Tendon Injuries of the Foot and Ankle

History

Open injuries or lacerations to the anterior ankle should elicit suspicion of an acute injury to the anterior tibial tendon. Often, other structures may be injured concomitantly, including the extensor hallucis longus (EHL), the extensor digitorum longus (EDL), the superficial peroneal nerve, and the anterior neurovascular bundle. Hockey players are at added risk because of the potential for boot-top lacerations from the hockey skate.

Chronic ruptures are frequently missed initially because of the history of minor trauma that results in forced plantar flexion of the foot, sometimes with acute pain and the feeling of a “snap.” Once the initial swelling and symptoms resolve, patients may notice a painless mass in the anterior ankle as a result of retraction of the proximal tendon. Often the diagnosis does not become apparent until the patient or a family member notices difficulty with walking or using stairs, a high-stepping gait, or weakness with dorsiflexion. Although chronic ruptures are not typically athletic injuries, several chronic ruptures have been reported after sporting activities such as cross-country skiing and fencing. The differential diagnosis should include foot drop as a result of peroneal nerve palsy or L5 radiculopathy.

Physical Examination

In the chronic setting, swelling in the anterior ankle is a common finding. A mass (pseudotumor) may be palpable in the supramalleolar region as a result of retraction of the proximal tendon and is more commonly the presenting complaint in persons with chronic ruptures. Weakness to resisted dorsiflexion is expected but is isolated to the anterior tibialis with normal sensory findings, clearly differentiating this presentation from a radiculopathy or peroneal nerve palsy. High-stepping gait with recruitment of the toe extensors is likely ( Fig. 118.1 ). If the patient has a chronic rupture, secondary claw toe formation may occur as a result of extensor recruitment. Walking on the heels demonstrates loss of dorsiflexion of the affected side.

Imaging

Magnetic resonance imaging (MRI) and dynamic ultrasound are the two most common imaging studies used to confirm the diagnosis. If the clinical situation is obvious based on the history and physical examination, further imaging is not necessary. However, if surgical intervention is planned, these studies may be useful for preoperative planning. Sagittal MRI scans provide the best view of the amount of retraction and subsequent gapping at the rupture site.

Decision-Making Principles

Surgical repair of an acute open injury should be performed. In the chronic setting, the patient's activity and lifestyle should be considered when determining whether operative or nonoperative treatment is appropriate. In a sedentary patient or a patient with multiple medical comorbidities who is a high surgical risk, nonoperative treatment is appropriate. In these patients the need for pain-free ambulation is easily resolved with the use of an ankle-foot orthosis. Patients who lead active lifestyles or refuse to use long-term bracing are best treated with surgical intervention in all cases. Use of age as a criterion is no longer appropriate because it has been clearly documented that older patients do very well with surgical intervention. The presence of a gastrocnemius contracture should be evaluated in all patients, and a gastrocnemius recession should be performed when such a contracture is present to increase range of motion (ROM) and decrease strain on the repair.

Treatment Options

Acute ruptures should be treated with an end-to-end repair. When a laceration is the cause of the rupture, exploration of the wound is important to evaluate and repair concomitant tendon or neurovascular injuries. Timing, location of the rupture, and residual tendon quality are also important considerations. In the subacute setting (i.e., <6 to 8 weeks), primary repair may still be possible, but the surgeon should be prepared to use an autogenous or allogeneic graft if necessary. In the chronic setting, delayed reconstruction is often necessary and is usually achieved with either interpositional grafts or a tendon transfer. Interpositional autograft options include plantaris, EHL, EDL, peroneus tertius, and Achilles tendon. The most common tendon transfer uses the EHL into the medial cuneiform, followed by the EDL. Lengthening the anterior tibial tendon utilizing a sliding autograft or half-thickness transposition has also been described. When the rupture occurs at the insertion of the tibialis anterior on the medial cuneiform, direct repair to the medial cuneiform can be achieved with use of suture anchors or an interference screw if the quality of the tendon is good. If the quality of the tendon is poor, tendon transfer or allograft reconstruction is preferred.

Author’s Preferred Technique

Anterior Tibial Tendon Injury

The incision is centered over the course of the anterior tibial tendon; preoperative MRI or ultrasound may facilitate location of the proximal stump and guide incision length. The incision should be carried proximal to the site of the rupture to visualize the proximal stump. Distally the incision must be carried down to the proximal aspect of the distal stump. Exposure can be achieved through one long incision or two separate proximal and distal incisions to minimize morbidity and preserve the extensor retinaculum, depending on the severity and the ability to visualize the tendon stumps. In cases of insertional rupture, this maneuver requires exposure of the medial cuneiform. Preservation of the superior extensor retinaculum should be attempted to minimize adhesions. Débridement of abnormal and diseased tendon should be performed prior to repair; this presentation is more likely to be seen in the older population. The amount of débridement may be significant enough to preclude end-to-end repair of the tendon, and the surgeon should be prepared to perform a graft reconstruction or tendon transfer in each case.

Intratendinous Rupture

In the setting of an acute intratendinous rupture, the proximal and distal stumps are prepared with a locking whipstitch. My preference is no. 0 nonabsorbable suture. Tension is placed on both the proximal and distal stumps, and the tendon should be apposed at neutral dorsiflexion of the ankle. In cases of late presentation, the proximal stump is contracted and direct apposition may not occur immediately. By placing traction on the proximal stump for 10 to 15 minutes, the muscle can be relaxed and end-to-end repair may be possible, mitigating the need for graft reconstruction. Placing additional suture crossing at the rupture site minimizes gapping of tendon under tension; this reinforcement can be performed with multiple figure-of-8 sutures on the anterior and posterior aspects of the tendon. The tendon should not demonstrate any gapping with intraoperative plantar flexion of the ankle.

Chronic intratendinous ruptures or cases in which débridement has created a tendon gap cannot be repaired with end-to-end fixation. For the reconstruction to be successful, the proximal muscle belly of the anterior tibial tendon must be healthy and viable. Critical aspects of the procedure are exposure of the muscle with release of any scar tissue and ensuring that elasticity is present. If the muscle is fibrotic and nonviable, a tendon transfer should be performed as described later in this chapter. Anterior tibial tendon or hamstring allograft, or hamstring autograft, can be used to bridge the gap in this case. A doubled or quadrupled hamstring graft should be used given the cross-sectional diameter of the normal anterior tibial tendon. Side-to-side tenodesis or placement of the graft through a soft tissue tunnel using the Pulvertaft weave technique within the proximal and distal stump of the tendon can be performed. Fixation to the proximal stump can be performed initially. Distal fixation can be performed either with a side-to-side tenodesis to the distal stump or through bone tunnel fixation into the medial cuneiform if the soft tissue quality of the distal stump is questionable. The use of fluoroscopy in conjunction with a guide wire facilitates placement of the bone tunnel. The ankle should be held in neutral dorsiflexion with maximal tension placed on the proximal limb. Fixation is then completed distally with multiple nonabsorbable sutures (my preference is no. 0) to the distal stump. In the setting of a bone tunnel through the medial cuneiform, an appropriately sized interference screw based on the circumference of the graft can be used, or the graft can be sewn upon itself. The use of a soft tissue button on the plantar aspect of the foot is a useful adjunct to fixation to further decrease the risk of pullout. After fixation, the sheath of the anterior tibial tendon is closed to prevent bowstringing of the reconstruction.

An alternative option to the use of a graft is an EHL transfer to reconstruct the anterior tibial tendon. An additional incision is made distally at the level of the first metatarsophalangeal joint, exposing both the EHL and extensor hallucis brevis. The EHL is affixed by tenodesis to the extensor hallucis brevis with the interphalangeal (IP) joint held in 20 degrees of dorsiflexion. The EHL is then sectioned immediately proximal to the tenodesis. The EHL is then passed through the medial cuneiform through a bone tunnel, and fixation can be performed with an interference screw or the tendon can be sewn back onto itself. The foot should be held in neutral with maximum tension placed on the tendon. Proximally, the stump of the anterior tibial tendon is secured to the EHL in a side-to-side fashion with moderate tension. Given the decreased power of the EHL relative to the Achilles tendon, an EHL transfer is more successful in the setting of a proximal tenodesis to increase the power that can be generated for dorsiflexion.

In the setting of a completely nonviable proximal anterior tibialis muscle belly, an isolated EHL transfer is unlikely to return full function. In this setting, transfer of the peroneus brevis or the posterior tibial tendon (PTT) may be required to provide sufficient dorsiflexion power.

Insertional Rupture

Insertional ruptures require a different approach relative to intratendinous ruptures. The lack of an adequate distal stump precludes tendon-to-tendon fixation. In these cases, fixation to the medial cuneiform with the aid of suture anchors is the most effective method. To maximize pullout, two suture anchors should be used and placed 45 degrees relative to the line of pull of the tendon, with the tip of the anchor angled proximally. Given the broad insertion of the tendon, one anchor can be placed within the medial cuneiform and the second anchor can be placed within the navicular or proximal aspect of the first metatarsal depending on the anatomy of the tendon and directed from plantar medial to dorsolateral. In the setting of a chronic rupture, use of a graft or an EHL transfer can be performed as previously described ( Fig. 118.2 ).

Postoperative Management

The patient's ankle is typically immobilized with a splint or cast and the patient is restricted from weight bearing for at least 2 to 4 weeks. For more complex or tenuous repairs, this period of nonweight bearing may be extended to a total of 6 to 12 weeks at the discretion of the surgeon. Patients are typically transitioned to a removable boot at 6 weeks, and weight bearing is started. Gentle ROM may be initiated; however, passive plantar flexion past neutral is avoided until 12 weeks after surgery. At 12 weeks most patients can be weaned from the boot and strengthening can be started. Athletic activities and high-impact activities are avoided for 6 months.

Results

One study showed comparable outcome scores between patients treated operatively and nonoperatively. However, an age bias was present and recognized by the authors, as elderly patients were treated nonoperatively and younger active patients were treated operatively. The authors still recommended surgical repair or reconstruction in younger patients with an active lifestyle. Four recent studies examined the results of surgical repair or reconstruction in both acute and chronic ruptures. A total of 56 anterior tibial tendon ruptures were included in the four studies. Seventeen ruptures were repaired primarily and reconstruction was delayed for 39 ruptures, including 12 EHL tendon transfers, 3 EDL tendon transfers, and 24 interposition autogenous grafts. The four studies all showed improved outcome scores and high patient satisfaction. Although dorsiflexion strength was noted to be weaker compared with the nonoperative side, primary repair compared with delayed reconstruction showed no difference in dorsiflexion strength. To decrease the morbidity of autograft harvest or tendon transfer, there is a trend toward the use of interpositional allograft reconstruction as opposed to tendon transfer, especially in those cases with large (>4 cm) gaps. One recent study utilizing primarily anterior tibial tendon and semitendinosis allografts showed this technique to be a safe and reliable alternative with satisfactory strength, good patient reported outcomes and no allograft-associated complications. The importance of a healthy anterior tibial muscle belly free of fatty infiltration or fibrosis cannot be overstated when utilizing this allograft technique.

Complications

Complications of nonoperative treatment include a flat, pronated foot, decreased ankle motion, and Achilles contracture. Operative complications were rare but included wound dehiscence, tendon adhesion to the extensor retinaculum, superficial peroneal nerve entrapment, and early failure requiring revision of interpositional autograft and tendon transfer operations.

History

Acute dislocations of the PTT usually occur after forced dorsiflexion and inversion of the ankle in the setting of a violent contraction of the posterior tibial muscle. The diagnosis is often missed initially, which leads the patient to report medial ankle pain or possibly a snapping sensation. Patients with tendinitis also report medial ankle pain and swelling that gets worse with activity. In athletes this pain may be debilitating because of the inability to run properly or perform any athletic activity that requires a strong push-off action. The athlete may note worsening pain with elevating on the toes. In the chronic setting of any of the aforementioned entities, patients may report a progressive collapse of the arch with associated valgus position of the heel.

Physical Examination

Tenderness with or without swelling at the medial aspect of the ankle along the course of the PTT is a hallmark of any PTT disease. The tenderness may be primarily in the retromalleolar region, at the insertion of the tendon on the navicular, or along its entire course. In the setting of an acute or chronic dislocation, the tendon may be palpated as a cordlike structure anterior to the posteromedial ridge of the medial malleolus, although this finding is not always present. Resisted inversion of the foot with dorsiflexion or plantar flexion may elicit instability of the tendon, although again this finding is uncommon. A high degree of clinical suspicion is necessary to accurately diagnose acute or chronic PTT dislocation because these pathognomonic findings are variable. Resisted inversion of the foot while the ankle is plantar flexed should be tested. The ability to perform a single-limb heel raise should be tested because this maneuver isolates the PTT and is associated with inversion of the heel ( Fig. 118.3 ). Patients who report medial ankle pain when attempting the single-limb heel raise or who are unable to perform this test should be suspected of having a pathologic condition of the PTT. The presence of an asymmetric pes planus deformity and hindfoot valgus is an indication that chronic PTTD is present. ROM of the hindfoot in inversion and eversion, as well as adduction and abduction of the transverse tarsal joints, should be tested to determine the flexibility of the deformity.

Imaging

Radiographs, MRI, and ultrasound are commonly used to confirm or diagnose pathologic conditions of the PTT. In the setting of PTT dislocation, standard ankle radiographs may show a chip fracture of the medial aspect of the medial malleolus, representing disruption of the flexor retinaculum. Axial MRI scans may show the dislocated PTT sitting anterior to the disrupted flexor retinaculum, as well as the depth of the retromalleolar groove. However, if the tendon is appropriately located, bone edema present in the posteromedial aspect of the medial malleolus may be an indication that an injury occurred to the flexor retinaculum with associated tendon instability ( Fig. 118.4 ). In these cases, dynamic ultrasound can be extremely useful to visualize the subluxation or dislocation of the PTT over the ridge of the medial malleolus. Associated tendon tears and excessive fluid in the tendon sheath can be visualized with either MRI or ultrasound. In the chronic setting, standing foot radiographs may demonstrate a pes planus deformity through an apex plantar lateral talo-first metatarsal angle, plantar gapping at the naviculocuneiform or first tarsometatarsal joint, or increased talonavicular uncoverage on the anteroposterior (AP) view. Hindfoot alignment views can also delineate the extent of hindfoot valgus that is present. Debate exists about whether ultrasound or MRI provides a better evaluation of the extent of PTT disease in the chronic setting.

Decision-Making Principles

Early diagnosis of PTT dislocation is difficult, which often leads to late presentation. If clinical suspicion is high and early diagnosis is achieved, it is reasonable to attempt conservative treatment with immobilization as long as the tendon is reliably located in the retromalleolar groove. However, because most cases have a delayed presentation, persistent symptoms are best treated with surgical intervention.

Acute PTT ruptures are most common in association with ankle fractures. When an acute rupture is identified during fracture fixation, primary repair should be performed in the same setting.

Posterior tibial tendinitis is almost exclusively treated conservatively initially because most patients, in particular younger patients and athletes, respond to nonoperative treatment. In the patient who does not respond to physical therapy, bracing modalities, and immobilization, surgical intervention is an option.

PTTD is an often-discussed and sometimes controversial topic. Initially, stage I PTTD should be treated conservatively. Most cases abate or resolve, although rarely, surgical intervention is warranted despite no progressive loss of arch. With progressive degeneration and failure of the PTT, ligament failure occurs, leading to the flexible flatfoot deformity described in stage II. The spring (calcaneonavicular) ligament attenuates, leading to the collapse of the talonavicular joint, and the interosseous ligament of the subtalar joint becomes involved, leading to a hindfoot valgus deformity. Initially stage II PTTD should also be treated conservatively, because many patients subjectively and functionally improve. However, if symptoms do not improve, surgical intervention should be considered prior to the development of a rigid deformity. This process can take many years; however, the surgical reconstruction of a rigid deformity (usually a triple arthrodesis) has significantly more morbidity than the joint-sparing procedures used to reconstruct a flexible flatfoot.

Treatment Options

Delayed presentation of a PTT dislocation commonly leads to surgical intervention based on persistent symptoms. The hallmark of surgery is retinaculum repair (if the tissue is amenable to repair) versus reconstruction. If advanced imaging shows evidence of a shallow retromalleolar groove, a groove-deepening procedure should be considered. Evaluation for concomitant injuries, such as a deltoid ligament tear, flexor digitorum longus (FDL) tear, or intra-articular ankle disease, should also be conducted, and these injuries should be addressed if they are identified.

Conservative treatment for posterior tibial tendinitis first involves ankle bracing and physical therapy. If a pes planus deformity is present, orthotics with a longitudinal arch support with medial heel posting may provide some relief. If the pain is moderate to severe with even limited activity, immobilization in a walking boot is appropriate. When conservative treatment fails, surgical options include an open surgical release of the tendon sheath, tendoscopy, and/or possible FDL tendon transfer. Open release of the tendon sheath involves excision of scar tissue, a partial tenosynovectomy, and possibly intratendinous débridement if degenerative lesions are present ( Fig. 118.5 ). Tendoscopy is a less invasive option that has gained in popularity in recent years, and can be utilized both for diagnostic purposes and to perform tenosynovectomy, release of adhesions, and débridement of partial tears. If the tendon is excessively degenerated and is deemed to be insufficient, an FDL tendon transfer may be necessary and is the most commonly performed procedure for this problem. In all surgical cases, evaluation for a possible gastrocnemius contracture should be undertaken and surgical release should be performed if such a contracture is present. Additionally, a concomitant medial slide calcaneal osteotomy can be considered in the setting of an FDL transfer despite lack of clinical deformity to prevent late recurrence.

The surgical options for stage II PTTD depend on the extent of the patient's dysfunction, as well as certain specific components of the developed deformity. Many patients with PTTD have a concomitant gastrocnemius contracture, and when such a contracture is present, a gastrocnemius recession should be performed. Second, the PTT itself should be evaluated and an FDL tendon transfer is performed to reconstruct the dynamic function of the tendon. The extent of PTT disease can vary from a mildly thickened tendon to severe degeneration with longitudinal and sometimes complete ruptures. In the case of moderate to severe degeneration of the tendon, the diseased tendon is resected, leaving the distal stump on the navicular. In the case of mild degeneration of the tendon, some surgeons opt to leave the PTT in place, whereas others choose to excise the tendon regardless of the extent of disease. Either way, an FDL tendon transfer is nearly always performed to augment the function of the damaged tendon. Third, because stage II PTTD implies a hindfoot valgus deformity, a medial displacement calcaneal osteotomy is usually performed to translate the weight-bearing portion of the heel back underneath the mechanical axis of the leg. These three procedures account for a high proportion of the surgical treatment options in a patient with stage II PTTD. However, for a more advanced disease process that is not yet rigid, other options are available. The spring ligament should always be evaluated and either repaired or reconstructed if it is torn or insufficient. With significant forefoot abduction (evidenced by significant talonavicular uncoverage on the AP foot radiograph), a lateral column-lengthening procedure can be performed. Options for lateral column lengthening are either through the anterior process of the calcaneus or through a calcaneocuboid distraction arthrodesis, although most surgeons today prefer to use the anterior process of the calcaneus. With midfoot collapse of either the first tarsometatarsal or naviculocuneiform joint, an associated arthrodesis of the involved joint helps to stabilize the medial column. This procedure also corrects a residual forefoot varus deformity, as does a plantar flexion osteotomy through the medial cuneiform.

Author’s Preferred Technique

Posterior Tibial Tendon Injury

Flexor Retinaculum Reconstruction

A curvilinear medial approach just posterior to the medial malleolus is made along the course of the PTT. The PTT and its sheath are evaluated for a possible false pouch anterior to the medial malleolus. A U-shaped flap consisting of retinaculum and medial malleolus periosteum is developed and cut anteriorly so that it is left attached to the posterior portion of the retinaculum. A trough is created at the anterior ridge of the retromalleolar groove using a small burr and is smoothed down with a rasp followed by bone wax. The retinaculum-periosteal flap is then passed into the trough from deep to superficial using intraosseous nonabsorbable sutures that lie posteriorly, minimizing soft tissue irritation. After imbrication of the retinaculum, the tendon should be stably located within the groove through all ROM of the ankle.

Posterior Tibial Tendoscopy

In a supine position without a hip bump, anatomical references including the navicular tuberosity, medial malleolus, and PTT are marked. The first portal is established about 2 cm distal to the medial malleolus along the course of the PTT sheath. A 2.7 mm arthroscope with saline inflow is used with a 30-degree inclination angle. The second portal is established about 2 to 4 cm proximal to the medial malleolus. A third portal can be established about 7 cm proximal to the medial malleolus for visualization of the myotendinous junction if necessary. The second portal typically serves as a working portal for blunt probe and shaver. Diagnostic evaluation is performed, with tenosynovectomy, release of adhesions, and possible tendon débridement as needed ( Fig. 118.6 ).

Posterior Tibial Tenosynovectomy and Débridement

The tendon is approached as previously described, the PTT sheath is incised, and the tendon is evaluated. Diseased synovium is excised, with the incision extended as needed to ensure adequate débridement. Degenerative portions of the tendon are identified by the thickened and amorphous appearance (smooth with a lack of striations). The diseased portion is incised longitudinally, the nonviable portion is excised, and the longitudinal rent is repaired with running 3-0 Prolene sutures. Care is taken to avoid creating a full-thickness disruption of the tendon, resulting in discontinuity. The tendon sheath is then closed to prevent subluxation. If more than 50% of the tendon has been débrided, a concomitant FDL tendon transfer is indicated.

Flexor Digitorum Longus Tendon Transfer

The same approach to the PTT is used, extending it distal along the medial border of the foot. In these cases, the severity of tendon degeneration does not allow for repair and therefore it is resected, leaving a 1-cm stump on the navicular tuberosity for fixation. Securing the tendon to this distal stump theoretically allows the FDL to restore the stabilizing effect to the plantar midfoot through the multiple distal connections of the PTT. Isolated reconstruction to the navicular does not allow for restoration of this critical function of the PTT. The FDL tendon sheath is incised in the floor of the PTT sheath, inferior to the medial malleolus, and opened to a point 2 to 3 cm distal to the navicular tuberosity. The FDL tendon is dissected from its attachments to the flexor hallucis longus (FHL; master knot of Henry) and transversely cut as far distal as possible. Distal tenodesis can be performed at this point to help restore the function of the FDL; however, given the lack of gait disturbance, it is not required and is not routinely performed in my practice. A more proximal transection of the FDL, proximal to the knot of Henry, preserves the interconnections between the FDL and FHL but results in less tendon length for reconstruction. A 4.5-mm drill hole is created in the medial navicular tuberosity from dorsal to plantar, using fluoroscopy as a guide for placement of the hole. While holding the foot in 20 degrees of inversion and 20 degrees of plantar flexion, the FDL is delivered through the drill hole from plantar to dorsal, an appropriately sized interference screw is placed typically from dorsal to plantar, and any residual tendon is sutured to surrounding periosteum and the PTT stump using size 0 nonabsorbable suture. Tensioning is critical and the foot should not be able to evert past neutral after repair. Alternatively, especially in the setting of a short segment of FDL, the tendon can be sutured directly to the stump of the PTT or fixed to the navicular with dual suture anchors. No clinical superiority of fixation has been demonstrated.

Medial Displacement Calcaneal Osteotomy

To perform a medial displacement calcaneal osteotomy, make an incision posterior and inferior to the course of the peroneal tendons along the lateral hindfoot at 45 degrees to the plantar border of the foot. Dissect through subcutaneous tissues while avoiding sural nerve branches. Sharply incise through periosteum along the line of the incision and elevate 2 to 3 mm of periosteum dorsally and plantarly. Check the position of the planned osteotomy by inserting a small Kirschner (K) wire or saw blade and assessing the position under fluoroscopy with a lateral and axial heel alignment view. Adjust as needed and perform the osteotomy using a larger saw blade, being careful to just perforate the far cortex to avoid injury to medial neurovascular structures; alternatively, the medial cortex can be perforated with an osteotome. Mobilize the posterior fragment using a wide osteotome or elevator, taking care not to crush the soft cancellous bone. Use of a wide elevator can minimize this complication. Translate the posterior tuberosity medially from 8 to 10 mm. Place one 6.5-mm partially threaded cannulated screw and check its position using lateral and axial fluoroscopy. Given the medial translation, the screw should be inserted relatively lateral on the tuberosity so that it remains with the distal calcaneus. Plates have also been developed for fixation, but given the low cost of the implant and high clinical success rate of screw fixation, they are not routinely used in my practice. Minimally invasive techniques have also recently been described and are gaining in popularity.

Postoperative Management

Patients who have undergone a flexor retinaculum reconstruction have a splint placed postoperatively and are instructed not to bear weight. After 2 weeks, a short leg cast or walking boot is applied and weight bearing is initiated. Six weeks after surgery an ankle lace-up brace is applied and ROM is initiated and progresses over the next 6 weeks. Physical therapy can be started for ROM and strengthening.

For patients undergoing posterior tibial tendoscopy, early motion is important. Patients can either be placed in short leg splint for 7 to 10 days or into a weight-bearing tall boot immediately. Early ROM exercises are initiated including active inversion and eversion, depending on the severity of the tendon disease seen intraoperatively. Patients are transitioned into an ankle lace-up brace at 4 to 6 weeks postoperatively, with consideration for formal physical therapy.

Patients who have undergone a tenosynovectomy for posterior tibial tendonitis are treated initially with a splint for the first 2 weeks, followed by the use of a removable walking boot for 4 weeks. Early ROM exercises are initiated and physical therapy can be considered, especially in athletes who are trying to return to play. At 6 weeks an ankle lace-up brace is worn, and full activity is allowed at between 6 and 8 weeks. For each of the aforementioned procedures, full return to sporting activity is variable but is expected at around 3 to 4 months after surgery. Use of an over-the-counter full-length arch support is encouraged to minimize recurrence.

Reconstructions for flatfoot deformity entail a longer recovery period. Patients wear a splint for the initial 2 weeks with the foot in an inverted and plantar-flexed position. A short-leg non-weight-bearing cast or controlled ankle motion boot is then used for 4 weeks, followed by weight bearing in a tall walking boot for 4 to 6 weeks. Physical therapy can be initiated about 8 to 10 weeks after surgery with an emphasis on inversion strengthening, with concomitant use of a lace-up ankle brace for a further 3 months. Sporting activity usually cannot be resumed until about 6 to 9 months postoperatively with the use of an over-the-counter orthotic to minimize stress on the reconstruction.

Results

Lohrer and Nauck performed a systematic review of the literature regarding PTT dislocations and noted a higher prevalence than originally thought. Nearly 60% of the injuries were induced by sport. Of the 61 cases reported, only 10 were treated conservatively. Surgical treatment included a variety of retinaculum reconstruction techniques, direct suture repair, and retromalleolar groove deepening combined with reconstruction or repair. Results were rated as excellent in 80%, good in 13%, and fair in 7%. No comparison between surgical and conservative treatment could be performed.

Most of the studies evaluating posterior tibial tendoscopy report good results with low complication rates, albeit with relatively low patient numbers. One study showed good results when treating pathologic vincula and synovitis associated with rheumatoid arthritis, but release of adhesions was less successful. The most recent study showed significant improvement in functional outcome scores and a potential improvement in diagnostic accuracy compared to MRI. Further studies are needed, but tendoscopy is a promising tool that allows for fewer wound problems, less morbidity, and earlier mobilization and recovery compared to open procedures.

Tenosynovectomy for posterior tibial tendinitis has generally good results. McCormack et al. published a series on tenosynovectomy in young competitive athletes. Twenty-two months after surgery, seven of eight patients had returned to full sports participation without difficulty. Teasdall and Johnson reported results on 19 patients treated with synovectomy and débridement for stage I PTTD. Complete relief was reported by 74% of patients, whereas 16% had minor pain, 5% had moderate pain, and 5% had severe pain. Only 10% required conversion to a subtalar arthrodesis for progressive deformity and pain.

As the treatment of PTTD has evolved, so have the reported results in the literature. Alvarez et al. reported the result of a structured nonoperative management protocol for stage I and stage II PTTD involving the use of a short-articulating ankle-foot orthotic and an aggressive physical therapy protocol including a home program. Their patients had successful subjective and functional outcomes 83% of the time, whereas only 11% did not respond to conservative treatment and required surgery. Surgical intervention has also been shown to be beneficial in patients who do not respond to nonoperative treatment. Combining FDL transfer with a medial displacement calcaneal osteotomy has been shown to restore functional inversion and provide excellent pain relief and patient satisfaction, with variable radiographic and patient-perceived arch correction.

Complications

The most common complication of PTT dislocation is missed diagnosis leading to delayed presentation, because 53% of patients in a systematic review were initially misdiagnosed. Low complication rates are reported for posterior tibial tendoscopy, with the most common being persistent pain as indications are still being evaluated. Tenosynovectomy for posterior tibial tendonitis is well tolerated with few reported complications, although if the tendon dysfunction is more chronic than originally thought, progression of the deformity may require further surgical intervention. Complications of PTTD correction include undercorrection with persistent pain, overcorrection resulting in varus hindfoot, and rarely, neurovascular injury either at the calcaneal osteotomy site or the FDL harvest site.

Future Considerations

The treatment of PTT injuries and dysfunction will likely continue to evolve. Tendoscopy techniques offer promise as appropriate indications are determined and instrumentation is improved. The importance of the spring ligament in both acute injuries and chronic PTTD has been demonstrated. Determining which patients will benefit from spring ligament repair or reconstruction and what effect this will have on the overall treatment algorithm is an area of current research. Novel rehabilitation protocols and early diagnosis may also lead to improved outcomes and more refined surgical protocols.

History

The most common presenting complaint is pain in the posteromedial ankle that is worsened with activity. Chronic repetitive plantar-flexion activities such as en pointe dancing tend to exacerbate the symptoms. Triggering of the hallux may also be present in patients in whom a stenosing tenosynovitis has developed. Triggering occurs as a result of a bulbous thickening of the FHL that causes the hallux to lock as the FHL attempts to pass through the fibro-osseous tunnel with plantar flexion or dorsiflexion of the ankle. Patients may also report limited dorsiflexion of the hallux, again as a result of stenosis at the proximal level of the fibro-osseous tunnel. Other less common complaints include pain medial and deep to the medial band of the plantar fascia in the midfoot and pain plantar to the first metatarsal.