What is the best treatment approach for a patient with right post tibial tendinitis and sprain who has been non-compliant with previous appointments?

Management of Right Post Tibial Tendinitis with Sprain in a Non-Compliant Patient

For a patient with right post tibial tendinitis and sprain who has been non-compliant with appointments, physical therapy combined with NSAIDs (continuing meloxicam 15 mg daily) is the most appropriate treatment approach.

Assessment and Diagnosis

When evaluating posterior tibial tendon dysfunction (PTTD):

• Assess for tenderness posterior to the medial malleolus
• Check for swelling along the tendon course
• Evaluate tendon power and ability to perform single heel rise
• Note that this condition is often misdiagnosed as an ankle sprain 1

Treatment Approach

Pharmacological Management

1. NSAIDs

   • Continue meloxicam 15 mg daily as prescribed
   • NSAIDs are recommended to reduce pain and swelling in tendon injuries 2
   • Evidence shows NSAIDs improve pain control, decrease swelling, and allow quicker return to activity 2

2. Avoid Corticosteroid Injections

   • Corticosteroid injections remain controversial for tendinitis 3
   • Local injections should be avoided in Achilles, patellar, and quadriceps tendons 2

Non-Pharmacological Management

1. Physical Therapy (Primary Intervention)

   • Physical therapy should be started as soon as possible to recover joint functionality 2
   • Exercise therapy is strongly recommended over immobilization 2
   • Active physical therapy and supervised exercise is strongly recommended over passive physical therapy 2
   • For posterior tibial tendinitis specifically:
     • Eccentric strengthening exercises have shown the most improvement in function and pain reduction 4
     • Include proprioception, strength, coordination, and functional exercises 2

2. Functional Support

   • A brace (such as PTTD airlift brace) may be beneficial for 3-6 months 1
   • Functional support is preferred over immobilization 2
   • Choice of modality should be based on patient preferences 2

3. Activity Modification

   • Advise relative rest and modification of activities that exacerbate pain
   • Avoid complete immobilization as this is not recommended 2

Addressing Non-Compliance

For patients with history of non-compliance:

• Set clear expectations about the importance of attending physical therapy sessions
• Explain that inadequate treatment can lead to chronic problems including decreased range of motion, pain, and joint instability 2
• Consider a written treatment plan with scheduled follow-up appointments
• Emphasize that even with optimal management, resolution typically requires 3-6 months of consistent therapy

Monitoring and Follow-up

• Schedule regular follow-up appointments every 4-6 weeks
• Adjust treatment plan if no improvement is seen after 8-12 weeks of consistent therapy
• Monitor for progression to more advanced stages of posterior tibial tendon dysfunction

Prognosis

• Early recognition and appropriate treatment is key to preventing long-term consequences 5
• With appropriate conservative management including physical therapy and NSAIDs, most patients with early-stage PTTD can avoid surgical intervention 4, 3
• If symptoms persist despite 3-6 months of well-managed conservative treatment, surgical options may need to be considered 3

This treatment approach prioritizes evidence-based interventions that address both pain management and functional recovery while being practical for a patient with compliance challenges.