Practice based evidence versus evidence based practice: reviewing the clinical tests currently used to diagnose posterior tibial tendon dysfunction

  • Hope R
  • Prescott D
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Relevance: Posterior Tibialis Tendon Dysfunction's (PTTD) poorly understood aetiology and pathophysiology make it a complex, challenging yet common musculoskeletal (MSK) condition (Fenn, 2006). It is a well‐recognised source of foot and ankle pain, particularly in females over the age of 40 years. PTTD is diagnosed through clinical history and examination (Edwards et al., 2008), early diagnosis is essential, in order to prevent long term disabling consequences or the need for surgical intervention. PTTD is often misdiagnosed and mismanaged with detrimental patient care and major financial implications. There are currently no national guidelines on the clinical diagnosis of PTTD but a dated classification staging system is routinely used to diagnose and guide patient management. Purpose: The overarching aim of this work was to undertake an extended literature review, in order to identify emergent trends and themes, regarding the accuracy and trustworthiness of clinical tests to help guide future practice. Methods/analysis: A comprehensive search of relevant electronic databases was undertaken using key search terms. The evidence sourced was scrutinised against inclusion/exclusion criteria for a decision regarding final inclusion. Selected studies were then critically reviewed for emergent themes. Results: Thirteen studies were included for final analysis, eleven non randomised comparative studies and two case series (publication between 1992 and 2014). Methodological quality varied with heterogeneity of identified clinical tests. Emergent themes included: lower limb gait kinematics; double leg heel rise; single leg heel rise (SLHR); posterior tibial muscle strength; posterior tibial oedema sign (PTES); first metatarsal rise sign; lower limb muscle strength and performance, and leg length discrepancy (LLD). Discussion and conclusions: Findings provided weak support regarding the utility of certain tests used in current clinical practice. PTTD may be suspected if a flat foot deformity is detected, a positive SLHR, an inability to complete a unipedal standing balance test, a PTES, with associated factors of LLD or bilaterally decreased lower limb strength. However, a 'confirm conclusion' cannot be made, regarding which test is superior, or if a combination of tests is more effective. The majority of studies reviewed have not confirmed PTTD diagnosis with the gold standard of imagery. Instead classification staging systems, such as that developed by Johnson and Strom (1989) have been widely implemented but lack substantive evidence for their use. Impact and implications: The clinical tests currently used in PTTD clinical practice lack accuracy and trustworthiness, requiring further scrutiny to prevent misdiagnosis and subsequent mismanagement. This highlights the need for clinicians to challenge widely accepted 'practice based evidence' in order to achieve effective evidence based practice. In‐depth exploration of the literature regarding similar pathologies needs to be undertaken, in order to identify any factors that might better facilitate PTTD diagnosis.




Hope, R., & Prescott, D. (2016). Practice based evidence versus evidence based practice: reviewing the clinical tests currently used to diagnose posterior tibial tendon dysfunction. Physiotherapy, 102, e216–e217.

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