lerEXPO Conversations*: Bracing Posterior Tibial Tendon Dysfunction Long Term

By Roger Marzano, CPO, CPed

Posterior Tibial Tendon Dysfunction (PTTD) is a pervasive condition impacting the foot and ankle, representing a significant challenge in long-term management for both the patient and the healthcare team. This dysfunction occurs when the posterior tibial tendon, a vital structural support for the arch that enables efficient foot function, becomes injured or degraded, either through trauma, the wear-and-tear of aging, or misaligned biomechanics. Chronic PTTD manifests as a persistently recurring issue, leading to progressive flatfoot deformity.

Bracing has evolved significantly as a viable treatment option for managing PTTD, particularly in stages II and beyond, where conservative measures have failed. Initially perceived as a last resort before considering surgical intervention, the adoption and innovation in ankle-foot orthoses (AFOs) have propelled bracing to the forefront of non-operative management for PTTD. Historical perspectives show that early interventions were primarily focused on symptomatic relief, whereas now, the goal extends to correcting foot deformity, improving functionality, and averting progression. Advances in materials, design, and customization of AFOs have greatly enhanced bracing efficacy, making it a cornerstone in long-term PTTD management.

The journey to manage and alleviate symptoms of chronic PTTD is a complex one, especially as patients often see multiple providers who offer various orthotic prescriptions, not all of which are accurately prescribed or adhered to by patients. Long-term management strategies, such as bracing, play a pivotal role in offering relief and enhancing the quality of life for patients. PTTD is one part of the Progressive Collapsing Foot Deformity (PCFD), which also includes:

• Adult Acquired Flatfoot Deformity (AAFD)
• Adult Flexible Flatfoot Deformity (AFFD)
• Posterior Tibial Tendon Rupture (PTR)
• Peritalar Subluxation (PTS)
• Progressive Talipes Equinovalgus (PTEV)

PTTD is characterized by the degradation of the posterior tibial tendon, which plays a critical role in supporting the arch of the foot. As the condition progresses, it can lead to a persistently flatfoot posture, resulting in pain, discomfort, and diminished mobility. Generally managed conservatively in its early stages, PTTD often progresses beyond the efficacy of initial treatments such as physical therapy or off-the-shelf orthotics. The transition to considering bracing options is a critical juncture in the management of chronic PTTD, and typically occurs after 12-18 months of unresolved pain for the patient.

Is Bracing Successful in Managing Chronic PTTD

Bracing, specifically using custom AFOs, has emerged as a cornerstone in the long-term management of PTTD. Research on the efficacy of various AFO designs has shown promising results, with significant percentages of patients reporting relief and improved function across multiple studies with various devices.

That evidence includes:

• Alvarez et al¹ reported that 89% of patients responded well to the rehabilitation program which required the ability to perform 50 heel raises with minimal or no pain, and to toe walk 100 feet and conversion from an AFO to foot orthoses. 83% of the patients successfully reached these goals and another 6% reported being satisfied with their treatments and continued to wear their AFO’s for pain control or personal choice even with minimal or no pain.
• In a retrospective cohort study that focused on nonoperative measures, including posterior shell bracing, physical therapy, and anti-inflammatory medications used to treat adult acquired flatfoot in 64 patients, Nielsen et al² found that 87.5% had successful nonsurgical treatment over the 27-month observation period.
• In a retrospective study by Lin et al³ with 7-10 year follow-up, patients were first treated for 6 weeks in a walking cast, then transitioned to a double upright AFO with medial t-strap and rocker bottom shoes. The AFO was used until the patient’s symptoms were resolved (average 14.9 months). At an average of 8.6 year follow-up, 69.7% of patients were orthosis free, had avoided surgery, and reported quality of life scores that were similar to national norms. An additional 15.2% of the patients had symptom improvement and avoided surgery but continued to wear the orthosis full or part-time.
• Augustin et al⁴ looked at patients with PTTD (stages 1-111) who used an Arizona brace (AFO) and found 90% of patients had a statistically significant improvement in symptoms and quality of life after an average of 1 year follow up. A considerable percentage of patients (28.5%) had bilateral involvement and all of them saw improvement.
• In a study out of the United Kingdon, Jari et al⁵ reviewed their institution’s standard treatment using bracing and found that 82% were satisfied with nonsurgical results (average age 60 years, average follow up 2 years) and did not wish to consider surgery.

While many of these patients have significant co-morbidities which increase the risk of surgical management, this research shows that more than 60% of patients will avoid surgery with conservative therapy. Furthermore, there is no evidence that conservative treatment allows progression of their deformity. And rehabilitation—namely physical therapy—has been shown to improve outcomes in conservative management.

Clinical Insights into Bracing Solutions

Bracing for PTTD is nuanced. It’s not merely about prescribing an AFO; it’s about timing and customizing the bracing approach to address the specific mechanics and symptoms presented by each patient. Innovations such as medial forefoot posting within AFOs have been particularly effective in managing the biomechanical challenges posed by PTTD. Moreover, embracing a dynamic bracing strategy that evolves with the patient’s symptoms and progress underscores the importance of personalized care in managing this condition over the long term.

Types of AFOs Used in PTTD

Ankle Foot Orthoses come in various designs, each tailored to address specific needs in PTTD management. Notable types include:

• Hinged AFOs: These allow controlled ankle movement enabling joint mobility while offering support. They are particularly useful in intermediate stages of PTTD where motion preservation is desirable.
• Solid AFOs: For advanced cases, solid AFOs restrict ankle movement, providing maximum support to stabilize the foot and reduce pain effectively.
• Gauntlet AFOs: These encase the foot and ankle, offering comprehensive support. They are adaptable to various stages of PTTD, focusing on alignment correction and pain alleviation.
• Custom-fitted AFOs: Tailored to the patient’s foot, custom AFOs ensure better fit, comfort, and effectiveness, making them a preferred choice for long-term management.

Customizing Bracing for Individual Needs

The individualization of bracing solutions plays a pivotal role in managing PTTD effectively. Different types of AFOs (articulated, gauntlet-style, posterior shell brace) have been employed to match the unique needs of each case, with significant emphasis on adjusting for comorbidities and proximal joint issues. For example, adjusting or completely locking the ankle joint in cases where lateral pain due to dorsiflexion moment has already manifested. Another adaptation involves using medial forefoot posting on AFOs and foot orthotics to address forefoot to hindfoot misalignment, illustrating how specific adjustments can enhance the effectiveness of the bracing solution.

Early Intervention and Proper Device Selection

The success of bracing in managing PTTD underscores the importance of early intervention and the selection of the correct bracing device. Implementing bracing as a treatment option during the earlier stages of PTTD, even when symptoms might still respond to less aggressive treatments, can prevent the progression of the condition. Proper device selection, customized to the individual’s specific condition and lifestyle needs, significantly contributes to achieving positive outcomes, demonstrating the necessity of a tailored approach to treatment.

To learn more about how to customize your approach to PTTD management with bracing and hear 3 case studies, see Roger Marzano’s full lecture, “Bracing PTTD Long Term, Have We Been Successful?,” from the 38^th Annual No-Nonsense Seminar, available at https://nononsense2024.lerexpo.com/.

Roger Marzano, CPO, CPed, is Vice President of Clinical Services at Yanke Bionics in Akron, Ohio. He has been a practicing orthotist/prosthetist/pedorthist for more than 40 years.