Effect of Bracing and Strengthening Exercises on Posterior Tibial Tendon Dysfunct

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DESCRIPTION (provided by applicant): This project will compare the effects of bracing and strengthening exercises, a combination of passive and active treatments, to bracing and stretching exercises, passive treatments, for subjects with stage II posterior tibial tendon dysfunction (PTTD). Current clinical evidence suggests active treatments, not passive, lead to improved clinical results in subjects with other lower limb tendinopathies (e.g. Achilles tendinopathy). Our hypothesis is that active treatment (bracing and strengthening exercises) will lead to improved foot kinematics, posterior tibial muscle length, isometric strength and functional status as compared to subjects receiving passive treatment (bracing and stretching exercises) for stage II PTTD. All subjects included in the study will have stage II PTTD, diagnosed by an orthopedic surgeon. The study is designed to be a prospective, single blind, controlled trial. The intervention is bracing and strengthening exercises. The control treatment is bracing and stretching exercises. The primary outcome variables include foot kinematics, posterior tibial muscle length, isometric strength and validated self assessment scales. The key outcome variables determined from motion analysis will include abnormal foot kinematics and posterior tibial muscle length. Abnormal foot kinematics is a key indicator of PTTD progression which strengthening exercises are expected to improve (Specific Aim #1a). A validated model based on foot kinematics will be used to determine if improvements in foot kinematics are suggestive of shorter muscle length (Specific Aim #1b). Isometric strength tests are expected to document the effectiveness of the strengthening exercise (intervention) over passive treatments (control) (Specific Aim #2), suggesting restoration of posterior tibial muscle function. The extent to which the self assessment scales provide a means to judge the overall effect of the intervention and control treatments on function (Specific Aim #3), strengthening exercises (an active treatment) are expected to show greater increases in function compared to bracing and stretching alone (passive treatments). At the conclusion of this clinical trial we will determine if there is a benefit of augmenting bracing and stretching with strengthening exercises for treatment of stage II PTTD. This proposal will evaluate the effect of a less restrictive brace augmented by strengthening exercises, using a randomized controlled trial experimental design. If successful bracing augmented with strengthening exercises could be an alternative to orthopedic surgery. Because this conservative management approach (bracing augmented by strengthening) does not usually interfere with work, costs less than orthopedic surgery and is associated with fewer adverse events (e.g. infection) there is a clear benefit to the individual and society.