October 2020

Using Shockwave, Foot Core Exercises to Manage Tibialis Posterior Tendinopathy

Figure. Three primary exercises of foot core progression: A) foot doming, B) toe yoga, and C) intrinsic foot abduction. Used with permission; all rights reserved.

Tibialis posterior tendon dysfunction/tendinopathy (PTTP) is a common debilitating condition. The diagnosis is largely clinical with physical examination sufficient to make the determination. Patients will commonly complain of pain in the medial foot and behind the medial malleolus that worsens with prolonged standing and activity.

A recent systematic review found conservative management approaches poorly described and most often ineffective. Typically, they include a plantar cast/removable fracture boot for immobilization and oral anti-inflammatories. Physical therapy traditionally focuses on improving strength and flexibility of the tibialis posterior and ankle and includes use of orthotics. Corticosteriods are then considered for select recalcitrant cases. And finally, surgical options are considered.

These authors present a case series that examines a combination of radial shockwave therapy (R-SWT) and a foot core progression exercise regimen that was used with 10 patients who had failed standard conservative treatment techniques including physical therapy and shoe orthotics.

The shockwave procedure was delivered over 3 weekly sessions, with additional treatments provided if response was positive but not complete. R-SWT was delivered using the Storz extracorporeal pulse activation (EPAT®) technology device (Storz Medical, Tagerwilen, Switzerland). The authors describe treatment specifics in detail, noting that use of shockwave for treatment of PTTD has not been described before.

The foot core exercise program consisted of “foot dooming,” toe yoga, and toe abduction/adduction (see Figure), practiced 3 times/day with additional balance exercises and hopping and landing exercises added as patient progression allowed. These exercises focused on activation and recruitment of the intrinsic muscles. Exercises to strengthen the extrinsic foot muscles were added as well.

After 4 months, clinically important differences in the Foot and Ankle Ability Measure were met in 9 (90%) and 8 (80%) of patients for activities of daily living and sport sub-scores, respectively, with no adverse effects.

The results suggest R-SWT with a formal physical therapy program using foot core progression may be an effective and noninvasive treatment alternative approach for refractory tibialis posterior tendinopathy.

Source: Robinson D, Mitchkash M, Wasserman L, Tenforde AS. Nonsurgical approach in management of tibialis posterior tendinopathy with combined radial shockwave and foot core exercises: a case series. J Foot Ankle Surg. 2020 Sep-Oct;59(5):1058-1061.

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