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Beverly: PTTD stages

Posted by elliott on 1/08/02 at 14:03 (069226)

Since the docs havven't answered you yet (probably busy doctoring) and you seem t owant an answer urgently, I thought I'd chip in, but out of deference to them, not on the 'Ask the Doc' forum. I don't have it in front of me, but I think it goes something like this:

Stage 1: minor inhibition walking, MRI-detectable conditions such as tenosynovitis (inflammation of tendon sheath); try things like walking cast, orthotics, or tenosynovectomy (surgery cleaning out the inflammation)

Stage 2: more major trouble; try surgery such as tendon transfer to give more support to the weak PT tendon

Stage 3: terrible trouble walking, possibly arch flattened by troubles, perhaps not being able to lift up toes; requires surgery such as bone fusion

I think that's the general idea, although there may be some gray area (e.g. if you have pain but nothing shows up on an MRI, whether that's stage 0 or 1, and there's a lot of variations in both severity (e.g. inflamed, displaced, torn, ruptured tendon) and type of surgery (there are alternative approaches depending on the condition, e.g. Kidner procedure, alternatives to bone fusion, etc.) But basically, stage 1 means level of conservative approach or more minor cleaning-up surgery, stage 2 means level of tendon transfer, stage 3 means level of bone fusion.

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Re: Beverly: PTTD stages

paula on 1/08/02 at 18:07 (069250)

one doc said there are five stages. most foot docs didnt't even know there were stages. one doc said i need a bone fusion right away. that was the same doc who said i'm in stage six. there is no stage six. latest doc says i can rehabilitate out of this with no operation. i think pttd needs a doc who really knows pttd and sees a lot of it. that is my opinion. i wonder if severe pttd is rare? took forever to diagnose and my stage and treatment is anybody's guess. after maybe 20 pods and foot ankle docs! has your shoe size gotten bigger over the years? mine has. and all tthe docs say that's not possible. maybe aliens abducted my real feet and left these.

Re: the big three

elliott on 1/08/02 at 18:16 (069252)

The ones I listed are the big 3, the standard 3, the original 3. :-)

If I recall, your MRI was negative. MRIs aren't foolproof, but that also leavves the possibility that it could just be something else too.

Always find docs who know what they're doing.

Just about everyone knows shoe size can get bigger over the years. Heck, even I know that. I've seen it in print too. Arch tends to flatten with age, necessitating a bigger size. There was even a rule of thumb (half size every so many years after a certain age) but I forgot it. Your docs must be aliens.

BTW, did you ever try the shoes I recommended?

----

Re: Beverly: PTTD stages

rebecca h on 1/08/02 at 18:17 (069253)

That's funny, my shoe size has gotten bigger through the years too and I have some post tibial stuff going on. I don't think its very serious
because nothing showed up on MRI but it sure hurts anyway. Also, whenever I have my foot measured at a shoe store they SAY I'm an 8 1/2 B, but this always feels too narrow. I guess maybe my feet spread out when I walk on them?? I don't know. But EE feels lots better. Or at least D.

Re: Beverly: PTTD stages

Beverly on 1/08/02 at 21:21 (069273)

Most women get bigger feet with age. I know I have and the PTT has certainly added to that. I still have a normal arch. My MRI was negative. I know my PTTD is not in an advanced stage, but I'm not sure what stage it is in.
The ankle brace seems to be helping.
Thanks,
Beverly

Re: Beverly: PTTD stages

john h on 1/09/02 at 12:04 (069342)

Beverly: Not only do women's feet get bigger with age but all of us will have to increase our shoe size as we age. When I was age 21 I wore an 8 1/2D now I wear a 10/1/2 D. I think it is largely a result of gravity as our arches flatten out and muscles weaken. One of the Docs can probably give a better medical explanation but it is a fact of life. Seems like I read that our shoe size will increase somewhere around one-half size every decade or so after a certain age. I know you ladies think your feet never get bigger which is probably why you have more foot problems than men. You contine to try to squeeze into the same shoe size you wore to the senior prom. i know this will endear me to all you wonderful girls.

Re: Beverly: PTTD stages

wendyn on 1/09/02 at 13:17 (069350)

John, there are a lot of things that get bigger with age.

Not just feet.

Re: Beverly: PTTD stages

Ed Davis, DPM on 1/09/02 at 16:37 (069384)

Paula:
PTTD is such a common problem, well understood, that the only aliens could be the doctors who don't understand it. Your foot size will get bigger because as the arch flattens, the foot gains length---podiatry 101, pretty basic stuff. People in medicine love to come up with classification and staging systems. If their system comes into common use it will be named after them bestowing them some fame..... As far as PTTD is concerned, I have only seen one staging system in common use, it does not carry any particular doctors name and has 3 stages well described by Elliott. Not to say that other individuals have ever come up with a different staging system but none are in common use today.

It really is important to know what stage you are in because the treatment for each stage is fairly standardized. Stage 3 implies that the posterior tibial tendon is completely ruptured or attenuated to the point that it is essentially non-functional. Surgery is generally used for the third or final stage although it is possible to get by with an Arizona brace.
Stage 2 involves a partial rupture of the PTT and partial loss of function.
A specialized orthotic such as a Meuller TPD, Ritchie Brace or similar device is needed not only to provide could foot function but to prevent progression to stage 3. Stage 1 is the incipient stage, the beginning of instability but with inflammation and pain in the PTT as the tendon is struggling to maintain its function. We wish we could treat everyone in stage 1 before things get real bad.
Ed

Re: Beverly: PTTD stages

John h on 1/09/02 at 16:56 (069388)

wendy you are mischievous . Explain yourself!

Re: Dr. Davis or Dr. Z. Thanks. Question.

Beverly on 1/09/02 at 17:31 (069390)

Dr. Davis,

Thank you for describing those stages, and also for verifying that Elliot had the stages described well.

I wish I had know to ask my orthopedic surgeon what stage I'm in. I'm going to when I see him in about six weeks.

From what you and Elliot described, I think I am well into stage 1 and perhaps teetering on the edge of stage 2. Does this sound more like stage 1 to you?
Here are my symptoms/history:

1. Have had PTT chronically for over 1.5 years.

2. This summer I got remarkable improvement wearing a brace for one month and then custom orthodics. Pain at arch and inner ankle almost went away.

3. About six weeks ago, I landed hard getting out of my truck. I did not fall but took the landing impact in the arch. I had sudden acute pain at the arch and soon afterward at the PTT. It continued. It hurt alot to walk but I could walk.

4. I saw my ortho doctor a few days later. He said I'd reinjured it and it was inflammed, weakened, and bruised, but he felt sure it was not torn.
He put me back in a brace. (Currently wearing ASO Ankle Stablizer). And said to stay off it as much as possible. He said it I didn't have to wear it all the time, but to wear it when l was going to be on my feet more than a few minutes. I have been wearing it faithfully.

5. The ankle brace definitely is helping. I still can't be on my feet more than five to ten minutes without plenty of pain, but I'm not having 24/7 pain anymore. I am doing ice/heat/rest. My massage therapist says my ankle is less 'squishy' than a month ago. It is still tender in places when she works on me, but not painful.

I do NOT work on my feet.
This is definitely healing slower than it did last time I was put in a brace.
For instance, I'm still getting someone else to carry in and put away my groceries, because it hurts to do that.

The doctor did not say how long to wear the brace. I'm staying in it till I see him again.

So, do I sound like I'm still at stage 1? My original MRI did not show anything. The reinjury came after the MRI.
Thanks,
Beverly

Re: Also, is loss of function related to pain in walking or something else?

Beverly on 1/09/02 at 17:51 (069394)

That is the other part I'm trying to understand as you describe 'loss of function.' Is that something concrete in the tendon itself?
For instance, I can move my toes and lift my toes. I can do light passive flex/range of motion stretches with just a bit of tenderness. But I can't be on my ankle for more than a few minutes without bringing on pain. In the brace, I have less pain but still pain when on feet. I was walking with a limp a month ago. I am no longer walking with a limp.

My arch still makes a quick brief 'crunchy' every now and then then I'm on feet. Most often if I get up in middle of the night to go to bathroom. That is when I don't have brace. The crunchy tends to hurt.

Thanks,
Beverly

Re: Beverly: PTTD stages

paula on 1/09/02 at 18:44 (069404)

thanks for as usual clearing it up and making sense of it all when no one else seems able to. the alien line was funny. you are really the only doctor who knew about the feet getting bigger. if my feet expand any more than this i will open a small private wine press.

Re: Also, is loss of function related to pain in walking or something else?

Ed Davis, DPM on 1/09/02 at 21:45 (069426)

One test to try is a single limb toe raise. Try raising to your toes on the unaffected limb only, then on the affected limb only. If you are able to do a single limb toe raise on the injured side, you have a stage 1 TPPD but if you cannot, you may have progressed to stage 2.

Significance: One cannot raise up on their toes on a pronated foot. The tibialis posterior needs to supinate the foot before one can toe raise effectively.
Ed

Re: Also, is loss of function related to pain in walking or something else?

Jean M on 1/09/02 at 23:23 (069441)

I have a quick question, three weeks ago I was put back in a cast for PTTD. At the time I saw the Dr. I was not able to raise up on my toes on the affected foot. I was told that I may need surgery to repair the tendon but that I could try six weeks in a cast to see if it improved first. Followed by an orthotic. I really don't want to have surgery. My question is after the cast comes off, if it is healed will I be able to check by trying to raise up on my toes again, ( if not immediatley shortly after the cast comes off)? I was told that if the casting does not help the next step would be surgery. My ortho does not do this type of surgery but he has reccomended two Dr.'s that do one is an Ortho. and one is a Pod. I won't go into who I should have unless it becomes an issue. Thanks for all the info on PTTD. I know most people here suffer more from PF, I don't know how this compares to what they are going to but I do know this is debilitating as well. I have been reading the boards for awhile adn I really sympathize with all of you that are suffering.

Re: I tried the toe test.

Beverly on 1/10/02 at 14:39 (069536)

Thanks Dr. Ed.,

I did the toe test. I was afraid to use full weight; so I'm not sure if I did an accurate test, but I can raise up on my toes on both legs. I did the test standing up and raised up on my toes one side at a time, but I didn't use full weight or try to balance just on one side. What I did was more like this: I stood up. Both feet on floor. I raised up one foot at a time on toes but I didn't try to balance my weight on that one side. That left me a little sore. I think I could have raised up with full weight on one side, but it would have hurt and I wasn't sure if I was suppose to do that.
Thanks,
Beverly

Re: I tried the toe test.

paula on 1/10/02 at 20:06 (069585)

why does no one but me know that some doctors are trying physcial rehab plus afo's and succeeding in some cases with fairly advanced pttd. ? or at least this is what my doc and physical therapist tell me. is this such a new and rare phenomenom? or maybe i'm in the minority cause i'd do any conservative treatment to avoid foot surgery. i can't say my rehab is easy. it is very hard. i'm in all kinds of pain a lot. my p.t. just upped post tib exercise to 200 a day. i have to work up to it. to say the least.well back to the ice, which i p retty much live on inbeteen exercise

Re: I tried the toe test.

Beverly on 1/10/02 at 21:05 (069593)

Paula,

What on earth does your PT have you doing 200x a day? Is that a typo?
I don't think I'm in nearly as bad a shape as you are in, and I do a set of four stretches/range of motion things for five reps each 3x a day.

Beverly

Re: I tried the toe test.

paula on 1/11/02 at 16:49 (069668)

well i have two physical therapists. one is a general one, one a foot specialist. they disagree. the foot guy wants me to do 200 low impact theraband pulls a day on my post tib holding the foot in a very specific way. he is part of a post tib team put together by my orth surgeon foot doctor. my other pt thinks that's a good way to flare my tendonitis. the foot guy says build up slow. so i figure no harm in adding his regimen if i creep up on it slowly. can you describe your strethces and range of motions? do you do no strenthening?

Re: Also, is loss of function related to pain in walking or something else?

Ed Davis, DPM on 1/11/02 at 19:14 (069683)

The toe raise test is a good way to test if function has been restored or not. If you have improved sufficiently then an orthotic may suffice.
Ed

Re: I tried the toe test.

Ed Davis, DPM on 1/11/02 at 19:25 (069686)

Not really anything new. The Arizona brace is an example of a brace that can be used in stage 3 PTTD. It may depend on how you define 'succeeding.'
Certainly, an indvidual with stage 3 PTTD can wear the Arizona brace and walk a fair distance without pain. The bracing does not lead to a situation though in which one has PT function restored to the point where one can function without a brace.

Individuals with desk jobs, older individuals or those who are not involved in sports such as running may feel that the amount of function obtained from an Arizona brace is adequate for their lifestyle. Others who are more active would not agree. An individual with a job in which good function is critical such a firefighter, for example, would not obtain adequate restoration of function without surgery.
Ed

Re: another PTT story and some questions

matts on 1/12/02 at 15:09 (069767)

Dr Davis just answered several questions i was having about wearing a brace or I am now in an afo for PTT. Apparently this will only offer relief but not really healing of the tendon. After tuesday, I have recommendations from my podiatrist, who referred me to a foot and ankle ortho, who says that I need to have a tendon tranfer done if my foot is going to get much better from here. The podiatrist thought this was the thing to do also, he just does not do this sort of surgery. I went to a second foot and ankle orthopedist, so now three doctors say the same thing. I am seriously considering the surgery on the tendon. It will require about 8 weeks on crutches and then a month in a boot. I have been haveing this problem for two years, and have received much help and guidance from this message board during this time.

the ortho said mine was somewhat rare in that I have not lost much of the arch of the foot. I can still do the toe raise, but with some difficulty, and it takes about a week to recover to normal hurting levels after a do a toe raise at the doctor's office. I did ask if I would still need the brace after surgery, and the dr said we were shooting for not having to wear the brace. I was hoping for more absolute answer. The orthos do not think any bone work will be needed in my case, so it sounds like my foot is at low end of stage two, according to above messages. I was wondering if some of you with ptt still have an arch, and if anyone has had the tendon transfer surgery?

Another thought, none of the three dr thought physical therapy alone wwould help for very long, My attempt at pt went bad when I tried some non wweight bearing toe raises, which really hurt my arch area alot. One said pt after surgery, but the others did not mention it. So, I tried pt but only for about 3 weeks, 3 times a week.

Re: another PTT story and some questions

Beverly on 1/12/02 at 17:47 (069783)

Matt,

Is an AFO the same thing as an ASO? My brace is called an ASO. It laces up from foot up ankle. Then it has three velcro straps. The first two straps are long and they wrap around the ankle in a figure 8 with each strap going across the opposite side. The the third strap is short and secures above the ankle closer to the calf but not quite that high.

All this talk about stages has left me so curious. I guess I won't know for sure which stage I'm in till I can see my orthopedic surgeon in Feb. and ask him. I feel sure I could do that toe raise but it sounds painful and I'm a chicken to try it if he is not standing over me watching.

I still have a pretty decent arch. I used to have high arches and now I'd say my arch is about an average arch.

I think Paula asked which stretches I do. In comparision to some of you, mine probably sound very puny. I flex and hold to the count of five for five reps. I do a side-to-side stretch that I don't think I can describe well in words but I do that five times. Then I do a PTT stretch my doctor showed me that once again I don't quite know how to describe in words but I do that five times. Then I do five ankle circles both clockwise and counterclockwise. I do all of these three times a day. I do it after heat.
I never do them on cold muscles.

In a couple of weeks, if I keep feeling better, I'm going to add back the towel stretch and alphabet tracing.

I do think all this rest is helping me along with the brace. When I saw the doctor in early December, he thought I'd get back on track without any surgery. I want to think that means I'm either stage 1 or early stage 2.

Best wishes,
Beverly

Re: another PTT story and some questions

matts on 1/12/02 at 18:06 (069793)

afo is fairly rigid plastic and goes from the end of the toes to just below the knee and only has two velcro straps to hold in place, it is what I would have called a leg brace, until i actually got a prescrption for this thing. mine has a hinge at the ankle and the orthotist told me it somehow tranfers pressure off of the tendon to the leg. it is working better that any orthotic have tried before as far as helping with pain. I think afo stands for ankle foot orthotic. Good luck to you also, thanks!!

Re: another PTT story and some questions

paula on 1/12/02 at 18:16 (069795)

hey fellow ptt ers. who are your doctors and orthotists? also, matt, i found it is a rare physical therapist who knows much about more advanced cases of post tib. if my most recent attempt at an orthotic, which does not seem to be working fails, i'd like to contact your guys. i also heat before i stretch and i sorta tilt my foot in a little so as not to stretch the post tib. and i stretch really hardly at all like a mini stretch but i hold it for one minute. that;s what one therapist suggested. would love you to try to explain your stretches if they are working for you. then i can ask my physical therapist if i can try it. i am not a doctor and can't recommend anything i say am just sharing for info purposes.

Re: actually, it's called the "(single) heel rise test"

elliott on 1/12/02 at 21:01 (069814)

Not the toe test. You end up on your toes, but you are lifting up the heel. So if you want to sound knowledgeable to your doc...

Also, since no one else mentioned this, I thought I'd point out that they often ask you to repeat the heel rise test a few times in a row and compare to your good foot; a foot suffering from PTTD likely will weaken after a few raises faster than the good foot. But it's more a necessary rather than sufficient condition; that is, someone suffering significant PTTD should show weakness in the heel rise test, but so may someone suffering other problems, e.g. where the pain limits the heel rise.

---

Re: Beverly: PTTD stages

paula on 1/08/02 at 18:07 (069250)

one doc said there are five stages. most foot docs didnt't even know there were stages. one doc said i need a bone fusion right away. that was the same doc who said i'm in stage six. there is no stage six. latest doc says i can rehabilitate out of this with no operation. i think pttd needs a doc who really knows pttd and sees a lot of it. that is my opinion. i wonder if severe pttd is rare? took forever to diagnose and my stage and treatment is anybody's guess. after maybe 20 pods and foot ankle docs! has your shoe size gotten bigger over the years? mine has. and all tthe docs say that's not possible. maybe aliens abducted my real feet and left these.

Re: the big three

elliott on 1/08/02 at 18:16 (069252)

The ones I listed are the big 3, the standard 3, the original 3. :-)

If I recall, your MRI was negative. MRIs aren't foolproof, but that also leavves the possibility that it could just be something else too.

Always find docs who know what they're doing.

Just about everyone knows shoe size can get bigger over the years. Heck, even I know that. I've seen it in print too. Arch tends to flatten with age, necessitating a bigger size. There was even a rule of thumb (half size every so many years after a certain age) but I forgot it. Your docs must be aliens.

BTW, did you ever try the shoes I recommended?

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Re: Beverly: PTTD stages

rebecca h on 1/08/02 at 18:17 (069253)

That's funny, my shoe size has gotten bigger through the years too and I have some post tibial stuff going on. I don't think its very serious
because nothing showed up on MRI but it sure hurts anyway. Also, whenever I have my foot measured at a shoe store they SAY I'm an 8 1/2 B, but this always feels too narrow. I guess maybe my feet spread out when I walk on them?? I don't know. But EE feels lots better. Or at least D.

Re: Beverly: PTTD stages

Beverly on 1/08/02 at 21:21 (069273)

Most women get bigger feet with age. I know I have and the PTT has certainly added to that. I still have a normal arch. My MRI was negative. I know my PTTD is not in an advanced stage, but I'm not sure what stage it is in.
The ankle brace seems to be helping.
Thanks,
Beverly

Re: Beverly: PTTD stages

john h on 1/09/02 at 12:04 (069342)

Beverly: Not only do women's feet get bigger with age but all of us will have to increase our shoe size as we age. When I was age 21 I wore an 8 1/2D now I wear a 10/1/2 D. I think it is largely a result of gravity as our arches flatten out and muscles weaken. One of the Docs can probably give a better medical explanation but it is a fact of life. Seems like I read that our shoe size will increase somewhere around one-half size every decade or so after a certain age. I know you ladies think your feet never get bigger which is probably why you have more foot problems than men. You contine to try to squeeze into the same shoe size you wore to the senior prom. i know this will endear me to all you wonderful girls.

Re: Beverly: PTTD stages

wendyn on 1/09/02 at 13:17 (069350)

John, there are a lot of things that get bigger with age.

Not just feet.

Re: Beverly: PTTD stages

Ed Davis, DPM on 1/09/02 at 16:37 (069384)

Paula:
PTTD is such a common problem, well understood, that the only aliens could be the doctors who don't understand it. Your foot size will get bigger because as the arch flattens, the foot gains length---podiatry 101, pretty basic stuff. People in medicine love to come up with classification and staging systems. If their system comes into common use it will be named after them bestowing them some fame..... As far as PTTD is concerned, I have only seen one staging system in common use, it does not carry any particular doctors name and has 3 stages well described by Elliott. Not to say that other individuals have ever come up with a different staging system but none are in common use today.

It really is important to know what stage you are in because the treatment for each stage is fairly standardized. Stage 3 implies that the posterior tibial tendon is completely ruptured or attenuated to the point that it is essentially non-functional. Surgery is generally used for the third or final stage although it is possible to get by with an Arizona brace.
Stage 2 involves a partial rupture of the PTT and partial loss of function.
A specialized orthotic such as a Meuller TPD, Ritchie Brace or similar device is needed not only to provide could foot function but to prevent progression to stage 3. Stage 1 is the incipient stage, the beginning of instability but with inflammation and pain in the PTT as the tendon is struggling to maintain its function. We wish we could treat everyone in stage 1 before things get real bad.
Ed

Re: Beverly: PTTD stages

John h on 1/09/02 at 16:56 (069388)

wendy you are mischievous . Explain yourself!

Re: Dr. Davis or Dr. Z. Thanks. Question.

Beverly on 1/09/02 at 17:31 (069390)

Dr. Davis,

Thank you for describing those stages, and also for verifying that Elliot had the stages described well.

I wish I had know to ask my orthopedic surgeon what stage I'm in. I'm going to when I see him in about six weeks.

From what you and Elliot described, I think I am well into stage 1 and perhaps teetering on the edge of stage 2. Does this sound more like stage 1 to you?
Here are my symptoms/history:

1. Have had PTT chronically for over 1.5 years.

2. This summer I got remarkable improvement wearing a brace for one month and then custom orthodics. Pain at arch and inner ankle almost went away.

3. About six weeks ago, I landed hard getting out of my truck. I did not fall but took the landing impact in the arch. I had sudden acute pain at the arch and soon afterward at the PTT. It continued. It hurt alot to walk but I could walk.

4. I saw my ortho doctor a few days later. He said I'd reinjured it and it was inflammed, weakened, and bruised, but he felt sure it was not torn.
He put me back in a brace. (Currently wearing ASO Ankle Stablizer). And said to stay off it as much as possible. He said it I didn't have to wear it all the time, but to wear it when l was going to be on my feet more than a few minutes. I have been wearing it faithfully.

5. The ankle brace definitely is helping. I still can't be on my feet more than five to ten minutes without plenty of pain, but I'm not having 24/7 pain anymore. I am doing ice/heat/rest. My massage therapist says my ankle is less 'squishy' than a month ago. It is still tender in places when she works on me, but not painful.

I do NOT work on my feet.
This is definitely healing slower than it did last time I was put in a brace.
For instance, I'm still getting someone else to carry in and put away my groceries, because it hurts to do that.

The doctor did not say how long to wear the brace. I'm staying in it till I see him again.

So, do I sound like I'm still at stage 1? My original MRI did not show anything. The reinjury came after the MRI.
Thanks,
Beverly

Re: Also, is loss of function related to pain in walking or something else?

Beverly on 1/09/02 at 17:51 (069394)

That is the other part I'm trying to understand as you describe 'loss of function.' Is that something concrete in the tendon itself?
For instance, I can move my toes and lift my toes. I can do light passive flex/range of motion stretches with just a bit of tenderness. But I can't be on my ankle for more than a few minutes without bringing on pain. In the brace, I have less pain but still pain when on feet. I was walking with a limp a month ago. I am no longer walking with a limp.

My arch still makes a quick brief 'crunchy' every now and then then I'm on feet. Most often if I get up in middle of the night to go to bathroom. That is when I don't have brace. The crunchy tends to hurt.

Thanks,
Beverly

Re: Beverly: PTTD stages

paula on 1/09/02 at 18:44 (069404)

thanks for as usual clearing it up and making sense of it all when no one else seems able to. the alien line was funny. you are really the only doctor who knew about the feet getting bigger. if my feet expand any more than this i will open a small private wine press.

Re: Also, is loss of function related to pain in walking or something else?

Ed Davis, DPM on 1/09/02 at 21:45 (069426)

One test to try is a single limb toe raise. Try raising to your toes on the unaffected limb only, then on the affected limb only. If you are able to do a single limb toe raise on the injured side, you have a stage 1 TPPD but if you cannot, you may have progressed to stage 2.

Significance: One cannot raise up on their toes on a pronated foot. The tibialis posterior needs to supinate the foot before one can toe raise effectively.
Ed

Re: Also, is loss of function related to pain in walking or something else?

Jean M on 1/09/02 at 23:23 (069441)

I have a quick question, three weeks ago I was put back in a cast for PTTD. At the time I saw the Dr. I was not able to raise up on my toes on the affected foot. I was told that I may need surgery to repair the tendon but that I could try six weeks in a cast to see if it improved first. Followed by an orthotic. I really don't want to have surgery. My question is after the cast comes off, if it is healed will I be able to check by trying to raise up on my toes again, ( if not immediatley shortly after the cast comes off)? I was told that if the casting does not help the next step would be surgery. My ortho does not do this type of surgery but he has reccomended two Dr.'s that do one is an Ortho. and one is a Pod. I won't go into who I should have unless it becomes an issue. Thanks for all the info on PTTD. I know most people here suffer more from PF, I don't know how this compares to what they are going to but I do know this is debilitating as well. I have been reading the boards for awhile adn I really sympathize with all of you that are suffering.

Re: I tried the toe test.

Beverly on 1/10/02 at 14:39 (069536)

Thanks Dr. Ed.,

I did the toe test. I was afraid to use full weight; so I'm not sure if I did an accurate test, but I can raise up on my toes on both legs. I did the test standing up and raised up on my toes one side at a time, but I didn't use full weight or try to balance just on one side. What I did was more like this: I stood up. Both feet on floor. I raised up one foot at a time on toes but I didn't try to balance my weight on that one side. That left me a little sore. I think I could have raised up with full weight on one side, but it would have hurt and I wasn't sure if I was suppose to do that.
Thanks,
Beverly

Re: I tried the toe test.

paula on 1/10/02 at 20:06 (069585)

why does no one but me know that some doctors are trying physcial rehab plus afo's and succeeding in some cases with fairly advanced pttd. ? or at least this is what my doc and physical therapist tell me. is this such a new and rare phenomenom? or maybe i'm in the minority cause i'd do any conservative treatment to avoid foot surgery. i can't say my rehab is easy. it is very hard. i'm in all kinds of pain a lot. my p.t. just upped post tib exercise to 200 a day. i have to work up to it. to say the least.well back to the ice, which i p retty much live on inbeteen exercise

Re: I tried the toe test.

Beverly on 1/10/02 at 21:05 (069593)

Paula,

What on earth does your PT have you doing 200x a day? Is that a typo?
I don't think I'm in nearly as bad a shape as you are in, and I do a set of four stretches/range of motion things for five reps each 3x a day.

Beverly

Re: I tried the toe test.

paula on 1/11/02 at 16:49 (069668)

well i have two physical therapists. one is a general one, one a foot specialist. they disagree. the foot guy wants me to do 200 low impact theraband pulls a day on my post tib holding the foot in a very specific way. he is part of a post tib team put together by my orth surgeon foot doctor. my other pt thinks that's a good way to flare my tendonitis. the foot guy says build up slow. so i figure no harm in adding his regimen if i creep up on it slowly. can you describe your strethces and range of motions? do you do no strenthening?

Re: Also, is loss of function related to pain in walking or something else?

Ed Davis, DPM on 1/11/02 at 19:14 (069683)

The toe raise test is a good way to test if function has been restored or not. If you have improved sufficiently then an orthotic may suffice.
Ed

Re: I tried the toe test.

Ed Davis, DPM on 1/11/02 at 19:25 (069686)

Not really anything new. The Arizona brace is an example of a brace that can be used in stage 3 PTTD. It may depend on how you define 'succeeding.'
Certainly, an indvidual with stage 3 PTTD can wear the Arizona brace and walk a fair distance without pain. The bracing does not lead to a situation though in which one has PT function restored to the point where one can function without a brace.

Individuals with desk jobs, older individuals or those who are not involved in sports such as running may feel that the amount of function obtained from an Arizona brace is adequate for their lifestyle. Others who are more active would not agree. An individual with a job in which good function is critical such a firefighter, for example, would not obtain adequate restoration of function without surgery.
Ed

Re: another PTT story and some questions

matts on 1/12/02 at 15:09 (069767)

Dr Davis just answered several questions i was having about wearing a brace or I am now in an afo for PTT. Apparently this will only offer relief but not really healing of the tendon. After tuesday, I have recommendations from my podiatrist, who referred me to a foot and ankle ortho, who says that I need to have a tendon tranfer done if my foot is going to get much better from here. The podiatrist thought this was the thing to do also, he just does not do this sort of surgery. I went to a second foot and ankle orthopedist, so now three doctors say the same thing. I am seriously considering the surgery on the tendon. It will require about 8 weeks on crutches and then a month in a boot. I have been haveing this problem for two years, and have received much help and guidance from this message board during this time.

the ortho said mine was somewhat rare in that I have not lost much of the arch of the foot. I can still do the toe raise, but with some difficulty, and it takes about a week to recover to normal hurting levels after a do a toe raise at the doctor's office. I did ask if I would still need the brace after surgery, and the dr said we were shooting for not having to wear the brace. I was hoping for more absolute answer. The orthos do not think any bone work will be needed in my case, so it sounds like my foot is at low end of stage two, according to above messages. I was wondering if some of you with ptt still have an arch, and if anyone has had the tendon transfer surgery?

Another thought, none of the three dr thought physical therapy alone wwould help for very long, My attempt at pt went bad when I tried some non wweight bearing toe raises, which really hurt my arch area alot. One said pt after surgery, but the others did not mention it. So, I tried pt but only for about 3 weeks, 3 times a week.

Re: another PTT story and some questions

Beverly on 1/12/02 at 17:47 (069783)

Matt,

Is an AFO the same thing as an ASO? My brace is called an ASO. It laces up from foot up ankle. Then it has three velcro straps. The first two straps are long and they wrap around the ankle in a figure 8 with each strap going across the opposite side. The the third strap is short and secures above the ankle closer to the calf but not quite that high.

All this talk about stages has left me so curious. I guess I won't know for sure which stage I'm in till I can see my orthopedic surgeon in Feb. and ask him. I feel sure I could do that toe raise but it sounds painful and I'm a chicken to try it if he is not standing over me watching.

I still have a pretty decent arch. I used to have high arches and now I'd say my arch is about an average arch.

I think Paula asked which stretches I do. In comparision to some of you, mine probably sound very puny. I flex and hold to the count of five for five reps. I do a side-to-side stretch that I don't think I can describe well in words but I do that five times. Then I do a PTT stretch my doctor showed me that once again I don't quite know how to describe in words but I do that five times. Then I do five ankle circles both clockwise and counterclockwise. I do all of these three times a day. I do it after heat.
I never do them on cold muscles.

In a couple of weeks, if I keep feeling better, I'm going to add back the towel stretch and alphabet tracing.

I do think all this rest is helping me along with the brace. When I saw the doctor in early December, he thought I'd get back on track without any surgery. I want to think that means I'm either stage 1 or early stage 2.

Best wishes,
Beverly

Re: another PTT story and some questions

matts on 1/12/02 at 18:06 (069793)

afo is fairly rigid plastic and goes from the end of the toes to just below the knee and only has two velcro straps to hold in place, it is what I would have called a leg brace, until i actually got a prescrption for this thing. mine has a hinge at the ankle and the orthotist told me it somehow tranfers pressure off of the tendon to the leg. it is working better that any orthotic have tried before as far as helping with pain. I think afo stands for ankle foot orthotic. Good luck to you also, thanks!!

Re: another PTT story and some questions

paula on 1/12/02 at 18:16 (069795)

hey fellow ptt ers. who are your doctors and orthotists? also, matt, i found it is a rare physical therapist who knows much about more advanced cases of post tib. if my most recent attempt at an orthotic, which does not seem to be working fails, i'd like to contact your guys. i also heat before i stretch and i sorta tilt my foot in a little so as not to stretch the post tib. and i stretch really hardly at all like a mini stretch but i hold it for one minute. that;s what one therapist suggested. would love you to try to explain your stretches if they are working for you. then i can ask my physical therapist if i can try it. i am not a doctor and can't recommend anything i say am just sharing for info purposes.

Re: actually, it's called the "(single) heel rise test"

elliott on 1/12/02 at 21:01 (069814)

Not the toe test. You end up on your toes, but you are lifting up the heel. So if you want to sound knowledgeable to your doc...

Also, since no one else mentioned this, I thought I'd point out that they often ask you to repeat the heel rise test a few times in a row and compare to your good foot; a foot suffering from PTTD likely will weaken after a few raises faster than the good foot. But it's more a necessary rather than sufficient condition; that is, someone suffering significant PTTD should show weakness in the heel rise test, but so may someone suffering other problems, e.g. where the pain limits the heel rise.

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