Ankle Tendon Disorders Flashcards
What is the gross anatomy that affects the tibialis posterior tendon?
Posteromedial tendon
- origin: posterior surface of tibia
- insertion: to the 3 cuneiforms, base of 2-4 MT, cuboid and navicular tubercle
What is the function of the tibialis posterior tendon?
plantar flexion
inversion
stabilizes the medial longitudinal arch
Important tendon in the foot
- affection of which causes more functional disability than TA rupture
What is the pathogenesis for the tibialis posterior tendon?
Tenosynovitis
incomplete tear
complete disruption
What two populations that are affected by the tibialis posterior tendon injury?
- younger patients with inflammatory arthropathy/traumatic rupture
- older, typically female patients with degenerative tears
What are the subjective findings of the posterior tibial tendonitis?
insidious onset of pain with pain in one of the 3 locations:
- distal to medial malleolus near the navicular
- proximal to medial malleolus
- at the muscle origin or insertion
Swelling on the medial surface of the ankle
What are the objective findings of the posterior tibial tendonitis?
Swelling and tenderness at the posterior and inferior of the medial malleolus
- along the course of the TP tendon to the insertion
Medial arch is decreased or all the way flat
Heel shows increased valgus
Pain at resisted ankle PF and inversion
What are the imaging used for posterior tibial tendonitis dx?
X-ray for degeneration
MRI for muscle
How do we manage tenosynovitis of the tibialis posterior?
Rest
NSAIDs
Short leg walking cast
orthoses
steroid injection in tendon sheath
synovectomy
How do we manage an incomplete tear of the tibialis posterior?
Repair or augmentation of:
- flexor digitorum longus
- flexor hallucis longus
How do we manage a complete disruption of the tibialis posterior?
- repair in traumatic young cases
- tendon transfer with medial calcaneal displacement osteotomy (mobile hindfoot)
- subtalar/triple arthrodesis (fixed hindfoot)
Explain the importance of taking account of kinetic chain during treatment
To think about tissues/injuries in what plane they are in - in order to decrease the compensation/pre-injury of the other structures in that plane
What is the anatomy of the peroneal tendons?
Peroneus longus and brevis are posterolateral tendons
- origin: fibula and interosseous membrane
- insert: at the base of metatarsal I and V
What is the pathology of the peroneal tendon injuries?
Two possible injuries
Tenosynovitis = common in high arch foot because of the increase in movement
Sprain/subluxation = inversion of ankle injuries
What are the sx of peroneal tendon injuries?
pain in the outer part of the ankle or just behind the lateral malleolus
- pain commonly worsens with activity and better with rest
How is a peroneal tendon injury diagnosed?
- Examination: tenderness or subluxation
- X-rays to determine fracture
- MRI
What is the non-surgical treatment for peroneal tendon injury?
Rest
Short leg walking cast or brace
lateral heel wedge
PT
NSAIDs and cortisone injections
What is the surgical treatment for peroneal tendon injury?
- Tenosynovectomy = repair of the tear
- Stabilization of dislocating tendons by groove deeping
- peroneal retinaculum reconstruction
- bone block procedures
What is achilles tendinitis?
In what population?
Pertiendinous inflammation
- usually seen in adults around 30s and 40s
- Most commonly affects runners
Older adults because of natural degeneration and weakness over time
What is achilles tendinosis?
Clinical inflammation but objective pathological evidence for cellular inflammation is lacking
What is a non-insertional achilles injury?
occurs proximal to retrocalcaneal bursa
usually responds well to non-operative treatment
What is an insertional achilles injury?
tenderness is localized in the calcaneal tendon insertion
more difficult to treat
What are the subjective findings of achilles tendonitis?
- Gradual onset of pain and swelling in the tendon (around 2-3 cm proximal to the insertion)
- gets worse with activity
- pain and stiffness along the tendon in the morning or pain when activity starts but gets better as move movement happens
What are the objective findings of achilles tendonitis?
- tenderness and warm to palpate along the tendon
- decreased AROM and PROM DF
- gait can have: antalgia, early heel off or leg in ER
What is the conservative treatment of achilles tendonitis?
Rest
Ice
NSAIDs
Orthoses
PT:
- eccentric strengthening of calf
- correction of lower chain asymmetries
Lower chain asymmetries (low back pain, knee flexion contracture, foot pronation)
What is the operational treatment of achilles tendonitis?
sometimes, achilles tendon decompression and debridement if the sx is unrelieved by 6 months of conservative measure
- 90% will have significant relief of sx
- 10% will have sx improvement
- complete symptomatic cure is NOT GUARNTEED
What is type 1 achilles tendinitis?
pain is only experienced after activity
- reduce by 25%
What is type 2 achilles tendinitis?
pain that happens both during and after activity but does not affect performance
- reduce activity by 50%
What is type 3 achilles tendinitis?
pain during and after acitivity but does affect performance
- stop activity for the time being
What is the treatment for insertional achilles tendinopathy?
Floor level eccentric will decrease pain greater than full ROM
= because it provides less stress on the insertion
What is the treatment for non-insertional achilles tendinopathy?
Eccentric exercises can take around 3-6 months to greatly improve sx
- 70% return to sports around 3 months
Morning stiffness pain is usually the first sx to get better
Pain and tenderness is usually the last to resolve
When starting = some increased soreness but should not go above a 4/10
What population is affected greatly by achilles tendon rupture?
Common sporting incidence affecting the young and middle ages
Young - not strong enough
Middle age - became weaker
What is the mechanism of injury usally involved by an achilles tendon rupture?
Loading on a DF ankle with the knee extended
Repeated microtrauma
eccentric loading
sudden dorsiflexion that came out of nowhere
direct blow or laceration
What are we considering regarding the mechanism of injury for an achilles tendon rupture?
We need to consider other systemic conditions:
- gout
- hyperparathyroidism
- Previous steroid injections
- impairement of tendon health
What is the recovery timeline for an achilles tendon rupture?
A major injury that will need 6-8 months to recovery when treated properly
What is the patient hx with an achilles tendon rupture?
They report being kicked in the leg or shot in the leg
What is the purpose of a thompson’s test?
Evaluates the integrity of the achilles tendon
What is the process of a thompson’s test?
Patient in prone or kneels on chair with the feet of the edge
PT squeezes the gastroc and watching for PF
What is a positive thompson’s test?
no PF when the muscle is squeezed
What is a non-operative treatment for achilles tendon rupture?
Usually indicated in older patients and minimally displaced ruptures
- cast for 10-12 weeks
- None or minimal DF
What is the operative treatment for achilles tendon rupture?
Usually indicated for younger patients with:
- clinically displaced ruptures
- delayed presentation between 48-72 hours
- neglected ruptures from casting treatment
What are the complications regarding treatment of achilles tendon rupture?
Wound healing
Sural nerve injury
DVT
sural nerve is right in the middle and in contact with achilles tendon
What is the patient return, satisfaction and rerupture % for non-operative ruptures?
Return = 69%
Satisfaction = 66%
Re-rupture = up to 33%
What is the patient return, satisfaction and rerupture % for operative ruptures?
Return = 83%
Satisfaction = 93%
Re-rupture = 2-3%
