Nearly 25 years ago, Hintermann and Gächter published a study that centered around a clinical test to help determine whether a patient needed surgery for posterior tibial tendon dysfunction (PTTD).1 They based their assertions on the fact that all 21 patients in the cohort with posterior tibial tendon disease (not necessarily rupture) exhibited a positive first metatarsal rise test. In each of these cases, with the patient standing and the heel inverted (or the leg externally rotated), the first metatarsal will rise off the ground in those with PTTD and stay on the ground for patients who have normal posterior tibial function.1 This test is now known more as the First Metatarsal Rise Test.
When I recently reviewed this article, many thoughts and questions have crossed my mind.
- One-hundred percent of the patients exhibited a positive test even though the surgical findings were all over the place (ranging from tendinitis only to complete ruptures).
- One-hundred percent of the patients without posterior tibial tendon disease had a negative first metatarsal rise, but the authors did not provide more detail on any of these patients. Also, they implied the test took place over four years.
- The study authors made no reference to preoperative use of orthotics nor was there any mention of posterior tibial strength or efforts to improve this preoperatively.
- The study authors also did not mention whether these patients had deformities like rearfoot varus, rearfoot valgus, forefoot valgus and forefoot varus. Any of these common deformities would greatly affect this test.
- For most of my patients with PTTD, 10 degrees of heel eversion and 10 degrees of positional forefoot supination, when I put the patient into heel varus, the first metatarsal is going to be way off of the ground. This does not mean I need to do anything but rehabilitate them.
Again, reviewing this classic study has caused me to pause and consider the true basis of this test. I am hopeful that my esteemed colleagues around the world will share their thoughts on the importance (or lack thereof) of the first metatarsal rise test in determining surgical candidacy for PTTD. Please share your comments below on this blog.
Dr. Blake is in practice at the Center for Sports Medicine, which is affiliated with St. Francis Memorial Hospital in San Francisco. He is a past president of the American Academy of Podiatric Sports Medicine. Dr. Blake is the author of the recently published book, “The Inverted Orthotic Technique: A Process Of Foot Stabilization For Pronated Feet,” which is available at www.bookbaby.com.
Editor’s note: This blog originally appeared at www.drblakeshealingsole.com. It is adapted with permission from the author.
- Hintermann B, Gächter A. The first metatarsal raise sign: a simple, sensitive sign of tibialis posterior tendon dysfunction. Foot Ankle Int. 1996;17(4):236-241.
I had the pleasure of meeting Dr. Hintermann about 15 years ago and asked him about this test and his own experience. He agreed that there were many shortcomings as you point out. In the end, this test reveals a forefoot supinatus deformity, which is common in PTTD patients. It does not detect TP tendon rupture as you astutely point out Rich.
Evaluating forefoot to rearfoot alignment in patients who are weightbearing has many challenges. I prefer doing this assessment off-weightbearing.
Thanks for sharing your insights into this often quoted article.