The conservative management of posterior tibialis tendon dysfunction.

Abstract

Background Posterior Tibialis Tendon Dysfunction (PTTD) is a progressive condition that affects foot biomechanics, leading to pain, dysfunction, and in severe cases, adult-acquired flatfoot deformity. Despite its prevalence, there is no universally accepted gold standard for diagnosing or treating PTTD conservatively. Current clinical assessments and treatment strategies vary widely, contributing to inconsistent patient outcomes. The classification systems have a main focus on surgery and provide vague information on conservative management of the condition, failing to define elements such as duration of treatment or material and design of the orthosis. This thesis aims to evaluate diagnostic methodologies, non-surgical treatments, and clinical decision-making processes to provide information to develop a more standardized approach to managing PTTD.

Methods A systematic review was conducted to assess existing diagnostic methods, including clinical tests such as the single-heel-rise test and imaging modalities like ultrasound and MRI. Another systematic review examined conservative treatment strategies, analyzing the effectiveness of foot orthoses, ankle-foot orthoses (AFOs), and physiotherapy. Additionally, a qualitative pilot study gathered insights from foot and ankle health professionals regarding their treatment practices, while a survey study explored variations in diagnostic and treatment practices among a variety of clinicians. Data were synthesized to identify trends, gaps, and inconsistencies in clinical practice.

Results Findings revealed a significant lack of standardization in both assessment and treatment. While MRI is often regarded as the most definitive imaging tool for staging PTTD, ultrasound is preferred for its accessibility and real-time diagnostic capabilities. Manual clinical assessments also showed variability, with the single-heel-rise test widely used but inconsistently interpreted. Conservative management approaches were similarly diverse, with no consensus on the optimal design or application of foot orthoses and AFOs. Some practitioners favored custom orthotics with medial posting, while others relied on prefabricated alternatives. Physiotherapy protocols also varied, with differences in exercise selection, intensity, and duration. The qualitative study highlighted discrepancies in orthotic prescription, particularly regarding material selection and alignment techniques. The survey confirmed significant variations in clinical practice, with many clinicians lacking formal classification criteria for staging PTTD. Conclusions The results underscore the urgent need for standardized guidelines in PTTD assessment and conservative treatment. A structured clinical framework incorporating validated diagnostic tools, classification criteria, and evidence-based treatment protocols would improve diagnostic accuracy and treatment consistency. Future research should focus on refining conservative management approaches, optimizing orthotic designs, clearly defined physiotherapy treatments. and evaluating the long-term effectiveness of various interventions to enhance patient outcomes and prevent disease progression.