Cerebral Palsy/Soft Knee Immobilizer

Left soft knee immobilizer
Cerebral palsy.
This 4-year-old female has no known allergies. She is not taking any medication. She had Botox injections on 03/21/2001 in both of her hamstrings.
The knee immobilizer will be used due to the patient having hamstring spasticity. A 9-inch knee immobilizer fit the patient very well. The parents were concerned because they were under the impression that Dr. ----- was going to order knee immobilizers for both legs. I placed a call to physician's office and left a message asking if physician did indeed wanted the patient to have one for each leg. Doctor wrote specifically just for the left. We will wait to her back. Today I fit and delivered 1 knee orthosis to the left leg.
We will wait for notification from Dr. regarding fit and delivery of a right knee immobilizer.
Evaluation and measurement for right soft knee immobilizer.

Bilateral Solid AFO's with Anterior Panels

The patient was seen today for fit and delivery of bilateral solid-ankle AFOs with anterior panels. A good fit was achieved. Proper donning and doffing instructions were given. A gradual wearing schedule was discussed and agreed upon. This patient ambulated without discomfort for approximately 10 minutes. I removed the braces, checked his skin, and no redness was noted. He will begin wearing the braces when he gets appropriate shoes. Otherwise, this patient will be seen as needed.

PTB Thigh Corset Addition

This patient was in our office today for measurements for a thigh corset and side joints to be added to his existing PTB socket. A standard fiberglass impression was taken over the patient's thigh and including the socket. Patient is fitting in the socket with a five-ply sock. We will contact the patient when the device is ready for fittin

VA Upset

Patient called on the telephone today, requesting to know when his leg is going to be fabricated. Currently on ------, we sent pricing out to VA. In return, we were to wait for a purchase order.Patient has contacted the VA, and they said they were in the process of getting that purchase order, and that they will be in touch with us within the next day or two. I called to confirm this. The secretary's name is -----. She seemed particularly upset that not only our company, but another company, was saying that we were waiting for authorization from the VA. She felt that this terminology only prompted fear and outrage in the veteran because they thought that they were not going to be eligible for,said benefits, and our new terminology is'we are waiting to have the VA process the paperwork for a purchase order which would allow us to go to the next step, and we are not to use "authorization any more" Miss ----- said that, via mail, we will get our purchase order number. I have called back patient and left a message to let him know this to that effect. We will contact him again when it is time to schedule and appointment for him to be seen.

Stabilizing Effect of Aircast Ankle Brace

*
* CME Programs

Reference Search
A Biomechanical Study of the Stabilization Effect of the Aircast Ankle Brace
Source:
Stuessi E, Tiegermann V, Gerber H, et al: Biomechanics X-A International Series 6A: 159-164, 1987
Summary:
Kinematics and kinetic analyses were used to assess the stabilization effect of the Aircast Ankle Brace on mediolateral movement of the ankle in static and dynamic situations. The authors concluded that "the Aircast Brace has a stabilizing effect on the ankle… the brace reduce[d] the amount of supination in static (isometric) as well as in dynamic (running) situations… The brace had no influence on the EMG activity of the peroneus longus. Therefore, it can be assumed that in the dynamic situation (running), the measured limitation of the range of movement was a result of the Aircast Ankle Brace and not of an increased muscle activity."

PTB Height Adjustment/New Shoes

This patient was seen in our office for adjustment to his left PTB endoskeletal below the knee prosthesis. What was done today was to realign and correct the height on his current prosthesis. The patient has switched shoes and has gone to a shoe that does not incorporate an AFO on the right side. This has left him 1/2 inch tall on the prosthetic side and the anterior tilt of the ptton are inappropriate in the new shoes. Both of these items were adjusted on the patient today. He reported after these adjustments that he was comfortable on the limb and was able to ambulate comfortably on the limb. Everything else is appropriate at this time. The patient is currently wearing 4 ply of sock. He will be followed through our office on an as needed basis and through the VA clinic.

UCB Inserts / Down's Syndrome

Prescription: UCB inserts. Diagnosis: Down's Syndrome
History: This is an eight year old white female (patient A) with Down's Syndrome who has a surgical history of having heart surgery in the past. She takes Catapril and Lanoxin. She has no allergies at this time. She has worn UCB-FO's in the past.
Assessment: This is a child who stands with pronated mid-feet, abducted fore-feet, and valgus heels. The feet do correct to a neutral position.
Plan: Fabricate bilateral UCB-FO's.

We attempted to fit patient A today with her bilateral UCB-FO's. These were fabricated out of 3/16" polypropylene and are far too heavy duty for someone of Amy's size. Additionally, the forefoot was wide on these orthoses. We will remanufacture these for her and supply them to her tomorrow.

Patient A returned to our office today for the fitting of her UCB-FO's. These looked much better today. They were fabricated from 1/8" polypropylene and fit quite nicely. These were trimmed and finished and Amy ambulated very comfortably in them. Everything appeares to be satisfactory in these orthoses at the present time. Patient A worn them out of the office.

Obama Puts CMS Competetive Bidding for O&P on Hold

Obama puts ICD-10 regulation on hold for review

By Jennifer Lubell / HITS staff writer
Posted: January 22, 2009 - 5:59 am EDT

HHS’ implementation of ICD-10 and several other rules issued last week could potentially be delayed, as the White House proceeds with a review of any new or pending regulations issued under the Bush administration.

A memorandum released by White House Chief of Staff Rahm Emanuel has “put a hold on all regulations that have either not been published or those that have not yet taken legal effect,” a CMS spokesman said.

Although the CMS has yet to produce a list of the affected regulations, it’s likely that at least four recent rulemakings could be put on hold, including HHS’ final rule for transitioning to the International Classification of Diseases, 10th Revision, the spokesman said.

The final rule for implementing ICD-10 CM (Clinical Modification) and ICD-10 PCS (Procedure Coding System) was issued on Jan. 15. However, the rule itself “doesn’t become effective until March 17, which means the ICD-10 regulation would fall within this additional layer of review” by the White House, said Don May, vice president for policy with the American Hospital Association. ICD-10’s compliance deadline isn’t scheduled to take effect until Oct. 1, 2013.

“We will be working with the new administration in their effort to review actions and regulations subject to the memo,” the CMS spokesman said.

Other recent rules that may be put on hold include an interim final rule to identify protected classes of prescription drugs under Medicare Part D; a proposed rule to make improvements to the cervical cancer proficiency testing program; and another interim final rule that addresses steps to restart the CMS’ competitive bidding program for durable medical equipment, prosthetics, orthotics and supplies.

An Rx for Ethics - New Rules on Doctors and Medical Firms

By BARRY MEIER - New York Times Business 1/25/09
When the sun goes down in Las Vegas, steer clear of doctors.
Those are the marching orders that Smith & Nephew, a leading maker of artificial hips and knees, has given executives and sales representatives attending a big meeting of orthopedic surgeons next month. The company has told them to limit their interactions with doctors to 9 a.m. to 5 p.m., the "business" hours of the convention of the American Academy of Orthopaedic Surgeons.
It remains to be seen whether such seeming magnets as doctors and sales executives can resist each other. But Smith & Nephew's convention curfew is a sign of an ethical makeover under way within the medical device industry, a field that has been troubled by federal investigations and bad publicity over the volatile issue of frequently undisclosed financial ties between companies and physicians.
On Thursday, two senators increased the pressure further by reintroducing legislation that would require device and drug makers to report all financial links with doctors on a federal Web site. That bill is known as the Physician Payments Sunshine Act, and a parallel effort is in the House.
"The public is clamoring for transparency," one of the Senate sponsors, Herb Kohl, a Wisconsin Democrat, said. The co-sponsor is Charles E. Grassley, Republicanlican of Iowa.

The nation's biggest hip and knee makers, including Smith & Nephew, are operating under Justice Department oversight as part of an agreement to resolve allegations that they gave some doctors illegal inducements to use their products.
Other sectors of the device industry face continuing federal inquiries or are voluntarily taking house-cleaning measures. Much of it involves the public disclosure of information that would be mandated under the Senate proposal — the names of the doctors who work for device manufacturers as consultants, lecturers, researchers or trainers, and how much each one is paid for those services.
Under their Justice Department settlements, the hip and knee makers are already disclosing such payments on their corporate Web sites. And seeing the writing on the wall, several other large device companies, including Boston Scientific and Edwards Lifes Sciences, recently announced they would do so voluntarily.
Meanwhile, the device industry's main trade group, the Advanced Medical Technology Association, said it had supported the Senate measure when it was introduced two years ago.
There is little question that battles over how much companies, doctors and medical institutions disclose about their financial ties will continue. But some experts on medical conflicts of interest, seeing the rapid fall of resistance by most major companies, say that a turning point has arrived.
"We are definitely moving towards more disclosure and disclosure of information that is useful to people," said Lisa Bero, a pharmacy professor at the University of California, San Francisco.
Recently, several big pharmaceutical companies have also said they plan to release the names of doctors they use as consultants. But the ties between medical device makers and physicians are often more entangled and can have a bigger impact on both patient care and product sales.
For one, doctors may be involved in the design of a medical device and can hold a patent on it. Further, device makers also hire surgeons to train other doctors on how to implant their products. And hospitals often give doctors a large say in determining the suppliers of products like artificial hips or heart defibrillators — companies with which those same doctors may have financial relationships. Some hospital systems, including the big Kaiser Permanente network, bar physicians from taking industry money and now require device suppliers to compete on the same basis on which most medical products are purchased — price.
In recent months, the ground has shifted so rapidly under device makers that companies find themselves scrambling to keep -up.
Take Edwards Lifesciences, a producer of heart valves and other devices. Last year, the company's chief executive, Michael A. Mussallem, decided that Edwards would voluntarily disclose all its payments to doctors.
Mr. Mussallem said that the decision came from the push for federal legislation and the passage in Massachusetts last summer of a state law requiring drug and device companies to disclose all payments to doctors in excess of $50.
Edwards, like other device makers, has also been the subject
of media articles raising questions about the motives of physicians with financial ties to the company.
"We make our living on innovation," said Mr. Mussallem, who is also the current president of the Advanced Medical Technology Association. "But every time we turned around there was a story that made this seem negative rather than positive."
But gathering that physician data is proving easier said than done. For instance, Edwards officials soon discovered that each company division had used a different process to account for its doctor payments, and technological havoc resulted when they tried to pull the data together.
The public is clamoring for transparency,' a senator says.
"You couldn't tell if Dr. Jones and Dr. Jones were the same guy," or different ones, said Dirk-sen Lehman, the company's vice president for government affairs.
Edwards hopes to resolve those issues in time to meet its self-imposed deadline of making physician disclosures public by December, he said.
For years, both device makers and their consulting doctors insisted that money did not affect how the physicians treated patients. And device makers rebuffed efforts to disclose such ties.
But the Justice Department changed all that through its investigation of orthopedics companies, which was headed by the United States attorney in Newark. Although federal prosecutors said they found that most financial ties between companies and doctors were legitimate, there was enough evidence of illegal sales inducements • and sham consulting contracts to warrant filing charges.
To avoid prosecution, the companies, without acknowledging wrongdoing, entered settlements in 2007 under which they agreed, among other things, to submit all their doctor ties to an outside monitor for review. They also agreed as a group to limit daily consulting payments to most doctors to $500, and to justify such expenses.
More recently, two companies involved in the Justice Department action, Zimmer Holdings and Biomet, said separately that they would no longer give educational funds directly to medical schools, but instead would give them to professional organizations, which would decide how they should be distributed.
The federal inquiry has also had an impact on surgeons who specialize in hip and knee replacements. Company-sponsored work on new products has largely been at a standstill since 2007, several doctors said. And other types of consulting relationships are just starting to resume under the new disclosure rules.
For instance, Dr. Michael C. Raklewicz, an orthopedic surgeon in Kingston, Pa., said he was notified just a few weeks ago by Zimmer Holdings, the biggest orthopedic implant maker, that it would again retain him to train other surgeons on the use of its products.
"All I knew was that I had a few teaching sessions left and they were canceled" back in late 2007, said Dr. Raklewicz. "Then, it was like, 'Hold on, hold on, we'll get back to you' and finally they did."
The possibility of similar Justice Department action may also be facing other companies that have declared themselves converts to the concept of disclosure.
Since 2005, for example, the Justice Department has been investigating ties between doctors and makers of heart pacemakers and defibrillators. The companies involved deny any wrongdoing. But two of them — Medtronic and St. Jude Medical — have said they support federal disclosure legislation.
A third big producer, Boston Scientific, has gone a step further. The company, which acquired the heart device business of the Guidant Corporation in 2006, recently said that it planned this year to publicly release data about its financial links to doctors among all its business units.

AFO's Improve Mobility After Stroke

Release Date:January 22, 2009

Ankle Splints Improve Mobility After Stroke
By Kurt Ullman, Contributing Writer
Health Behavior News Service


A new review shows that ankle and foot splints can help stroke patients regain the ability to walk and keep their balance, although splints — also called orthotics — offer less improvement for other activities, like climbing stairs.

Wrist splints, however, do not lead to signs of improvement in the hands or arms, according to the new review.

“A stroke causes weakness of one side of the body, making it difficult to move the affected arm and leg in everyday activities like walking or eating,” said co-author Sarah Tyson, Ph.D. “One common way to manage this problem is using a splint to control movement at weak joints, especially the wrist or the ankle. We undertook a Cochrane Review to clarify whether the splints were effective and to make recommendations about how they should be used in practice.”

The reviewers analyzed 14 clinical studies involving 429 participants. The leg splint studies looked for improvement in walking speed, balance and step/stride length. They also assessed foot drop during the swing phase of walking.

“The results for lower-limb splints show that they can improve walking and balance, at least in the short term,” Tyson said. “This is something of a surprise as, traditionally, physiotherapists have been reluctant to prescribe them, as it was felt orthotics may have a detrimental effect. However, views have been slowly shifting in the last few years as the body of evidence supporting their use has emerged.”

Tyson is a senior research fellow with the Centre for Rehabilitation and Human Performance Research at the University of Salford in Greater Manchester, England.

The new review appears in the latest issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews like this one draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.

The included studies only examined immediate effects of splints, rather than long-term impact.

Both kinds of splints usually are custom made of plastic or metal. Clinicians mold ankle foot splints to the lower leg and then adjust them to help compensate for the patient’s specific deficit. For the most part, the splints start around the ball of the foot and extend upwards to a few inches below the knee.

Arm and hand splints most often include the palm to an inch or so above the wrist. Initially, these braces are used to increase the range of motion in fingers and hands that may have been frozen into a fist or have muscles that are hard to control following a stroke. This is intended to help the patient regain use of their upper extremities to eat, write or pick things up more efficiently.

However, researchers saw no effect from wrist splints on the ability to use the arm; range of movement at the wrist, fingers or thumbs; or pain.

“This result was also surprising as the use of orthotics to prevent contractures (loss of range of movement) is thought to be very important in restoring use of the arm after stroke,” said Tyson. “These results throw that belief into doubt; however, the results are based on a very small number of studies, so we need to do larger trials and look at the use of orthotics combined with other established treatments, such as physiotherapy or botulinum toxin [Botox].”

“This review confirms what most rehabilitation professionals had assumed all along, that the lower extremity splints make an immediate, positive impact on a patient’s balance and walking ability,” said Kyle Covington, P.T, medical instructor and academic coordinator of clinical education at Duke University School of Medicine. “It is nice to have the evidence to back-up what clinical experience was telling us. It also gives more credence to the usefulness of splints, at least in the lower extremities.”

He agreed that the hand and arm results were unexpected.

“That was surprising in that some rehabilitation professionals had assumed that there was a benefit to the patient in splinting the hands and wrists, but as the authors point out, the jury is still out on that question.” Covington said.

Symptoms associated with rotator cuff tears:

Rotator cuff tears are tears of one, or more, of the four tendons of the rotator cuff muscles.

Rotator cuff tears are among the most common conditions affecting the shoulder.[1]

The tendons of the rotator cuff, not the muscles, are most commonly torn. Of the four tendons, the supraspinatus is most frequently torn; the tear usually occurs at its point of insertion onto the humeral head at the greater tuberosity.[2]
The most reliable symptom for determining a rotator cuff tear is probably the least common and is found when there is a complete rupture with detachment of the rotator cuff leading to the complaint of complete loss of function, such as, loss of the ability to actively move the arm away from the side of the body (loss of abduction). Fortunately this finding is rare and when tears are symptomatic, most tears present as pain with limitation of function, a non-specific complaint that cannot distinguish between tendinitis, bursitis or arthritis. The clinical picture of a completely detached tear is more clear-cut, while the more common shoulder problems greatly overlap in their clinical presentation.

Pain in the anterolateral aspect of the shoulder can be due to many causes, [4] symptoms may reflect pathology outside of the shoulder which cause referred pain to the shoulder from sites such as the neck, heart or gut.

Patient history will often include pain or ache over the front and outer aspect of the shoulder, pain aggravated by leaning on the elbow and pushing upwards on the shoulder (such as leaning on the armrest of a reclining chair), intolerance to overhead activity, pain at night when lying directly on the affected shoulder, pain when reaching forward (e.g. unable to lift a gallon of milk from the refrigerator). Weakness may be reported, but is often masked by pain and is usually found only through examination. With longer standing pain, the shoulder is favored and gradually loss of motion and weakness may develop which, due to pain and guarding are often missed by the patient and are only brought out during the examination.

Primary shoulder problems may cause pain over the deltoid muscle that is made worse by abduction against resistance, called the impingement sign. Impingement reflects pain arising from the rotator cuff but cannot distinguish between inflammation, strain, or tear. Patients may report their experience with the impingement sign when they report that they are unable to reach upwards to brush their hair or to reach in front to lift a can of beans up from an overhead shelf.

Ultra Sling ER Post-Op Care - Massive Rotator Cuff Tear

Surgical Procedure and Rehabilitation

Arthroscopic surgery was performed with the patient in a Beach-chair position (Tenet Tmax Beach Chair, Tenet Medical Engineering, Calgary, CN) following interscalene nerve blockade and administration of parenteral prophylactic antibiotics. An articulated hydraulic arm holder facilitated positioning of the arm for arthroscopy and arthroscopic rotator cuff repair (Spider Arm Holder, Tenet Medical Engineering, Calgary, CN). (Fig. 5).

Routine arthroscopic evaluation was performed in order to rule out comorbid pathology followed by a modified acromioplasty. Care was taken to preserve the coracoacromial ligament so as to prevent the risk of increased superior displacement of the humeral head by removal of this stabilizing barrier.

In all cases, a massive rotator cuff tear with marked medial and inferior retraction of the supraspinatus and infraspinatus respectively was identified (Fig. 6). Arthroscopic repair was performed by placing the arthroscope in a lateral portal so that the entire posterior extent of the tendon tear could be visualized. The tendon was then mobilized using a radiofrequency probe (VaprR, Mitek, Johnson and Johnson, Norwood, MA). The tendon tear was then repaired using a margin-convergence method as described by Burkhart along with direct reinsertion of the tendon in bone, or by partial reinsertion of the posterior component of the tendon tear if the supraspinatus was irreparable (Figs. 7A-C).9,10 After repair an intraarticular pain catheter was placed for postoperative pain control (PainbusterTM, DonJoy Orthopaedics, Carlsbad, CA).

All patients were then placed in a shoulder immobilizer with an external rotation pillow (UltraslingTM, DonJoy Orthopaedics, Carlsbad, CA) in order to protect the posterior component of the tendon repair.

Patients remained in the shoulder immobilizer with an external rotation pillow for six weeks and no therapy was performed during this time period. After six weeks active motion was permitted for daily living activities. Gentle assisted range of motion was performed and strengthening was delayed until four months after the surgical procedure.

Ultra-Sling II

DESCRIPTION:
ULTRA SLING II

Ideal Application

Both versions of the UltraSling II provide immobilization for rotator cuff repairs, capusular shifts, Bankhart repairs, glenohumeral dislocations/subluxation and soft tissue repairs/strains.

FEATURES:
Features and Benefits

Breathable extra padded fabric for greater comfort, particularly in longer term use.
Encourages effective healing by allowing the shoulder and arm to remain in a neutral position.
Helps prevent post-operative internal rotation contractures that can occur in a sling.
Promotes axiliary air exchange to reduce risk of secondary infections.
Exercise ball stimulates circulation.
Easy open front panel encourages forearm exercises.
Allows arm to be positioned in a variety of positions dependent on post-operative requirements (either more °°posterior or anterior).

Rotator Cuff Tear

Rotator Cuff
The rotator cuff is the name for the tendons that surround the shoulder joint. The rotator cuff is important in allowing the shoulder to function through a wide range of motions. In part due to the rotator cuff, the shoulder joint can move and turn through a wider range than any other joint in the body. This motion of the shoulder joint allows us to perform an amazing variety of tasks with our arms.

Unfortunately, a rotator cuff tear is not an uncommon problem, and these injuries make many routine activities difficult and painful. The rotator cuff is part of this mechanism that, when healthy functions very well, but when injured can be a difficult and frustrating problem.

What is the rotator cuff?
The rotator cuff is a group of four muscles and their tendons that wraps around the front, back, and top of the shoulder joint. Together the rotator cuff muscles help guide the shoulder through many motions, and also lend stability to the joint. The ends of the rotator cuff muscles form tendons that attach to the arm bone (humerus). It is the tendinous portion of the rotator cuff that is usually involved in a rotator cuff tear.

What is a rotator cuff tear?
A rotator cuff tear occurs when there is an injury to one of the rotator cuff tendons. Rotator cuff tears occur in many shapes and sizes, but can be thought of as a hole in one of the tendons around the shoulder joint. Like most orthopedic conditions, the most common mechanisms of a rotator cuff tear are separated into 'repetitive use' and 'traumatic injuries.'

* Repetitive Use Injury
In repetitive use injuries to the rotator cuff, repeated activities cause damage to the rotator cuff tendons. Over time, the tendons wear thin and a rotator cuff tear can develop within the tendons. Patients with repetitive use injuries to the rotator cuff often have complaints of shoulder bursitis prior to developing a rotator cuff tear through the tendons.

* Traumatic Injuries
Traumatic injuries to the rotator cuff are seen after events such as falling on to an outstretched hand. The traumatic event can cause a rotator cuff tear by injuring the rotator cuff tendons. This mechanism is much less common than repetitive use injuries, but when a rotator cuff tear occurs in a patient younger than 60 years old it is usually a traumatic injury.

Who is most susceptible to a rotator cuff tear?
A rotator cuff tear is seen both in the young and old, but they are much more common in the older population. Usually in younger patients, there is either a traumatic injury, or the patient is demanding unusual use of their shoulder, as seen in professional athletes.

As people age, the muscle and tendon tissue of the rotator cuff loses some elasticity, becomes more susceptible to injuries, and is often damaged while performing everyday activities. This is the reason that rotator cuff tears are more commonly seen in older patients.

How common are rotator cuff tears?
Not every rotator cuff tear causes significant pain or disability. In fact, autopsy studies have shown rotator cuff tears in up to 70 of people over the age of 80 and 30 of the population under the age of 70. Clearly, all of the people with rotator cuff tears are not complaining of painful symptoms. However, in many individuals, a rotator cuff tear can cause significant disability, and prompt diagnosis and treatment can have a profound improvement in symptoms.
Provides immobilization for rotator cuff repairs, capusular shifts, Bankhart repairs, glenohumeral dislocations / subluxation and soft tissue repairs and strains. For use after initial anterior shoulder dislocation or post operatively when external rotation is desired.
Surgery is also considered in patients who have tried conservative treatment, and still have difficulty with their shoulder.

For more information on what factors are used to decide when rotator cuff surgery is necessary:

o When is rotator cuff surgery needed?

There are several surgical procedures that are possible for rotator cuff treatment. The three most common procedures are:

* Open Repair
Prior to the use of the arthroscope, all rotator cuffs were repaired by looking directly at the torn tendon, through an incision about 6-10 centimeters in length. The advantage is the rotator cuff tendons are easily seen by this method, but the incision is large, and the recovery can be longer and more painful.

* Mini-Open Repair
The mini-open method of repairing a rotator cuff involves both the use of an arthroscope, and a short incision to get access to torn tendon. By using the arthroscope, the surgeon can also look into the shoulder joint to clean out any damaged tissue or bone spurs. The incision is about 3-4 cm, and the recovery is somewhat less involved than the open cuff repair.

* Arthroscopic Repair
An arthroscopic repair is done with small incisions, and the repair is done by the surgeon looking through a small camera to watch his or her repair on a television monitor. This is a more recent development in treatment of rotator cuff tears, and not all types of tears can be treated by this method. Some advantages and disadvantages of this procedure are discussed in the article comparing arthroscopic rotator cuff repairs to open methods.

The surgery to perform the rotator cuff repair generally lasts about two hours.

How long is the recovery from rotator cuff repair surgery?
This will depend on several factors, including your level of strength before the operation and the severity of the rotator cuff tear. Some period of immobilization of the shoulder joint is needed to protect the newly placed sutures from being disrupted. After one to two weeks, physical therapy begins. Initially, the therapy is gentle so as not to affect the rotator cuff repair. After four to six weeks, more active lifting with the arm begins. Several months after the rotator cuff repair, physical therapy will become more intense in an effort to strengthen the rotator cuff muscles. Complete recovery usually requires at least four to six months.

Ultra-Sling for Unstressed Wound Healing

Shoulder Pain, Fever, and Chills in a Fifty-Three-Year-Old Man (continued)

Answer: Abscess between the subscapularis and posterior portion of the chest wall.

Multiplanar magnetic resonance images of the area about the right shoulder girdle, including T1-weighted images, STIR (short-tau-inversion-recovery) images, and T1-weighted images with fat saturation following intravenous injection of gadolinium, demonstrated a multiloculated fluid collection between the subscapularis muscle and the posterior portion of the chest wall (Figs. 1 and 2). The rotator cuff muscles, including the subscapularis muscle, demonstrated no abnormalities. The walls of the lesion were thickened and irregular, with multiple septations that were enhanced with the gadolinium. There was moderate surrounding edema. The abscess extended inferiorly from the area anterior to the scapula, along the midaxillary and posterior axillary lines, to the level of the diaphragm. The pleura, hilum, and mediastinum of the lung appeared to be normal. Aspiration of fluid from the lesion was not performed before the operation.
The patient was taken to the operating room for urgent open drainage of the abscess on the evening of admission. After induction of general anesthesia, the patient was placed in the lateral decubitus position on a beanbag. Routine preparation and draping were performed. A curvilinear incision was made over the medial border of the scapula and was extended inferiorly. The inferior border of the trapezius muscle was retracted superiorly to expose the lower half of the medial scapular border. Electrocautery was used to release the rhomboid musculature from the medial scapular edge and to expose the underlying space. Upon entrance into the scapulothoracic space, a massive amount of purulent fluid was immediately encountered. Approximately 500 mL of purulent material was evacuated. Intraoperative gram-staining of the specimen yielded gram-positive cocci in clusters.

Multiple areas of loculation were released by gently sweeping an index finger through the area. A moderate degree of necrotic tissue was found to be forming the septations and lining the edges of the abscess and was removed with a rongeur. The space was then irrigated with pulsatile lavage with use of 9 L of saline solution with cefazolin antibiotic (2 g of cefazolin per 3-L bag). Two large Hemovac drains were placed to evacuate fluid from the scapulothoracic space. The rhomboid musculature was reapproximated to the medial scapular border with absorbable PDS (polydioxanone) monofilament suture. Prolene monofilament suture (Ethicon, Somerville, New Jersey) was used for skin closure. A shoulder sling (DonJoy UltraSling; dj Orthopedics, Vista, California) was used postoperatively, with the arm positioned at the side to allow unstressed wound-healing.

Ultra-Sling ER Video Application

Click here for video.

DonJoy Velocity for PTTD

Velocity™ Ankle Brace
Introduction

The Velocity™ represents an evolution in DonJoy ankle brace technology, utilising several new, proprietary design features, resulting in a new level of ankle brace performance and providing the foundation for successful ankle injury prevention and treatment. The Velocity can also be used for mild PTTD dysfunction.

Indications

• Anterior talofibular ligamant sprains grade 1-3
• Calcaneofibular ligamant sprains grade 1-3
• Posterior talofibular ligamant sprains grade 1-3
• Combined lateral ligamant sprains grade 1-3
PTTD Dysfuntion
• Rehabilitation after lateral collateral ligamant reconstruction


Information on Ordering

At OrthopaedicsAndTrauma.com we only supply the ES version and you can have "any colour as long as it is black". This is because the ES can be cut down to the MS or LS versions and most athletes need the ES version at first.
Choose left or right
Choose calf circumference standard fitting (STD)<25.5cm or wide fitting (WD)>25.5cm by measuring the calf circumference 20cm above the ground in bare feet.

Size / UK Men / UK Women
x=2=small / <7 / <7.5
x=3=medium / 7-11 / 7.5-11.5
x=4=large / >11 / >11.5

Innovations

• Low profile, lightweight
• Controls ankle inversion, eversion and rotation while allowing natural, unrestricted dorsi and plantar flexion.
• The combination of soft goods with a rigid, hinged foot plate and calf cuff provides unsurpassed levels of control, fit, and support.
• This Velocity ES (extra support) version can be cut down as the inate stability of your patient's ankle improves to the LS (light support) version affording patients and athletes two ankle support levels at the same price.
• Available only in black
• ES offers extra support and rigidity.
• Left and Right versions.
• Standard and wide calf cuff.

Posterior Tibial Tendon Anatomy

Anatomy:

The posterior tibial tendon is the extension of the posterior tibial muscle that lies deep to the calf. The origin of the posterior tibial muscle is the posterior aspect of both the tibia and fibula and the interosseus membrane. The insertion of the posterior tibial muscle is the medial navicular where the tendon divides into nine different insertion site on the bottom of the foot.

Anatomy_tibialis_posterior_muscle Anatomy_Posterior_leg_muscles Anatomy_posterior_leg_exploded_view Anatomy_medial_ankle

Biomechanics:

The function of the posterior tibial tendon is to plantarflex the foot at the toe off phase of the gait cycle and to stabilize the medial arch and subtalar joint as the body passes over the foot.

Symptoms:

The symptoms of stage I PTTD include a dull ache of the medial arch. The pain become worse with activity, better on days with limited time on the feet. Continued weight bearing activity may result in a partial rupture of the tendon, moving to stage II. Stage I typically show no swelling but presents with pain along the course of the PT tendon from the medial ankle to the insertion of the PT tendon on the medial arch.

Stage II symptoms are persistent and only partially relieved by rest. Pain is present at the onset of weight bearing and continues throughout the day. Some limitation of the ability to raise up on the toes will be present and limited by pain. Mild swelling may be present in the medial arch.

Stage III symptoms are severe with an inability to complete most normal daily activities. Collapse of the medial arch will be obvious. Abduction of the forefoot will show 'too many toes sign'. Patients are unable raise up on their toes.

Posterior Tibial Tendon Dysfunction: A Review of Pain and Activity Levels of Twenty-one Patients

Christopher Lake, CPO
Gary S. Trexler, CO
William J. Barringer, CO.
ABSTRACT

Posterior tibial tendon dysfunction (PTTD), which results in painful pes planus, is a common clinical problem that requires careful orthotic management. The purpose of this study was to conduct a chart review and telephone survey to determine the effectiveness of orthotic treatment. In this preliminary study the authors define effective orthotic treatment as treatment that reduces pain and assists the patient in returning to pre-PTTD activity levels. When comparing orthotic management among foot orthoses fabricated from cork and pelite, UCB-type foot orthoses, and various types of AFOs, strong trends were noted. UCBs and AFOs reduced pain in five and seven subjects respectively, but only AFO management successfully increased activity levels of the subjects.

Key Words: Posterior tibial tendon dysfunction, pes planus, orthoses, ankle-foot.

First described in the orthopedic literature in 1969, posterior tibial tendon dysfunction (PTTD) can be caused by a partial or complete tear of the distal muscle tendon.1 Since the initial report, several authors have commented on the presentation and progressive nature of this pathology in regard to orthotic and/or surgical management.2-5

This pathology is more common in middle-aged and older individuals. The progression is insidious and often unnoticed until significant deformity is present. Though rare, PTTD has been described in young athletes.6 The mechanism of injury involves an excessive amount of stress placed on the tendon during rapid changes in direction, as in playing basketball or hockey.

The posterior tibial muscle originates at the proximal third of the tibia and interroseus membrane. The distal tendon takes a course that passes posterior to the medial malleolus. The muscle's tendonous insertions include the navicular, all three cunieforms, talonavicular capsule, cuboid, and corresponding metatarsals.5 This muscle has a significant role in supporting the medial longitudinal arch; however, it is more the unopposed eversion action of the peroneal brevis that initiates the deformity than it is the absent inversion of the posterior tibialis.2 Furthermore, the medial longitudinal arch does not necessitate muscle force to maintain it.7 The bony anatomy and ligaments alone are sufficient for maintaining arch integrity until the presentation of muscle imbalance, as found in PTTD, slowly introduces a painful deformity.

In addition to its influence on the medial longitudinal arch, the posterior tibial muscle plantarflexes and inverts the foot. PTTD will cause collapsing of the medial longitudinal arch, subtalar eversion, valgus at the ankle, and forefoot abduction. There will be stretching of the spring and deltoid ligaments as well as the talonavicular capsule. Increasing equinus with progression and the possible development of contractures are also suspected.5 The posterior tibialis initiates inversion and stabilizes the subtalar joint, allowing the gastrocnemius to plantarflex and invert the heel as the patient rises onto his/her toes. When the posterior tibialis is compromised, patients with PTTD will be unable to single-limb heel rise as the pathology progresses.

Several variables contribute to the etiology of this pathology. The PTTD patient often exhibits: obesity, hypertension, diabetes, previous trauma to the foot and ankle, and steroid treatment in the area of the posterior tibial tendon. Holmes and Mann found that obesity, diabetes, and hypertension were common clinical diagnoses in this patient population, noting higher incidences than found in the general population.8

Frey concluded that there is an area of hypovascularity in the tendon just distal to the area of the tendon that courses around the medial malleolus.9 He attributes this finding to the sharp angle the tendon takes as it courses around the medial malleolus. This hypovascularity is not seen in the flexor digitorum longus, which takes a common path around the medial malleolus.
Clinical Presentation

During orthotic evaluation, the patient might verbalize that he or she has been experiencing pain on the medial aspect of the ankle, secondary to the stretching of the medial ligaments and soft tissues. Severity of valgus angulation should be measured and the orthotist should note if medial edema is present from repetitive stretching and traumatizing of the area (Figure 1a , Figure 1b , and Figure 1c ). If the patient is progressing, pain will develop laterally as the fibula impinges on the calcaneus. Muscle testing inversion strength and single-limb heel rise are helpful in determining severity of the problem as well as in developing the orthotic plan.

The orthotist should be aware of the classification specifics of Myerson.11 This classification is an adaptation of Johnson and Strom's staged classification.10 Stage I involves patient complaints of medial pain and edema. The patient can still perform a single-limb heel rise and has a flexible hindfoot. Orthotic treatment options include medial heel and sole wedges, arch support, and articulated AFOs. In stage II, individuals present with heel valgus and cannot perform single-limb heel rise. Pain is now present on the lateral aspect of the ankle. Orthotic treatment is the same as that in stage I, with the addition of more rigid arch supports. With progression to stage III, the hindfoot is now rigid, and solid ankle AFOs are suggested. Finally, stage IV is distinguished by a valgus angulation of the talus with rigid AFO management as the orthotic treatment.

The only other finding in the literature pertaining to orthotic treatment was an abstract and paper presented by Chao, et al., to the American Academy of Orthopaedic Surgeons.11 The authors found that PTTD "can be effectively treated with aggressive conservative management using molded ankle foot orthoses and UCB inserts." In addition ,"67% of the subjects had results that were considered good to excellent based on pain, function, use of an assistive device, distance of ambulation and patient satisfaction." While all the papers reviewed were informative, there was a lack of solid orthotic observations in regard to what to expect and how to treat these patients. Questions of pain and activity levels with orthotic management encouraged the authors to review cases seen in their clinic and to observe similarities and differences within this patient population.
Methodology

A chart review and telephone survey was conducted of all patients under the direct care of the authors for a period of 11 months. No statistical tests were performed during this case review due to the variety of treatments. Comparisons among foot orthoses fabricated from cork and pelite, UCB-type foot orthoses, and AFO users were made. Variables reviewed were patients' age, side affected, sex, duration of orthotic treatment, weight, incidence of diabetes, and hypertension. The authors were particularly interested in activity level and pain level with orthotic treatment. Though subjective, activity level and pain level prove to be good measurements of the effectiveness of orthotic treatment from the patient's perspective. In regard to activity level, some patients, as noted in the results, expressed that they were able to walk further and for longer duration with orthotic treatment.
Results

Of the 25 patients seen, 21 were available for follow-up. The sample consisted of 17 females and 4 males with a mean age of 57 years. After calculating a body mass index for each patient, 86% were found to be overweight for their height and age,12 24% were diabetic, and 62% were hypertensive. Three individuals presented with deformity bilaterally.

Orthotic treatment was determined by the prescribing orthopedic surgeon, usually as an effort to avoid surgery. All patients described varying levels of both medial and lateral pain before treatment, indicating that orthotic management was initiated late, often after bed rest, short leg cast, or pain-management injection treatments failed.
Foot Orthoses Fabricated with Cork and Pelite

Orthoses in this group were fabricated with an arch support and 5º medial wedge. This group consisted of six subjects with a mean duration of treatment of 7.2 months (4- to 10-month range). Three individuals in this group perceived their condition as good since the initiation of orthotic treatment. One subject was within the average weight range and another would not discuss weight characteristics. The other four individuals averaged 36.8 pounds over the upper limit of the average weight range. Activity level increased in only one subject and pain decreased in three subjects.
UCB-Type Orthoses

Orthoses in this group were posted medially, and relief for the prominent plantar aspect was made accordingly. This group consisted of six subjects with a mean duration of treatment of 6.2 months (1- to 9-month range). Five individuals in this group stated that they were doing well and not progressing. Only one subject was within the average weight limits. The other five subjects were an average of 48.2 pounds overweight. Activity level increased in one subject and pain decreased in five subjects.
AFOs

Three different types of AFOs were used, as deemed appropriate after evaluation of the patient's needs. All AFOs incorporated a valgus-controlling trimline (Figure 2 ).

Articulated AFOs were used in cases where the valgus present could be controlled with a minimal amount of surface area contact medially with a well-molded medial longitudinal arch support and where the hindfoot exhibited no pathological related rigidity. The ankle was free motion unless the physician anticipated the development of an equinus contracture. If this was the case, a 90º plantarflexion stop was included.

A dorsiflexion-assist AFO with valgus-controlling trimlines, as described by Smith,13 was used when ankle motion needed no restriction and a UCB, or articulated AFO insert would not provide sufficient ankle control due to lack of medial surface area contact (Figure 3 ). The flexibility of this type of AFO seems to affect the function of the patient minimally and exhibits ground reaction forces to a lesser degree than solid ankle orthoses.

Solid ankle AFOs with valgus-controlling trimlines and neutral ankle alignment were used for patients who presented a rigid hindfoot, obesity, and extensive valgus angulation that required maximum control. No correction of deformity could be obtained in these patients. Seven subjects were studied in this group. (Originally there were eleven subjects; three had shoe conflicts and refused to acquire proper footwear, and one was attending an orthotic clinic closer to her home.) Mean duration of treatment was 5.6 months, with a range of 1 to 11 months. All seven subjects wearing their AFOs felt that they were doing well. One subject was within the average weight range; the others averaged 51 pounds over the superior limits of the weight range. Activity levels increased in six and pain decreased in all seven. Pertinent was the finding that four of the AFO subjects were previously managed in cork and pelite foot orthoses. These orthoses did not provide adequate control of the ankle valgus and allowed the deformity to progress.
Discussion

While pain reduction was evident in UCB type orthoses and AFO treatment, activity level was most influenced by AFO treatment. AFOs provided a greater degree of control over the ankle. As patient weight increased, so did the degree of orthotic control, indicating the careful consideration of this variable in orthotic design as well as in material selection.

The orthotist must be aware that, in many cases, the deformity that presents around the ankle should be accommodated more than corrected. The orthotist should specifically be aware that with progression of this pathology, the navicular becomes very prominent on the plantar aspect of the foot. Adequate relief is essential for patient comfort and success of treatment.

The authors find it particularly helpful to take a plaster impression with partial weight bearing to provide a more accurate impression of the plantar surface. It is necessary during the impression process to provide a low-durameter foam block on which the patient can bear weight. We have also found that the use of impression foam is not advantageous in the effective treatment of this pathology. It is difficult to determine bony alignment and adequately distinguish bony prominences using impression foam.

Padding the medial aspect of the orthosis will not only increase comfort but also allow for a soft and flexible correction, provided the positive model was modified accordingly. Insufficient modification will cause discomfort as the ankle is wedged medially/laterally within the orthosis.

The dorsiflexion-assist AFO with valgus-controlling trimlines provides more control by design than does the UCB-type orthoses. It has a lower profile than articulated AFOs, allowing it to fit more easily in shoes. Smith outlined a plastic thickness guide based on the patient's weight.13 He suggests 1/8 inch for less than 100 pounds, 3/16 inch for 100 to 200 pounds, and 1/4 inch polypropylene for 200 to 300 pounds. Our experience has shown that simply varying the distal aspect of the medial trimline can increase the rigidity. As the trimline courses distally, there is a point where the trimline makes a 180º turn proximally to form the medial valgus control extension. If this point is located more superior and rigidity is increased, a wider range of weights can be accommodated with the same plastic thickness.
Conclusion

Orthotic management of posterior tibial tendon dysfunction requires careful consideration of progression of deformity and tolerable corrective forces. Orthoses must be fabricated with adequate relief of all medial bony prominences. Given the progressive and biomechanical nature of this pathology, a radiographical study comparing effectiveness of the above orthoses and any other orthoses deemed appropriate is necessary to develop definitive orthotic plans.

As orthotists, we try to provide adequate control without limiting the function or causing severe biomechanical consequences at other joints. This is noted if one should induce a rigid neutral ankle alignment while ignoring a knee flexion contracture, compromising the patient's balance. In the case of posterior tibial tendon dysfunction, insufficient control could lead to progression of the deformity. Orthotic management should be, as Chao11 stated, "aggressive."

References:

1. Kettelkamp DB. Spontaneous rupture of the posterior tibial tendon. JBJS. 1969;51-A:4:759-764.
2. Mann RA, Coughlin, MJ. Surgery of the foot and ankle. 6th ed., Vol 1. Chicago: Mosby. 1993:757-784.
3. Teitz CC, et al. Tendon problem in athletic individuals. JBJS 1997;79-A:1:138-152.
4. Mann RA., et al. Rupture of the posterior tibial tendon causing flat foot. JBJS. 1985;67-A:4:556-561.
5. Myerson MS. Adult acquired flatfoot deformity. JBJS. 1996;78-A:5:780-792.
6. Conti SF. Posterior tibial tendon problems in athletes. Ortho Clinics of North America 1994;25:1:109-21.
7. Basmajian VJ, Stecko G. The role of muscles in arch support of the foot: an electromyographic study. JBJS. 1963;45-A:1184.
8. Holmes GB, Jr., Mann RA. Possible epidemiological factors associated with rupture of the posterior tibial tendon. Foot and Ankle. 1992;13:2:70-79.
9. Frey C., et al. Vascularity of the posterior tibial tendon. JBJS. 1990; 72-A:6:884-888.
10. Johnson KA, Strom DE. Tibialis posterior tendon dysfunction. Clinical Orthopedics. 1989;239:196-206.
11. Chao W, et al. Conservative management of posterior tibial tendon rupture. Orthopedic Transcriptions. 1994-95;18:1030.
12. Bray GA, MD. Obesity in America. U.S. Department of Health. NIH Publication # 79 - 359. Nov 1979:4-7.
13. Smith R. The AFO and ankle control-technical note. Orthotics & Prosthetics. 1979;33:1:46-8.

What is PTTD?

What is PTTD?pttd
Posterior tibial tendon dysfunction (PTTD) is an inflammation and/or overstretching of the posterior tibial tendon in the foot. An important function of the posterior tibial tendon is to help support the arch. But in PTTD, the tendon’s ability to perform that job is impaired, often resulting in a flattening of the foot.

The posterior tibial tendon is a fibrous cord that extends from a muscle in the leg. It descends the leg and runs along the inside of the ankle, down the side of the foot,
and into the arch. This tendon serves as one of the major supporting structures of the foot and helps the foot to function while walking.

PTTD is often called “adult-acquired flatfoot” because it is the most common type of flatfoot developed during adulthood. Although this condition typically occurs in only one foot, some people may develop it in both feet. PTTD is usually progressive, which means it will keep getting worse—especially if it isn’t treated early.


Symptoms of PTTD
The symptoms of PTTD may include pain, swelling, a flattening of the arch, and an inward rolling of the ankle. As the condition progresses, the symptoms will change.

For example:posterior tibial tendon

* When PTTD initially develops, typically there is pain on the inside of the foot and ankle (along the course of the tendon). In addition, the area may be red, warm, and swollen.
* Later, as the arch begins to flatten, there may still be pain on the inside of the foot and ankle. But at this point, the foot and toes begin to turn outward and the ankle rolls inward.
* As PTTD becomes more advanced, the arch flattens even more and the pain often shifts to the outside of the foot, below the ankle. The tendon has deteriorated considerably and arthritis often develops in the foot. In more severe cases, arthritis may also develop in the ankle.

What Causes PTTD?
Overuse of the posterior tibial tendon is frequently the cause of PTTD. In fact, the symptoms usually occur after activities that involve the tendon, such as running, walking, hiking, or climbing stairs.


Treatment:
Non-surgical Approaches
Because of the progressive nature of PTTD, it’s best to see your foot and ankle surgeon as soon as possible. If treated early enough, your symptoms may resolve without the need for surgery and progression of your condition can be arrested. In contrast, untreated PTTD could leave you with an extremely flat foot, painful arthritis in the foot and ankle, and increasing limitations on walking, running, or other activities.

In many cases of PTTD, treatment can begin with non-surgical approaches that may include:

* Orthotic devices or bracing. To give your arch the support it needs, your foot and ankle surgeon may provide you with an ankle stirrup brace or a custom orthotic device that fits into the shoe.
* Immobilization. Sometimes a short-leg cast or boot is worn to immobilize the foot and allow the tendon to heal, or you may need to completely avoid all weightbearing for a while.
* Physical therapy. Ultrasound therapy and exercises may help rehabilitate the tendon and muscle following immobilization.
* Medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, help reduce the pain and inflammation.
* Shoe modifications. Your foot and ankle surgeon may advise you on changes to make with your shoes and may provide special inserts designed to improve arch support.

When is Surgery Needed?
In cases of PTTD that have progressed substantially or have failed to improve with non-surgical treatment, surgery may be required. For some advanced cases, surgery may be the only option. Surgical treatment may include repairing the tendon, realigning the bones of the foot, or both. Your foot and ankle surgeon will determine the best approach for your specific case.

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Advances in Foot Care: PTTD - A New Way to Treat an Old Problem

Advances in Foot Care: PTTD – a New Way to Treat an Old Problem

Posterior tibial tendon dysfunction (PTTD) is a progressive form of tendonitis that occurs on the inside of the ankle. A new innovative brace, The AirCast AirLift is addressing this neglected condition with a cost effective solution.

(PRWEB) August 4, 2006 -- Posterior tibial tendon dysfunction (PTTD) is a progressive form of tendonitis that occurs on the inside of the ankle. Symptoms of PTTD include pain when first standing due to inflammation of the tendon. But if left untreated, this inflammation can progress to a tear in the posterior tibial tendon. Early intervention in this condition can often prevent extensive reconstructive surgery.

"PTTD is a progressive condition that is often misdiagnosed" said Dr. Jeffrey Oster, medical director of Myfootshop.com. "In the early stages of PTTD, control of the load applied to the posterior tibial tendon is critical in affecting a cure" Dr. Oster went on to describe the success that he’s recently experienced with a new over the counter (OTC) brace from AirCast called AirLift. "AirLift is the first OTC brace specifically designed to treat PTTD. It’s easy to use, affordable and popular in our patients with early PTTD".

PTTD occurs in middle aged patients. PTTD is stage in grades 1-4. Stage 1 is the stage where the tendon in inflamed but shows no evidence of physical damage. As PTTD becomes worse, MRI findings will actually be able to define partial to complete ruptures of the posterior tibial tendon. "Stages 1 and 2 will respond to bracing while stages 3 and 4 typically require some form of surgical repair" Oster said.

The AirLift Brace is unique in that it is the first brace to integrate a medial air bladder that can be increased or decreased by patients depending upon their need for support. The supportive air bladder accommodates different shapes of arches and arch heights. Medial and lateral semi-rigid ankle stays are also integrated into the brace for support. Velcro closure enables patient’s easy on-off use.

"We use the AirLift Brace as a first line support in cases of PTTD. It’s less than a tenth of the cost of a prescription brace and quite popular with our patients" Oster said.

Readers can find additional information on the treatment of posterior tibial tendonitis at Myfootshop.com.

PTTD Control

Orthoses
Conservative treatment eases PTTD impact
BY ROGER MARZANO, CPO, CPed


To understand how conservative treatment of posterior tibial tendon dysfunction affects gait, the function of the posterior tibial tendon in normal gait must first be clarified. Action of the posterior tibial tendon begins at its origin at the tibialis posterior muscle, which is found deep in the posterior compartment of the leg, at the beginning of the posterior surfaces of the proximal tibia and fibula, as well as the interosseous membrane of the leg. The PT tendonis formed in the distal third of the leg and travels posterior to the medial malleolus and on to its broad insertion at the nav-icular tuberosity, the plantar capsule of the medial navic-ular-cuneiform joint, and the plantar medial cuneiform. The origin and insertion create the desired normal actions across three joints of the foot/ankle complex.
Those actions primarily consist of plantar flexion of the talocruraljoint, inversion of the sub talar joint, and locking of the transverse tarsal joint, which in turn provides the rigid lever necessary for normal propulsion. With this action in mind, the importance of normal tendon function and length cannot be overemphasized.

Figure 1. The rigid UCBL orthosis is commonly prescribed for triplanar control of the foot.
Pathophysiology of the tendon includes elongation caused by the repetitive strains of supination and inflam-

mation associated with tenosynovitis, which contributes further to degeneration or rupture of the tendon. Johnson and Strom1 and Myerson2 classified posterior tibial tendon dysfunction into four stages involving classification of tendon degeneration and bony alignment. Some form of conservative treatment is most often prescribed for the latter three stages. Of these, end-stage deformities are the least responsive to intervention with orthoses.
Much has been written about the pathophysiology of the tibialis posterior tendon, including discussion of the presence of an accessory navicular contributing to the pathology; most authors agree that PTTD can cause severe deformities in the foot. Gastrocnemius and/or soleus con-tractures can contribute further to breakdown of the talon-avicular joint and must be considered when treating PTTD conservatively. Dysfunction of the tibialis posterior tendon can severely affect the performance of the foot/ankle complex, and can be further complicated by valgus alignment of the knee, which may be a contributing factor and is often seen by those treating PTTD.
To further understand the effects of PTTD on gait, we need to review possible treatment alternatives. Conservative intervention often begins with footwear. Extended medial counters, flared heels and soles, and broad midfoot construction are all desirable characteristics that can help when shoes fit and are worn appropriately. In the later stages of PTTD, custom-made shoes may be the only available footwear alternative due to the significant deformities often seen with this disorder.
Footwear treatments
Footwear modifications are often helpful in managing the myriad of clinical presentations associated with PTTD. Reinforcing the medial counter of the shoe with crepe or other materials can help the shoe support the foot and prevent breakdown of the medial column of the foot. Medial sole flaring and wedging can help attain the desirable effect of reducing tension on the posterior tibial tendon when used either in conjunction with or independent of the medial counter reinforcement. In more fixed deformities, splitting and widening, or relasting, when used with a custom foot orthosis, is an excellent method of widening the base of the shoe to provide strong medial column support. This shoe modification also allows for the forefoot abduction so often seen with this deformity, and serves to reduce lateral toe pressures.
Rigid rocker soles can assist in providing a rigid lever for better toe-off capabilities and can smooth out the gait of those with later stages of PTTD. It is important to note that the rocker sole should be sanded in the line of progression, which is unique to each patient based on the severity of the foot deformity.
Orthotic options
Foot orthoses are frequently prescribed as a primary treatment alternative for those with PTTD. A basic rule that can be followed when offering recommendations to or fitting patients with PTTD is that the more flexible the foot structure, the more rigid the orthoses can be. Conversely, the more rigid the foot structure, the more shock absorbent the orthoses should be. Another important point when providing foot orthoses for this pathology is to evaluate and recognize any equinus contractures that are present. If the foot cannot dorsiflex 10° with the knee extended and the calcaneus at neutral or slightly inverted, a heel lift may need to be incorporated in the orthosis. This will serve to reduce the forces acting about the subtalar joint, further minimizing midfoot collapse.
Those patients in the early stages of this disorder, while the foot still has some flexibility, appear to find rigid orthoses more amenable to their condition. The UCBL orthosis has, since its development, been commonly prescribed for triplanar control of the foot (Figure 1). The high medial and lateral walls of the orthosis work to limit pronation and forefoot abduction while the heel cup controls the eversion tendencies associated with PTTD. Softer multidensity designs can be effective and comfortable when treating more significant deformities. Hindfoot and forefoot posting are critical components in any foot ortho-sis and can make or break the attempt at conservative treatment.
Since hypermobility of the first ray and forefoot varus in some goes hand in hand with this pathology, full-length orthoses can and should incorporate the forefoot posting necessary to assist the dysfunctional foot with propulsive needs at heel-off and toe-off.
Ankle foot orthoses provide an additional conservative treatment alternative when conventional shoe and foot orthosis therapy fails. Traditionally, a double-upright AFO attached to a custom or medical-grade shoe, with or without a medial t-strap, has been a mainstay of AFO use for the PTTD foot. Thermoplastic designs can and should be considered for this patient population, particularly the short articulated AFO with an incorporated soft interface.
The short articulated AFO (Figure 2) is an excellent treatment alternative for those with PTTD, as the short anterior shell helps reduce the internal rotation of the tibia that accompanies pronation. The incorporated soft interface can provide medial forefoot varus posting to help align the foot and at the same time protect the medial bony prominences seen with this foot disorder.3
When presented with significant end-stage nonopera-tive deformities, a solid ankle or a patellar tendon bearing (PTB) design AFO may be the only option left. The solid ankle AFO or PTB can assist in controlling end-stage patients by reducing the advancement of the tibia over the planted weight-bearing foot, further diminishing pronato-ry stresses and providing maximum hindfoot control. The PTB-design AFO is a necessary option for those deformities or secondary ankle-joint arthrosis often seen in later stages. Any AFO that limits ankle-joint motion should be used in conjunction with a rocker sole to provide for lost motion and to minimize gait irregularities.

Altered gait

With these basic conservative treatment objectives outlined, we can begin to understand the impact of these treatment alternatives on gait as well as the influence this disorder has on gait when no treatment options are attempted. In normal human locomotion, it is necessary for the ankle to dorsiflex 10° over the planted foot with the knee in extension. This dorsiflexion takes place from the foot-flat to heel-off stages of gait. It is at this time that the posterior tibial tendon is most active to reduce longitudinal arch depression and begin locking the midtarsal joint for efficient propulsion, including ankle plantar flexion at heel-lift and toe-off.
In the dysfunctional foot, the longitudinal arch depresses excessively, the forefoot abducts further, and the midtarsal joint never achieves a locked position. Because of this action, the talar head continues on a plantar-grade course, the forefoot abducts even further, and the dorsiflexion needed for tibial advancement takes place at the midfoot rather than the ankle, never allowing the foot to become a rigid lever for propulsion. Continued ambulation with this faulty alignment will progressively shorten the gastrocnemius-soleus complex, further feeding the progression of this disorder. The resulting antalgic gait presents in several ways.
There is a shorter stance phase on the affected extremity due to pain avoidance, as well as marked decrease in stride length to minimize the painful pronato-ry forces exerted on the foot. The shorter stride length is also a product of the marked increase in forefoot abduction, which, at the same time, shortens the distal lever that the foot normally creates for efficient propulsion, further minimizing stance-phase timing. It is important to note knee alignment in this patient population, in that many of those treated for PTTD also have a predisposing valgus alignment of the knee. The valgus alignment of the knee widens the base of support, which further increases the valgus hindfoot stresses normally present in gait. All of these points combined make for painful, energy-inefficient gait.
Orthoses and footwear can have a tremendous impact on these gait deviations, as well as decreasing significant pain and progression of the deformity. Medial posting, whether on the orthosis or the shoe, can reduce the endpoint of the deformity and provide a more stable, better aligned medial column for propulsive phases of gait. Reducing the forefoot abduction, either with a UCBL or by adjusting the lateral trimlines of an AFO, combined with medial or sometimes even lateral forefoot posting, will help align the forefoot. Medial hindfoot posting and a mild heel elevation may help reduce the hindfoot valgus position and the negative effects of a shortened gas-trocnemius and soleus, while at the same time reducing the subfibular impingement often associated with PTTD. The heel counter of the shoe, the heel cup of the UCBL, and the tibial component of an AFO all work to reduce hindfoot valgus or excessive eversion and can be effective in maintaining better alignment of the subtalar complex, improving the efficiency of the foot/ankle complex as a whole.
Any changes that can help minimize the flexible deformities, as well as stabilize the more rigid structures, will result in a more energy-efficient gait with longer strides,and greater distances traveled with less discomfort. The benefits of shoe modifications that help to normalize gait, particularly rocker soles with extended shanks for those with more significant involvement, cannot be underestimated. They serve to advance the tibia over the foot by simulating dorsi-flexion and plantar flexion, while the extended shank can simulate the rigid column necessary for normal propulsion and at the same time reduce pain and increase endurance.
It would be difficult to determine what percentages pain and inefficient biomechanics contribute to disruption of normal gait, but we do know that PTTD affects a large part of our patient population. By addressing faulty mechanics, improving alignments, and decreasing endpoints of the deformities using various conservative modalities, we can have a tremendous impact on the efficiency of normal human locomotion, and more importantly, reduce the associated pain often seen with posterior tibial tendon dysfunction.
Conservative measures are usually effective to some degree, and more emphasis on prevention through footwear and orthoses can have a significant impact on overall foot health. Many of the patients we treat for plantar fasciitis, Morton's neuroma, and tarsometatarsal arthrosis may also be suffering with the deformities frequently seen with PTTD. Whatever the reason, PTTD can affect gait significantly, but we can respond with focused treatment and implement sound alternatives as outlined here to direct patients toward a more normal gait. %
Roger Marzano, CPO, CPed, is past president of the Pedorth-ic Footwear Association and is employed by Yanke Bionics in Akron, OH, as a staff clinician.
References
1. Johnson KA, Strom DE. Tibialis posterior tendon dys
function. Clin Orthop Rel Res 1989;239:196-206.
2. Myerson MS. Adult acquired flatfoot deformity. J Bone
Joint Surg 1996;78A:780-792.
3. Marzano R. The shorter cure for tibialis posterior tendon
dysfunction. Biomechanics 1995; 2(10):43-45

AirLift PTTD Brace by Aircast

AirLift T PTTD Brace AirLift T PTTD Brace - An off-the-shelf brace, the AirLift PTTD Brace is designed for the treatment of posterior tibial tendon dysfunction (PTTD), or for early signs and symptoms of the adult acquired flat foot. Depending on the severity of the condition, it can be prescribed for use as part of a conservative treatment to stabilize the condition and help prevent its degeneration, or post-surgically and during rehabilitation.

AFO Challenge/ROM Issue/Change Angle PT Request

The patient was seen today for adjustments to her bilateral solid-ankle AFOs with anterior panels. She continues to have problems on the left AFO. The right solid-ankle AFO is not causing any skin problems, but on the left over the medial malleolus it is still causing problems. The front panel was padded with Aliplast and flared at the problem area. She was given more room medially. She is still unable to get her heel all the way back. Therefore, 2 calcaneal pads were added on each brace to try to hold the heel down. After the adjustments were made, I applied the braces. She wore them for 20 minutes. I checked for redness. The right brace is fine. She continued to have redness on the left and I added a third strap on the left to even the pressure. She wore the brace for an additional 10 minutes. I rechecked the brace and everything looked much better. I told mom to allow the patient to wear the brace for 1 more hour today. She has had this brace on for 2 hours currently. Tomorrow she may wear the left brace for 3 hours, the following day 4 hours, the following day 5 hours working back up to 8 hours. On the right, she is not having any problems and her mother will allow her to wear it for 8 hours. I told her to return if there are any further problems. We may have to remake the left brace depending if she continues to get pressure in that area. We will change the angle slightly. She is set at 90 degrees, and this was per the therapist's request. The patient continues to be a challenge on that side due to the lack of range of motion, in my opinion. I believe this is from where the difficulty is caused. This patient will be seen as needed.

PTB Prosthesis/Minimize Slight Trendelenburg

The patient was seen in the office today for follow-up on his right patella tendon bearing prosthesis. He is doing very well at this time. He has lost volume on his residuum. He is now wearing 6-ply of sock plus a double lined gel liner. He has also grown. We had to increase the height of his prosthesis by Vi inch. We also dynamically aligned him today. All screws were Lok-Tited and torqued to manufacturer's specifications. He continues to walk with a slight Trendelenburg to the right. He has made some marked advances that were noticed today such that he is able to ambulate without the use of assistive devices. The second thing is that he is able to fully bear weight on his prosthesis by standing on his right leg only. He is also walking very well and has gained some confidence in his prosthesis. He still has to gain more confidence in his ability to bear weight through the prosthesis. I think this is the reason why he continues to have this slight Trendelenburg. I have discussed this with his parents. I will followup with him in 3 months. Between today's followup and the 3-month followup, I have asked him to work on 3 goals. One is to gain full knee extension at heel strike. The second is to minimize the Trendelenburg, and the third is to utilize his upper body in a more natural fashion as he is walking with a stiff upper body at this time. His parents have also requested additional socks and a suction suspension sleeve for him and also a double-lined gel liner from Silipos. I will look into this order and have the father pick it up upon approval.

Inhibitive AFO's / Cerebral Palsy/Quadriparesis

Bilateral solid-ankle inhibitive AFOs in neutral.
Cerebral palsy and quadriparesis.
This 9-year-old male has no known allergies. He has not had surgery on his lower extremities, and he takes a variety of medicines including oral baclofen, breathing medications and Depakote. He stands in a stander daily. He has outgrown his current orthoses.
We note that on assessment, the patient is postured into pronation bilaterally. He has mild tone and nonsustained clonus. His heels are in valgus, and his forefeet are abducted. He stands in a stander only.
Fabricate bilateral solid-ankle AFOs set at 90 degrees.

Left AFO ground-reactive type.
Lumbosacral reflexopathy.
This 26-year-old female presents with left lower extremity paralysis. Her medical status has improved to the point where she feels she can ambulate effectively in this ground-reaction orthosis.
I had her in the parallel bars, flex and extend her left knee with her right foot completely off the ground. She was able to go into a crouch and then extend under her own power, use her arms for assistance.
Fabricate left ground-reaction AFO SET AT 90 degrees.

Custom Shoes/Patient/Periperal Vascular Disease

Shoes. Talk to the therapist to request a custom made insert.
Peripheral vascular disease.
This 81-year-old female is allergic to CODEINE & ESTROGEN.
Surgery includes a femoral bypass on the right leg on 11/29/2000. She was recently hospitalized approximately 1 week ago with sores on her toes and the lateral arch of the right foot. She currently takes blood pressure medication and blood thinners. She is nonambulatory at this time unless the foot heals. She receives physical therapy each day. She walks with pressure only on the left foot. She has not worn any type of brace previously.
The patient's right foot is wrapped in gauze and she is nonweightbearing on this side. According to the patient, there are ulcers along the 1st and 5th toes as well as the lateral arch of the foot. There is no history of open ulcers on the left foot and the skin integrity looks good. There is a shiny appearance to the skin and it is cool to touch. She has poor protective sensation on the left foot. I requested that the therapist talk to the doctor regarding using an insert on this side to protect the foot against future ulcerations. The therapist stated that she will talk to the doctor and call us. Measurements were taken for extra depth shoes. An impression was taken of the left foot for a diabetic insert. The therapist was also informed regarding the healing boot for the right leg, which they might be interested in using for the patient. She stated that she will see the doctor on Saturday and contact us.
Once we are notified by the therapist regarding this matter, we will order the shoes as well as fabricate an insert as indicated.
Evaluation, measurement and impression.

AFO-Ground Reaction Repair

The patient's father dropped off a right AFO-GR with SVSP trimlines for repair. The medial screw is backing out. Again, the top section is again wider than the bottom section. I heated the top section in several places and brought it in to match the bottom section. I allowed it to cool for several hours and it remained in place. I trimmed the joint surfaces to make them more congruent. I replaced the screws and Lok-Tited them in place. I tested this several times, and the screw did not back out. The parent will pick up the brace this afternoon.

prosthesis, preparatory, endoskeletal, PTB insert, distal end pad, cuff suspension, and SACH foot.

This is a 54-year-old black male who had his left BKA done in August of 1996 secondary to insulin dependent diabetes mellitus and peripheral vascular disease. This began by having his small toe amputated in 1993, he then went on to have his great toe amputated in January of 1996. This failed to heal and osteomyelitis set in. At that time he also began having problems with his right foot. He went on to have his amputation in August. He has a Charcot foot on the right side. Patient denies any problems but does wear an orthosis on this side attached to a shoe. This is not a custom molded shoe but does have a molded insert. He has in addition to the amputation hypertension, congestive heart failure, and proteinuria. He takes Lasix and Capitril. He takes approximately 7-8 other medications but does not recall their names. He has had knee and foot surgery done to his right side to correct problems. He has had eye surgery done bilaterally. He has had a lumbar laminectomy. He has had bilateral rotator cuff surgeries. He states that the left has failed. He has had heart catheterization which revealed no blockage. He had a penile prosthesis installed which became infected and had to be removed. He also has mild right hemiplegia secondary to a stroke which he suffered in March of 2006. He is wheelchair and scooter mobile and does not ambulate using a walker or crutches at this time. He states that the stroke has limited his ability to balance well.
Fabricate a left PTB temporary prosthesis with soft insert and SACK foot and cuff suspension made of ultra lightweight construction.
Cast and measurement today.
Approximately 2-3 weeks for a return visit and fitting.

Abducting R-Foot in AFO - Correction

The patient was seen today for a recheck of her bilateral WHOs and her bilateral solid-ankle AFOs. Everything is still fitting appropriately. She has not outgrown these devices. The nurse and the father understand how to apply the devices correctly. The patient was abducting her foot in the right AFO more than we wanted her to. I added a pad along the lateral 5th metatarsal. This straightened out her foot nicely. Everything else was appropriate. She was not getting any red marks from the braces. They are concerned about the fungus that is grown on her right toes. The brace is not touching the toenails in that area. She is also not wearing shoes, and not able to take any medication to treat the fungus due to numerous seizure medications. Other than keeping clean socks on her feet, I did not have any other advice for them. I advised them to contact their doctor with their concerns. The patient will be seen as needed.

Happy New Year 2009!

Lots of new stuff on the horizon for this blogger and the IndianaBraceStore. Adding full orthotic line from DJ, ProCare, and Aircast.

I am working on an OTS face mask. Sold several in '08 - suprisingly few fit problems.

Will continue to add to Sweet-Spot line. The turf toe product has sold well over the net last year. Plan to expand to sales people.

Determined to continue chart postings.