The prevalence of symptomatic posterior tibialis tendon dysfunction in women over the age of 40 in England

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Abstract

Background

To investigate the prevalence of posterior tibial tendon dysfunction (PTTD) in women over the age of 40.

Methods

A validated survey was posted to a random sample of 1000 women (over 40 years) from a GP group practice in Hertfordshire, England. Survey positive women were telephoned and when indicated, a detailed examination was performed.

Results

There were 582 usable responses. The majority indicated they had minor forefoot or no problems. Telephone contact was made with 116 women and of those 79 required examination. The diagnosis of symptomatic flatfeet was made in 9 patients, 7 patients had stage I PTTD, 12 patients had stage II PTTD and 9 patients had an adult acquired flatfoot deformity.

Conclusions

This is the first report of the prevalence of stage I and II PTTD in women (over 40 years). The prevalence is 3.3% and all patients were undiagnosed despite characteristic and prolonged symptoms.

Introduction

Posterior tibial tendon dysfunction (PTTD) is a foot condition characterised by loss of the action of the tibialis posterior muscle unit [1], [2], most often due to a degenerative process in the tendon of the tibialis posterior [3] (tendinosis). Due to the tibialis posterior tendon’s key role as a dynamic support to the longitudinal arch of the foot, loss or dysfunction of the tibialis posterior tendon causes an acquired flat foot deformity to develop [4], [5]. Patients often present with a change in foot shape having developed a valgus heel, flattening of the medial longitudinal arch and an abducted forefoot [1], [6]. Patients may also present with a decreased walking distance, medial hindfoot pain, and medial hindfoot swelling or some patients will present with lateral hindfoot pain secondary to impingement of the calcaneus on the fibula [7].

Posterior tibial tendon dysfunction occurs along a continuum and is usually classified in the manner proposed by Johnson and Strom [6] which describes the progression of the PTTD. In stage I PTTD, the tendon is still intact and to some degree functioning and it can be inflamed. In stage II PTTD, the tendon has become dysfunctional and the foot has developed an acquired flatfoot deformity but the deformity is passively correctable. In stage III PTTD, the foot deformity has become fixed, and degenerative changes are seen in the subtalar joint. Stage IV was not described by Johnson and Strom but has been subsequently added by Myerson [4]. Stage IV PTTD occurs when degenerative changes are also present in the ankle joint as well as the subtalar joint.

Although this condition is normally diagnosed based solely on a history and examination [1], [7] (and as needed radiographs to exclude other causes of an adult acquired flatfoot deformity) it is often observed that patients experience a significant lag between seeking medical help and receiving a diagnosis and treatment [7], [8]. It has lead our group to wonder if the diagnosis is much more prevalent among the general population as compared to the number of patients with posterior tibial tendon dysfunction who eventually filter into our clinics. One of the purposes of our research was to investigate whether the individuals with tibialis posterior dysfunction in the general community have indeed been diagnosed and treated.

No previously published data exists to estimate the prevalence of posterior tibial tendon dysfunction but it is known to be more common amongst women [5], [9] and is known to increase with age [8]. The aim of our study was therefore to establish the prevalence of PTTD in an at-risk population, namely women over the age of 40. The second aim was to establish how many of the patients with PTTD had in fact been diagnosed and had had treatment initiated.

Section snippets

Ethical approval and funding

Ethical approval was sought and obtained from the Royal National Orthopaedic Hospital Trust and from the Hertfordshire NHS Authority. Partial funding was received from the Royal National Orthopaedic Hospital Trust. All study subjects signed a consent form prior to participation in the study.

Screening survey development

A survey was developed (Appendix A) which asked patients about common symptoms of posterior tibial tendon dysfunction. The symptoms enquired about were: medial hindfoot pain, medial hindfoot swelling, a

Results

The returned surveys numbered 588, 6 surveys were unusable leaving and another 4 later pulled out from the study due to inability to attend the research clinic. This left 578 responses for analysis. The unusable surveys either indicated that the patient had moved or that the patient did not wish to participate in the study. Three of the patients indicated that they were too frail and immobile to participate.

There was a trend toward a bimodal age distribution, amongst the non-responders, with a

Discussion

Our study establishes the prevalence of PTTD amongst women, older than 40 years of age in the United Kingdom. The prevalence was 3.3% and none of these patients had been previously diagnosed or treated despite characteristic symptoms of a chronic nature.

We elected to study women over 40 years of age because of the higher observance of PTTD in women and especially women with increasing age in epidemiologic studies [5], [9]. Posterior tibial tendon dysfunction does occur in men. In fact, PTTD has

Acknowledgement

We would like to thank Mr. Andrew Morris for his statistical support with this research.

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