Tendon Injuries About the Ankle in Athletes

Ultrasound Examination and Navigation for Repeat/Delayed Reconstruction of the Ankle Extensor Tendons

Herein, we describe a 46-year-old woman with persistent pain and weakness in her left ankle/foot one year after surgical repair of all three ankle extensor tendons following a penetrating injury. This report presents a unique case whereby US imaging played a paramount role in the diagnosis and surgical management of a previous nonanatomic repair of the ankle extensor tendons after a penetrating injury one year prior. The above-quoted findings were subsequently corrected with end-to-end sutures. On the third postoperative month follow-up, the patient was free of any complaints or complications.

Soft-Tissue Radiography, Computed Tomography, and Ultrasonography of Partial Achilles Tendon Ruptures

Ultrasonography (US) was compared with soft-tissue radiography (STR) and computed tomography (CT) for demonstration of partial Achilles tendon ruptures. Thirty-nine patients suffering from chronic localized painful Achilles tendon swelling were examined. The patients had all undergone a previous clinical examination, resulting in a suspicion of a non-healed partial tear in 62 out of the 78 tendons. STR showed unspecific tendon pathology such as thickening and diffuse tendon margins. CT resulted in a better delineation of intra- as well as extratendinous abnormalities compared to STR. Various pathologic changes were seen on CT in 54 tendons and in 29 of these, localized intratendinous hypodensities indicated partial ruptures. At US, abnormal changes were observed in 69 tendons, of which 54 had discontinuity of tendon fibers, focal hypoechoic areas, and localized swelling indicating partial ruptures. In 9 cases with surgically proven partial ruptures, US was correct in all cases, while CT was false-negative in 3. STR only showed localized swelling. It was concluded that US was a better method than STR and CT for the detection of partial ruptures and the US findings correlated well with the surgical findings.

Closed Medial Malleolar Multifragment Fracture With a Posterior Tibialis Tendon Rupture: A Case Report and Review of the Literature

Ankle fractures represent an exciting field of traumatology because of the wide variety of clinical presentations, injury mechanisms, and treatment options. Rupture of the posterior tibialis tendon (PTT) with ankle fracture can occur during trauma that involves pronation and external rotation of the foot or, less commonly, secondary to direct trauma to the ankle. This tendon injury is uncommon and probably misdiagnosed in many cases, because of the difficult clinical examination secondary to the pain and swelling. The identification and early treatment of PTT tears is essential for good functional outcomes to prevent the main mid- to long-term complication of disabling acquired flatfoot due to tendon failure. In the present report, we provide a review of the published data regarding ankle fractures associated with PTT rupture and describe our experience with a case of a multifragment medial malleolus fracture and complete rupture of the PTT diagnosed intraoperatively and surgically treated in a 34-year-old male, with 2.5 years of follow-up.

Tibialis posterior tendon rupture associated with a closed medial malleolar fracture: a case report and review of the literature

We report an acute rupture of a macroscopically normal tibialis posterior tendon in the setting of an acute closed ankle fracture. This injury is considered to be rare, although it is probably frequently overlooked preoperatively because of limitations of the clinical examination secondary to pain. The tibialis posterior tendon rupture was identified at the time of operative repair of the ankle fracture, and direct suture repair of the tendon was undertaken. After primary suture and osteosynthesis, the patient's progress was favorable and a satisfactory outcome was achieved. A clear history of the mechanism of injury as well as a high index of suspicion should be maintained, because failure to repair rupture of the tibialis posterior tendon, in the presence of an ankle fracture, is likely to lead to long-term patient disability and a planovalgus foot.

Acute and chronic peroneal tendon dislocations

Peroneal tendon dislocation is an infrequent sports injury and can be difficult to diagnose. Posterior fibula tenderness and pain with eversion are useful signs to discriminate this from an ankle sprain. In the acute setting, a direct repair provides good results but may need to be augmented with additional soft tissue or bony restraints. For chronic injuries there are several methods of reconstruction, all with acceptable outcomes, although bone block procedures have the highest rate of secondary procedures.

The flexible flatfoot in the adult

The adult acquired flatfoot deformity is characterized by flattening of the medial longitudinal arch with insufficiency of the supporting posteromedial soft tissue structures of the ankle and hindfoot. While the etiology of this deformity can be arthritic or traumatic in nature, it is most commonly associated with posterior tibial tendon dysfunction (PTTD). By one estimate, PTTD affects approximately five million people in the United States. The clinical presentation of adult flatfoot can range from a flexible deformity with normal joint integrity to a rigid, arthritic foot.

Stage I and II posterior tibial tendon dysfunction treated by a structured nonoperative management protocol: an orthosis and exercise program

BACKGROUND

Posterior tibial tendon dysfunction (PTTD) is a relatively common problem of middle-aged adults that usually is treated operatively. The purpose of this study was to identify strength deficits with early stage PTTD and to assess the efficacy of a focused nonoperative treatment protocol.

METHODS

Forty-seven consecutive patients with stage I or II posterior tibial tendon dysfunction were treated by a structured nonoperative protocol. Criteria for inclusion were the presence of a palpable and painful posterior tibial tendon, with or without swelling and 2) movement of the tendon with passive and active nonweightbearing clinical examination. The rehabilitation protocol included the use of a short, articulated ankle foot orthosis or foot orthosis, high-repetition exercises, aggressive plantarflexion activities, and an aggressive high-repetition home exercise program that included gastrocsoleus tendon stretching. Isokinetic evaluations were done before and after therapy to compare inversion, eversion, plantarflexion, and dorsiflexion strength in the involved and uninvolved extremities. Criteria for successful rehabilitation were no more than 10% strength deficit, ability to perform 50 single-support heel rises with minimal or no pain, ability to ambulate 100 feet on the toes with minimal or no pain, and ability to tolerate 200 repetitions of the home exercises for each muscle group.

RESULTS

Before therapy weakness for concentric and eccentric contractures of all muscle groups of the involved ankle was significant (p<0.001). After a median of 10 physical therapy visits over a median period of 4 months, 39 (83%) of the 47 patients had successful subjective and functional outcomes, and 42 patients (89%) were satisfied. Five patients (11%) required surgery after failure of nonoperative treatment.

CONCLUSION

This study suggests that many patients with stage I and II posterior tibial tendon dysfunction can be effectively treated nonoperatively with an orthosis and structured exercises.

Nerve and tendon lacerations about the foot and ankle

Nerve and tendon lacerations of the foot and ankle region are relatively common. Acute nerve and tendon injuries should be repaired with appropriate techniques at the time of initial wound exploration. Primary nerve repair may help minimize the risk of painful neuroma formation; primary tendon repair can lead to better functional results than delayed repair. Most chronic nerve injuries, except those to the tibial nerve or its major divisions, are managed by resection of a painful neuroma and burying the nerve ending in a protected area. Delayed reconstruction of tendon injuries is performed when correction of the functional deficit outweighs the morbidity of surgery.

Nonoperative treatment of adult acquired flat foot with the Arizona brace

Nonoperative treatment of posterior tibial tendon dysfunction can be successful with the Arizona AFO brace, particularly when treatment is initiated in the early stages of the disease. This mandates that the orthopedist has a high index of suspicion when evaluating patients to make an accurate diagnosis. Although there is a role for surgical management of acquired flat feet, a well-fitted, custom-molded leather and polypropylene orthosis can be effective at relieving symptoms and either obviating or delaying any surgical intervention. In today's climate of patient satisfaction directed health care, a less invasive treatment modality that relieves pain may prove to be more valuable than similar pain relief that is obtained after surgery. Questions regarding the long-term results of bracing remain unanswered. Future studies are needed to determine if disease progression and arthrosis occur despite symptomatic relief with a brace. Furthermore, age- and disease stage-matched control groups who are randomized to undergo surgery or bracing are necessary to compare these different treatment modalities. At this time, the Arizona AFO brace can be a useful weapon in the orthopedist's armamentarium for treating acquired flat foot deformity.

Ankle and foot disorders in skeletally immature athletes

As one of the most commonly injured areas in the immature athlete, the foot and ankle has many disorders. Knowledge of congenital and developmental abnormalities and possible injury patterns enables the clinician to correctly diagnose these disorders. Physical examination and appropriate use of imaging technology provide confirmation of the initial impression. As children and adolescents participate in sports with greater intensity, there is a higher incidence of overuse injuries that may have long-term implications.

Superior peroneal retinaculoplasty: a surgical technique for peroneal subluxation

A modification of a soft tissue reconstruction procedure for treatment of peroneal tendon subluxation and dislocation is presented. The procedure is based on creating one periosteal flap from the posterior fibula in the region of the peroneal groove. The flap is used to reinforce the superior peroneal retinaculum and prevent anterior displacement of the tendons. This reconstructive procedure has several advantages over existing procedures. The major advantage is that it recreates the normal anatomy of the superior peroneal retinaculum with little disturbance of the surrounding tissues. In addition, the procedure is simple and can be done relatively quickly for patients with acute and chronic subluxation and/or dislocation. Finally, because metallic hardware (such as screws or suture anchors) is not used, artifacts are minimized on magnetic resonance imaging scans.

Peroneal tendon injuries

Peroneal tendon pathology is a common cause of lateral ankle pain. Because of the difficulty of distinguishing peroneal tendon injuries from lateral ligament injuries in the setting of ankle trauma, early diagnosis is often missed. Failure to recognize and adequately treat these injuries can result in significant long-term disability. Focused history and physical examination are critical, as is a thorough understanding of the local anatomy and biomechanics involved. Acute injuries may be successfully treated conservatively; however, chronic injuries have demonstrated unsatisfactory response to conservative measures. When considering surgical management of peroneal tendon injuries, as much information as possible must be gathered through history, clinical exam, and diagnostic studies. The level of injury in correspondence with the myriad of possible etiologic factors dictates the ideal procedure to be performed. Surgery is highly individualized according to the pathology encountered, and to the skill and experience of the surgeon.

The use of orthotic devices in adult acquired flatfoot deformity

PTT dysfunction is the most common cause of adult acquired flat foot deformity. The aggressive nonoperative approach has become accepted more widely, in part because of the advances in orthotic and bracing technology and options. Many patients with a PTT dysfunction can be treated effectively with conservative management protocols. The goal of alleviating pain and correcting deformities is being accomplished with the proper application of the wide spectrum of orthotic modalities available today.

Foot and ankle problems in the young athlete

In the U.S., greater than half of boys and one quarter of girls in the 8- to 16-yr-old age range are engaged in some type of competitive, scholastic, organized sport during the school year. Children and adolescents are becoming more involved in sports at earlier ages and with higher levels of intensity. Foot and ankle problems, in particular, are the second most common musculoskeletal problem facing primary care physicians in children under 10 yr of age next to acute injury. This report focuses on foot and ankle problems, trauma, and overuse in the young athletic population. Guidelines are given for both conservative and surgical management. Specific problems addressed include pes planus, tarsal coalition, adolescent bunion, os trigonum, accessory navicular, physeal fractures, sprains, peroneal tendon subluxation, metatarsal fractures, sesamoid fractures, turf toe, stress fractures, tendonitis, osteochondritis dissecans, ankle impingement, bursitis, Haglund's deformity, sesamoiditis, plantar fasciitis, apophysitis, osteochondroses, cuboid syndrome, and reflex sympathetic dystrophy. An extensive review of the literature is performed and presented in combination with the extensive experience of a well-established sports medicine clinic at the Boston Children's Hospital.

Ankle sprains expedient assessment and management

Most ankle injuries occur from excessive inversion, but it is important to be able to differentiate a simple inversion sprain from a potentially disabling injury. Expedient diagnosis includes first screening for deformities and then performing specific tests like the anterior drawer and side-to-side test. To optimize assessment, the examiner needs to take advantage of the preswelling period on the sidelines. Physicians can treat most ankle injuries nonoperatively, taking steps to ensure a quick return to play. Fracture signs and treatment are covered in a comprehensive table.

Peroneal tendon injuries

Injury to the peroneal tendons is a frequently overlooked cause of persistent lateral ankle pain after trauma. Peroneal tendon anatomy, biomechanics, diagnostic studies, and traumatic disorders were reviewed.

Peroneal tendons: use of kinematic MR imaging of the ankle to determine subluxation

The purpose of this study was to develop a technique for kinematic MRI of the ankle to evaluate subluxation of the peroneal tendons. A special device was used to perform incremental, passive positioning of the ankle from dorsiflexed to plantarflexed positions for the kinematic MRI examination. A fast spoiled gradient-recalled acquisition in the steady state pulse sequence was used to obtain axial images to assess the peroneal tendons during different positions of the ankle. Seven asymptomatic volunteers and five patients with suspected peroneal tendon subluxation were studied. There was no transverse displacement of the peroneal tendons observed in the asymptomatic subjects nor in two of the patients. Two patients had peroneal tendon subluxation observed on the kinematic MRI studies, and one patient had the peroneal tendons maintained in a displaced position in all ankle positions. The preliminary results suggest that kinematic MRI of the ankle is a potentially useful technique to facilitate evaluation of patients with suspected subluxation of the peroneal tendons, particularly in instances in which subluxation is position-dependent, and spontaneous reduction of the tendons may occur.

Recurrent dislocation of the peroneal tendons

Peroneal tendon dislocations occur in sports, particularly in skiing and soccer. This paper presents the outcome of 15 patients with post-traumatic recurrent peroneal tendon dislocations, operated on with a soft-tissue reconstruction of the superior peroneal retinaculum, i.e. reattachment and reinforcement, in combination with a retrofibular groove deepening. Mean follow-up was 3.5 (2-7) years after surgery. There were no redislocations and no neurovascular injuries. The functional results were satisfactory in 13/15 (87%) patients, with full range of ankle motion and no pain. The two patients with unsatisfactory functional results had restricted ankle motion and pain on exertion. This simple reconstruction seems to be a good alternative to other more complex procedures and can be recommended in patients with recurrent peroneal tendon dislocations. Conservative treatment is not an option in patients with recurrent peroneal tendon dislocations, due to persistent symptoms of instability and pain.

Calcification of the tibialis posterior tendon: a case report and literature review

The tibialis posterior muscle and tendon are subject to a number of pathological conditions and injuries that have recently received much attention in the literature. Because of its function as a main stabilizer of the subtalar complex against hindfoot valgus and forefoot pronation, the mechanical demand on the posterior tibial tendon is high. Problems with dislocation, tenosynovitis, rupture, and laceration have all been described with this tendon. In this report, we present a case of dysfunction of the posterior tibial tendon associated with chronic tendinitis and intratendinous calcifications. After removal of the calcifications, the patient became asymptomatic and returned to work. Proposed etiologies of these calcifications are discussed.

Traumatic focal posterior tibialis muscle denervation

The purpose of this case presentation is to demonstrate posterior tibialis muscle (PTM) denervation as a cause of traumatic plantarflexion inversion weakness. In a 42-year-old woman, severe pain, swelling, and ecchymosis over the medial aspect of her left ankle developed after she twisted it while playing tennis. Plantarflexion inversion weakness developed (grade 3/5). The strength of all other muscle groups of the lower extremity was normal. Her pin and light touch sensation were normal in the left lower extremity. Deep tendon reflexes were equal and active at both knees and ankles. A magnetic resonance image of the left leg, ankle, and foot performed 1 month after injury demonstrated an intact posterior tibialis tendon behind the medial malleolus and edema-like increased signal intensity in the PTM on the T1-weighted image consistent with denervation. On electromyographic testing, there were continuous fibrillation and positive sharp wave potentials in every site tested in the PTM without any voluntary motor unit activity. The left extensor hallucis, left gastrocnemius, and lumbar paraspinal muscles were normal. In conclusion, combined magnetic resonance imaging and electromyographic studies supported denervation of the PTM as the cause of plantarflexion inversion weakness, rather than posterior tibialis tendon rupture in this patient.

MRI of the ankle and hindfoot

MRI of the ankle and hindfoot has become a widely used diagnostic test. The major indications for MRI of this region are disorders of tendons and bones. Avascular necrosis is common in the foot, usually seen after talus fractures or spontaneously in the metatarsal heads. Other causes of a marrow edema pattern include occult fractures, arthritic disorders, reactions to altered biomechanics, osteomyelitis, and regional migratory osteoporosis. The most frequently diseased tendons in the ankle are the Achilles, posterior tibial, and peroneal. MRI can be used to diagnose most disorders of these tendons, as well as stage these disorders to allow appropriate therapy. Most of these tendon disorders follow a recognized sequence of progression using the Achilles tendon as a model.

Evaluation of abnormal biomechanics of the foot and ankle in athletes

Athletes often suffer from recurrent or chronic overuse symptoms of the lower extremities. During the office visit it is essential to analyse the patient's shoes, gait cycle, lower extremities and, especially, the talocrural, subtalar and more distal joints of the ankle and foot. The basic (clinical) biomechanical analysis can be supplemented by radiographs, treadmill and video analysis and mirror table (podoscope) examinations. Ideally, successful pain relief by correction of the observed abnormality with an orthotic device completes the diagnostic procedure, especially if symptoms return soon after the removal of the device. In treatment custom-made, expensive orthotics should not be prescribed for overuse symptoms without an obvious malalignment, for asymptomatic athletes with a malalignment, or for symptoms in which the causal relationship between the biomechanical abnormality and symptoms is difficult to see. Strict indications for prescription of orthotics and close cooperation between the attending physician, physical therapist and orthotist are prerequisites for obtaining good, long-lasting results.

Chronic tendinitis: pathomechanics of injury, factors affecting the healing response, and treatment

This paper is adapted from: Gross MT: Tendinitis. In: Prentice W, Hooker DN (eds), Postgraduate Advances in Sports Physical Therapy, I-III, pp 1-14. Berryville, VA: Forum Medicum, Inc., 1990. Figures and segments of text in this paper are reprinted with permission of Forum Medicum, Inc. Chronic tendinitis is a common and debilitating musculoskeletal pathology that can be particularly recalcitrant to treatment. Details of the composition and structure of tendon are presented, enabling clinicians to understand the mechanical function of tendon under different loading conditions and the various mechanisms of tendinitis injury. The effects of exercise, disuse, the incidence of injury, and tendinitis terminology are discussed. Other purposes of this paper are to describe the natural course of tendon healing, the clinical assessment of tendinitis, and suggested treatments for chronic tendinitis. The paper concludes with two case studies. Information in this paper should assist the clinician in treating chronic tendinitis more successfully. J Orthop Sports Phys Ther 1992;16(6):248-261.