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Three Part Question

In [Posterior Tibialis Tendon Dysfunction] are [clinical tests and questions] diagnostically valid compared to [MRI/Surgery]?

Clinical Scenario

A 50 year old female patient presents to the physiotherapy department for assessment of medial ankle and foot pain that came on insidiously 6 months ago. She has been diagnosed with posterior tibialis tendon dysfunction (PTTD) by an orthopaedic consultant, but the patient would like to know what the accuracy/validity of the clinical diagnosis is without also having an MRI scan.

Search Strategy

Medline 1966-09 using the Pubmed Clinical Queries database was searched up to December 2009 using the following terms ... (Posterior[All Fields] AND Tibialis[All Fields] AND ("tendons"[MeSH Terms] OR "tendons"[All Fields] OR "tendon"[All Fields])) AND Diagnosis/Broad[filter]. In addition bibliographies were screened for relevant papers. Finally, BestBETS database was searched using familiar terms.

Pub Med: http: //www.ncbi.nlm.nih.gov/sites/pubmedutils/clinical
Best BETS: http://www.bestbets.org

Search Outcome

After duplicates had been removed, 120 abstracts were identified as being possibly relevant from the combined searches. 14 papers were identified that potentially answered the three part search question and the full articles were retrieved. No papers were of sufficient quality, and therefore no evidence to be used to answer the PICO question proposed.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses

Comment(s)

Despite many papers reporting that posterior tibialis tendon dysfunction is a diagnosis made by clinical history and examination, there is no high quality evidence to support this. This, in part, is due to a lack of large clinical studies, but also perhaps more importantly an ongoing lack of awareness of the condition in the general medical and allied health community. The current body of evidence does report common clinical presentations, but none have rigorously assessed these against a suitable gold standard of MRI or surgery in a robust clinical trial setting.

Clinical Bottom Line

There is currently only weak evidence to support history, clinical tests or clinical variables in the diagnosis of posterior tibial tendon dysfunction. Local guidelines should be sought for guidance, and if there are none in place local guidelines should be developed by a specialist MDT team.

References

1. Edwards MR, Jack C, Singh SK Tibialis posterior dysfunction Current Orthopaedics 2008; 22(3): 185-192
2. Funk DA, Cass JR, Johnson KA Acquired flat foot secondary to posterior tibial-tendon pathology The Journal of Bone and Joint Surgery 1986; 68(1): 95-102
3. Geideman WM, Johnson JE Posterior Tibial Tendon Dysfunction Journal of Orthopaedic & Sports Physical Therapy 2000; 30(2): 68-77
4. Hintermann B, Gächter A The First Metatarsal Rise Sign: A Simple, Sensitive Sign of Tibialis Posterior Tendon Dysfunction Foot & Ankle International 1996;1(4): 236-241
5. Johnson KA Tibialis Posterior Tendon Rupture Clinical Orthopaedics and related Research 1983; 177: 140-147
6. Johnson KA, Strom DE Tibialis Posterior Tendon Dysfunction Clinical Orthopaedics and related Research 1989; 239: 196-206
7. Khoury NJ, EI-Khoury GY, Saltzman CL, Brandser EA MR imaging of posterior Tibial Tendon Dysfunction American Journal of Roentgenology 1996; 167: 675-682
8. Kohls-Gatzoulis J, Angel J, Singh D Tibialis posterior dysfunction as a cause of flatfeet in elderly patients The Foot 2004; 14: 207–209
9. Kohls-Gatzoulis J, Angel JC, Singh D, Haddad F, Livingstone J, Berry G Tibialis posterior dysfunction a common and treatable cause of adult aquired flat foot BMJ 2004; 329:1328–33
10. Lee MS, Vanore JV, Thomas JL, Catanzariti AR, Kogler G, Kravitz SR, Miller SJ, Gassen SC Diagnosis and treatment of adult flatfoot The Journal of Foot and Ankle Surgery 2005;44(2):78-113
11. Mann RA, Thompson FM Rupture of the posterior tibial tendon causing flat foot surgical treatment The Journal of Bone and Joint Surgery 1985; 67: 556-561
12. Marcus RE, Pfister ME The Enigmatic Diagnosis of Posterior Tibialis Tendon Rupture The Iowa Orthopaedic Journal 1993; 13: 171-177
13. Pomeroy GC, Pike HR, Beals TC, Manoli A Acquired flatfoot in adults due to dysfunction of the posterior tibial tendon The Journal of Bone and Joint Surgery 1999; 81-A(8); 1173-1182
14. Trnka HJ Dysfunction of the tendon of tibialis posterior The Journal of Bone and Joint Surgery (Br) 2004; 86-B(7): 939-46