strength of the effect size was interpreted based on Hopkins,29 as follows: 1.2–2.0 large effect and 2.0–4.0 extremely large effect. Inter-rater reliability of methodological quality was calculated in Stata V.13 using the ĸ-statistic (95% CI). The reliability of the quality ratings between the two assessors was interpreted as ĸ15 m) and age (>40 years)32 as
study selection criteria.
n
Intervention group
BMI† (kg/
m2)
Female
(%)
Participant characteristics
A total of 93 individuals with PTTD were enrolled across
all trials, with individual sample sizes ranging from 14 to 40
participants (5–19 per group) (table 1). Studies enrolled
participants with a mean age from 52.931 to 57.532 years
and BMI between 23.331 and 30.532 kg/m2. All studies
had a predominance of women, with the percentage of
women ranging from 77.7%32 33 to 100%.31 Two trials31 33
included individuals with stage I or II PTTD, and one
trial32 included those with only stage II PTTD.
n
Comparator group
BMI† (kg/m2) Female (%)
of outcome assessment; online supplementary table 2).
Considering attrition, two trials were deemed to have
low risk of bias as reasons were provided for missing data
(dropouts), which were unrelated to outcomes of the
intervention, and dropouts were balanced across groups.
The third trial had an imbalance of missing data across
groups (2 (29%) vs 0 (0%)) for all outcomes, and due to
the already small sample size (n=14) it is plausible this
was large enough to induce clinically relevant bias. Selective reporting overall had a high risk of bias. Of the two
trials in which a judgement could be made, there were
outcomes specified in the trial protocol that were omitted
from the final analyses and the manuscript.
Ross MH, et al. BMJ Open Sport Exerc Med 2018;4:e000430. doi:10.1136/bmjsem-2018-000430
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Table 2 Selection criteria as stated in each study
Medial
foot/ankle Pain
pain
PTT
Trial
32
Swelling
of PTT
TOP
PTT
Correctable
flatfoot
deformity
Foot
flattening
Abducted Duration of
mid-foot
symptoms
Imaging
Other inclusion criteria
NR
√
NR
NR
NR
NR
Able to walk >15 m
>40 years of age
Houck et al
NR
Either
Jeong et al31
√
√
NR
√
NR
NR
NR
NR
NR
NR
√
NR
NR
√
√
√
√
>3 months
NR
NR
33
Kulig et al
√, essential eligibility criteria for the study; either, one finding from this group of tests/clinical findings was required.
NR, not reported; PTT, posterior tibial tendon; TOP, tender on palpation.
dysfunction and bother indexes. Jeong et al31 reported
the American Orthopaedic Foot and Ankle Society score,
which combines both patient self-report and clinician
physical examination findings into one aggregate score.34
Reassessment of outcomes varied from 6 weeks31 32 to 12
weeks.32 33
Interventions
The exercise intervention protocol varied in each of
the included trials. Local tibialis posterior exercises
were compared with foot orthoses and stretching in two
trials32 33; however, the type of exercise (concentric, eccentric or isotonic) varied. Participants in the Kulig et al33
trial were randomly assigned to either an eccentric or
concentric exercise group (combined with stretching and
orthoses) or a stretching and orthoses-only group (three
groups in total). Houck et al32 used an isotonic strengthening regimen combined with stretching and orthoses
compared with stretching and orthoses only. Participants
in the Jeong et al31 trial were randomised to receive either
an isotonic ankle strengthening, stretching and balance
programme, or no intervention.
Completeness of reporting
Completeness of intervention reporting based on the
TIDieR checklist is provided in online supplementary table
4. Of the 12 items, Jeong et al31 provided adequate information for 4 items, Houck et al32 for 11 items and Kulig
et al33 for all 12 items. Houck et al32 and Kulig et al33 both
included sufficient information in regard to adherence
(both the plan for assessment of adherence and reports of
actual adherence).
No trial provided complete reporting of interventions
based on the Toigo and Boutellier27 exercise prescription
descriptors (table 3). Of the 13 items, Jeong et al31 provided
adequate information for 5 items, Houck et al32 for 7 items
and Kulig et al33 for 11 items. Of the six classical descriptors,
only the number of sets and repetitions of the exercises and
duration of the experimental period over which exercises
were performed were consistently described for all exercises in all trials (table 3). Load magnitude (% repetition
maximum) was only described in one trial.33 Of the seven
remaining mechanobiological descriptors, the range of
motion and an anatomical definition of the exercise were
described in the methodology of two trials,32 33 and time
under tension was described in one trial.33
Main findings
Physical impairments
Isotonic ankle strengthening, balance and stretching
improved ankle dorsiflexion range at 6 weeks beyond that
of no intervention (SMD (95% CI) 1.71 (0.29 to 3.12))
(figure 2). Plantar flexion inversion torque was not different
at 6 weeks following isotonic tibialis posterior strengthening
exercise combined with stretching and orthoses compared
with stretching and orthoses alone (SMD (95% CI) 0.59
(−0.08 to 1.26)) (figure 2). Isotonic ankle strengthening,
balance and stretching did not improve ankle torque in
any direction at 6 weeks beyond that of no intervention
(figure 2). Local strengthening was not superior to control
comparator for any other physical impairment outcomes at
6 weeks (figure 2).
Neither concentric nor eccentric tibialis posterior
strengthening exercises combined with stretching and
orthoses were significantly different from the control for
the distance covered during the 5MWT at 12 weeks (SMD
(95% CI) 0.51 (−0.34 to 1.36) and 0.25 (−0.57 to 1.07),
respectively),33 nor were there differences between eccentric and concentric strengthening groups (SMD (95% CI)
−0.39 (−1.22 to 0.44)) (figure 3). There was no difference
between isotonic tibialis posterior strengthening and the
control group for tibialis posterior strength (isometric
combined plantarflexion and inversion) at 12 weeks (SMD
(95% CI) 0.59 (−0.08 to 1.26)) (figure 3).32
Patient-reported outcomes
Isotonic ankle strengthening, balance and stretching
reduced pain on VAS beyond that of no intervention,
with a large, significant effect size at 6 weeks (SMD (95%
CI) −2.39 (−4.02 to –0.75)) (figure 2).31 Isotonic strengthening moderately reduced scores for the mobility and
dysfunction subscales of the SMFA at 6 weeks (SMD (95%
CI) −1.10 (−1.81 to −0.4) and −0.87 (−1.55 to −0.18),
respectively) (figure 2), but not at 12 weeks (SMD (95%
CI) 0.32 (−0.98 to 0.34) and −0.41 (−1.07 to 0.26), respectively) (figure 3).32 There were no differences between
local strengthening and control groups for the mean
change on the FFI subscales or total score at 6 weeks
(figure 2) or the SMFA bother subscale at 6 or 12 weeks
(figure 3).32
Eccentric strengthening combined with stretching
and orthoses reduced the mean scores for FFI-pain,
Ross MH, et al. BMJ Open Sport Exerc Med 2018;4:e000430. doi:10.1136/bmjsem-2018-000430
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Ross MH, et al. BMJ Open Sport Exerc Med 2018;4:e000430. doi:10.1136/bmjsem-2018-000430
Full
BW
10 → 30
2→3
NR
2×/day
12 weeks
Isotonic
NR
NR
No
Full
1. Load magnitude
2. Number of repetitions
3. Number of sets
4. Rest in between sets (s or min)
5. Number of exercise interventions (per day or week)
6. Duration of experimental period (days or weeks)
7. Fractional/temporal distribution of the contraction per
repetition and duration (s) of one repetition
8. Rest in between repetitions (s or min)
9. Time under tension (s)
10. Volitional muscular failure
11. Range of motion
Yes
Yes
7
13. Anatomical definition of the exercise (exercise form)
described
Total
Yes
NR
Full
No
NR
NR
Isotonic
12 weeks
2×/day
NR
2→3
10 → 30
BW
Kulig et al33
4
No
NR
NR
NR
NR
NR
Isotonic
6 weeks
NR
30 s
4
20
No
NR
NR
NR
NR
NR
Isotonic
6 weeks
NR
30 s
4
20
Red → blue → black Partial BW
No
NR
NR
NR
NR
NR
Isotonic
6 weeks
NR
30 s
3
15
BW → loaded
No
NR
NR
NR
NR
NR
Isotonic
6 weeks
NR
30 s
3
15
BW
11
Yes
NR
Neutral →
EOR
No
5s
NR
Concentric
12 weeks
2×/day
1–2 min
3
15
15 RM
Yes
NR
EOR →
Neutral
No
5s
NR
Eccentric
12 weeks
2×/day
1–2 min
3
15
15 RM
Theraband PF, DF, Seated HR BLHR
SLHR
ADD in PF
ADD in PF
INV, EV (weeks 1–6) (weeks 1–2) (weeks 3–4, 5–6) (weeks 5–6) (concentric) (eccentric)
Jeong et al31
Items 1–6, classical set of descriptors; items 7–13 (shaded),new set of descriptors.
ADD, adduction; BLHR, bilateral heel raise; BW, body weight; DF, dorsiflexion; EV, eversion; EOR, end of range; HR, heel raise; INV, inversion; NR, not reported; PF, plantar flexion; RM, repetition maximum; SLHR, single leg
heel raise.
NR
12. Recovery time in between exercise sessions (hours or days) NR
Yes
NR
NR
Isotonic
12 weeks
2×/day
NR
2→3
10 → 30
Increasing
resistance
BLHR
TheraBand
ADD/INV in PF SLHR
Houck et al32
Exercise descriptors (from Toigo and Boutellier27 for included trials)
Exercise descriptors
Table 3
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Figure 2 SMD (95% CI) for outcomes at 6 weeks. 5MWT, 5 min walk test; AOFAS, American Orthopaedic Foot and Ankle
Society; BW, body weight; deg, degree; FFI, Foot Function Index; N/kg, Newtons per kilogram; ROM, range of motion; SMD,
standardised mean difference; SMFA, Short Musculoskeletal Function Assessment; VAS, Visual Analogue Scale.
FFI-disability and FFI-total beyond that of concentric
strengthening, stretching and orthoses combined, and
stretching and orthoses alone at 12 weeks with moderate
effect sizes (SMD (95% CI) −1.1 (−1.97 to −0.23), −0.97
(−1.82 to −0.11) and −0.96 (1.81 to −0.1), respectively;
and SMD (95% CI) 1.1 (−1.97 to −0.23), −0.96 (−1.81
to −0.11) and −0.85 (−1.69 to −0.01), respectively)
(figure 3).33 Neither concentric nor isotonic tibialis
posterior strengthening combined with stretching and
orthoses was significantly different from stretching and
orthoses alone for the three subscales of the FFI and
FFI-total at 12 weeks (figure 3).32 33
Figure 3 SMD (95% CI) for outcomes at 12 weeks. 5MWT, 5 min walk test; FFI, Foot Function Index; SMD, standardised
mean differences; SMFA, Short Musculoskeletal Function Assessment; VAS, Visual Analogue Scale.
Ross MH, et al. BMJ Open Sport Exerc Med 2018;4:e000430. doi:10.1136/bmjsem-2018-000430
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Discussion
This systematic review evaluated pain and functional
outcomes following local strengthening exercise in individuals with PTTD. Two main findings emanate from this
systematic review: the first is the lack of rigorous RCTs
investigating the effects of non-surgical management
on impairments, activity limitations and participation in
adults with PTTD, and the second is that exercise parameters are poorly reported.
Detailed reporting of exercise parameters for musculoskeletal interventions trialled in RCTs is essential for
clinical replication and translation of research into practice. The implications of omitting important exercise
parameters in reporting, however, extend beyond just
clinical replication of exercise prescription. Exercise
parameters such as time under tension, range of motion
and rest or recovery time can be manipulated and are
expected to influence both physiological response to
and efficacy of the exercise prescription,22 27 meaning
that slight variations in prescription parameters may
have vastly different physiological effects. Factors related
to biophysical response to exercise were not sufficiently
described in the included studies, and strengthening
interventions failed to improve strength-related outcome
measures at both 6 and 12 weeks. Lack of detailed
reporting becomes an important matter when a primary
goal in rehabilitation of tendinopathies is to improve
the load management capacity of the musculotendinous
unit.35
Current literature implicates appropriate load management as the most important component of rehabilitation
for tendinopathies.35–37 The benefit of therapeutic exercise in the management of lateral epicondylalgia and
Achilles, patellar and rotator cuff tendinopathies has
been established in previous systematic reviews.38–41
While early literature has focused on eccentric exercise
for tendinopathies,42–44 more recent approaches with
good efficacy include patient education on load management strategies and individualised, progressive loading
exercises.45 Overall, effect sizes from this systematic
review provide limited evidence to suggest that isotonic
tibialis posterior strengthening, stretching and orthoses
and general isotonic ankle strengthening, balance and
stretching exercises similarly improve pain, mobility
and dysfunction in PTTD in the short term compared
with no strengthening. Considering the specific type of
strengthening protocol, data from this review suggest
that eccentric strengthening may be marginally more
effective than other types of strengthening, with eccentric but not concentric exercise resulting in significant
reductions in self-reported pain, disability and overall
foot function compared with controls at 12 weeks.
The mechanism of effect for improved outcomes in
tendinopathy following strengthening exercise is understood to be related to load. It has been suggested that the
load through the tendon during therapeutic exercises
needs to be sufficiently high enough to elicit physiological changes within the tendon. While the relationships
8
between internal tendon structure and pain and function
are currently unclear,37 heavy-slow resistance appears to
be beneficial in managing Achilles and patellar tendinopathies.46 It has been suggested that the physiological
response to therapeutic exercise may be greater with
heavy-slow resistance and eccentric strengthening due to
higher loads applied through the tendon during these
exercises. The device used for strengthening exercise in
the study by Kulig et al 33allowed for quantification of load
and constant resistance throughout the exercise. Participants in the eccentric exercise group in their clinical trial
achieved loads 3.3 times higher than those in the concentric group by the end of the 12-week intervention.33 This
raised the possibility that differences in outcomes were
dependent on load rather than specific contraction
type. Tolerance and ability to perform the exercise with
good form were the criteria for progressing load, which
suggests that participants in the eccentric group were
better able to tolerate higher loads during the exercise
programme, optimising tendon response, and leading to
the reporting of greater improvements in pain, disability
and overall foot function. Physical tests of function
(distance covered during 5MWT), however, were not
different between groups. This suggests that while participants felt more confident loading their tendon, physical
capacity of the tendon might not have improved.
Exercise prescription parameters can be manipulated
depending on the desired physiological response to exercise stimulus, for example, to improve skeletal muscle
strength, endurance or power. Each of the three trials
indicated that the intention of the prescribed exercises
was to improve strength. On further examination of the
exercise prescription parameters (table 3) in reference to
the current American College of Sports Medicine (ACSM)
guidelines for muscular strength,47 some discrepancies
were apparent. Considering load magnitude, the ACSM
guidelines for strength recommend up to 12 repetition
maximum, where Kulig et al33 prescribed 15, fitting the
ACSM guidelines for muscular endurance.47 Similarly,
papers prescribed between 15 and 30 repetitions, which
is above the recommendations for inducing strength
adaptations (8–12) and falls into the recommended repetitions for improving muscular endurance.47
Adherence should be considered in calculating
the exercise stimulus (load) actually delivered to the
musculotendinous unit and any strength gains accrued.
Adherence was not reported in Jeong et al,31 but ranged
between 29% and 126% (average 79%) in Houck et al32
and 39%–98% (average=68%) in Kulig et al.33 Considering this, it is possible the actual load participants
performed was not high enough to elicit adaptations in
skeletal muscle that would subsequently result in clinical
improvements in strength (Houck et al32) or physical
tests of function (Kulig et al33). Houck et al32 examined
tibialis posterior force production in plantarflexion and
forefoot adduction at baseline and at 6 and 12 weeks
following isotonic tibialis posterior exercises against the
heaviest TheraBand resistance that could be tolerated,
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in addition to bilateral and unilateral heel raises.32 The
strengthening group did not exhibit increases in tibialis
posterior strength at 6 or 12 weeks, which suggests that
while the intention of the prescribed exercise programme
was to increase strength, with poor adherence taken into
consideration, actual load may not have been appropriate to elicit changes in musculotendinous strength.
It was common among included trials for the intervention protocol to include cointerventions such as
stretching and orthoses, in addition to specific local
strengthening exercises. It is possible that the effect of
the local strengthening intervention was affected by
these cointerventions. As no randomised trial has looked
at local strengthening in isolation (ie, not combined with
stretching/orthoses or balance and stretching exercises),
it is difficult to ascertain to what degree improvements
can be attributed to targeted exercises only. Two trials
that investigated stretching, orthoses and local strengthening compared with stretching and orthoses alone
showed similar improvement in pain and function in
all groups. It is possible that orthoses and/or stretching
play a role in the reduction of pain. Future research is
required to investigate strength interventions in isolation
of other treatments to establish its efficacy in the management of PTTD.
Interestingly, stretching exercises were included in
all intervention groups across the three included trials.
Both gastrocnemius and soleus stretches were prescribed
for 3–10 repetitions of 30 s duration, 2–4 times per day.
This stretch is performed in maximal dorsiflexion, which
increases the compressive as well as the tensile load on
the posterior tibial tendon posterior to the medial malleolus,48 the combination of which has been found to be
most damaging to the tendon.49 Load management for
pain relief in tendinopathy rehabilitation is twofold,
incorporating the reduction of both compressive and
tensile loads.50 So while foot orthoses and activity modification may aid in altering tensile loads (supporting
the medial longitudinal arch and reducing the torque
required from the tibialis posterior during activities),
accompanying these interventions with static stretches
in full dorsiflexion may be counterproductive to pain
management and rehabilitation.
Pain with palpation, pain on tendon loading and
impaired function are key features in the clinical presentation of tendinopathies.51–54 Pain and difficulty during
activities that load the medial aspect of the foot and the
posterior tibial tendon, such as the single leg heel raise,
are key clinical features of PTTD. The results from this
systematic review have highlighted that interventions
that aim to modify the load through the tendon and
foot locally (ie, via tibialis posterior strengthening and/
or arch-supporting devices such as foot orthoses) have
limited ability to improve pain and functional outcomes
in PTTD. As such, alternative means of modifying load
to improve clinical outcomes warrant further investigation. Hip function can affect motion at the foot during
gait,55–57 and weak hip external rotators and abductors
have been associated with increased femoral internal rotation58 59 and adduction,60 increased knee valgus,59 61 tibial
internal rotation61–63 and subtalar joint pronation,62 64
which may impact on tibialis posterior. Increased rearfoot eversion65–69 and hip abduction strength2 deficits
have been demonstrated in PTTD, which suggests that
some proximal changes may be evident in the condition.
Further research investigating proximal muscle function
and kinematics in PTTD would provide further support
for interventions targeting proximal hip motor control
and strength.
Limitations
While this is the first systematic review to investigate the
efficacy of exercise as a treatment for PTTD, there are
several limitations that must be acknowledged. The small
number and variability of interventions and outcomes of
included studies did not allow meta-analysis or pooling
of results. Meta-analysis was prevented due to variability
in selection criteria, methodological quality, interventions and outcome measures assessed among the three
included studies. Small sample sizes of individual studies
can influence the ability to detect true effects. With very
few outcomes replicated between studies, meta-analysis
was prohibited and effect sizes presented in this review
should be interpreted with this in mind. These aspects
of the literature limit the inferences that might be
drawn from the findings. Notwithstanding, this review
is a synthesis of all available evidence from randomised
controlled trials relating to exercise management for
PTTD and highlighted the dearth of evidence on which
to guide management. It must be acknowledged that
studies included in this review related to stage I and/or II
PTTD only. This is an important consideration in terms
of the clinical application of findings and the generalisability of results, given that patient presentation may vary
as the condition progresses.
Conclusion
This is the first systematic review on exercise therapy
for PTTD. Based on the limited available literature, it
appears that local strengthening exercises provide some
benefit in PTTD, and eccentric exercises may be superior
for improving pain, disability and self-reported overall
foot function than concentric exercises and foot orthoses
and stretching alone. No recommendations can currently
be made regarding optimal exercise prescription based
on published clinical trials. Clinicians should be guided
by presenting impairments to prescribe exercise, which
holds some promise in managing PTTD.
Contributors All authors contributed equally to this manuscript.
Funding BV is supported by the National Health and Medical Research Council
(NHMRC) Program Grant (#631717), MHR is supported by the University of
Queensland Research Training Program (RTP) Scholarship
Competing interests None declared.
Patient consent Not required.
Provenance and peer review Not commissioned; internally peer reviewed.
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9
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Open access This is an open access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non-commercially,
and license their derivative works on different terms, provided the original work is
properly cited, appropriate credit is given, any changes made indicated, and the
use is non-commercial. See: http://​creativecommons.​org/​licenses/​by-​nc/​4.​0/
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