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Evaluating the Impact of Posterior Tibial Tendon Dysfunction in Rheumatoid Arthritis Patients and Considering the Evidence Base for the Clinical Use of Gait Analysis Techniques used in the Management of such a Condition

Evaluating the Impact of Posterior Tibial Tendon Dysfunction in Rheumatoid Arthritis Patients and Considering the Evidence Base for the Clinical Use of Gait Analysis Techniques used in the Management of such a Condition

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An essay for the 2012 Undergraduate Awards Competition by Andrea Mahon. Originally submitted for Podiatry at None, with lecturer Ms. Amanda Walsh in the category of Medical Sciences
An essay for the 2012 Undergraduate Awards Competition by Andrea Mahon. Originally submitted for Podiatry at None, with lecturer Ms. Amanda Walsh in the category of Medical Sciences

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Published by: Undergraduate Awards on Aug 30, 2012
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10/27/2013

 
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Evaluating the Impact of Posterior Tibial Tendon Dysfunction inRheumatoid Arthritis Patients and Considering the Evidence Basefor the Clinical Use of Gait Analysis Techniques used in theManagement of such a Condition
 
Rheumatoid arthritis (RA) usually begins as an insidious symmetrical polyarthropathy withnon-specific symptoms such as malaise and fatigue (Egelius, Havermark & Jonsson, 1949).Up to 90% of RA patients experience foot problems (Birtane
et al.,
2009) and according toClavaguera
et al.
(1997), pes planus has been reported in up to 46% of these patients. Astrong correlation exists between this deformity and dysfunction of the principle pedalinverter, the posterior tibial tendon (PTT).PTTD (posterior tibial tendon dysfunction) causes problems from stage I into Adult AcquiredFlatfoot of stage III/IV. Heel valgus, flattening of the medial longitudinal arch (MLA) andforefoot abduction are evident in the latter stages of PTTD, or Adult Acquired Flatfoot. According to Gibson and Prieskorn (2007), there are 4 stages of PTTD. Stage I typicallypresents as oedema and tenderness along the PTT but with no associated posturalchanges. Stage II consists of a weightbearing flexible flatfoot deformity which is associatedwith gait changes and pressure loading alterations. The deformity becomes rigid at stage IIIwith associated heel valgus deformity. Stage IV was developed by Myerson (1996) and ischaracterized by arthritis of the tibiotalar joint. PTTD injury mechanisms can be subdividedinto acute and chronic. Acute PTTD is common in young, athletic individuals and is related tooveruse. Regarding the appearance of acute PTTD, Beltran, Bencardino and Rosenberg
 
(2000) report
that “
 
the tendon demonstrates normal signal intensity and morphologiccharacteristics, although nodular or diffuse thickening in chronic tenosynovitis and scarring
of the peritenon may be encountered”
. Chronic PTTD typically develops in women over 40and is associated with rupture. The tear is commonly noted behind the medial malleolus,where the tendon is subjected to a significant amount of friction. A common site of tear or rupture of the PTT is the portion inferior to the medial malleolus as there is a lack of 
 
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adequate blood supply to this area. It is possible to be anatomically predisposed todeveloping PTTD as the presence of either an accessory navicular or a cornuate navicular isa risk factor for posterior tibialis tendon tears (Karasick & Schweitzer, 2000). From the studyby Beltran, Bencardino and Rosenberg (2000),
 
see figures 1, 2 and 3 for magneticresonance images of advanced type 1 PTT tear, type 2 PTT tear and type 3 PTT tear respectively.
Figure 1: Type 1 PTT Tear (as illustrated in Beltran, Bencardino & Rosenberg, 2000)
 
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Figure 2: Type 2 PTT Tear (as illustrated in Beltran, Bencardino & Rosenberg, 2000)Figure 3: Type 3 PTT Tear (as illustrated in Beltran, Bendcardino & Rosenberg, 2000)

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