Finite element simulation on posterior tibial tendinopathy: Load transfer alteration and implications to the onset of pes planus

  • Duo Wai-Chi Wong
    Affiliations
    Interdisciplinary Division of Biomedical Engineering, Faculty of Engineering, The Hong Kong Polytechnic University, Hong Kong, China

    The Hong Kong Polytechnic University Shenzhen Research Institute, Shenzhen, China
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  • Yan Wang
    Affiliations
    Interdisciplinary Division of Biomedical Engineering, Faculty of Engineering, The Hong Kong Polytechnic University, Hong Kong, China

    The Hong Kong Polytechnic University Shenzhen Research Institute, Shenzhen, China
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  • Aaron Kam-Lun Leung
    Affiliations
    Interdisciplinary Division of Biomedical Engineering, Faculty of Engineering, The Hong Kong Polytechnic University, Hong Kong, China

    The Hong Kong Polytechnic University Shenzhen Research Institute, Shenzhen, China
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  • Ming Yang
    Affiliations
    Interdisciplinary Division of Biomedical Engineering, Faculty of Engineering, The Hong Kong Polytechnic University, Hong Kong, China

    Department of Pediatric Orthopedics, The Third Affiliated Hospital, Southern Medical University, Guangzhou, China
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  • Ming Zhang
    Correspondence
    Corresponding author at: Interdisciplinary Division of Biomedical Engineering, Faculty of Engineering, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong, China.
    Affiliations
    Interdisciplinary Division of Biomedical Engineering, Faculty of Engineering, The Hong Kong Polytechnic University, Hong Kong, China

    The Hong Kong Polytechnic University Shenzhen Research Institute, Shenzhen, China
    Search for articles by this author

      Highlights

      • Pes planus is started by posterior tibial tendinopathy that is hard to investigate.
      • A theoretical study using a finite element foot model was conducted.
      • Tendinopathy was resembled by unloading the tendon during gait.
      • Tendinopathy stretched the midfoot plantar ligaments during stance.
      • Load transfer along the medial longitudinal arch was affected.

      Abstract

      Background

      Posterior tibial tendinopathy is a challenging foot condition resulting in pes planus, which is difficult to diagnose in the early stage. Prior to the deformity, abnormal internal load transfer and soft tissue attenuation are anticipated. The objective of this study was to investigate the internal load transfer and strain of the ligaments with posterior tibial tendinopathy, and the implications to pes planus and other deformities.

      Methods

      A three-dimensional finite element model of the foot and ankle was reconstructed from magnetic resonance images of a 28-year-old normal female. Thirty bones, plantar fascia, ligaments and tendons were reconstructed. With the gait analysis data of the model subject, walking stance was simulated. The onset of posterior tibial tendinopathy was resembled by unloading the tibialis posterior and compared to the normal condition.

      Findings

      The load transfer of the joints at the proximal medial column was weaken by posterior tibial tendinopathy, which was compromised by the increase along the lateral column and the intercuneiforms during late stance. Besides, the plantar tarsometatarsal and cuboideonavicular ligaments were consistently over-stretched during stance. Particularly, the maximum tensile strain of the plantar tarsometatarsal ligament was about 3-fold higher than normal at initial push-off.

      Interpretation

      Posterior tibial tendinopathy altered load transfer of the medial column and unbalanced the load between the proximal and distal side of the medial longitudinal arch. Posterior tibial tendinopathy also stretched the midfoot plantar ligaments that jeopardized midfoot stability, and attenuated the transverse arch. All these factors potentially contributed to the progress of pes planus and other foot deformities.

      Keywords

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      References

        • Alvarez R.G.
        • Marini A.
        • Schmitt C.
        • Saltzman C.L.
        Stage I and II posterior tibial tendon dysfunction treated by a structured nonoperative management protocol: an orthosis and exercise program.
        Foot Ankle Int. 2006; 27: 2-8
        • Anderson A.E.
        • Ellis B.J.
        • Weiss J.A.
        Verification, validation and sensitivity studies in computational biomechanics.
        Comput. Methods Biomech. Biomed. Engin. 2007; 10: 171-184
        • Arnold E.M.
        • Ward S.R.
        • Lieber R.L.
        • Delp S.L.
        A model of the lower limb for analysis of human movement.
        Ann. Biomed. Eng. 2010; 38: 269-279
        • Athanasiou K.
        • Liu G.
        • Lavery L.
        • Lanctot D.
        • Schenck Jr., R.
        Biomechanical topography of human articular cartilage in the first metatarsophalangeal joint.
        Clin. Orthop. Relat. Res. 1998; 348: 269-281
        • Beeson P.
        Posterior tibial tendinopathy: what are the risk factors?.
        J. Am. Podiatr. Med. Assoc. 2014; 104: 455-467
        • Bluman E.M.
        • Title C.I.
        • Myerson M.S.
        Posterior tibial tendon rupture: a refined classification system.
        Foot Ankle Clin. 2007; 12: 233-249
        • Bubra P.S.
        • Keighley G.
        • Rateesh S.
        • Carmody D.
        Posterior tibial tendon dysfunction: an overlooked cause of foot deformity.
        J. Family Med. Prim. Care. 2015; 4: 26
        • Campbell K.J.
        • Michalski M.P.
        • Wilson K.J.
        • Goldsmith M.T.
        • Wijdicks C.A.
        • LaPrade R.F.
        • Clanton T.O.
        The ligament anatomy of the deltoid complex of the ankle: a qualitative and quantitative anatomical study.
        J. Bone Joint Surg. Am. 2014; 96e62
        • Chen W.-P.
        • Ju C.-W.
        • Tang F.-T.
        Effects of total contact insoles on the plantar stress redistribution: a finite element analysis.
        Clin. Biomech. 2003; 18: S17-S24
        • Cheung J.T.
        • Zhang M.
        Finite element and cadaveric simulations of the muscular dysfunction of weightbearing foot.
        in: HKIE Transactions. vol. 13. 2006: 8-15
        • Cheung J.T.-M.
        • Zhang M.
        • Leung A.K.-L.
        • Fan Y.-B.
        Three-dimensional finite element analysis of the foot during standing—a material sensitivity study.
        J. Biomech. 2005; 38: 1045-1054
        • Clemson B.
        • Tang Y.
        • Pyne J.
        • Unal R.
        Efficient methods for sensitivity analysis.
        Syst. Dyn. Rev. 1995; 11: 31-49
        • Deland J.T.
        • Richard J.
        • Sung I.-H.
        • Ernberg L.A.
        • Potter H.G.
        Posterior tibial tendon insufficiency: which ligaments are involved?.
        Foot Ankle Int. 2005; 26: 427-435
        • Edwards W.B.
        • Troy K.L.
        Finite element prediction of surface strain and fracture strength at the distal radius.
        Med. Eng. Phys. 2012; 34: 290-298
        • Fröberg Å.
        • Komi P.
        • Ishikawa M.
        • Movin T.
        • Arndt A.
        Force in the Achilles tendon during walking with ankle foot orthosis.
        Am. J. Sports Med. 2009; 37: 1200-1207
        • Galbusera F.
        • Freutel M.
        • Dürselen L.
        • D'Aiuto M.
        • Croce D.
        • Villa T.
        • Sansone V.
        • Innocenti B.
        Material models and properties in the finite element analysis of knee ligaments: a literature review.
        Front. Bioeng. Biotechnol. 2014; 2
        • Gluck G.S.
        • Heckman D.S.
        • Parekh S.G.
        Tendon disorders of the foot and ankle, part 3 the posterior tibial tendon.
        Am. J. Sports Med. 2010; 38: 2133-2144
        • Gu Y.
        • Li J.
        • Ren X.
        • Lake M.J.
        • Zeng Y.
        Heel skin stiffness effect on the hind foot biomechanics during heel strike.
        Skin Res. Technol. 2010; 16: 291-296
        • Haleem A.M.
        • Pavlov H.
        • Bogner E.
        • Sofka C.
        • Deland J.T.
        • Ellis S.J.
        Comparison of deformity with respect to the talus in patients with posterior tibial tendon dysfunction and controls using multiplanar weight-bearing imaging or conventional radiography.
        J. Bone Joint Surg. Am. 2014; 96e63
        • Hicks J.
        The mechanics of the foot: II. The plantar aponeurosis and the arch.
        J. Anat. 1954; 88: 25-30
        • Imhauser C.W.
        • Siegler S.
        • Abidi N.A.
        • Frankel D.Z.
        The effect of posterior tibialis tendon dysfunction on the plantar pressure characteristics and the kinematics of the arch and the hindfoot.
        Clin. Biomech. 2004; 19: 161-169
        • Johnson J.E.
        • James R.Y.
        Arthrodesis techniques in the management of stage-II and III acquired adult flatfoot deformity.
        J. Bone Joint Surg. Am. 2005; 87: 1865-1876
        • Kamiya T.
        • Uchiyama E.
        • Watanabe K.
        • Suzuki D.
        • Fujimiya M.
        • Yamashita T.
        Dynamic effect of the tibialis posterior muscle on the arch of the foot during cyclic axial loading.
        Clin. Biomech. 2012; 27: 962-966
        • Kitaoka H.B.
        • Luo Z.P.
        • Growney E.S.
        • Berglund L.J.
        • An K.-N.
        Material properties of the plantar aponeurosis.
        Foot Ankle Int. 1994; 15: 557-560
        • Kitaoka H.B.
        • Luo Z.P.
        • An K.-N.
        Effect of the posterior tibial tendon on the arch of the foot during simulated weightbearing: biomechanical analysis.
        Foot Ankle Int. 1997; 18: 43-46
        • Kohls-Gatzoulis J.
        • Angel J.C.
        • Singh D.
        • Haddad F.
        • Livingstone J.
        • Berry G.
        Tibialis posterior dysfunction: a common and treatable cause of adult acquired flatfoot.
        BMJ. 2004; 329: 1328-1333
        • Ledoux W.R.
        • Hillstrom H.J.
        The distributed plantar vertical force of neutrally aligned and pes planus feet.
        Gait Posture. 2002; 15: 1-9
        • Lemmon D.
        • Shiang T.
        • Hashmi A.
        • Ulbrecht J.S.
        • Cavanagh P.R.
        The effect of insoles in therapeutic footwear—a finite element approach.
        J. Biomech. 1997; 30: 615-620
        • Lever C.J.
        • Hennessy M.S.
        Adult flat foot deformity.
        Orthop. Trauma. 2016; 30: 41-50
        • Levinger P.
        • Murley G.S.
        • Barton C.J.
        • Cotchett M.P.
        • McSweeney S.R.
        • Menz H.B.
        A comparison of foot kinematics in people with normal-and flat-arched feet using the Oxford Foot Model.
        Gait Posture. 2010; 32: 519-523
        • Lin Y.-C.
        • Mhuircheartaigh J.N.
        • Lamb J.
        • Kung J.W.
        • Yablon C.M.
        • Wu J.S.
        Imaging of adult flatfoot: correlation of radiographic measurements with MRI.
        Am. J. Roentgenol. 2015; 204: 354-359
        • Milz P.
        • Mhz S.
        • Steinborn M.
        • Mittlmeier T.
        • Putz R.
        • Reiser M.
        Lateral ankle ligaments and tibiofibular syndesmosis: 13-MHz high-frequency sonography and MRI compared in 20 patients.
        Acta Orthop. Scand. 1998; 69: 51-55
        • Morales-Orcajo E.
        • Bayod J.
        • de Las Casas E.B.
        Computational foot modeling: scope and applications.
        Arch. Comput. Meth. Eng. 2016; 23: 389-416
        • Ness M.E.
        • Long J.
        • Marks R.
        • Harris G.
        Foot and ankle kinematics in patients with posterior tibial tendon dysfunction.
        Gait Posture. 2008; 27: 331-339
        • Neville C.
        • Flemister A.S.
        • Houck J.
        Total and distributed plantar loading in subjects with stage II tibialis posterior tendon dysfunction during terminal stance.
        Foot Ankle Int. 2013; 34: 131-139
        • Neville C.
        • Bucklin M.
        • Ordway N.
        • Lemley F.
        An ankle-foot orthosis with a lateral extension reduces forefoot abduction in subjects with stage II posterior Tibial tendon dysfunction.
        J. Orthop. Sports Phys. Ther. 2016; 46: 26-33
        • Ni M.
        • Wong D.W.-C.
        • Mei J.
        • Niu W.
        • Zhang M.
        Biomechanical comparison of locking plate and crossing metallic and absorbable screws fixations for intra-articular calcaneal fractures.
        Sci. China Life Sci. 2016; 59: 958-964
        • Pailler-Mattei C.
        • Bec S.
        • Zahouani H.
        In vivo measurements of the elastic mechanical properties of human skin by indentation tests.
        Med. Eng. Phys. 2008; 30: 599-606
        • Perry J.
        • Burnfield J.M.
        Gait Analysis: Normal and Pathological Function.
        1993 (Slack)
        • Ren S.
        • Wong D.W.-C.
        • Yang H.
        • Zhou Y.
        • Lin J.
        • Zhang M.
        Effect of pillow height on the biomechanics of head-neck complex: investigation on crano-cervical pressure and cervical spine alignment.
        PeerJ. 2016; 4
        • Siegler S.
        • Block J.
        • Schneck C.D.
        The mechanical characteristics of the collateral ligaments of the human ankle joint.
        Foot Ankle Int. 1988; 8: 234-242
        • Singh R.
        • King A.
        • Perera A.
        Posterior tibial tendon dysfunction: a silent but disabling condition.
        Br. J. Hosp. Med. (London, England: 2005). 2012; 73: 441-445
        • Spratley E.M.
        • Matheis E.A.
        • Hayes C.W.
        • Adelaar R.S.
        • Wayne J.S.
        Validation of a population of patient-specific adult acquired flatfoot deformity models.
        J. Orthop. Res. 2013; 31: 1861-1868
        • Squires N.A.
        • Jeng C.L.
        Posterior tibial tendon dysfunction.
        Oper. Tech. Orthop. 2006; 16: 44-52
        • Viceconti M.
        • Olsen S.
        • Nolte L.-P.
        • Burton K.
        Extracting clinically relevant data from finite element simulations.
        Clin. Biomech. 2005; 20: 451-454
        • Vulcano E.
        • Deland J.T.
        • Ellis S.J.
        Approach and treatment of the adult acquired flatfoot deformity.
        Curr. Rev. Musculoskelet. Med. 2013; 6: 294-303
        • Wang Y.
        • Li Z.
        • Wong D.W.-C.
        • Zhang M.
        Effects of ankle arthrodesis on biomechanical performance of the entire foot.
        PLoS One. 2015; 10e0134340
        • Wang Y.
        • Wong D.W.-C.
        • Zhang M.
        Computational models of the foot and ankle for pathomechanics and clinical applications: a review.
        Ann. Biomed. Eng. 2016; 44: 213-221
        • Watanabe K.
        • Kitaoka H.B.
        • Fujii T.
        • Crevoisier X.
        • Berglund L.J.
        • Zhao K.D.
        • Kaufman K.R.
        • An K.-N.
        Posterior tibial tendon dysfunction and flatfoot: analysis with simulated walking.
        Gait Posture. 2013; 37: 264-268
        • Wong D.W.-C.
        • Zhang M.
        • Leung A.K.-L.
        First ray model comparing normal and hallux valgus feet.
        in: Computational Biomechanics of the Musculoskeletal System. 2014: 49
        • Wong D.W.-C.
        • Zhang M.
        • Yu J.
        • Leung A.K.-L.
        Biomechanics of first ray hypermobility: an investigation on joint force during walking using finite element analysis.
        Med. Eng. Phys. 2014; 36: 1388-1393
        • Wong D.W.-C.
        • Wang Y.
        • Zhang M.
        • Leung A.K.-L.
        Functional restoration and risk of non-union of the first metatarsocuneiform arthrodesis for hallux valgus: a finite element approach.
        J. Biomech. 2015; 48: 3142-3148
        • Wong D.W.-C.
        • Niu W.
        • Wang Y.
        • Zhang M.
        Finite element analysis of foot and ankle impact injury: risk evaluation of calcaneus and talus fracture.
        PLoS One. 2016; 11e0154435
        • Wong D.W.-C.
        • Wang Y.
        • Chen T.L.-W.
        • Leung A.K.-L.
        • Zhang M.
        Biomechanical consequences of subtalar joint arthroereisis in treating posterior tibial tendon dysfunction: a theoretical analysis using finite element analysis.
        Comput. Meth. Biomech. Biomed. Eng. 2017; https://doi.org/10.1080/10255842.2017.1382484
        • Yavuzer G.
        • Öken Ö.
        • Elhan A.
        • Stam H.J.
        Repeatability of lower limb three-dimensional kinematics in patients with stroke.
        Gait Posture. 2008; 27: 31-35
        • Yu J.
        • Wong D.W.-C.
        • Zhang H.
        • Luo Z.-P.
        • Zhang M.
        The influence of high-heeled shoes on strain and tension force of the anterior talofibular ligament and plantar fascia during balanced standing and walking.
        Med. Eng. Phys. 2016; 38: 1152-1156
        • Zhang M.
        • Mak A.
        In vivo friction properties of human skin.
        Prosthetics Orthot. Int. 1999; 23: 135-141
        • Zhang Y.
        • Xu J.
        • Wang X.
        • Huang J.
        • Zhang C.
        • Chen L.
        • Wang C.
        • Ma X.
        An in vivo study of hindfoot 3D kinetics in stage II posterior tibial tendon dysfunction (PTTD) flatfoot based on weight-bearing CT scan.
        Bone Joint Res. 2013; 2: 255-263
        • Zhang Y.-J.
        • Xu J.
        • Wang Y.
        • Lin X.-J.
        • Ma X.
        Correlation between hindfoot joint three-dimensional kinematics and the changes of the medial arch angle in stage II posterior tibial tendon dysfunction flatfoot.
        Clin. Biomech. 2015; 30: 153-158