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Martínez-Sañudo B, Lopezosa-Reca E, Vallejo-Márquez M, Fornell S, Martínez-Franco A, Tejero S. Ultrasound assessment of the spring ligament and posterior tibial tendon in healthy subjects: A descriptive study. J Tissue Viability 2024; 33:481-486. [PMID: 38806377 DOI: 10.1016/j.jtv.2024.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 05/03/2024] [Accepted: 05/15/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND The main aim of this study was to ultrasonographically analyse the thickness and the relationship between the Superomedial Bundle of the Spring Ligament and the Posterior Tibial Tendon in healthy subjects and its relationship with different epidemiological variables. METHODS Fifty-five healthy feet with a mean of 47 years old measuring the same ultrasound model and researcher. Demographic variables (age, sex, laterality, BMI, type of sports activity performed, and type of work activity) were collected from all participants. The thickness of the PTT and the Spring Ligament was measured in both longitudinal and transverse diameters. The intraclass correlation coefficient (ICC) was also analysed to assess the agreement of the measurements between a researcher and the ultrasound specialist radiologist. RESULTS The mean thickness of the Spring ligament was 5.07 mm (95 % CI 4.75-5.38), while that of the PTT in its long axis was 3.58 mm (95 % CI 3.37-3.79). Regarding the interobserver agreement analysis, the intraclass correlation coefficient for measurements between observers was 0.91 (CI95 %: 0.698-0.977) which denotes a high degree of similarity between the clinician and the radiologist. CONCLUSION This study describes the relationships between the thickness of the posterior tibial tendon and the superomedial Bundle of the Spring ligament in healthy subjects, as well as their variability according to certain epidemiological variables such as age, gender, occupation, and sport. On the other hand, the measurements taken by a researcher high agreement with those taken by a radiologist specialized in ultrasound.
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Affiliation(s)
- Beatriz Martínez-Sañudo
- Department of Orthopaedic Surgery, Hospital Universitario Virgen del Rocío, Manuel Siurot s/n 41013, Sevilla, Spain.
| | - Eva Lopezosa-Reca
- Department Nursing and Podiatry, Faculty of Health Sciences, University of Málaga. Málaga, Spain.
| | - Mercedes Vallejo-Márquez
- Department of Radiology, Hospital Universitario Virgen del Rocío, Manuel Siurot s/n 41013, Sevilla, Spain.
| | - Salvador Fornell
- Department of Orthopaedic Surgery, Hospital Universitario Virgen del Rocío, Manuel Siurot s/n 41013, Sevilla, Spain.
| | | | - Sergio Tejero
- Department of Orthopaedic Surgery, Hospital Universitario Virgen del Rocío, Manuel Siurot s/n 41013, Sevilla, Spain.
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Bruni DF, Pierson SR, Sarwar F, Ring D, Ramtin S. Are the Pathologic Features of Enthesopathy, Tendinopathy, and Labral and Articular Disc Disease Related to Mucoid Degeneration? A Systematic Review. Clin Orthop Relat Res 2023; 481:641-650. [PMID: 36563131 PMCID: PMC10013668 DOI: 10.1097/corr.0000000000002499] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 10/31/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Tendinopathy, enthesopathy, labral degeneration, and pathologic conditions of the articular disc (knee meniscus and ulnocarpal) are sometimes described in terms of inflammation or damage, while the histopathologic findings are often consistent with mucoid degeneration. A systematic review of the histopathology of these structures at diverse locations might reconceptualize these diseases as expected aspects of human aging. The potential benefits of this evolution might include healthier patient and clinician mindsets as well as a reduced likelihood of overdiagnosis and overtreatment resulting from greater awareness of base rates of pathology. QUESTION/PURPOSE In this systematic review of studies of surgical specimens, we asked: Are there are any differences in the histopathologic findings of structural soft tissue conditions (mucoid degeneration, inflammation, and vascularity) by anatomic site (foot, elbow, or knee) or structure (tendon body, muscle or tendon origin or insertion [enthesis], labrum, or articular disc)? METHODS Studies between 1980 and 2021 investigating the histopathologic findings of specimens from surgery for trigger digit, de Quervain tendinopathy, plantar fasciitis, lateral and medial elbow enthesopathy, rotator cuff tendinopathy, posterior tibial tendinopathy, patellar tendinopathy, Achilles tendinopathy, or disease of the hip labrum, ulnocarpal articular disc, or knee meniscus were searched for in the PubMed, EMBASE, and CINAHL databases. Inclusion criteria were the prespecified anatomic location or structure being analyzed histologically and any findings described with respect to inflammation, vascularity, or mucoid degeneration. Studies were excluded if they were nonhuman studies or review articles. Search terms included "anatomy," "pathology," and "histopathology." These terms were coupled with anatomic structures or disorders and included "trigger finger," "de Quervain," "fasciitis, plantar," "tennis elbow," "rotator cuff tendinopathy," "elbow tendinopathy," "patellar tendonitis," "posterior tibial tendon," and "triangular fibrocartilage." This resulted in 3196 studies. After applying the inclusion criteria, 559 articles were then assessed for eligibility according to our exclusion criteria, with 52 eventually included. We recorded whether the study identified the following histopathologic findings: inflammatory cells or molecular markers, greater than expected vascularity (categorized as quantitative count, with or without controls; molecular markers; or qualitative judgments), and features of mucoid degeneration (disorganized collagen, increased extracellular matrix, or chondroid metaplasia). In the absence of methods for systematically evaluating the pathophysiology of structural (collagenous) soft tissue structures and rating histopathologic study quality, all studies that interpreted histopathology results were included. The original authors' judgment regarding the presence or absence of inflammation, greater than expected vascularity, and elements of mucoid degeneration was recorded along with the type of data used to reach that conclusion. RESULTS Regarding differences in the histopathology of surgical specimens of structural soft tissue conditions by anatomic site, there were no differences in inflammation or mucoid degeneration, and the knee meniscus was less often described as having greater than normal vascularity. There were no differences by anatomic structure. Overall, 20% (10 of 51) of the studies that investigated for inflammation reported it (nine inflammatory cells and one inflammatory marker). Eighty-three percent (43 of 52) interpreted increased vascularity: 40% (17 of 43) using quantitative methods (14 with controls and three without) and 60% (26 of 43) using imprecise criteria. Additionally, 100% (all 52 studies) identified at least one element of mucoid degeneration: 69% (36 of 52) reported an increased extracellular matrix, 71% (37 of 52) reported disorganized collagen, and 33% (17 of 52) reported chondroid metaplasia. CONCLUSION Our systematic review of the histopathology of diseases of soft tissue structures (enthesopathy, tendinopathy, and labral and articular disc) identified consistent mucoid degeneration, minimal inflammation, and imprecise assessment of relative vascularity; these findings were consistent across anatomic sites and structures, supporting a reconceptualization of these diseases as related to aging (senescence or degeneration) rather than injury or activity. CLINICAL RELEVANCE This reconceptualization supports accommodative mindsets known to be associated with greater comfort and capability. In addition, awareness of the notable base rates of structural soft tissue changes as people age might reduce overdiagnosis and overtreatment of incidental, benign, or inconsequential signal changes and pathophysiology.
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Affiliation(s)
- David F. Bruni
- Department of Surgery and Perioperative Care, Dell Medical School, the University of Texas at Austin, Austin, TX, USA
| | - S. Ryan Pierson
- Department of Surgery and Perioperative Care, Dell Medical School, the University of Texas at Austin, Austin, TX, USA
| | - Faiza Sarwar
- Department of Surgery and Perioperative Care, Dell Medical School, the University of Texas at Austin, Austin, TX, USA
| | - David Ring
- Department of Surgery and Perioperative Care, Dell Medical School, the University of Texas at Austin, Austin, TX, USA
| | - Sina Ramtin
- Department of Surgery and Perioperative Care, Dell Medical School, the University of Texas at Austin, Austin, TX, USA
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Henry JK, Hoffman J, Kim J, Steineman B, Sturnick D, Demetracopoulos C, Deland J, Ellis S. The Foot and Ankle Kinematics of a Simulated Progressive Collapsing Foot Deformity During Stance Phase: A Cadaveric Study. Foot Ankle Int 2022; 43:1577-1586. [PMID: 36259688 DOI: 10.1177/10711007221126736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Progressive collapsing foot deformity (PCFD) is a complex pathology associated with tendon insufficiency, ligamentous failure, joint malalignment, and aberrant plantar force distribution. Existing knowledge of PCFD consists of static measurements, which provide information about structure but little about foot and ankle kinematics during gait. A model of PCFD was simulated in cadavers (sPCFD) to quantify the difference in joint kinematics and plantar pressure between the intact and sPCFD conditions during simulated stance phase of gait. METHODS In 12 cadaveric foot and ankle specimens, the sPCFD condition was created via sectioning of the spring ligament and the medial talonavicular joint capsule followed by cyclic axial compression. Specimens were then analyzed in intact and sPCFD conditions via a robotic gait simulator, using actuators to control the extrinsic tendons and a rotating force plate underneath the specimen to mimic the stance phase of walking. Force plate position and muscle forces were optimized using a fuzzy logic iterative process to converge and simulate in vivo ground reaction forces. An 8-camera motion capture system recorded the positions of markers fixed to bones, which were then used to calculate joint kinematics, and a plantar pressure mat collected pressure distribution data. Joint kinematics and plantar pressures were compared between intact and sPCFD conditions. RESULTS The sPCFD condition increased subtalar eversion in early, mid-, and late stance (P < .05), increased talonavicular abduction in mid- and late stance (P < .05), and increased ankle plantarflexion (P < .05), adduction (P < .05), and inversion (P < .05). The center of plantar pressure was significantly (P < .01) medialized in this model of sPCFD and simulated stance phase of gait. DISCUSSION Subtalar and talonavicular joint kinematics and plantar pressure distribution significantly changed with the sPCFD and in the directions expected from a PCFD foot. We also found that ankle joint kinematics changed with medial and plantar drift of the talar head, indicating abnormal talar rotation. Although comparison to an in vivo PCFD foot was not performed, this sPCFD model produced changes in foot kinematics and indicates that concomitant abnormal changes may occur at the ankle joint with PCFD. CLINICAL RELEVANCE This study describes the dynamic kinematic and plantar pressure changes in a cadaveric model of simulated progressive collapsing foot deformity during simulated stance phase.
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Affiliation(s)
- Jensen K Henry
- Foot & Ankle Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Jeffrey Hoffman
- Biomechanics, Hospital for Special Surgery, New York, NY, USA
| | - Jaeyoung Kim
- Foot & Ankle Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Brett Steineman
- Biomechanics, Hospital for Special Surgery, New York, NY, USA
| | - Daniel Sturnick
- Biomechanics, Hospital for Special Surgery, New York, NY, USA
| | | | - Jonathan Deland
- Foot & Ankle Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Scott Ellis
- Foot & Ankle Surgery, Hospital for Special Surgery, New York, NY, USA
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Histologic grading correlates with inflammatory biomarkers in tibialis posterior tendon dysfunction. Foot Ankle Surg 2022; 28:1266-1271. [PMID: 35667952 DOI: 10.1016/j.fas.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 04/17/2022] [Accepted: 05/23/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND It has been theorized that tibialis posterior tendon dysfunction (TPTD) is a degenerative process unrelated to inflammation. The purpose of this study was to determine if inflammatory cytokines, matrix metalloproteases (MMPs), and glutamate were elevated in diseased tibialis posterior tendons (TPTs). METHODS Matched diseased TPT, TPT insertion, and flexor digitorum longus (FDL) samples were collected from 21 patients. The samples were individually incubated in media, which was analyzed for inflammatory cytokines, MMPs, and glutamate. Histology and statistical analyses were performed. RESULTS Diseased TPT and TPT insertion were significantly elevated compared to transferred FDL in eight inflammatory markers (p < 0.005). Only the diseased TPT was significantly elevated compared to the transferred FDL tendons for glutamate (p < 0.01). Histologic grading correlated with inflammatory cytokine levels. CONCLUSION Diseased TPT and TPT insertion demonstrated significantly elevated levels of inflammatory markers compared to the transferred tendons used as controls, suggesting a role for inflammation in the disease process. The amount of inflammation correlated with increased tendon degradation. LEVEL OF EVIDENCE Level III.
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Histoarchitecture of the fibrillary matrix of human fetal posterior tibial tendons. Sci Rep 2022; 12:17922. [PMID: 36289254 PMCID: PMC9606372 DOI: 10.1038/s41598-022-19695-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 09/02/2022] [Indexed: 01/20/2023] Open
Abstract
Adult tendons are highly differentiated. In mature individuals, tendon healing after an injury occurs through fibrotic tissue formation. Understanding the intrinsic reparative properties of fetal tendons would help to understand the maturation tissue process and tendon tissue repair. The present study evaluated the evolution of histoarchitecture, cellularity and the distribution of collagens I, III and V in the posterior tibial tendon in human fetuses at different gestational ages. Morphological profiles were assessed in nine fresh spontaneously aborted fetuses (Group I: five fetuses aged between 22 and 28 weeks of gestation; Group II: four fetuses aged between 32 and 38 weeks of gestation), characterized by a combination of histology, fluorescence and immunohistochemistry. In Group I, the posterior tibial tendon showed statistically significant greater cellularity and presence of collagen III and V than in Group II tendon, which showed a predominance of collagenous I and a better organization of the extracellular matrix compared with Group I tendons. In addition, a statistically significant higher rate of CD90, a marker of mesenchymal cells, was found in Group I tendons. In fetuses with gestational age between 22 and 28 weeks, the posterior tibialis tendons showed a thin and disorganized fibrillar structure, with an increase in collagen III and V fibers and mesenchymal cells. In the posterior tibialis tendons of fetuses with gestational age between 32 and 38 weeks, the fibrillar structure was thicker with a statistically significant increase in type I collagen and decreased cellularity.
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Soft Tissue Reconstruction and Osteotomies for Pes Planovalgus Correction. Clin Podiatr Med Surg 2022; 39:207-231. [PMID: 35365324 DOI: 10.1016/j.cpm.2021.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The correction of the flexible pes planovalgus foot and ankle is a complicated and somewhat controversial topic. After conservative methods fail, there is a wide range of possible soft tissue and bony procedures. The appropriate work up and understanding of the pathomechanics are vital to the correct choice of procedures to correct these deformities. Once the work up and procedure selection are done, the operation must also be technically performed well and with efficiency, as most often the condition is corrected with a variety of procedures. This article discusses some of the most common procedures necessary to fully correct the pes planovalgus foot and discusses the authors' technique and pearls.
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Park JH, Kim D, Kwon HW, Lee M, Choi YJ, Park KR, Youn KH, Cho J. A New Anatomical Classification for Tibialis Posterior Tendon Insertion and Its Clinical Implications: A Cadaveric Study. Diagnostics (Basel) 2021; 11:diagnostics11091619. [PMID: 34573961 PMCID: PMC8466387 DOI: 10.3390/diagnostics11091619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 08/27/2021] [Accepted: 09/01/2021] [Indexed: 11/18/2022] Open
Abstract
The variations in the tibialis posterior tendon (TPT) could not be defined by previous classification; thus, this study used a larger-scale cadaver with the aim to classify the types of TPT insertion based on the combination of the number and location of TPT insertions. A total of 118 feet from adult formalin-fixed cadavers were dissected (68 males, 50 females). The morphological characteristics and measurements of TPT insertion were evaluated. Four types of TPT insertions were classified, wherein the most common type was type 4 (quadruple insertions, 78 feet, 66.1%), which was divided into four new subtypes that were not defined in the previous classification. The second most common type was type 3 (triple insertions, 25 feet, 21.2%) with three subtypes, including the new subtype. Type 2 was found in 13 feet (11%), and the rarest type was type 1 (2 feet, 1.7%), wherein the main tendon was only attached to the navicular bone and the medial cuneiform bone. We suggest high morphological variability of the TPT in relation to the insertion location, along with the possibility of significant differences according to race and gender. Moreover, this classification will help clinicians understand adult flatfoot deformity-related posterior tibial tendon dysfunction (PTTD).
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Affiliation(s)
- Jeong-Hyun Park
- Department of Anatomy & Cell Biology, School of Medicine, Kangwon National University, Chuncheon 24341, Korea; (J.-H.P.); (D.K.); (H.-W.K.); (M.L.); (Y.-J.C.)
| | - Digud Kim
- Department of Anatomy & Cell Biology, School of Medicine, Kangwon National University, Chuncheon 24341, Korea; (J.-H.P.); (D.K.); (H.-W.K.); (M.L.); (Y.-J.C.)
| | - Hyung-Wook Kwon
- Department of Anatomy & Cell Biology, School of Medicine, Kangwon National University, Chuncheon 24341, Korea; (J.-H.P.); (D.K.); (H.-W.K.); (M.L.); (Y.-J.C.)
| | - Mijeong Lee
- Department of Anatomy & Cell Biology, School of Medicine, Kangwon National University, Chuncheon 24341, Korea; (J.-H.P.); (D.K.); (H.-W.K.); (M.L.); (Y.-J.C.)
| | - Yu-Jin Choi
- Department of Anatomy & Cell Biology, School of Medicine, Kangwon National University, Chuncheon 24341, Korea; (J.-H.P.); (D.K.); (H.-W.K.); (M.L.); (Y.-J.C.)
| | - Kwang-Rak Park
- Department of Anatomy, School of Medicine, Keimyung University, Daegu 42601, Korea;
| | - Kwan Hyun Youn
- Division in Biomedical Art, Incheon Catholic University Graduate School, Incheon 21987, Korea;
| | - Jaeho Cho
- Department of Orthopaedic Surgery, Chuncheon Sacred Heart Hospital, Hallym University, Chuncheon 24253, Korea
- Correspondence:
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Willegger M, Seyidova N, Schuh R, Windhager R, Hirtler L. The tibialis posterior tendon footprint: an anatomical dissection study. J Foot Ankle Res 2020; 13:25. [PMID: 32430082 PMCID: PMC7236122 DOI: 10.1186/s13047-020-00392-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 05/08/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The tibialis posterior tendon (TPT) is the main dynamic stabilizer of the medial longitudinal arch of the foot. Especially in adult acquired flatfoot deformity (AAFD) the TPT plays a detrimental role. The pathology and function of the tendon have been extensively investigated, but knowledge of its insertional anatomy is paramount for surgical procedures. This study aimed to analyze the complex distal footprint anatomy of the TPT. METHODS Forty-one human anatomical specimens were dissected and the distal TPT was followed to its bony footprints. After tendon removal the footprints were marked with ink. Standardized photographs were taken and consecutively analyzed by digital imaging measurements. Footprint length, width, area of insertion, location, and shape was studied regarding the main insertion at the navicular bone. RESULTS All specimens had the main TPT insertion at the navicular bone (41/41, 100%). Sixty-three percent of navicular TPT insertions were located at the plantar aspect. The mean navicular footprint measured 12.1 mm × 6.9 mm in length and width, respectively. The tendon further spread into several slips which anchored the tibialis posterior deep in the plantar arch. TPT insertions were highly variable with an involvement of up to eight distinct bony footprints in the mid- and hindfoot. The second most common additional footprint was the lateral cuneiform (93% of dissected feet), followed by the medial cuneiform (80%), the metatarsal bases [1-5] (80%), the cuboid (46%), the intermediate cuneiform (19%), and the calcaneus (12%). CONCLUSIONS The present study adds to current knowledge on the footprint anatomy of the TPT. Based on the findings of this study we advocate a plantar location of flexor digitorum longus tendon transfer in flexible AAFD in order to restore the anatomical lever and insertion of the TPT.
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Affiliation(s)
- Madeleine Willegger
- Department of Orthopedics and Trauma Surgery, Division of Orthopedics, Medical University of Vienna, Waehringer Guertel, 18-20 1090, Vienna, Austria.
| | - Nargiz Seyidova
- Department of Orthopedics and Trauma Surgery, Division of Orthopedics, Medical University of Vienna, Waehringer Guertel, 18-20 1090, Vienna, Austria
| | - Reinhard Schuh
- Department of Orthopedics and Trauma Surgery, Division of Orthopedics, Medical University of Vienna, Waehringer Guertel, 18-20 1090, Vienna, Austria
| | - Reinhard Windhager
- Department of Orthopedics and Trauma Surgery, Division of Orthopedics, Medical University of Vienna, Waehringer Guertel, 18-20 1090, Vienna, Austria
| | - Lena Hirtler
- Center for Anatomy and Cell Biology, Division of Anatomy, Medical University of Vienna, Vienna, Austria
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Abstract
Adult-acquired flatfoot deformity (AAFD) comprises a wide spectrum of ligament and tendon failure that may result in significant deformity and disability. It is often associated with posterior tibial tendon deficiency (PTTD), which has been linked to multiple demographic factors, medical comorbidities, and genetic processes. AAFD is classified using stages I through IV. Nonoperative treatment modalities should always be attempted first and often provide resolution in stages I and II. Stage II, consisting of a wide range of flexible deformities, is typically treated operatively with a combination of soft tissue procedures and osteotomies. Stage III, which is characterized by a rigid flatfoot, typically warrants triple arthrodesis. Stage IV, where the flatfoot deformity involves the ankle joint, is treated with ankle arthrodesis or ankle arthroplasty with or without deltoid ligament reconstruction along with procedures to restore alignment of the foot. There is limited evidence as to the optimal procedure; thus, the surgical indications and techniques continue to be researched.
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Affiliation(s)
- Jensen K. Henry
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Rachel Shakked
- Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, PA, USA
| | - Scott J. Ellis
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
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Sirlyn Q. Ultrasound evaluation of adult-acquired flatfoot deformity: Emphasis on the involvement of spring ligament. Australas J Ultrasound Med 2017; 20:83-90. [PMID: 34760477 PMCID: PMC8409874 DOI: 10.1002/ajum.12050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Adult-acquired flatfoot deformity (AAFD), a condition commonly caused by tibialis posterior tendon (TPT) dysfunction, has recently been recognised to encompass a spectrum of other deformities, including the disruption of the spring ligament complex. This case series reviews eight examples of chronic AAFD, outlines the sonographic assessment of the TPT and spring ligament and depicts various abnormalities of the TPT and spring ligament that are relevant to AAFD. The importance to always include the spring ligament during the assessment of AAFD will be addressed, as misdiagnosis of the involvement of the spring ligament could lead to inappropriate operative management.
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Abstract
BACKGROUND Posterior tibial tendinopathy (PTT) is the most common cause of acquired (progressive) flatfoot deformity in adults. To date, PTT research has mainly focused on management rather than on causal mechanisms. The etiology of PTT is likely to be multifactorial because both intrinsic and extrinsic risk factors have been reported. We sought to critically evaluate reported etiologic factors for PTT and consider the concept of genetic risk factors. METHODS A detailed review of the literature published after 1936 was undertaken using English-language medical databases. RESULTS No clear consensus exists as to the relative importance of the risk factors reported, and neither has any consideration been given to a possible genetic basis for PTT. CONCLUSIONS To date, studies have examined various intrinsic and extrinsic risk factors implicated in the etiology of PTT. The interaction of these factors with an individual's genetic background may provide valuable data and help offer a more complete risk profile for PTT. A properly constructed genetic association study to determine the genetic basis of PTT would provide a novel and alternative approach to understanding this condition.
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Affiliation(s)
- Paul Beeson
- Division of Podiatry, The University of Northampton, Park Campus, Boughton Green Road, Northampton, Northamptonshire, NN2 7AL, England. (E-mail: )
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12
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Abstract
BACKGROUND Posterior tibial tendon dysfunction is a common cause of adult acquired flatfoot deformity. The cause of posterior tibial tendon dysfunction is often multifactorial and may include repetitive microtrauma, poor blood supply to the tendon, and, rarely, traumatic rupture. CASE DESCRIPTION We present the case of a 69-year-old male with posterior tibial tendon dysfunction secondary to a stingray injury that occurred directly into the posterior tibial tendon. This injury led to an acquired adult flatfoot deformity that ultimately required surgical reconstruction. At the time of surgery, the posterior tibial tendon was severely degenerative at the site of skin penetration. LITERATURE REVIEW Previous case reports of stingray injury describe full-thickness skin penetration with a subsequent inflammatory response and large zone of necrobiosis. This is the first reported case of stingray trauma and envenomation directly into tendon with subsequent tendon dysfunction. CLINICAL RELEVANCE There are thousands of stingray injuries in the United States annually. Injuries vary in severity depending on the type of stingray, size of stingray, and depth and location of injury. For certain injuries, such as direct penetration into tendon, early irrigation and debridement may limit subsequent deficits caused by progressive tendon dysfunction. LEVELS OF EVIDENCE Therapeutic, Level IV: Case study.
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Affiliation(s)
- Dustin Hambright
- Department of Orthopaedics, Brigham and Women's Hospital, Boston, Massachusetts
| | - Daniel Guss
- Department of Orthopaedics, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jeremy T Smith
- Department of Orthopaedics, Brigham and Women's Hospital, Boston, Massachusetts
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Maskill JT, Pomeroy GC. Flexor Digitorum Longus Tendon Transfer and Modified Kidner Technique in Posterior Tibial Tendon Dysfunction. Clin Podiatr Med Surg 2016; 33:15-20. [PMID: 26590720 DOI: 10.1016/j.cpm.2015.06.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The modified Kidner procedure and flexor digitorum longus tendon transfer are common procedures used today when addressing posterior tibial tendon dysfunction. These techniques are often used in conjunction with a combination of osteotomies to correct flatfoot deformity, and have been proved to be reliable and predictable.
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Affiliation(s)
- James T Maskill
- Orthopaedic Associates of Kalamazoo, 3810 Center Avenue, Portage, MI 49024, USA.
| | - Gregory C Pomeroy
- University of New England, 195 Fore River Parkway Suite 210, Portland, ME 04102, USA
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Yao K, Yang TX, Yew WP. Posterior Tibialis Tendon Dysfunction: Overview of Evaluation and Management. Orthopedics 2015; 38:385-91. [PMID: 26091214 DOI: 10.3928/01477447-20150603-06] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Accepted: 04/30/2014] [Indexed: 02/03/2023]
Abstract
EDUCATIONAL OBJECTIVES As a result of reading this article, physicians should be able to: 1. Recognize posterior tibialis tendon dysfunction and begin to include it in differential diagnoses. 2. Recall the basic anatomy and pathology of the posterior tibialis tendon. 3. Assess a patient for posterior tibialis tendon dysfunction with the appropriate investigations and stratify the severity of the condition. 4. Develop and formulate a treatment plan for a patient with posterior tibialis tendon dysfunction. The posterior tibialis is a muscle in the deep posterior compartment of the calf that plays several key roles in the ankle and foot. Posterior tibialis tendon dysfunction is a complex but common and debilitating condition. Degenerative, inflammatory, functional, and traumatic etiologies have all been proposed. Despite being the leading cause of acquired flatfoot, it is often not recognized early enough. Knowledge of the anatomical considerations and etiology of posterior tibialis tendon dysfunction, as well as key concepts in its evaluation and management, will allow health care professionals to develop appropriate intervention strategies to prevent further development of flatfoot deformities.
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Manske MC, McKeon KE, Johnson JE, McCormick JJ, Klein SE. Arterial anatomy of the tibialis posterior tendon. Foot Ankle Int 2015; 36:436-43. [PMID: 25411117 DOI: 10.1177/1071100714559271] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Tibialis posterior tendon dysfunction is a common disorder leading to pain, deformity, and disability, although its pathogenesis is unclear. A vascular etiology has been proposed, but there is controversy regarding the existence of a hypovascular region that may render the tendon vulnerable. The purpose of this study was to provide a description of the arterial anatomy supplying the tibialis posterior tendon. METHODS Sixty adult cadaveric lower extremities were obtained from a university-affiliated body donation program. Thirty specimens obtained within 72 hours of death were used for microscopic analysis. Thirty specimens were previously frozen and used for macroscopic analysis. The tibialis anterior, tibialis posterior, and peroneal arteries were injected with India Ink and Ward's Blue Latex. The specimens used for macroscopic analysis were debrided with sodium hypochlorite to expose the extratendinous anatomy. For the microscopic analysis, the tendon was cleared using a modified Spälteholz technique to expose the intratendinous vascular anatomy. RESULTS Macroscopically, an average of 2.5 ± 0.7 vessels entered the tendon proximal to the navicular insertion. In all, 28/30 (93.3%) specimens had a vessel entering 4.1 ± 0.6 cm proximal to the medial malleolus and 24/30 (80.0%) specimens had a vessel entering 1.7 ± 0.9 cm distal to the medial malleolus. Microscopically, an average of 1.9 ± 0.3 vessels entered each tendon proximal to the navicular insertion. In total, 27/30 (90%) specimens had a vessel entering the tendon 4.8 ± 0.8 cm proximal to the medial malleolus and 30/30 (100%) specimens had a vessel entering the tendon 1.9 ± 0.8 cm distal to the medial malleolus. In all specimens, a hypovascular region was observed, starting 2.2 ± 0.8 cm proximal to the medial malleolus and ending 0.6 ± 0.6 cm proximal to the medial malleolus with an average length of 1.5 ± 1.0 cm. The insertion of the tendon was well vascularized both on microscopic and macroscopic specimens. CONCLUSION The tibialis posterior tendon was supplied by 2 vessels entering the tendon approximately 4.5 cm proximal and 2.0 cm distal to the medial malleolus. A retromalleolar hypovascular region was observed. CLINICAL RELEVANCE Improved understanding of the vascularity of the tibialis posterior tendon may be helpful in clinical practice and potentially provides a basis for further evaluation of the causative factors of tibialis posterior tendinopathy.
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Affiliation(s)
- Mary Claire Manske
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | | | - Jeffrey E Johnson
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Jeremy J McCormick
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Sandra E Klein
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO, USA
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Bubra PS, Keighley G, Rateesh S, Carmody D. Posterior tibial tendon dysfunction: an overlooked cause of foot deformity. J Family Med Prim Care 2015; 4:26-9. [PMID: 25810985 PMCID: PMC4367001 DOI: 10.4103/2249-4863.152245] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Posterior tibial tendon dysfunction is the most common cause of adult acquired flatfoot. Degenerative changes in this tendon, lead to pain and weakness and if not identified and treated will progress to deformity of the foot and degenerative changes in the surrounding joints. Patients will complain of medial foot pain, weakness, and a slowly progressive foot deformity. A “too many toes” sign may be present and patients will be unable to perform a single heal raise test. Investigations such X-ray, ultrasound and magnetic resonance imaging will help stage the disease and decide on management. The optimal manage may change based on the progression of deformity and stage of disease. Early identification and prompt initiation of treatment can halt progression of the disease. The purpose of this article is to examine the causes, signs, symptoms, examinations, investigations and treatment options for posterior tibial tendon dysfunction.
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Affiliation(s)
| | - Geffrey Keighley
- Mona Vale Hospital, 1 Coronation Drive, Mona Vale NSW, Australia
| | - Shruti Rateesh
- Mona Vale Hospital, 1 Coronation Drive, Mona Vale NSW, Australia
| | - David Carmody
- Mona Vale Hospital, 1 Coronation Drive, Mona Vale NSW, Australia
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Sherlock CE, Mair TS, Ireland J, Blunden T. Do low field magnetic resonance imaging abnormalities correlate with macroscopical and histological changes within the equine deep digital flexor tendon? Res Vet Sci 2014; 98:92-7. [PMID: 25555604 DOI: 10.1016/j.rvsc.2014.12.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 11/24/2014] [Accepted: 12/04/2014] [Indexed: 10/24/2022]
Abstract
Correlating magnetic resonance (MR) imaging and histopathological findings is essential to validate low field MR imaging in lame horses. This study aimed to compare signal changes in the deep digital flexor tendon (DDFT) of the distal limb on low field MR imaging with macroscopical and histological findings. Cadaver limbs from lame horses with DDFT lesions were selected. The DDFT MR imaging findings and histopathological results were graded, and macroscopical abnormalities were recorded. There was a strong correlation between MR imaging and histopathology grades (rs = 0.76, p < 0.001) in the foot. There was moderate agreement (Kappa statistic 0.52) between the MR and histopathology grades; agreement was superior further proximal in the foot. The presence and severity of pathology in the DDFT are well represented by the presence and severity of MR imaging signal changes. The study supports the use of low field MR imaging for diagnosis of equine distal limb DDFT lesions.
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Affiliation(s)
- C E Sherlock
- Bell Equine Veterinary Clinic, Mereworth, Kent ME18 5GS, UK.
| | - T S Mair
- Bell Equine Veterinary Clinic, Mereworth, Kent ME18 5GS, UK
| | - J Ireland
- Animal Health Trust, Lanwades Park, Kentford, Newmarket, Suffolk CB8 7UU, UK
| | - T Blunden
- Animal Health Trust, Lanwades Park, Kentford, Newmarket, Suffolk CB8 7UU, UK
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18
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Abstract
Adult acquired flatfoot deformity is generally associated with a collapsing medial longitudinal arch and progressive loss of strength of the tibialis posterior tendon. It is most commonly associated with posterior tibial tendon dysfunction that can have an arthritic or traumatic cause. With an increasing population of obese patients, the often misdiagnosed and overlooked posterior tibial tendon dysfunction will only continue to present more often in the foot and ankle specialist's office. This article focuses on the anatomy, classification, and pathomechanics of the flexible adult flatfoot.
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Affiliation(s)
- Jeremy L Walters
- West Houston Medical and Surgical Residency Program PMSR/RRA, West Houston Medical Center, 12121 Richmond Avenue, Suite 417, Houston, TX 77082, USA.
| | - Samuel S Mendicino
- West Houston Medical and Surgical Residency Program PMSR/RRA, West Houston Medical Center, 12121 Richmond Avenue, Suite 417, Houston, TX 77082, USA
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19
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Disfunción del tendón tibial posterior: ¿qué otras estructuras están implicadas en el desarrollo del pie plano adquirido del adulto? RADIOLOGIA 2014; 56:247-56. [DOI: 10.1016/j.rx.2011.12.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2011] [Revised: 10/25/2011] [Accepted: 12/19/2011] [Indexed: 11/18/2022]
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20
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Posterior tibial tendon dysfunction: What other structures are involved in the development of acquired adult flat foot? RADIOLOGIA 2014. [DOI: 10.1016/j.rxeng.2014.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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21
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Abstract
Tendon transfers are critical to successful surgical correction of adult flexible flatfoot deformity and may be beneficial in correcting rigid deformities as well. Patients with refractory stage I and II deformities often require selective osteotomies in addition to tendon transfer. Patients with stage III and IV deformities typically require hindfoot arthrodesis. One of several tendons can be used for transfer based on surgeon's preference. Flexor digitorum longus (FDL) and flexor hallucis longus (FHL) transfers have been shown to have good results. A peroneus brevis transfer is typically used to supplement small FDL or FHL transfer donors or in revision cases.
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Affiliation(s)
- Jonathon D Backus
- Department of Orthopaedic Surgery, Washington University School of Medicine in St Louis, Campus Box 8233, 660 South Euclid Avenue, St Louis, MO 63110, USA
| | - Jeremy J McCormick
- Department of Orthopaedic Surgery, Washington University School of Medicine in St Louis, 14532 South Outer Forty Drive, Suite 210, Chesterfield, MO 63017, USA.
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22
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Singh R, King A, Perera A. Posterior tibial tendon dysfunction: a silent but disabling condition. Br J Hosp Med (Lond) 2012; 73:441-5. [DOI: 10.12968/hmed.2012.73.8.441] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Rahul Singh
- Orthopaedic Department, University Hospital of Wales, Cardiff Heath Hospital, Cardiff CF14 4XW
| | - Amanda King
- Orthopaedic Department, University Hospital of Wales, Cardiff Heath Hospital, Cardiff CF14 4XW
| | - Anthony Perera
- Orthopaedic Department, University Hospital of Wales, Cardiff Heath Hospital, Cardiff CF14 4XW
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23
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Abstract
Patients undergoing surgery for posterior tibial tendon dysfunction may require tendon transfer. The flexor digitorum longus is most commonly transferred, although the flexor hallucis longus and peroneus brevis have also been described in the literature. This article discusses the advantages and disadvantages of the different tendons, the surgical techniques used to perform them, and their results in the literature, concentrating principally on studies in which additional bone procedures were not performed. This article will also discuss the potential role for isolated soft tissue procedures in the treatment of stage 2 posterior tibial tendon dysfunction.
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Affiliation(s)
- Michael S Aronow
- Department of Orthopaedic Surgery, University of Connecticut School of Medicine, Medical Arts and Research Building, 263 Farmington Avenue, Farmington, CT 06034-4037, USA.
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24
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Abstract
Every alternative to triple arthrodesis in the rigid acquired flatfoot deformity is predicated on limiting the patient exposure to the complication associated with triple arthrodesis. When possible, avoiding arthrodesis of either the talonavicular and calcaneocuboid joints, with their higher nonunion rates, seems a cogent option. Successful treatment is dependent on thoughtful patient evaluation and examination, meticulous joint preparation, careful positioning with rigid fixation, and judicious use of adjunctive procedures to achieve the goal of a plantigrade foot that functions well and is minimally painful.
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25
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Corps AN, Robinson AHN, Harrall RL, Avery NC, Curry VA, Hazleman BL, Riley GP. Changes in matrix protein biochemistry and the expression of mRNA encoding matrix proteins and metalloproteinases in posterior tibialis tendinopathy. Ann Rheum Dis 2012; 71:746-52. [PMID: 22241901 PMCID: PMC3329235 DOI: 10.1136/annrheumdis-2011-200391] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Objectives Adult-acquired flat foot secondary to a dysfunctional posterior tibialis tendon (PTT) is often treated by surgical transfer of the flexor digitorum longus tendon (FDLT). In this study, the authors compared normal PTT, stage II dysfunctional PTT and replacement FDLT, aiming to define changes in collagen modification, glycosaminoglycan (GAG) and the expression of matrix and metalloproteinase mRNA. Methods Normal PTTs were obtained from patients with no history of tendon problems. Samples of dysfunctional PTT and replacement FDLT tissue were obtained from patients undergoing surgical reconstruction. Tissue samples were analysed for total collagen and GAG, pentosidine and collagen cross-links. Total RNA was assayed for mRNA encoding matrix proteins and metalloproteinases, using real-time reverse transcription PCR. Differences between clinical groups were assessed using non-parametric statistics. Results Dysfunctional PTT contained higher levels of GAG and lower levels of pentosidine than normal PTT or FDLT. In contrast, collagen in FDLT contained fewer ketoimine and more aldimine cross-links than either normal or dysfunctional PTT. mRNA encoding types I and III collagens, aggrecan, biglycan, matrix metalloproteinase (MMP)-2, -13 and -23, and a disintegrin and metalloproteinase (ADAM)-12L each showed increased levels in dysfunctional PTT compared with either normal PTT or (except MMP-13) FDLT. In contrast, MMP-3 and ADAM with thrombospondin domain (ADAMTS)-5 mRNA were lower in both dysfunctional PTT and FDLT than in normal PTT, while ADAMTS-1 mRNA was lower in dysfunctional PTT than in FDLT. Conclusions Stage II dysfunctional PTT shows biochemical and molecular changes consistent with a chronic remodelling of the extracellular matrix, rather than rupture, while the replacement FDLT resembles normal PTT in many, but not all, parameters.
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Affiliation(s)
- Anthony N Corps
- Rheumatology Research Unit, Addenbrooke's Hospital, Cambridge, UK
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26
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Durrant B, Chockalingam N, Hashmi F. Posterior tibial tendon dysfunction: a review. J Am Podiatr Med Assoc 2011; 101:176-86. [PMID: 21406702 DOI: 10.7547/1010176] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Posterior tibial tendon dysfunction is a progressive deformity that can result in the development of a pathologic flatfoot deformity. Numerous publications have studied the effects of clinical interventions at specific stages of progression of posterior tibial tendon dysfunction, but there is still uncertainty regarding the clinical identification of the condition. It is clear that more information regarding the etiology, progression, and risk factors of posterior tibial tendon dysfunction is required. Clear evidence exists that suggests that the quality of life for patients with posterior tibial tendon dysfunction is significantly affected. Furthermore, evidence suggests that early conservative intervention can significantly improve quality of life regarding disability, function, and pain. This would suggest that significant cost burden reductions could be made by improving awareness of the condition, which would improve early diagnosis. Early conservative intervention may help reduce the number of patients requiring surgery. This review focuses on the etiologic factors, epidemiologic features, and pathogenesis of posterior tibial tendon dysfunction. It aims to analyze, discuss, and debate the current understanding of this condition using the available literature. In addition, there is a discussion of the evidence base surrounding disease characteristics associated with the different clinical stages of posterior tibial tendon dysfunction.
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Affiliation(s)
- Beverley Durrant
- Podiatry, University of Brighton, Eastbourne, East Sussex, England.
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27
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Mansour R, Jibri Z, Kamath S, Mukherjee K, Ostlere S. Persistent ankle pain following a sprain: a review of imaging. Emerg Radiol 2011; 18:211-25. [DOI: 10.1007/s10140-011-0945-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2010] [Accepted: 02/21/2011] [Indexed: 12/26/2022]
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28
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Haddad SL, Myerson MS, Younger A, Anderson RB, Davis WH, Manoli A. Symposium: Adult acquired flatfoot deformity. Foot Ankle Int 2011; 32:95-111. [PMID: 21288442 DOI: 10.3113/fai.2011.0095] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Bridgeman JT, Zhang Y, Donahue H, Wade AM, Juliano PJ. Estrogen receptor expression in posterior tibial tendon dysfunction: a pilot study. Foot Ankle Int 2010; 31:1081-4. [PMID: 21189209 DOI: 10.3113/fai.2010.1081] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The pathophysiology of posterior tibial tendon dysfunction (PTTD) is poorly understood. It has been theorized that changes in hormone physiology may be a factor influencing tendon health. Estrogen's influence on the fibroblast has been studied in other musculoskeletal tissues. Gender differences in anterior cruciate ligament (ACL) injuries have been studied and it has been discovered that the Estrogen receptor (ER) as well as Progesterone receptor (PR) are expressed in the ACL. MATERIAL AND METHODS Eight patients with PTTD requiring surgery were enrolled in our pilot study. The mean patient age was 52.4 (range, 18 to 73) years. There were five female and three male patients. Tendon samples were harvested from diseased PTT. Tendon samples harvested from healthy PTT and healthy flexor digitorum longus (FDL) tendon were used as controls. Tendon samples were processed using specific protocols for total RNA isolation from hypocellular, dense connective tissues. ERα and ERβ transcripts were quantified using real time RT-PCR. Quantitative values were obtained from the threshold cycle (Ct) number at which the increase in fluorescent signal associated with an exponential increase of PCR products can be detected. RESULTS Transcripts of both ERα and ERβ were reproducibly detected in RNA samples isolated from our tendon samples. There was no difference in receptor expression between diseased and control tendon samples. There was no difference in receptor expression between male and female patients. CONCLUSION We found that the tenocyte of the PTT and FDL tendons express ERα and ERβ. Normal and diseased tendons of both male and female patients expressed both estrogen receptors. CLINICAL RELEVANCE Identifying ERα and ERβ gene expression in the fibroblast was an initial step in discovering whether tenocytes are targets for estrogen function. Estrogen receptors were identified indirectly by measuring receptor gene expression but we were unable to show a significant difference between diseased and control tendons.
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Affiliation(s)
- Jay T Bridgeman
- Department of Orthopaedics and Rehabilitation, Penn State College of Medicine, Hershey, PA 17033, USA
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30
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Buck FM, Grehn H, Hilbe M, Pfirrmann CW, Manzanell S, Hodler J. Magnetic resonance histologic correlation in rotator cuff tendons. J Magn Reson Imaging 2010; 32:165-72. [DOI: 10.1002/jmri.22222] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Bowring B, Chockalingam N. Conservative treatment of tibialis posterior tendon dysfunction--a review. Foot (Edinb) 2010; 20:18-26. [PMID: 20434675 DOI: 10.1016/j.foot.2009.11.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2009] [Accepted: 11/27/2009] [Indexed: 02/04/2023]
Abstract
BACKGROUND Appropriate conservative treatment is considered essential to address symptoms associated with tibialis posterior tendon dysfunction (TPTD) and prevent its potential long-term disabling consequences. The main aim of this review, undertaken in 2007, was to evaluate the evidence from studies for the effects of conservative treatment modalities in the management of TPTD. This evidence could then be used as a basis for the development of a clinical guideline for the management of the condition. METHODOLOGY Studies were selected according to specific criteria and evaluated for methodological quality. As preliminary literature searches had identified no randomised controlled trials at the time of the review, studies of lower hierarchy were included. RESULTS Five uncontrolled observational studies evaluating the outcomes of various orthotic treatments alone or in combination with other therapies were included in the review. Different study designs, methodological quality, population characteristics, interventions and outcome measures were found. DISCUSSION Limited and poor quality evidence was found in this review regarding the conservative treatment of TPTD. Thus a cause-effect relationship between intervention and outcome could not be established nor an optimal conservative treatment regime for the condition. Further better quality research is warranted in this area to inform practice, particularly as there is no consensus in the literature regarding treatment of this condition.
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Affiliation(s)
- Beverly Bowring
- Cornwall and Isles of Scilly Primary Care Trust, Penzance, Cornwall, United Kingdom
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32
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The collateral ligaments of the distal interphalangeal joint: Magnetic resonance imaging and post mortem observations in 25 lame and 12 control horses. Equine Vet J 2010; 40:538-44. [DOI: 10.2746/042516408x313661] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Lesions of the deep digital flexor tendon in the digit: A correlative MRI and
post mortem
study in control and lame horses. Equine Vet J 2010; 41:25-33. [DOI: 10.2746/042516408x343028] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Fujii T, Uchiyama E, Kitaoka HB, Luo ZP, Zhao KD, An KN. The influence of flatfoot deformity on the gliding resistance of tendons about the ankle. Foot Ankle Int 2009; 30:1107-10. [PMID: 19912723 DOI: 10.3113/fai.2009.1107] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Various tendinopathies occur about the ankle, but there are few publications investigating their etiology or pathoanatomy. The purpose of this investigation was to determine the gliding resistance of the tendons about the posteromedial ankle: the posterior tibial (PT), flexor digitorum longus (FDL), and flexor hallucis longus (FHL) tendons. MATERIALS AND METHODS The gliding abilities of the posterior tibial, flexor digitorum longus, and flexor hallucis longus tendons at the ankle-hindfoot level were compared, in terms of gliding resistance, with use of a system that was developed in this laboratory. Six cadaveric specimens were used and tested in a dorsiflexed position, then in simulated flatfoot in a dorsiflexed position. RESULTS The gliding resistance was found to be significantly greater in the simulated flatfoot in dorsiflexion compared to the dorsiflexed position with an intact arch for the PT, FDL, and FHL tendons. The gliding resistance was significantly higher in the PT tendon than FDL or FHL tendons in the flatfoot/dorsiflexion condition. There was no significant difference between the FDL and FHL tendons in resistance in either condition. CONCLUSION We concluded that the gliding ability of the PT tendon was inferior to that of the FDL and FHL tendons in a simulated flatfoot model. CLINICAL RELEVANCE The findings of the present study are consistent with the clinical observations that tendinitis and rupture of the PT tendon commonly occurs at the malleolar level, whereas FDL and FHL ruptures do not. A pre-existing flexible flatfoot deformity may be associated with PT tendon dysfunction in the adult due to poor gliding ability of the PT tendon.
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Affiliation(s)
- Tadashi Fujii
- Mayo Clinic, Department of Orthopedics, Rochester, MN 55905, USA
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Kohls-Gatzoulis J, Woods B, Angel JC, Singh D. The prevalence of symptomatic posterior tibialis tendon dysfunction in women over the age of 40 in England. Foot Ankle Surg 2009; 15:75-81. [PMID: 19410173 DOI: 10.1016/j.fas.2008.08.003] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2008] [Revised: 07/25/2008] [Accepted: 08/04/2008] [Indexed: 02/04/2023]
Abstract
BACKGROUND To investigate the prevalence of posterior tibial tendon dysfunction (PTTD) in women over the age of 40. METHODS A validated survey was posted to a random sample of 1000 women (over 40 years) from a GP group practice in Hertfordshire, England. Survey positive women were telephoned and when indicated, a detailed examination was performed. RESULTS There were 582 usable responses. The majority indicated they had minor forefoot or no problems. Telephone contact was made with 116 women and of those 79 required examination. The diagnosis of symptomatic flatfeet was made in 9 patients, 7 patients had stage I PTTD, 12 patients had stage II PTTD and 9 patients had an adult acquired flatfoot deformity. CONCLUSIONS This is the first report of the prevalence of stage I and II PTTD in women (over 40 years). The prevalence is 3.3% and all patients were undiagnosed despite characteristic and prolonged symptoms.
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Brodsky JW, Charlick DA, Coleman SC, Pollo FE, Royer CT. Hindfoot motion following reconstruction for posterior tibial tendon dysfunction. Foot Ankle Int 2009; 30:613-8. [PMID: 19589306 DOI: 10.3113/fai.2009.0613] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Due to advances in technology, segmental gait analysis of the foot is now possible and can elucidate hindfoot deformity in persons with posterior tibial tendon dysfunction (PTTD). This study evaluated the motion of the hindfoot and ankle power following surgical reconstruction for PTTD utilizing a segmental foot model during gait. MATERIALS AND METHODS Twenty patients who underwent posterior tibial tendon reconstruction for Stage 2 PTTD using transfer of the flexor digitorum longus tendon to the navicular tuberosity, reconstruction of the calcaneo-navicular ligament complex, and a medial displacement calcaneal osteotomy were evaluated at a minimum followup of 1 year. Three-dimensional gait analysis was performed utilizing a 4-segment foot model. Temporal-spatial parameters included walking velocity, cadence, step length, and single support time. Sagittal, coronal, and transverse hindfoot motion with respect to the tibia/fibula and ankle power was calculated throughout the gait cycle. RESULTS Walking velocity, cadence, and step length were not significantly different between the study subjects and the normal control group. Study patients did show a significantly smaller single support time on both the affected and unaffected limbs compared to controls. There was no statistical difference in plantarflexion-dorsiflexion, varus-valgus, or ankle push-off power between the affected and unaffected sides of the study subjects, or between the affected side and the controls. CONCLUSION In this preliminary postoperative study, surgical reconstruction for PTTD effects quantifiable objective improvement in walking velocity, hindfoot motion and power.
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Affiliation(s)
- James W Brodsky
- Baylor University Medical Center, Department of Orthopaedic Surgery, 411 North Washington Avenue, Suite 7000, Dallas, TX 75246, USA.
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Effects of the AirLift PTTD brace on foot kinematics in subjects with stage II posterior tibial tendon dysfunction. J Orthop Sports Phys Ther 2009; 39:201-9. [PMID: 19252264 DOI: 10.2519/jospt.2009.2908] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN Experimental laboratory study. OBJECTIVES To investigate the effect of inflation of the air bladder component of the AirLift PTTD brace on relative foot kinematics in subjects with stage II posterior tibial tendon dysfunction (PTTD). BACKGROUND Orthotic devices are commonly recommended in the conservative management of stage II PTTD to improve foot kinematics. METHODS AND MEASURES Ten female subjects with stage II PTTD walked in the laboratory wearing the AirLift PTTD brace during 3 testing conditions (air bladder inflation to 0, 4, and 7 PSI [SI equivalent: 0, 27,579, and 48,263 Pa]). Kinematics were recorded from the tibia, calcaneus (hindfoot), and first metatarsal (forefoot), using an Optotrak motion analysis system. Comparisons were made between air bladder inflation and the 0-PSI condition for each of the dependent kinematic variables (hindfoot eversion, forefoot abduction, and forefoot dorsiflexion). RESULTS Greater hindfoot inversion was observed with air bladder inflation during the second rocker (mean, 1.7 degrees; range, -0.7 degrees to 6.1 degrees). Less consistent changes in forefoot plantar flexion and forefoot adduction occurred with air bladder inflation. The greatest change toward forefoot plantar flexion was observed during the third rocker (mean, 1.4 degrees; range, -3.8 degrees to 3.9 degrees). The greatest change towards adduction was observed during the third rocker (mean, 2.3 degrees; range, -3.4 degrees to 6.5 degrees). CONCLUSIONS On average, the air bladder component of the AirLift PTTD brace was successful in reducing the amount of hindfoot eversion observed in subjects with stage II PTTD; however, the effect on forefoot motion was more variable. Some subjects tested had marked improvement in foot kinematics, while 2 subjects demonstrated negative results. Specific foot characteristics are hypothesized to explain these varied results.
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Nonsurgical management of posterior tibial tendon dysfunction with orthoses and resistive exercise: a randomized controlled trial. Phys Ther 2009; 89:26-37. [PMID: 19022863 DOI: 10.2522/ptj.20070242] [Citation(s) in RCA: 94] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
BACKGROUND AND PURPOSE Tibialis posterior tendinopathy can lead to debilitating dysfunction. This study examined the effectiveness of orthoses and resistance exercise in the early management of tibialis posterior tendinopathy. SUBJECTS Thirty-six adults with stage I or II tibialis posterior tendinopathy participated in this study. METHODS Participants were randomly assigned to 1 of 3 groups to complete a 12-week program of: (1) orthoses wear and stretching (O group); (2) orthoses wear, stretching, and concentric progressive resistive exercise (OC group); or (3) orthoses wear, stretching, and eccentric progressive resistive exercise (OE group). Pre-intervention and post-intervention data (Foot Functional Index, distance traveled in the 5-Minute Walk Test, and pain immediately after the 5-Minute Walk Test) were collected. RESULTS Foot Functional Index scores (total, pain, and disability) decreased in all groups after the intervention. The OE group demonstrated the most improvement in each subcategory, and the O group demonstrated the least improvement. Pain immediately after the 5-Minute Walk Test was significantly reduced across all groups after the intervention. DISCUSSION AND CONCLUSION People with early stages of tibialis posterior tendinopathy benefited from a program of orthoses wear and stretching. Eccentric and concentric progressive resistive exercises further reduced pain and improved perceptions of function.
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Introduction to diagnostic musculoskeletal ultrasound: part 2: examination of the lower limb. Am J Phys Med Rehabil 2008; 87:238-48. [PMID: 18174843 DOI: 10.1097/phm.0b013e31816198c2] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
This is the second of two articles focusing on ultrasound examination of musculoskeletal components of the upper and lower limbs. Treatment of musculoskeletal injuries is based on establishing an accurate diagnosis. No one would dispute that a good history and physical examination by a competent clinician can help achieve that in the majority of cases. However, musculoskeletal imaging is also an essential adjunct in the work-up of many musculoskeletal disorders. This article describes the ultrasound examination of the lower limb in terms of anatomic structure. Normal and pathologic ultrasound features of these structures, including muscles, tendons, ligaments, bursae, and other soft tissues of the lower limb, will be described by reviewing several representative pathologies commonly seen in musculoskeletal medicine.
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Satomi É, Teodoro WR, Parra ER, Fernandes TD, Velosa APP, Capelozzi VL, Yoshinari NH. Changes in histoanatomical distribution of types I, III and V collagen promote adaptative remodeling in posterior tibial tendon rupture. Clinics (Sao Paulo) 2008; 63:9-14. [PMID: 18297201 PMCID: PMC2664193 DOI: 10.1590/s1807-59322008000100003] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2007] [Accepted: 09/18/2007] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Posterior tibial tendon dysfunction is a common cause of adult flat foot deformity, and its etiology is unknown. PURPOSE In this study, we characterized the morphologic pattern and distribution of types I, III and V collagen in posterior tibial tendon dysfunction. METHOD Tendon samples from patients with and without posterior tibial tendon dysfunction were stained by immunofluorescence using antibodies against types I, III and V collagen. RESULTS Control samples showed that type V deposited near the vessels only, while surgically obtained specimens displayed type V collagen surrounding other types of collagen fibers in thicker adventitial layers. Type III collagen levels were also increased in pathological specimens. On the other hand, amounts of collagen type I, which represents 95% of the total collagen amount in normal tendon, were decreased in pathological specimens. CONCLUSION Fibrillogenesis in posterior tibial tendon dysfunction is altered due to higher expression of types III and V collagen and a decreased amount of collagen type I, which renders the originating fibrils structurally less resistant to mechanical forces.
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Affiliation(s)
- Érika Satomi
- Department of Rheumatology, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo - São Paulo/SP, Brazil
| | - Walcy R. Teodoro
- Department of Rheumatology, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo - São Paulo/SP, Brazil
| | - Edwin R. Parra
- Department of Pathology, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo - São Paulo/SP, Brazil.
| | - Túlio D. Fernandes
- Department of Orthopedics, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo - São Paulo/SP, Brazil
| | - Ana Paula P. Velosa
- Department of Rheumatology, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo - São Paulo/SP, Brazil
| | - Vera Luiza Capelozzi
- Department of Pathology, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo - São Paulo/SP, Brazil.
| | - Natalino Hajime Yoshinari
- Department of Rheumatology, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo - São Paulo/SP, Brazil
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Hix J, Kim C, Mendicino RW, Saltrick K, Catanzariti AR. Calcaneal osteotomies for the treatment of adult-acquired flatfoot. Clin Podiatr Med Surg 2007; 24:699-719, viii-ix. [PMID: 17908638 DOI: 10.1016/j.cpm.2007.07.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Calcaneal osteotomies are useful procedures for the treatment of stage 2 adult-acquired flatfoot. Often combined with adjunctive soft-tissue procedures, the posterior calcaneal displacement osteotomy and Evans procedure provide effective realignment of pes planovalgus deformity. Preoperative evaluation, indications, contraindications, surgical considerations and techniques are discussed.
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Affiliation(s)
- Joel Hix
- The Foot and Ankle Institute of Western Pennsylvania, The Western Pennsylvania Hospital, 4800 Friendship Avenue, North Tower, First Floor, Pittsburgh, PA 15224, USA
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Abstract
The adult acquired flatfoot is a deformity that results from the loss of dynamic and static supportive structures of the medial longitudinal arch. The severity of the deformity is dependent upon the role of ligamentous disruption on the hindfoot that can be determined by careful clinical examination. Treatment of the adult flatfoot requires an understanding of the biomechanical effects of deforming forces, tendon dysfunction, ligament disruption, and joint sublaxation.
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Affiliation(s)
- Douglas H Richie
- Department of Applied Biomechanics, California School of Podiatric Medicine at Samuel Merritt College, 370 Hawthorne Avenue, Oakland, California 94609, USA.
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Arai K, Ringleb SI, Zhao KD, Berglund LJ, Kitaoka HB, Kaufman KR. The effect of flatfoot deformity and tendon loading on the work of friction measured in the posterior tibial tendon. Clin Biomech (Bristol, Avon) 2007; 22:592-8. [PMID: 17360087 DOI: 10.1016/j.clinbiomech.2007.01.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2006] [Revised: 12/01/2006] [Accepted: 01/17/2007] [Indexed: 02/07/2023]
Abstract
BACKGROUND There is limited information regarding the mechanical factors contributing to the progression of posterior tibial tendon dysfunction. Therefore, an investigation of the mechanical forces on the posterior tibial tendon may improve our understanding of this pathology. METHODS The gliding resistance and excursion of the posterior tibial tendon in the retromalleolar region was measured in seven cadaveric lower limbs in the coronal, transverse, and sagittal planes. These data were used to calculate the work of friction and to characterize the effect of different tendon loading levels (0.5, 1.0, and 2.0 kg) in the intact and flatfoot conditions. FINDINGS Flatfoot deformity significantly increased the excursion of the posterior tibial tendon (P<0.05), increased forefoot and hindfoot range of motion in the coronal and transverse planes (P<0.05) and the work of friction in the coronal and transverse planes (P<0.05), but not in the sagittal plane. There was a significant increase in the work of friction between 0.5 and 2 kg (P<0.05) in all three planes of motion. INTERPRETATION The motions in the coronal and transverse planes have a greater effect on the work of friction of the posterior tibial tendon than sagittal plane motion in the flatfoot condition. This study suggests that aggressive treatment of early stage PTT dysfunction with bracing designed to limit coronal and transverse motions, while permitting sagittal motion should be investigated further. Such bracing may decrease the potential of progressive deformity while allowing for more normal ambulation.
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Affiliation(s)
- Kenichiro Arai
- Biomechanics Laboratory, Division of Orthopedic Research, Mayo Clinic, 200 First Street SW, Rochester, MN 55095, USA
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Uchiyama E, Kitaoka HB, Fujii T, Luo ZP, Momose T, Berglund LJ, An KN. Gliding resistance of the posterior tibial tendon. Foot Ankle Int 2006; 27:723-7. [PMID: 17038285 DOI: 10.1177/107110070602700912] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Abnormal gliding of the posterior tibial tendon may lead to mechanical trauma, degeneration, and eventually posterior tibial tendon dysfunction. Our study analyzed the gliding resistance of the posterior tibial tendon in intact feet and in feet with simulated flatfoot deformity. METHODS An experimental system was developed that allowed direct measurement of gliding resistance at the tendon-sheath interface. Seven normal fresh-frozen cadaver foot specimens were studied, and gliding resistance between the posterior tibial tendon and sheath was measured. The effects of ankle and hindfoot position and the effect of flatfoot deformity on gliding resistance were analyzed. Gliding resistance was measured for 4.9 N applied load to the tendon. RESULTS Mean gliding resistance for the neutral position was 77 +/- 13.1 (x10(-2) N). Compared to neutral position, dorsiflexion increased gliding resistance and averaged 130 +/- 38.9 (x10(-2) N), and plantarflexion decreased gliding resistance and averaged 35 +/- 12.6 (x10(-2) N). Flatfoot deformity increased gliding resistance compared to normal feet, averaging 104 +/- 17.0 (x10(-2) N) for neutral, 205 +/- 55.0 (x10(-2) N) for dorsiflexion, and 58 +/- 21.3 (x10(-2) N) for plantarflexion. CONCLUSIONS The findings indicate that patients with a preexisting flatfoot deformity may be predisposed to develop posterior tibial tendon dysfunction because of increased gliding resistance and trauma to the tendon surface.
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Affiliation(s)
- Eiichi Uchiyama
- Department of Anatomy, Sapporo University, Sapporo, Hokkaido, Japan
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Abstract
Insufficient posterior tibial tendons in 28 specimens from patients with clinical Stage II or III disease were examined to clarify the etiology of adult-acquired flatfoot deformity. Hematoxylin and eosin and Masson trichrome-stained sections of formalin-fixed tissue were viewed in plain and polarized light. We performed a qualitative analysis for abnormalities in collagen orientation, degree of vascularization, tenocyte cellularity, mucinous change, and chondroid metaplasia. Tendons were divided into three zones: tenosynovial lining cell layer, subtenosynovial lining cell layer, and tendon proper. All tendons showed neovascular infiltration causing collagen fibril disruption; 50% of specimens had diffuse involvement. Increased mucin content and chondroid metaplasia occurred in 28% and 36% of specimens, respectively. The tenosynovial lining cell layer showed hyperplasia in 28% of specimens. The subtenosynovial lining cell layer showed thickening and neovascularization in 79% of specimens, which appeared to be the source for the diffuse neovascular infiltrative process. There is little histopathologic evidence to support an inflammatory etiology to the posterior tibial tendons in acquired-adult flatfoot deformity. Neoangiogenesis, the prominent histologic finding, is consistent with an obscure insult. We postulate that overuse, tension, or stretching may activate the tenosynovial lining cells and incite angiogenesis.
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Affiliation(s)
- Vincent A Fowble
- Division of Orthopaedic Surgery, Kingsbrook Jewish Medical Center, 585 Schenectady Avenue, Brooklyn, NY 11203, USA.
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Prado MP, de Carvalho AE, Rodrigues CJ, Fernandes TD, Mendes AAM, Salomao O. Vascular density of the posterior tibial tendon: a cadaver study. Foot Ankle Int 2006; 27:628-31. [PMID: 16919217 DOI: 10.1177/107110070602700811] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Degenerative pathology of the posterior tibial tendon, a common cause of foot and ankle dysfunction, frequently affects women over 40 years of age. Its etiology is still controversial. The literature reports decreased vascularization coinciding with the most common site of the lesion, near the medial malleolus. METHODS Forty pairs of PTT obtained from human cadavers were transversally cut into six levels, from the musculotendon transition to its insertion point. In each segment, a histologic cut was made and stained with Masson's trichrome allowing viewing of the vascular structure of the tendon under a light microscope. By using an integrating eyepiece on the microscope, vascular density was calculated. This verified any variation of the vascular concentration in the normal tendon, a possible cause of its degeneration. RESULTS When the results were compared by side, sex, and age, no statistically significant difference was observed. When the levels were compared, no area of decreased vascularization was seen in the midportion of the tendons, the most common site of degeneration of the posterior tibial tendon. CONCLUSION These results indicate that an area of decreased vascularity is not a factor in degeneration of the posterior tibial tendon at the medial malleolus.
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Affiliation(s)
- Marcelo Pires Prado
- Centro de Ortopedia e Reabilitação do Esporte, Hospital do Coração, Sao Paulo, Brazil.
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Abstract
Plantar fasciitis is a musculoskeletal disorder primarily affecting the fascial enthesis. Although poorly understood, the development of plantar fasciitis is thought to have a mechanical origin. In particular, pes planus foot types and lower-limb biomechanics that result in a lowered medial longitudinal arch are thought to create excessive tensile strain within the fascia, producing microscopic tears and chronic inflammation. However, contrary to clinical doctrine, histological evidence does not support this concept, with inflammation rarely observed in chronic plantar fasciitis. Similarly, scientific support for the role of arch mechanics in the development of plantar fasciitis is equivocal, despite an abundance of anecdotal evidence indicating a causal link between arch function and heel pain. This may, in part, reflect the difficulty in measuring arch mechanics in vivo. However, it may also indicate that tensile failure is not a predominant feature in the pathomechanics of plantar fasciitis. Alternative mechanisms including 'stress-shielding', vascular and metabolic disturbances, the formation of free radicals, hyperthermia and genetic factors have also been linked to degenerative change in connective tissues. Further research is needed to ascertain the importance of such factors in the development of plantar fasciitis.
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Affiliation(s)
- Scott C Wearing
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Queensland, Australia.
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Kohls-Gatzoulis J, Angel JC, Singh D, Haddad F, Livingstone J, Berry G. Tibialis posterior dysfunction: a common and treatable cause of adult acquired flatfoot. BMJ 2004; 329:1328-33. [PMID: 15576744 PMCID: PMC534847 DOI: 10.1136/bmj.329.7478.1328] [Citation(s) in RCA: 114] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Wilder RP, Sethi S. Overuse injuries: tendinopathies, stress fractures, compartment syndrome, and shin splints. Clin Sports Med 2004; 23:55-81, vi. [PMID: 15062584 DOI: 10.1016/s0278-5919(03)00085-1] [Citation(s) in RCA: 100] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Approximately 50% of all sports injuries are secondary to overuse and result from repetitive microtrauma that causes local tissue damage. Injuries are most likely with changes in mode, intensity, or duration of training and can accumulate before symptoms appear. Intrinsic factors contributing to injuries are individual bio-mechanical abnormalities such as malalignments, muscle imbalance, inflexibility, weakness, and instability. Contributing extrinsic (avoidable) factors include poor technique, improper equipment, and improper changes in duration or frequency of activity. Injuries are often related to biomechanical abnormalities removed from the specific injury site, requiring evaluation of the entire kinetic chain. This article discusses common overuse injuries of the lower leg, ankle, and foot: tendinopathies, stress fractures, chronic exertional compartment syndrome, and shin splints.
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Affiliation(s)
- Robert P Wilder
- Department of Physical Medicine and Rehabilitation, The University of Virginia, 545 Ray C. Hunt Drive, Suite 240, P.O. Box 801004, Charlottesville, VA 22908-1004, USA.
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