Posterior tibialis

Posterior tibialis

Molly Pitcher

4/13/1998

Dear list, thank you for your many responses which are contained in this
message:


I agree with the UCBL idea as I've been doing similar things. Recently
a new
Orthopedic Doctor opened a practice in my area. He's been sending me
pt. with
similar problems (posterior tendon dysfunction, sreched, not torn).
He's been
ordering solid ankle AFOs with the hindfoot set in 5-7 degrees of varus.
This
is what he expects to see radiographically. I'm finding that to really
correct this and to maintain it that we actully need to put the AFO in
15-20
degrees of varus. This is giving him the results he wants. While we've
only
been doing this for about three months, we've seen a real improvement
in the
condition of the pt. (Less pain, better gait). I've done a few people
who've
been fairly active (40s, working people). While this may not be the end
all,
it does merit consideration. I would figure our major drawbacks our
using a
solid ankle, and of course the cost and bulk of an AFO vs. a UCBL. Any
questions, please contact me.


Perhaps the problem lies with the materials used. I too suffer from such
a
condition (less the knee pain). I have fitted myself with a pair of
Orthotics. I own my Orthotics lab. The material I use is specially
designed
to offer maximum correction and still be semi-flexable. Casting is done
in a
non weight bearing, subtalar neutral position with the first ray
dorsiflexed. The material used also has excellent memory properties to
it. I
have spend much time invested to derive such a blend of plastics to give
me
the features that I want. The Orthotics maintain there correctiveness
for a
period of 3-6 years.
My tendinitis is gone. I am very active and play Tennis at a high and
competitive level. Without my devices I would be lame.

If you are interested in seeing a sample, please give me a mailing
address.

Paul


Paul A. Scotti
President
Body Sync
200 Soudan Ave.
Toronto, ON M4S 1W1
Tel: 416-487-4642
Fax: 416-487-7023
<Email Address Redacted>

You do not mention what you did in your UCB with regard to the forefoot
supination. I have had some success with this type of patient by
casting and fabricating the rear foot in neutral and posting under the

1st met head with 1/4 PPT to allow the fore foot to supinate some.
This makes control of the rear foot easier and reduces the tendency for
pressure on the navicular prominence. I also aggressively employ the
Gillette modification on the medial anterior of the calcaneous. I
would appreciate you posting the responses you get. Hope this helps.

John Hatch CPO (ABC)
The only success I have had is using the UCB-St, the foot-plate from the

Oregon Orthotic System. I laminate my orthoses with epoxy resin and use

carbon graphite in the lay-up. I have long term good success using this

system. Good Luck Keith

I see alot of PTT injuries because I work with a few Orthopedists that
specialize in feet. I use alot of UCBL's and insert arch supports- all
custom
only of course. I do alot of medial posting and accommodating rigid
forefoot
supination.

Suggest that you re-do UCBL as you have thought, but perhaps
incorporating
some extrinsic shock absorption such as a layer of PORON (P.P.T.)
betwwen
foot and orthosis. Met. doming is probably essential in this appliance;
have you included adequate transverse arch support? What have you done
with
the contralateral foot, does it have compensatory height and balance
support? Just a few thoughts, Richard Ziegeler (P&O Australia)


Ideal approach.... I see a tone of that stuff and do primarily the
same thing. I do reccomend a hightop shoe to go with that UCBL.

In response to your 50+ year old man with a foot injury I would first
reevaluate his present UCBL to check if it has fatigued. Since he is
complaining of patellar femoral pain I would suspect that he is
excessively
pronating which results in internal tibial rotation and usually patellar

femoral dysfunction. I would probably fabricate a new UCBL with maximum

longitudinal arch support to prevent any pronation. You also stated
that this
gentleman is complaining of foot pain, but did not specify where.
Assuming
it is on the plantar aspect, I would pad the UCBL with a shock
absorbing
material such a PPT. I hope this helps!

The OOS system is the solution if you want to commit yourself.
Otherwise,
just what you have done is a good start. I have followed the OOS
doctrine but
have used thermoplastics with consistent results. I would refab your
initial
design, due to plastic fatigue and tissue changes. For the foot you
describe, it is under loads like a BK socket. We know tissues change
in
volume and shape under that load. If he has a PF contracture , add
heel lift
as a temporary fix to relive midfoot collapse. I would also consider
adding
a rocker to change the timing of the forces and prevent them from the
peak
load at midstance. What I learned and have practiced from OOS was a
great
help in dealing with these feet. Even withthe limitations of
thermoplastics,
just getting the shape correct is the majority of the solution.
Good Luck
Pat Peick

We have had a few of these cases and have had some success with this
protocol. We have built a foot orthosis with significant posting on the

medial side, usually about 3/16 to 1/4 inch, we couple this with the use
of an
active ankle orthosis, to use when walking on uneven ground, we have
also
used an AFO, free ankle, usually using habilitation joints, and an
anterior
lower leg shell. Thats what I know, hope this helps.

I have seen many tendonitis patients, and many FO pts. What you could
also try is posting not only the posterior is varus, but accomodating
the forefoot in varus also in a neutral postion. It is worth a try, and
I have found that extra firm crepe works well for this.

Have delt with approx. one dozon PT as you described. Used rotational
control FO (ala. UCBL) and had very similar results as, again, you
mentioned. These are unfortunately difficult cases to treat in both
active/ semiactive population, and the heavier the individual the more
difficult. Your approach as described is direltly on course. Do you
incorporate a met pad and ST pad in attempts of controling the hind and
mid foot? Our design stems off the Oregon principles, still the
problems never seem to be solved, only temporaily resolved. The concern

regards a slow progressive rotary deformity with the stretching of the
ligaments. Age has a factor to play; the younger the longer they will
be with the problem and the more opportunity (time) for progression. I
have creased attempting to treat older folks and choose to accomodate
their anatomy with distributive pressure.
Molly ,I have not offered advise as you are seeking, but know there
exist others who share your frustrations. If you hear of any approach
that sounds novel and promising , please let me know.
Bradd Rosenquist, CPO

Molly, I have been using a polypro solid ankle AFO placed in 5 degrees
of
plantar flexion and add a medial flare just above the malleous to push
on the
tibia. The flare is padded with pelite or bocklite. Our patient
acceptance is
favorable. This plan is used only when conventional treatment is not
working.
If you try this or need any additional information let me know how
things go.

I just had great success treating a similar patient (female) with a UCB
ST
OOS style that provided a good forefoot adduction and good ST support.
The
trick for me was to create a medial calcaneal base modification which
gives
medial floor reaction,(creating a base more medially than usual).

I also gave her a jointed ankle free motion AFO with the same foot plate
and
a medial slot strape for walking on uneven terrain. If you can prevent
forefoot abduction and calc.valgus you've got it .

The knee pain should dissappear with time. As the OOS saying goes,This
is a
normal reaction to the corrected alignment your orthosis is providing.
That
is unless his patella is now tracking more medially than it used to and
he
has chondromalacia patella so bad that he'll now scratch new grooves as
deep
as the ruts a cement truck would make on a dirt road in mud season.