Tendon injuries Flashcards
Plantar fasciitis FHL injury Peroneal Dislocation achilles tendonitis achilles tendon rupture Posterior tibial tendon insufficiency
What is plantar fascitis?
- Inflammation of the aponeurosis at its origin on the calcaneus
What is the epidemiology of plantar fascitis?
- men = women
- effects POSTEROMEDIAL Heel
- Risk factors
- Obesity
- decreased ankle DORSIFLEXION in an non- athelete population ( tightness of foot/calf muscl)
- weight bearing endurance activity- running
What is the pathophysiology of plantar fascitis?
- chronic overuse leads to microtears in origin of plantar fascitis
- repititive trauma-> recurrent inflammation and periostitis
- Abductor hallucis, flexor digitorium brevis & quadratus plantae- same origin on medial calcaneal tubercle- may become inflammed
What are the associated conditions of plantar fascitis?
- Calcaneal apophysitis- inflamation of heel pad growth plate= Sever’s disease- affects children
- gastronemius soleus contracture
- heel pad triad
- plantar fascitis
- post tibital tendon dysfunction
- tarsal tunnel syndrome
What is the anatomy of plantar fascitis?
- is a thin layer of connective tissue supporting arch of foot
What are the signs and symptoms of planar fascitis?
- Symptoms
- SHARP heel pain, often when first getting out of bed
- may prefer to walk on toes initially
- worse at end of day after prolonged standing
- relieved by amputation
- common bilateral symptoms
- Signs
- tender to palpation over medial tuberosity of calcaneus
- dorsiflexion of toes and foot increases tenderness with palpation
- limited ankle dorsiflexion due to tight achilles tendon
- tenderness at origin of abductor hallucis- entrapment /irriation of 1st branch of lateral plantar nerve = baxter’s
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What imaging is useful in plantar fascitis?
xrays
- may show plantar heel spur
- ap and lateral standing may show structural changes
MRI
- useful for surgical planning
Bone scan
- can quantify inflammation and quide management
What is the tx of plantar fascitis?
Non operative
-
Pain control, splinting and stretching therapy regime
- first line of tx
-
plantar fascia specific stretching and achilles tendon stretching
- recreate windlass mechanism and achieve tissue tension thru controlled stretch of PF
- anti-inflammatories
- Foot orthosis
- cushioned heel inserts, prefabricated shoes inserts,
- If no relief 6wks think night splints, walking casts or steriod injection
- steriod injection-> heel pad necrosis/planar fascia rupture
- short leg casts 8-10 wks
- Outcomes
- prefab shoe inserts better than custom orthotics in relieving symptoms + stretching exercises
- NWB plantar fascia specific strecthing programme better than WB achilles tednon stretching programme
- Stretching programmes have equal satisifaction at 2 years
-
Shock wave Tx ( post 6 months of failed tx)
- 2nd line
- chronic pain lasting >6 months
- painful for pts
- efficacous at 6 months FU
Operative
- Gastronemius recession
- Surgical release w plantar fasciotomy
- surigcal release w planter fasciotomy and distal tarsal tunnel decompression
what is the tier of t for plantar fascitis?
- Intial padding /strapping foot , therapeutic insoles , oral antiinflammatories & regular achilles/ plantar fascia stretching
- symptoms persist > 6 weeks
- Shock wave therapy
- corticosteriod injections
- Night splints
- Symptoms > 6months
- Surgical release
Non surgical tx is successful in 90% pts
Can you describe the indications for sugery?
- Gastronemius recession- no clear indications established
-
Surgical release w planar fasciotomy
- Pain persists > 9 months of failed consx
- complx common & recovery protracted
-
Surgical release w planar fasciotomy with distal tarsal tunnel release
- concomitant compression neuropathy ( tibial n in tarsal tunnel)
- success rate 70-90%
can you describe the surgical release of plantar fascia?
- Open vs arthroscopic
- open is indicated if tarsal tunnel symptoms is present
- incision= anteropr border of weight bearing surface of calcaneum.superifical fascia over abductor hallucis is identified and incised to reveal plantar fascia inferior adn beneath. Incise abductor hallucis muscle to reveal planar fascia beneath
- release
- medial 1/3rd to 2/3rds
-
avoid complete release can lead to
- destabilisation of longitudinal arch
- overload of lateral column
- dorsolateral foot pain
-
consider stimulanteous release of abxter’s nerve
- release deep fascia of abductor hallucis
-
may improve outcomes
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What are the complications of plantar fascitis?
- Lateral plantar nerve injury
- Complete release of the plantar fascia with destabilisation of medial longitudinal arch
- increased stress on dorsolateral midfoot
- chronic pain
What is FHl tendonitis?
- Flexor hallucis longus impingment -> tendonitis- inflammation and even rupture can occur at level of posterior ankle
What is the epidemiology of FHL tendonitis?
location
- Posterior ankle
- great toe
risk factors
-
Excessive plantar-flexion
- dancers/ on pointe position
- gymnasts
What is the pathophysiology of FHL tendonitis?
- Activties involving maximal planar-flexion
- In chronic cases- nodule formation may lead to triggering
Can you name any associated conditions of FHL tendonitis?
- Os trigonum ( posteriorlateral tubercle)
- posterior ankle inpingement
Can you describe the anatomy of FHL?
What is its actions?
- originates from posterior fibula
- travels between posteriomedial/posteriolateral tubercles of talus
- contained with fibro-osseous tunnel
- passes beneath sustentaculum tali
- crosses dorsal to FDL ( at knot of henry)
- multiple connections exists between FDL /FHL
- distally is stays dorsal to FDL and NV bundle
- inserts onto distal phalanx of great toe
Actions
- PLANTARFLEXION of hallux IP and MPJ
- PLANTARFLEXION at ankle
- Supplied by tibial nerve
What are the signs and symptoms of FHL tendonitis?
Symptoms
- _Posteriomedial a_nkle pain
- Great toe locking with active range of motion
- Crepitus along posterior medial ankle
Signs
- Pain with resisted flexion of IPJ
- Pain with forced plantarflexion of ankle
-
great toe triggering with active/passive motion but no tenderness at level of 1st MT head
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What investigations would help woth dx of FHL tendonitis?
- MRI
- Find fluid around tendon at level of ankle joint
- intra-substance tendinous signal
What is the tx for FHL tendonitis?
Non operative
-
Rest, activity modification, NSAIDS
- first line of tx
- arch supports
- physical therapy
Operative
-
Release of FHL from fibro-ossoeus tunnel , tenosynovectomy +/- tendon repair
- in athletes when symptoms persist
- arthroscopic/open-post medial
Describe the surgical decompression of FHL for tendonitis?
- consider medial approach, made posterior to the medial malleolus at the the level of the superior border of calcaneus;
- FHL is identified just anterior to the Achilles tendon;
- identify the N/V bundle and the underlying FHL tunnel;
- flex and extend the great toe to identify the tunnel, and attempt to palpate for a nodule;
- release the _posteromedial aspect of the tunne_l down to the level of the sustentaculum tali;
- ensure that there is unrestricted motion of the FHL;
- look for a longitudinal rent in the FHL tendon;
consider removal of an os trigonium is one is present
How is the FHL tendon injured?
- laceration form direct trauma in acute setting
What signs of FHL laceration?
- inablity to actively flex IPJ great toe
What are the most useful investigations to aid dx of FHL laceration?
MRI
- tendon ends may retract
What is the tx of FHL laceration?
- Acute repair when FHL and FHB lacerated
- debateable depends on location
- If the FHL is lacerated proximal to the Knot of Henry where FHL and FDL cross, then the intact FDL acts through the interconnection with the remaining FHL to allow plantarflexion of the great toe. If FHL is lacerated distal to the Knot of Henry then FHL will no longer function. This would then lead to an absence of hallux plantarflexion at the interphalangeal joint and possibly also to gait disturbances.
name the tendons in this axial view
no next card - keep guessing
name the tendons in this axial view 2?
Tendons are
Define Peroneal tendon injury ?
- Tendon dislocation and repetitive subluxation from behind lateral malleolus
What is the epidemiology of peroneal tendon injuries?
What is the mechanism of peroneal tendon injuries?
- Most injuries occur in young, active patients
- Rapid dorsiflexion of an inverted foot inversion leading to rapid reflexive contraction of the PL and PB tendons
- Rapid contraction can lead to injury to superior peroneal retinaculum
- Longitudinal split tears more common than transverse
Pathophysiology of peroneal tendon injuries?
- subluxation of the peroneal tendons lead to longitudinal tears over time which usually involves the peroneus brevis at fibular groove
Describe the anatomy of peroneus brevis and longus?
-
Peroneus brevis
- Innervated by superificial peroneal n S1
- Acts as primary EVERTOR of foot
- tendinous about 2-4cm prox to tip of fibula
- lies anterior and medial to peroneus longus at level of lateral malleolus
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Peroneus Longus
- Innervated by superficial peroneal nerve S1
- Acts as primarly PLANTAR FLEXOR FOOT/1st MT ( longus want to make foot look long)
- Can have ossicle- os peroneum in tendon body
Describe the space and compartment within which Peroneus longus and brevis are contained?
- Peroneal tendons contained within common synovial sheath that splits at the level of the peroneal tubercle
- the sheath runs in the RETROMALLEOLAR SULCUS on the fibula- see pic
- Peroneus longus is POSTERIOR in sulcus (longest takes the longway round!!)
- deepened by fibrocartilaginous rim ( 5mm deep)
- Covered by SUPERIOR PERONEAL RETINACULUM
- orginates from posterolat ridge of fibula & inserts into lat calcaneus
- Inf aspect of SPR blends w Inf peroneal retinaculum
- It is the primary restraint the peroneal tendons within the retrimalleolar sulcus
Name the classification of superifical peroneal retinaculum tears?
- Ogden ( NB hilda ogden - nora battie- wrinkles aorunf ankles)
- Grade 1- SPR- is partially elevated off the fibula allowing for subluxation of both tendons
- Grade 2- SPR is separated from cartilofibrous ridge of lat malleolus , allowing tendons to sublux between SPR and cartiofibrous ridge
- Grade 3 -cortical avulsion of SPR off fibula, allowing subluxed tendons to move underneath the cortical fragment
- Grade 4- Spr is torn from calcaneous not fibula
What is the signs and symptoms of peroneal nerve disslocation/subluxation?
Hx
- Pt reports they felt a POP with DORSIFLEXION ANKLE Injury
Symptoms
- Clicking and popping and feeling of instability or pain on the LATERAL aspect of the ankle
Signs
- swelling posterior to lateral malleolus
- tenderness over tendons
- ‘pseudotumour’ of peroneal tendons
- Provocational test
- Subuxation with active dorsiflexion and eversion against resistance -> subluxation/dislcation /apprehension
- Compressive test- pain on active dorsiflexion and eversion
What investigations aid DX of peroneal tendon dislocation?
- Xray
- internal rotation view
- may see distal tip of lateral malleolus- RIM FRACTURE
- need to evaluate for varus hindfoot
- MRI
- axial views w slightly flexed ankle gd
- demonstrate peroneus quartus muscle
- low lying peroneus brevis muscle belly
What is the tx of peroneal tendon subluxation/dislocation?
Non operative
-
Short leg cast immobilisation & protected weight bearing 6 weeks
- all acute injuries
- tendons must be reduced at time of casting
- success rates approx 50%
Operative
-
Acute repair of superior peroneal retinaculum and deeping of fibular groove
- acute dislocations in serious athletes who desire QUICK return to sport/active lifestyle
- presence of longitudinal tears
-
Groove deepening with soft tissue transfer adn or osteotomy
- Chronic/recurrent dislocations
- less able to reconstruct SPR
- Deepening groove in addition to soft tissue transfer or one block techniques
- Plantaris graft can be used to reinforce the SPR
- Hindfoot varus must be corrected prior to any SPR reconstructive procedure
What is the signs and symptom of peroneus brevis tendon tears?
- presentation & exam similar to peroneal tendon dislocation but there is no instability of the tendon
- MRI is required for diagnosis
What is the TX of peroneal tendon tears?
Non operative
- NSAIDS activity restriction & walking boots
- failure rate as much as 83%
Operative
- Simple tear
- Core repair and tubularization of tendon
- Complex tears in which multiple longitudinal tears and significant tendinosis >50% tendon involved
- debride tendon with tenodesis of distal and proximal ends to BREVIS tendon to peroneus longus or reconstruct with allograft