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Three Part Question

In [Posterior Tibialis Tendon Dysfunction] is [conservative management (including podiatry, exercises and other conservative treatments)] more effective than [no intervention]?

Clinical Scenario

A 50 year old female patient presents to the physiotherapy department for treatment of medial ankle and foot pain that came on insidiously 6 months ago. The clinical diagnosis of Stage 2a posterior tibialis tendon dysfunction (PTTD) has been confirmed with an MRI scan and she has been referred to physiotherapy and podiatry for a trial of conservative management.

Search Strategy

Medline 1966-09 was searched using the Pubmed database was searched up to December 2009 using the following terms

("Posterior Tibial Tendon Dysfunction"[MeSH Major Topic]) AND ("Exercise"[Mesh] OR "Exercise Therapy"[Mesh] OR "Exercise Movement Techniques"[Mesh] OR "Resistance Training"[Mesh] OR "Muscle Stretching Exercises"[Mesh] OR "Exercise Tolerance"[Mesh])

AND

("Orthotic Devices"[Mesh]) AND ("Posterior Tibial Tendon Dysfunction"[Mesh])

Finally Cochrane, PeDro, and the Best BETs databases were checked for any pre-existing reviews of the literature on this question.

Search Outcome

After duplicates had been removed, 7 abstracts were identified as being possibly relevant and the full articles retrieved. No papers were of sufficient quality. Therefore no evidence was found to answer the proposed PICO question.

Comment(s)

There is no high quality evidence to support of the frequently used modalities for conservative management. There is very little literature and research into this subject area, and the few research articles reviewed were not of sufficient quality to support one particular form of conservative management. Part of the reason why PTTD may not have received significant investigation is that there is a lack of epidemiological studies into the incidence, prevalence and natural history of the condition, which is key information for any clinical investigation.

Clinical Bottom Line

There is currently only very weak evidence to support conservative management for the treatment of posterior tibial tendon dysfunction. We agree with the authors Bowring and Chockalingam that in lieu of good evidence or established national guidelines, then local guidelines should be developed by the specialist MDT team.