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Tendon injuries Flashcards

Plantar fasciitis FHL injury Peroneal Dislocation achilles tendonitis achilles tendon rupture Posterior tibial tendon insufficiency

1
Q

What is plantar fascitis?

A
  • Inflammation of the aponeurosis at its origin on the calcaneus
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2
Q

What is the epidemiology of plantar fascitis?

A
  • 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
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3
Q

What is the pathophysiology of plantar fascitis?

A
  • 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
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4
Q

What are the associated conditions of plantar fascitis?

A
  • 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
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5
Q

What is the anatomy of plantar fascitis?

A
  • is a thin layer of connective tissue supporting arch of foot
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6
Q

What are the signs and symptoms of planar fascitis?

A
  • 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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7
Q

What imaging is useful in plantar fascitis?

A

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
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8
Q

What is the tx of plantar fascitis?

A

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
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9
Q

what is the tier of t for plantar fascitis?

A
  1. Intial padding /strapping foot , therapeutic insoles , oral antiinflammatories & regular achilles/ plantar fascia stretching
  2. symptoms persist > 6 weeks
    • Shock wave therapy
    • corticosteriod injections
    • Night splints
  3. Symptoms > 6months
    • Surgical release

Non surgical tx is successful in 90% pts

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10
Q

Can you describe the indications for sugery?

A
  • 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%
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11
Q

can you describe the surgical release of plantar fascia?

A
  • 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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12
Q

What are the complications of plantar fascitis?

A
  • Lateral plantar nerve injury
  • Complete release of the plantar fascia with destabilisation of medial longitudinal arch
  • increased stress on dorsolateral midfoot
  • chronic pain
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13
Q

What is FHl tendonitis?

A
  • Flexor hallucis longus impingment -> tendonitis- inflammation and even rupture can occur at level of posterior ankle
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14
Q

What is the epidemiology of FHL tendonitis?

A

location

  • Posterior ankle
  • great toe

risk factors

  • Excessive plantar-flexion
    • dancers/ on pointe position
    • gymnasts
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15
Q

What is the pathophysiology of FHL tendonitis?

A
  • Activties involving maximal planar-flexion
  • In chronic cases- nodule formation may lead to triggering
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16
Q

Can you name any associated conditions of FHL tendonitis?

A
  • Os trigonum ( posteriorlateral tubercle)
  • posterior ankle inpingement
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17
Q

Can you describe the anatomy of FHL?

What is its actions?

A
  • 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
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18
Q

What are the signs and symptoms of FHL tendonitis?

A

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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19
Q

What investigations would help woth dx of FHL tendonitis?

A
  • MRI
    • Find fluid around tendon at level of ankle joint
    • intra-substance tendinous signal
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20
Q

What is the tx for FHL tendonitis?

A

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
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21
Q

Describe the surgical decompression of FHL for tendonitis?

A
  • 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
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22
Q

How is the FHL tendon injured?

A
  • laceration form direct trauma in acute setting
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23
Q

What signs of FHL laceration?

A
  • inablity to actively flex IPJ great toe
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24
Q

What are the most useful investigations to aid dx of FHL laceration?

A

MRI

  • tendon ends may retract
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25
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.
26
name the tendons in this axial view
no next card - keep guessing
27
name the tendons in this axial view 2?
Tendons are
28
Define Peroneal tendon injury ?
* Tendon dislocation and repetitive subluxation from behind lateral malleolus
29
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
30
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**
31
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 * **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
32
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
33
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
34
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
35
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
36
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_
37
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_**
38
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**
39
What is achilles tendonitis?
* A family of conditions that include * **Insertional achilles tendonitis** * **Retrocalcanceal bursitis and Haglund deformity** * **Achilles tendonitis**
40
What is insertional achilles tendonitis?
* **Pain and tendon thickening** at **insertion of achilles tendon**
41
What is the epidemiology of insertional achilles tendonitis?
* Occurs in middle aged & elderly patients with a tight heel cord
42
What is the aetiology of achilles tendonitis?
* **Repetitive trauma** leads to **inflammation followed by cartilagenous then bony metaplasia**
43
What are the signs and symptoms of achilles tendonitis?
Symptoms * **Posterior heel pain**, swelling, burning, stiffness * shoe wear due tio direct presure * **progressive bony enlargement** of calcaneus at insertion site O/E * **Midline tenderness at insertion** of achilles tendon
44
What are the imaging useful for dx of insertional achilles tendonitis?
* XRay * Lateral xray foot may show spur nad intratendinous calcification * MRI/ultrasound * can show amount of degeneration
45
What is the histology of insertional achilles tendonitis?
* **Disorganised collagen with mucoid degeneration**, although few inflammatory cells
46
What is the tx of insertional achilles tendonitis?
Non operative * Activity modification, shoe modification, therapy * first line of tx * PT with eccentric training * gastronemius-soleus stretching * Shoe * **Heel sleeves and pads** * **small heel lift** * locked ankle afo 6-9 months ( if other nonop fail) * Injections- avoid steriods= risk of Achilles tendon rupture Operative * **Retrocalcaneal bursa excision, debridement of diseased tendonm calcaneal bony prominence resection** * failure of nonop mx and _\<50% of achilles_ needs to be removed * midline, lateral or J shaped incisions * **Tendon augmentation or transfer FDL/FHL or PB vs Suture anchor repair** * When _\>50% of achilles tendon insertion_ must be removed during thorough debridement
47
What is retrocalcaneal bursitis?
* **Inflammation of bursa between the anterior aspect of the Achilles and posterior aspect of calcaneus**
48
What is this?
* **Haglund deformity** * Enlargement of **posterosuperior tuberosity** of the **calcaneus**
49
Describe the epidemiology, signs and symptoms of retrocalcaneal bursitis and Haglund deformity?
* Young patients Signs * **Pain localised to anterior /2-3 cm proximal to achilles tendon insertion** * _Fullness and tendereness medial and lateral_ to tendon * Pain with _dorsiflexion_ * Bony prominence at achilles insertion
50
What imaging is useful in dx of haglund defomrmity and retrocalcaneal bursitis?
* Xrays * show haglund deformity * MRI- rarely required
51
What is the tx of haglund deformity and retrocalcaneal bursitis?
Non operative * Activity modification, shoe wear modification, PT, NSAIDS * first line * ice * shoewear- external padding of achillles tendon * Avoid steriod injections -\> tendon rupture Operative * Retrocalcaneal bursa excision adn resection of haglund deformity * **Refractory to non op measures** * Midline, lateral or medial J shaped incisions
52
What is the aetiology of achilles tendonitis?
* Overuse * imbalance of dorsiflexors & plantar flexors * poor tendon blood supply * Genetic redisposition * Fluoroquinolones antibiotics * inflammatory arthropathy
53
What is the pathoanatomy of achilles tendonitis?
* Theorized to **abnormal vascularity 2-6cm Proximal to achilles insertion** in response to **repetitive microscopic tearing of the tendon**
54
What is the classification of achilles tendonitis?
* **Achilles tendinosis** * _Tendon thickening_ * thought to be caused by **anaerobic degeneration in portion of tendon with poor blood suply** * **Achilles peritendonitis** * _inflammation of tendon sheath_ * ​Inflammation of paratenon
55
What are the signs and symptoms of achilles tendonitis?
Symptoms * _Pain, swelling,warmth_ * worse with activity * _difficulty running_ Signs * _Tendon thickening and tenderness 2-6cm proximal to achilles insertion_ * pain throughout entire ROM
56
What imaging is useful in dx of achilles tendonitis?
* MRI * disorganised tissue will show up as _intrasubstance intermediate signal intensity_ * **thicked tendon** * chronic rupture will show _hypoechoic region_ between tendon ends
57
What is the tx of achilles tendonitis?
Non operative * Activity modification, shoe wear modificiation, nsaids, PT * first line * PT with **eccentric training**- strengthen skeletal muscle- constant muscle tension whilst lengthening muscle- see pic * modalities- Ultrasound * shoewear * heel lifts * cast/removal boot ( severe disease) * **Non op is 65-90% successful** * **Glyceryl trinitrate patches-** evolving lack of evidence yet ​​Operative * **Percutaneous Tentomies** * Mild - moderate disease * _longitudinal tenotomy made in degenerate area_ * strip the anterior achilles tendon with a large suture to free adhesions * **Open excision of degenerative tendon with tubularisation** * mod- severe disease * _70-100% successful_ * **Tendon transfer= FHL/FDL/ PB** * _degeneration \>50% of achilles tendon_ * **\>55yrs old** * **MRI evidence of diffuse tendon thickening without focal area of disease**
58
What is the epidemiology of achilles tendon rupture?
* 18:100,000 per year * more common in men * most common in ages 30-40 risk factors * **episode athelete 'weekend warrior"** * **flouroquinolone antibiotics** * steriod injections
59
What is the mechanism of achilles tendon rupture?
* Usually traumatic during sporting event * may occur with * sudden forced plantar flexion * violent dorsiflexion in a plantar flexed foot
60
What is the pathoanatomy of achilles tendon ruptures?
* Rupture normally **4-6cm above calcaneus** in hypovascular location
61
Decribe the anatomy of achilles tendon ?
* Longest tendon in bocy * formed from **soleus** - * post fibular- post medial tibial to achlles tendon post 3rd of calcaneus * plantarflxoe of ankle * Tibial nerve * 2 heads of **medial and lateral gastronemius** * Medial head -post medial femoral condyle * lateral head - post lat femoral condyle * insert into achilles- calcaneus * Tibial nerve
62
What are the symptoms and signs of achilles tendon rupture?
* Hx- pt reports a **'pop'** Symptoms * weakness and difficulty walking * pain in heel Signs * Incease ankle dorsiflexion in prone position with knees bent * calf atrophy- chronic cases * palpable gap * Weakness to plantarfelxion * Thompson/**Symmons test**- calf squeeze and no passive Dorsiflexion
63
What investigations are useful in dx of achllles tendon rupture?
* Xray- rule out other pathology * USS- distinquish **partial from full thickness tear** * MRI- equivoical diagnosis, chronic tear will show retracted edges
64
What is the tx and indications of tx of achilles tendon rupture?
Non operative * Pt non op, medially frail,sedentry pt * Functional bracing/ equinus cast * 20 degrees of plantarflexion * **re-repture lower in early Wb with protective rom cf NWB cast** * **decreased plantarflexion strength** cf operative fixation * i**ncreased risk of re- rupture** cf op fixation * fewer wound complications Operative * **End to end achilles tendon repair** * \<3/12 old ruptures * No diff in re-repture rates cf consx * No sig diff in plantarflexion strength cf non op - both level 1 evidence * **percutaneous achilles tendon repair** * concerns over comesis of scar * risk of sural nerve damage * **Reconstruction with VY advancement** * Chronic ruptures w 4cm defect * **FHL transfer with VY advancement of gastronmenius** * chronic defect with gap .4cm
65
Describe the technique for acute achilles tendon repair?
* **_medial incision to achilles tendon_**- to avoid _sural nerve_ * Incise paratenon * expose edges * reapir heavy **non absorable suture** * imobilise in 20o planarflexion- to reduce skin tension and protect tendon repair 4-6 weeks
66
Describe the technique for v to y advancement for acute achilles tendon repair?
* V shaped incision, apex of v at musculotendinoius border limbs divergent to edge * V incised only thru superifical tendinous portion leaving muscle fibres intact
67
Describe the techque for repairt of achilles tendon injury with \>.4cm defect?
* FHL transfer and n V turndown of gastronemius * Excise degenerative tendon edges * Take FHL prox to knot of henry and ransfer thru calcaneus * FHl used to proximiity and vascular supply * V of gastronemiu 6cm long at apex and thru superficial tendon
68
What are the complication of achilles tendon repair?
* **Re-repture** * Generaly considered hiogher with non op 10-40% vs 2% but new level 1 evidence suggests no difference * **Wound healing complications** * **5-10%** * Risk factors * **smoking** * female gender * steriod use * Tx of chronic infection * debridment, no try at repair * culture specific antibiotics 6 weeks * Soft tissue coverage and reconstruction * **Sural nerve injury** * higher when percutanoeus approach used *
69
What is the mechanism for anterior tibilalis tendon rupture?
* Result of either **laceration** of the tendon * **Blunt trauma** * Most common in middle aged pts following **eccentric loading of a degenerative tibialis anterior tendon against plantar flexed foot**
70
Why is there a delay in diagnosis?
* **intact dorsiflexion** because of **EHL and extensor digitorium longus muscles**
71
Decribe the anatomy of tibialis anterior?
* origin- lateral condyle of tibia * inserts- **medial and planar surfaces of 1st cuneiform on base of 1st MT** * Action= dorsiflexion of ankle and INVERTOR of foot * **Deep Peroneal Nerve L4/5**
72
Name the secondary ankle dorsiflexors?
* **Extensor Hallucis longus** * origin- anterior surface of fibula * inserts- **base and dorsal centre of distal phalanx** * Action= **Extends Great Toe/ Dorsiflexes Ankle** * **Deep Peroneal nerve** * **Extensor Digitorium Longus** ( Nb long attachement and tendons)- see pic * origin- _lat condyle of fibula, 2/3-3/4 fibular shaft_ * inserts- splis into 4 tendon slips inserts into dorsum **middle & distal phalnanges** of toes * action= **extends toes 2-5 and Dorsiflexes ankle** * **Deep peroneal Nerve**
73
What are the signs of tibialis anterior tendon rupture?
* Traumatic injury * associated ossous or soft tissue injury * Pain and weakness on ankle dorsiflexion * Atraumatic injury * Pseudotumour at anteriomedial aspect of ankle * loss of ocntour of tibilalis anterior tenson over the ankle- see pic * use of EHL and EDC to dorsiflex ankle
74
What investigaitons are helpful in tibialis anterior tendon tears?
* Xrays * exclude bony injury * MRI * Helful to dx patial from incomplete tears
75
What is the tx of tibialis anterior tendon ruptures?
Non operative * Ankle- foot Orthosis * tx individualised ot pt Operative * **Direct repair** * More acute \<6 wks post injury * **R****econstruction with interposition of EDL or Plantaris** * **​**more in chronic injuries \>6weeks
76
What is the most common cause of flatfoot?
Posterior Tibial tendon insufficiency
77
What is the epidemiology of Posterior Tibial tendon insufficiency?
* More common **females** * often present **6th decade** * Risk factors * **obesity** * **older athletes** * **inflammatory disorders**
78
What is the mechanism of Posterior Tibial tendon insufficiency?
* Exact **aetiology unknown** * Assumed to be **MULTIFACTORAL** * **20% report acute injury**
79
Describe the pathoanatomy of Posterior Tibial tendon insufficiency?
* _Tendon degeneration occurs in_ the **watershed region distal to medial malleolus** * Begins as **_tenosynovitis a_nd progresses to significant _tendinosis_ with an incompetent, painful tendon that lacks exercusion** * **Medial longitudinal arch collapses, subtalar joint everts and heel goes into valgus** * **Achilles tendon is then held lateral to axis of rotation of subtalar joint and begins to act as an evertor of calcaneus. loss of longitudinal arc-\>fixed eqinus of hindfoot and contracture of achilles-\> equinus mechanically disadvantage-\> worsens collapse** * fixed bony deformities occur later
80
What conditions are associated with Posterior Tibial tendon insufficiency?
* Young males with Posterior Tibial tendon insufficiency may have * **Seronegative spondyloarthropathy** * **inflammatory arthropathy**
81
What is the anatomy of tibialis posterior?
* origin: posterior aspect of interosseous membrane, superior medial posterior of tibia * inserts- spits into **3** after passing **INFERIOR to plantar calcaneonavicular ligament and behind Medial malleolus** * _​anterior slip_ **inserts onto tuberosty of navicular/ medial cuneiform** (sometimes) * _middle slip_ inserts **2nd 3rd cuneiforms, cuboid and 2-5 MT** * _post slip_**- inserts sustenaculum tali** * ​Action- **INVERTOR of FOOT- primary** * **​Adducts foot** * **plantar flexes ankle** * **supinates foot** * **​TIBIAL Nerve L4/L5**
82
What is the blood supply of tibialis posterior?
* Branches of **posterior tibial artery** * A _watershed area_ of poor intrinsic blood supply exisits between **navicular and distal medial malleolus** ( _2-6cm proximal to navicular insertion)_
83
Decribe the biomechanics of tibialis posterior tendon?
* Lies in axis **posterior to tibiotalar joint** and **medial to aaxis of subtalar joint** * **_Primary dynamic support of arch_** * **Hindfoot INVERTOR** * **ADDUCTS **and **SUPINATES the forefoot suring stance phase of gait** * **acts as secondary plantar flexor of ankle**
84
Descirbe the classification system of Posterior Tibial tendon insufficiency?
* Johnstone and Stromm
85
Describe stage 1 of Posterior tibial insufficiency?
* **Tenosynovitis** * **No deformity** O/E * Single leg raise xray * Normal
86
Describe stage 2 of PTT insufficiency?
* **STAGE 2A** * **Flatfloot deformity** * **flexible hindfoot** * **Normal forefoot** * **unable to do SINGLE** heel raise * mild sinus tarsi pain * xray- arch collapse deformity * Stage 2B * Flatfoot deformity * Flexible HIndfoot * **Forefoot abduction too many toes \>40% Talonavicular coverage- important in tx** * unable to do SINGLE heel raise * mild sinus tarsi pain * xray- arch collapse deformity *
87
Descirbe stage 3 PTT insufficiency?
* Flatfoot deformity * **Rigid forefoot abduction** * **_Rigid hindfoot_** valgus * **Severe sinus tarsi pain** * **unable to do single leg stance** **​xray** * **arch collapse** * **subtalar arthritis**
88
Describe stage IV PTT insufficiency?
* Flatfoot deformity * Rigid forefoot abduction * rigid Hindfoot valgus * **Deltoid ligament compromise** * Ankle pain * severe sinus tarsi pain * Unable to single heel raise xray * arch collapse deformity * subtalar arthritis * talar tilt ankle mortise
89
What are the signs and symptoms of PTT insuficiency?
Symptoms * **medial ankle/foot pain** and **weakness** is seen early * progressive loss of arch * lateral ankle pain due to subfibular impingment is a late symptom Signs * **Pes planus**- collapse of medial arch * **hindfoot valgus deformity** * flexible stage 2 * rigid stage 3,4 * **Forefoot abduction** * **​stage 2B- 'too many toes sign'** * ROM * **Single limb heel rise** * unable to preform stage 2,3,4 * **Fixed or flexible deformity** * ​flexible stage 2 * fixed stage 3/4
90
What is seen on plain radiographs with PTT insufficiency?
Ap foot * Increased talonavicular uncoverage * increased talo- first metatarsal angle ( Simmons angle) * stage 2-4 Lateral * **Increased talo-forst MT ankle** = meary angle normal 0 * **decreased calcaneal pitch** * normal 17=30 * inidcates loss of arch height * **decreased medial cuneform- floor height** * Loss of arch height * **Subtalar arthritis** * stage 3 & 4 * **talar tilt due to deltoid insufficiency** * stage 4
91
Can you describe Meary's angle?
The angle formed between the talus and 1st metatarsal normal is 0 Angles \<4o = Ped planus
92
What are the other differentials of pes planus?
* **Midfoot pathology** * OA * Lis Franc Injury * I**ncompetent of Spring ligament** * primary static stabiliser of the talonavicular joint * Tx with adjunctive **spring ligament reconstruction** in addition to standard flatfoot reconstruction
93
What are the tx for PTT insufficiency?
non operative * Immobilisation in walking cast/boot 3-4 months * first line in stage 1 * Custom moulded shoe orthosis= **medial heel lift & longitudinal arch support** * stage 1 post immobilisation * Stage 2 * **Ankle foot orthosis** * stage 2-4 in low, sedentary pts * AFO most effectivewant medial orthotic post to support valgus collapse Operative * Stage 1= **Tensosynovectomy** * Stage 2= **FDL transfer, calcaneal osteotomy. TAL +/- forefoot correction osteotomy +/- spring ligament repair+/- PTT debridement** * **​**_Stage 2B= forefoot correction will needed to be done_ * ​CI= hypermobility, neuromuscular conditions. severe subtalar arthritis, obesity, age 60-70 * Stage 3= **Triple arthrodesis +TAL** * **Stage 4= Triple arthrodesis +TAL + deltoid ligament reconstruction** * **Stage 4** w rigid hindfoot, valgus talus, tibiotalar and subtalar arthritis**= Tibiotalocalcaneal arthrodes**
94
Why is FDL used in stage 2 disease?
* **FDL is Synergistic with tibialis posterior ** * can _augment function_ of deficient PT * **Insert FDL into navicular near insertion of PT** * FDL cf FHL - FHL more complicated to mobilise & not shown improved results * In midfoot FHL runs under FDL
95
What are the techniques for correcting hindfoot valgus?
* **Medial displacement calcaneal osteotomy** * in Stage 2A * [http://www.orthobullets.com/video/view?id=230](http://www.orthobullets.com/video/view?id=230) * **Evans Lateral column lengthening osteotomy** * in Stage 2B- forefoot ABDUCTION * [http://www.orthobullets.com/video/view?id=228](http://www.orthobullets.com/video/view?id=228) * ​To correct abduction * _​_**_Plantarflexion_ ( opening wedge) Medial cuneiform osteotomy - 'Cotton'- see pic** * in Stage 2B- forefoot **varus** correction after hindfoot corrective surgery * creates a plantigrade foot and retores tripod effect * [http://www.orthobullets.com/foot-and-ankle/7020/posterior-tibial-tendon-insufficiency-ptti](http://www.orthobullets.com/foot-and-ankle/7020/posterior-tibial-tendon-insufficiency-ptti) * Medial column fusion - of unstable medial column
96
Name the joints involved in a triple arthrodesis?
* Calcaneocuboid * Talonavicular * Subtalaar

Foot and Ankle FRCS (31 decks)

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