# Effectiveness of Resistance Training Plus Orthoses in Posterior Tibial Tendon Dysfunction

> Posterior Tibial Tendon Dysfunction is one of the most common causes of acquired flatfoot in adults.

## International Collaboration on Evidence-Based Physical Therapy
In week 44 of 2025, an International Course on Evidence-Based Physical Therapy (EBP) was held at the Faculty of Physiotherapy at the University of A Coruña, Spain. The event was organized by The European Network of Physiotherapy in Higher Education (ENPHE). 

More than 30 physiotherapy students and 9 teachers from six universities participated:
* Savonia University of Applied Sciences, Finland
* Universidade da Coruña, Spain
* Charles University, Czech Republic
* CERRFF, France
* École D´Assas, France
* Escola de Santa María de O Porto, Portugal

Students collaborated on articles covering neurology, respiratory and musculoskeletal disorders, geriatric and pediatric care, and sports injuries.

## Project Overview: Posterior Tibial Tendon Dysfunction (PTTD)
This student team focused on PTTD, a common cause of acquired flatfoot in adults, characterized by medial ankle pain, reduced muscle strength, and collapse of the medial arch. The project involved a systematic literature search and critical appraisal to evaluate whether combining resistance training with foot orthoses offers superior outcomes compared to traditional stretching exercises with orthoses for stages I–III PTTD.

## Methodology
The team utilized the PICOS framework to structure the research:
* **Population:** Adults (≥18 years) with stage I–III PTTD.
* **Intervention:** Resistance training (including Heavy Slow Resistance) combined with foot orthoses.
* **Comparison:** Stretching exercises combined with foot orthoses.
* **Outcomes:** Pain, function, and strength.
* **Study Design:** Randomized Controlled Trials (RCTs) published after 2005.

Databases searched included PubMed, PEDro, Google Scholar, Science Direct, and the Cochrane Library. Methodological quality was assessed using the PEDro scale.

## Findings
Four RCTs met the eligibility criteria:

* **Bek et al. (2012):** Compared supervised center-based rehabilitation with unsupervised home-based programs. Both groups improved, but the supervised group achieved significantly greater posterior tibial muscle strength (p < 0.05).
* **Jeong et al. (2008):** Evaluated a 6-week combined stretching and strengthening program versus standard care. The exercise group showed significant improvements in pain, ankle strength, and range of motion.
* **Houck et al. (2015):** Compared orthoses with stretching/strengthening versus orthoses with stretching alone. Both groups improved in pain and function, with the strengthening group showing better short-term gains at 6 weeks, though differences were not significant by week 12.
* **Kulig et al. (2009):** Investigated orthoses with supervised resistance exercises versus orthoses alone. The intervention group showed significant improvements in pain, Foot Function Index, and muscle strength, with eccentric resistance training yielding the greatest gains.

## Conclusion
The evidence suggests that both orthoses combined with stretching and orthoses combined with strengthening are effective for managing early-stage PTTD. While resistance training often produces slightly greater strength gains and short-term functional improvements, the long-term differences between these interventions are small. Further high-quality research is required to determine if resistance training is definitively superior.

## Authors
* **Anas Khida**, physiotherapy student, Charles University, Czech Republic.
* **Tereza Mezerová**, physiotherapy student, Charles University, Czech Republic.
* **Pablo Otero**, physiotherapy student, University of A Coruña, A Coruña, Spain.
* **Nicolas Metoi**, physiotherapy student, École D´Assas, France.
* **Dagmar Pavlu**, PT. Assoc. Prof. Charles University, Czech Republic.
* **Ivana Vláčilová**, PhD., PT. Charles University, Czech Republic.
* **Marja Äijö**, PT, PhD Principal Lecturer of gerontology and rehabilitation, Savonia, University of Applied Sciences, Kuopio, Finland.
* **Veronica Robles García**, PhD. PT. OT. Associate Professor, University of A Coruña, A Coruña, Spain.
* **Zeltia Naia Entonado**, PhD. PT. University of A Coruña, A Coruña, Spain.
* **María Vilanova Pereira**, PhD., PT. University of A Coruña, A Coruña, Spain.
* **Adrien Pallot**, PT, MSc, Lecturer at École D´Assas, France.
* **Aurel Bellaïche**, PT, Lecturer at CEERRF, France.

## References
* Bek, N., Simsek, İ., Erel, S., Yakut, Y., & Uygur, F. (2012). Home-based general versus center-based selective rehabilitation in patients with posterior tibialtendon dysfunction. Acta orthopaedica et traumatologicaturcica, 46(4), 286-292. 10.3944/aott.2012.2488
* Houck, J., Neville, C., Tome, J., & Flemister, A. (2015). Randomized Controlled Trial Comparing Orthosis Augmented by Either Stretching or Stretching and Strengthening for Stage II Tibialis Posterior Tendon Dysfunction. Foot & ankle international, 36(9), 1006–1016. https://doi.org/10.1177/1071100715579906
* Jeong, T. H., Oh, J. K., Lee, H. J., Yang, Y. J., Nha, K. W., & Suh, J. S. (2008). The effect of the combined stretching and strengthening exercise on the clinical symptoms in posterior tibial tendon dysfunction patient. Journal of Korean Foot and Ankle Society, 47-54.
* Kulig, K., Reischl, S. F., Pomrantz, A. B., Burnfield, J. M., Mais-Requejo, S., Thordarson, D. B., & Smith, R. W. (2009). Nonsurgical management of posterior tibialtendon dysfunction with orthoses and resistive exercise: a randomized controlled trial. Physical Therapy, 89(1), 26-37.