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Tibialis posterior tendinopathy unwrapped with Stuart Imer

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In this episode, Stuart Imer discusses the importance of systemic factors and heavy load resistance training in current evidence-based treatment of tibialis posterior tendinopathy. He also takes us through the Johnson classification system for tibialis posterior tendinopathy and how this should impact your treatment plan.

Want to learn more about tibialis posterior tendinopathy? Stuart recently did a brilliant Masterclass with us, called “Tibialis Posterior Tendinopathy: Assessment and Treatment Strategies” where he goes into further depth on tibialis posterior assessment and treatment. 

👉🏻 You can watch his class now with our 7-day free trial: https://physio.network/masterclass-imer

Stuart is a clinician Foot and Ankle Physiotherapist and is the founder of Foot & Ankle Physiotherapy Australia. Stuart has worked in Foot and Ankle surgical clinics for 24 years, alongside seven of Australia’s leading sub-speciality trained Foot & Ankle orthopaedic surgeons.

If you like the podcast, it would mean the world if you're happy to leave us a rating or a review. It really helps!

Our host is @sarah.yule from Physio Network

SPEAKER_02:

Our job in that subjective is to obviously create within the way that we're questioning them a safe space for any sensitive conversations around that. But to listen is really important. Sometimes that's difficult when there's a lot of extraneous information thrown in that's mostly irrelevant to what we're dealing with at that point. But you'll get those one or two little gems that if your ears are open, you'll be able to pick them up and then work towards your hypothesis so much quicker and then be able to prove it with your objective exam.

SPEAKER_01:

Today we explore tib-post tendinopathy, its classification, its diagnosis and its management. Stuart Imer is a foot and ankle physiotherapist who is the founder of Foot and Ankle Physio Australia. Stuart has done a masterclass with Physio Network on tib-post tendinopathy, where you can dive a whole lot deeper into this area than we were able to do in today's episode. So make sure you click the link in the show notes to watch Stuart's masterclass for free with our seven-day trial. I think you're going to love today's podcast. I'm Sarah Yule, and this is Physio Explained. Welcome to the podcast, Stuart.

SPEAKER_02:

Many thanks for having me. Thanks, Sarah.

SPEAKER_01:

So today we are exploring all things tibialis posterior related, as you have done in your masterclass. So launching straight into it, can you discuss the differences between tib post tendinopathy and acquired adult flat foot deformity?

SPEAKER_02:

Yeah, it's a very topical question at the moment, Sarah. So thanks for kicking off with that one. I guess the simplest way of explaining that, and it's probably worth teasing out some of the more significant differences, is that really acquired adult flat foot deformity is the subset of tibialis posterior tendinopathy. And if you look through the masterclass, you'll actually see that the traditional grading system, which was the Johnson-Strom classification for tibialis posterior tendinopathy, at stage one, there is no foot deformity. So, Obviously, a quite adult flat foot deformity needs to have some deformity associated with it for it to reach that level of diagnosis. So once we get into stage two, and there's stage two A to B, stage three and stage four, Those stages do have foot deformity, but it's a much bigger question that has probably had a lot of recent attention to it. And the most recent papers only hit the inbox in the last few weeks. And there's some work that's coming out of a multinational study group looking at a new classification system. So we've used this Johnson-Strom classification since 1989. And I think it's still the classification system that most people will be aware of and the classical teaching around tib-post tendinopathy. With that being the case, any conversations that physios, podiatrists and foot and ankle surgeons are having will usually be couched around, well, what grade of tibialis posterior tendinopathy or acquired adult flat foot deformity are we dealing with? And that grading traditionally, I think for the next decade four or five years will probably still be referenced under the Johnson classification system. But this new work by, and Doug Rich is a name in the podiatric space in the US that a lot of your listeners will know of, that Richie Brace, for instance, is one that's rather readily available in a few different iterations. Doug Rich is a big proponent in this space as well. And they've just released a paper that looks at a triple classification system for acquired adult flat foot deformity or progressive collapsing foot deformity. Probably the simplest way to think of tibialis posterior tendinopathy is probably the all-encompassing diagnosis that we want to use when we're discussing cases of medial ankle rear foot pain that are associated with disease in the tib post. The issues around the additional deformities are rather quite interesting to tease out because tibialis posteriors relied on as being a mainstay of dynamic support for the medial longitudinal arch. If we lose that support, then we often end up with progressive structural deterioration where we then get that gradually increasing planus foot deformity and then valgus positioning on the rear foot. Those feet end up with a banana-shaped foot. Normally, we'd like to see a neutral or slightly curved in-foot position if we're looking from the front, but these patients have a foot that does this interesting curve out with an abducted forefoot position. And the Johnson-Strong classification, there was a fourth grade that was added eventually to that because there was only three grades in the original paper. And the fourth grade is when the ankle structures are under such significant load that the ankle deforms into a valgus position. Obviously, valgus is movement away from the midline, so tibia, It's sort of facing straight ahead. The talonavicular joint's becoming congruent and the navicular's fallen down towards the floor. The first tarsometatarsal medial cuneiform navicular joint can become unstable. So they're collectively usually known as the first ray or the medial column. They become unstable in dorsiflexion. And it's that series of different deformities that span across different areas that this new classification system from Passapool has tried to address. So they call it the triple classification system because they look at physiological foot morphology. So what's the starting foot posture that that patient had? Typically in the clinic, if we're looking at a patient presenting in front of us for their initial consultation and we've got some suspicions around tibialis posterior, we'll be looking at what's their affected painful side look like and what's their unaffected side look We don't always have that luxury if we've got bilateral presentations, which are a bit more rare than some other things. But there may well be previous traumas or other history to the opposite contralateral foot that doesn't allow for us to get a really accurate idea on what their normal physiologic structure is. But if you do have that chance, you can probably then make a guesstimate as to what their starting physiological foot posture is. And those three are the plainest foot, the neutral foot, and the cabest foot. So, they just sort of put those three labels around, you know, what shape is the natural foot posture for this individual. So, they've looked at that as one part. That's one third of the triple. Then they look at where the ligament laxities are occurring and at what level are they from spring ligament deficiency under the tail and the vicular joint. And that's at grade zero, if that's all that's happening. And then all the way up to grade four, which sort of is similar to johnson's grade four which is deltoid ligament failure as well and then the third part to the triple classification system is the deformity and where it's occurring is zones so is it at the ankle that gets an a is it below the ankle in the subtalar joint that gets a b for below ankle c have allocated to show part joint which to remind the The listeners is the combination of the talonavicular and the calcaneocuboid joints. So normally if we see talonavicular joint incongruity, then that's that zone that is a C zone. And then D refers to whether the first ray or the medial column has become dorsiflex, so whether it's unstable and whether that dorsiflexion of the first ray allows the foot to flatten even further. So I think it's quite comprehensive, Sarah, to look at that new system, but it's not in common usage at present. So, look out for that.

SPEAKER_01:

So, just to summarise, so the triple classification is obviously discussing that spectrum from tib post dysfunction ranging all the way through to that progressive collapsing foot deformity. And just to summarise, it was that physiological foot morphology, the ligamentous laxity and actually identifying where that deformity is.

SPEAKER_02:

Yeah, so ligamous laxity, the stage of that and which areas it's occurring at and that, yeah, the deformity zoning with respect to that third part to the triple classification system. But the main cohort that practitioners will see coming into the clinic, your bread and butter tibialis posterior tendinopathy patient is middle-aged or older female post or perimenopausal and increasing BMI, some other systemic factors that might be playing out for that patient. And now we know that there are likely hormonal and metabolic influences on tendon health as well. And some of these patients have all of the typical mechanical factors playing out for them. But the time at which their tendon fails and their spring ligament goes and the first ray may collapse, they may not be loading those structures terribly greatly at that point in time. I know Jill Cook talks about failure of tendon, lifetime loading being a thing with that, and I fully agree with that. You know, what's preceded that 55-year-old presenting to the clinic with this tendinopathy? You know, did they play a lot of netball in their teens, 20s, 30s, that sort of stuff? But I think the other components playing out there is we are scratching the surface, I think, on what happens with hormonal and metabolic health of tendons. And in my subjective now, when a patient's present with a tendon, I'm quizzing them quite deeply about those metabolic factors and do they know their numbers. And we remind our patients in those circumstances that the healthy levels for blood sugars, total cholesterol are not established around what's healthy for tendons. It's are you going to become diabetic and have peripheral neuropathy or are you going to have a coronary heart disease or a stroke if your cholesterol is too elevated? So, The numbers that fit in what we would say the inverted commas normal range, we see plenty of patients that are coming in with slightly elevated cholesterol, slightly elevated blood sugars within the normal range that are suffering substantial tendinopathy. They may have had a previous plan of fasciopathy. They might have greater trochanteric pain syndrome. And hey, I've had two shoulder reconstructions for supraspinatus tears, for instance. So that's a tendinopathic patient presentation. And their latest iteration of that is the painful tibialis posterior that we're dealing with. So teasing out those conversations and asking the correct subjective questions will help. And we go through that in the masterclass as to what to look for in that space.

SPEAKER_00:

Want to take your physio skills to the next level? Look no further than our masterclass video lectures from world-leading experts. With over 100 hours of video content, I think that's a perfect reminder for us

SPEAKER_01:

clinicians is that a lot of the time, whilst the objective assessment is crucial, we can actually get an incredibly rich amount of information from our subjective assessment before we actually launch into any objective assessment?

SPEAKER_02:

Yeah, totally. Our patients are a goldmine of information for us. Our job in that subjective is to obviously create within the way that we're questioning them a safe and space for any sensitive conversations around that. But You know, to listen is really important. Sometimes that's difficult when there's a lot of extraneous information thrown in that's mostly irrelevant to what we're dealing with at that point. But you'll get those one or two little gems that if your ears are open, you'll be able to pick them up and then work towards your hypothesis so much quicker and then be able to prove it with your objective exam.

SPEAKER_01:

Absolutely. And so the next question, I suppose, is around the rehab. We've spoken about the assessment of tib post tendinopathy, but what do you find are the major pitfalls in the rehab of tib post tendinopathy?

SPEAKER_02:

When we're heading down a conservative management pathway, when the deformity and the tendinopathy components aren't necessarily at a level where they're requiring surgical intervention, I suppose before we even get down to the How do you effectively conservatively rehabilitate grade 2A tibialis posterior tendinopathy when we grade it on the Johnson system? Is it a grade 2A? So getting the classification right, because grade 2B is pretty likely to need operative management or lifelong significant orthotic. Second part is, I suppose, in those conservatively managed patients, if we go back to basic principles, and I suppose Hock and Alfredson spoke about this in 98 with heavy load eccentric training for Achilles tendinopathy. A component to Alfredson's Achilles program is something that needs to be brought across into tibialis posterior tendinopathy. The interesting part to that is the major cohort that we've just discussed. Some of those patients that I've had recently are very active 60, 70-year-old females who are looking to go hiking on Canani near Hobart where I currently live and they want to rehabilitate their tib post to the point where They can hike on the side of a hillside all day and not be troubled by medial ankle, rear foot pain. So those outcomes, we do need to rehabilitate the patient to that level where their loading tolerance includes a full day hiking, for instance. However, because this cohort's mostly in that peri- and postmenopausal age group and activity levels are generally a little bit less than what we're talking about with our 20-year-old athletes, a 20-year-old Achilles tendinopathy that wants to get back to elite level sprinting may be a very different rehab prospect when we're dealing with this particular patient. So, we sometimes get pretty lucky in that respect that we don't often have to do the absolute top end of the loading programs to get these patients up to that absolute elite level of performance, which we may need to do in other tendinopathies because often these patients are doing sports and other day-to-day loading activities that that aren't quite at that same level as a younger cohort might be. And sometimes a very well-administered, what we consider early rehab program for some of those cases can get patients dramatically better with a handful of exercises and correct monitoring and support and progression.

SPEAKER_01:

Presumably the early education to go with that is crucial.

SPEAKER_02:

Absolutely. I mean, the patient's got to have buy-in from the start because there's virtually not much in the way of any passive treatment for these patients, including orthotic bracing combos, etc., that will change the underlying disease process to a point where the symptoms associated with that degenerative tendon problem settle right down. They'll only get that from the active contribution that they get from doing the loading program. So, if we don't get buy-in, then we're sort of not really having our patient help them work for themselves. So that part's critical. That's relatively easy to establish in the first consultation with being accurate in your diagnosis and precise with your language, but also understanding of this foot and ankle problems affecting this person's life. You know, that Mental health benefits of exercise in green space are well established. Blue space as well, you know, going for a surf or even walking by the ocean or a river or those types of things. These have lifestyle impacts on people. And by the time those patients are in the clinic and they're seeking treatment for it, they're already pretty much affected at their mental health level by this point in time. So they're being aware of that and having some approaches that assist patients with that. I'll get patients in preference using outdoors bicycle if they can manage it to exercise bike if there's no other risk factors involved. We're lucky down here to have a massive amount of mountain biking available. So, we have to just put the caveat on patients. I don't want you taking off jumps and getting big air and that sort of stuff. But yeah, some good non-weight-bearing physiological fitness building activity and mental health restoring plus just general leg load that's not provocative for the tendon. Cycling is a great activity for patients to be doing in their early and mid stages of rehab. And if they're one of the other types of presentations in the younger patients, then we might ask them to look at incorporating cycling or a cycling session per week in their usual running program, maybe one less run and add one bike session in as well. And we can get a lot of physiologic improvement for patients without losing a lot of running conditioning, for instance. I'm thinking perhaps now, let's say, a pulmy lesion, deltoid scarring, tibialis posterior, tenosynovitis case, for instance.

SPEAKER_01:

Fantastic, Stuart. Well, that is a wealth of information, I think, for clinicians to apply, hopefully tomorrow or today. So thank you once again for your time this afternoon. And just a reminder that you can click the link in the show notes today to watch Stuart's Masterclass for free with our seven-day trial. And I encourage you to do this because I think you can really tease out the classification systems you referred to and just getting that accurate diagnosis and treatment and management so we can get patients back to bike riding and doing all the things they enjoy.

SPEAKER_02:

Yeah, thanks very much, Sarah. I guess one final comment on that space would be, you know, our patients come to us with their foibles and their issues around how their overall health is going and treating the person is the important part here. sort of got a deep dive into the particular pathology. But if we limit our thoughts to what's happening at the foot and ankle in that case, we won't effectively rehabilitate them. There's some good information in the masterclass as well about why we need to work upstream from the ankle as well. So yeah, rehabilitating the whole limb and the whole person. And, you know, once again, I can't overstate how important it is to consider what's happening with mental health with patients that have these problems as well.

SPEAKER_01:

Great advice. Thanks so much, Stuart.

SPEAKER_02:

Nice to chat to you.

SPEAKER_01:

You too.