Ligamentous and Tendon Injuries About the Ankle

1
Ligamentous and Tendon Injuries About the Ankle

• Erik N. Kubiak, MD
• Kenneth A. Egol, MD
• New York University-Hospital for Joint Diseases
• Original Authors J. Stephen Brecht, MD and Neil
  F. Watnik, MD March 2004
• New Authors Erik N. Kubiak, MD Kenneth A.
  Egol, MD Revised June 2006

2
Outline

• Ankle and Foot Anatomy
• Lateral and Medial Ankle Sprains
• Syndesmotic Injuries
• Ankle Dislocations
• Achilles Tendon Ruptures
• Peroneal Tendon Dislocations
• Poster Tibial Tendon ruptures

3
Ankle Anatomy

• Distal fibula and distal tibia form a bony
  mortise that allows talar dorsiflexion and
  plantarflexion
• Talar body is wider anterior than posterior which
  leads to less stability with plantarflexion and
  internal rotation

4
Talar Anatomy

• The talus has a shallow bicondylar appearance
  that has reciprocal articulations on the tibial
  plafond
• Injuries that leave the ankle unstable can change
  the ankle articulation and contribute to
  premature articular cartilage damage

5
Medial Collateral Ligaments

• Superficial
• Superficial talotibial, naviculotibial, and
  calcaneotibial fibers
• Deep
• Deep anterior talotibial and posterior talotibial
  fibers from posterior colliculus to talus
• Strongest portion of the Deltoid ligament

6
Lateral Collateral Ligaments

• Anterior Talofibular Ligament
• First injured in lateral sprain with
  plantarflexed ankle
• Calcaneofibular Ligament
• Strongest lateral ligament
• First injured in lateral sprain with dorsiflexed
  ankle
• Posterior Talofibular Ligament

7
Syndesmosis

• Anterior inferior tibiofibular ligament
• Posterior inferior tibiofibular ligament
• Transverse tibiofibular ligament
• Interosseous membrane

8
Anatomy

• Tendons
• Achilles Tendon
• Posterior Tibial Tendon
• FDL and FHL
• Tibialis Anterior tendon
• Vessels
• Saphenous vein anteriorly
• Posterior tibial artery
• Nerves
• Tibial nerve posteriorly

9
Anatomy

• Tendons
• Peroneus Brevis
• Peroneus Longus
• Nerves
• Superficial peroneal nerve
• Sural nerve

10
Anatomy

• Extensor retinaculum
• Tendons
• Tibialis Anterior
• EHL
• EDL
• Dorsalis Pedis Artery
• Deep Peroneal Nerve

11
Ankle Sprains

• Most common ligamentous injury
• One sprain per day per 10,000 people
• 40 will have intermittent chronic problems
  (Garrick, Am J Sports Med, 1977)
• More common on the lateral aspect of the ankle

12
Ankle Sprain

• Differential Diagnosis
• Syndesmotic Injury
• Peroneal tendon subluxation
• Posterior tibial tendon tear
• Achilles tendon tear
• 5th metatarsal base fracture
• Midfoot injuries
• Lateral talar process fracture
• Anterior process of calcaneus fracture

13
Ankle Sprain

• History
• Description of the injury
• Position of the ankle during the injury
• Able to continue to play or bear weight
• Previous injury
• Site of injury

14
Ankle Sprain

• Physical Exam
• Palpation over medial and lateral malleoli
• Palpation over deltoid ligament
• Palpation over ATFL, CFL, and PTFL
• Neurovascular exam
• Anterior drawer test for ATFL
• Talar tilt to assess CFL
• Squeeze test to look for syndesmotic injury

15
Ankle Sprains

• Most common mechanism of ankle injury is
  inversion stress with plantarflexion
• May lead to ankle fracture, sprain, or
  syndesmotic injury
• Abduction or adduction are other mechanisms

16
Ankle Radiographs

• AP of the Ankle
• AB lt 5mm is normal
• BC gt 10 mm is normal

17
Ankle Radiographs

• Mortise View
• Ankle internally rotated
• AB clear space
• BC
• Talocrural angle (83 degrees)
• Medial clear space lt4 mm

18
Ankle Stress Radiographs

• Talar tilt view
• Ankle block allows better exam
• Demonstrates complete ligamentous instability
• Talar tilt lt2 mm
• External rotation view
• Useful in identifying syndesmotic injury

19
Ankle Stress Radiographs

• Anterior drawer stress view
• No fracture seen
• gt3 mm anterior translation compared to
  contralateral side or gt10 mm translation
• Incongruency of ankle joint present
• Ligamentous instability present

20
Ankle Sprain Classification

• Histologic Classification
• Grade I Ligamentous stretching without
  macroscopic tearing
• Grade II Partial macroscopic tearing
• Grade III Complete ligamentous rupture

21
Ankle Sprain Classification

• Anatomic Classification
• Grade I ATFL disruption
• Grade II ATFL and CFL disruption
• Grade II Complete ligamentous disruption
• Clinical Grading
• Grade I
• Stress tests normal
• Grade II
• Increased pain swelling
• May have positive stress tests
• Grade III
• Severe pain swelling
• Positive stress tests

22
Lateral Ankle Sprains

• Commonly missed diagnoses
• Peroneal tendon injuries
• Achilles injuries
• FXs
• Lateral process of talus
• Anterior process of calcaneus
• Fifth metatarsal
• Lisfranc injuries
• Osteochondritis dessicans

23
Lateral Ankle Sprains
Lateral Process FX of the Talus Snowboarders
injury
24
Lateral Ankle Sprains

• X-rays are based on careful physical exam
• MRI rarely indicated in the acute setting
• Consider stressing syndesmosis and Lisfranc
  joints if injury is suspected

25
Ankle Sprain Treatment

• RICE (Rest, Ice, Compression, Elevation) with
  ankle brace initially and protected weight
  bearing for Grade I and II
• ROM exercises
• Peroneal strengthening and proprioceptive
  training
• Bracing or taping for 4-6 weeks depending on
  activity
• Return to sports when able to cut without pain
• Severe sprain may require up to 6 months of
  protective bracing

26
Ankle Sprain Treatment

• Grade III sprain may require a walking boot or a
  cast for 4 6 weeks
• Extended period of protective bracing may be
  warranted
• Return to play criteria remain the same
• Need to be aware of possibility for syndesmosis
  injury (high ankle sprain)

27
Lateral Ankle Sprains

• Management surgical
• Acute surgical repair not supported by literature
• symptomatic chronic instability may require
  surgical intervention
• Anatomic Brostrom repair favored over nonanatomic
  rerouting procedures

28
Medial Ankle Sprain

• 5 ankle sprains
• Forced eversion
• Injury to deltoid ligament
• May be associated with syndesmotic injury and/or
  Weber C fibula FX

29
Medial Ankle Sprain

• Tenderness/swelling over deltoid
• External rotation test elicits pain in the
  deltoid and possibly in syndesmosis

30
Medial Ankle Sprain

• AP/LAT/OBLIQUE ankle x-rays to assess mortise and
  syndesmosis
• Medial joint space widening
• Syndesmotic widening
• Presence fibula FX
• Consider external rotation stress x-rays if
  syndesmotic disruption is suspected

31
Medial Ankle Sprain

• Management
• Stable (no talar subluxation)
• Similar to lateral sprains
• RICE, early wgt bearing, early ROM, functional
  brace, functional rehab
• Unstable (talar subluxation)
• No talar subluxation is acceptable
• Anatomic reduction and surgical stabilization of
  syndesmosis

32
Chronic Lateral Ankle Instability

• Persistent mechanical instability of the
  talocrural joint
• Develops after acute rupture in up to 20 of
  patients
• Related to functional lateral ankle instability
• Defined by frequent sprains, diff running on
  uneven surfaces, diff jumping or cutting
• Related to previous ankle sprain, chronic ankle
  instability, peroneal weakness
• Treatment supervised rehabilitation program
  focusing on peroneal strengthening,
  proprioception, and coordination

33
Surgical Indications Chronic Ankle Instability

• Continued instability or recurrent injury despite
  supervised rehabilitation and functional bracing
  (Semirigid pneumatic ankle brace).
• Surgical treatments
• Evans Procedure- recon using entire P.Brevis
• Watson-Jones entire P.Brevis anatomic recon ATFL
  
• Chrisman-Snook recon ATFL and CFL using split P.
  Longus graft
• Modified Brostrom procedure direct repair of
  ligament, modified by Gould such that inferior
  ext retinaculum is used to reinforce repair

34
Ligament Reconstructions

• These procedures use the peroneal tendons to
  reconstruct the lateral ligamentous complex
• Higher complication rates than Brostrom
• More restricted ankle and subtalar motion
  (Colville, JAAOS, 1998)

35
Ligament Repair Modified Brostrom

• Repair of the ATFL
• Repair of the CFL
• Reefing of the lateral extensor retinaculum
• May be modified to advance the ligaments through
  drill holes or use of suture anchors

36
Syndesmosis Injury

• 10 of ankle sprains
• Rupture of the interosseous ligaments between the
  tibia and fibula with or without fibular fracture
  
• Medial malleolar fracture or deltoid ligament
  rupture
• Persistent instability and gap in the joint after
  bimalleolar fixation

37
Syndesmosis Exam

• Squeeze Test
• Squeeze the syndesmosis above the ankle?pain
• Abduction-External Rotation Stress Test
• Further instability with external rotation (may
  be shown with x-ray)

38
Stress Radiograph - Technique
39
Syndesmotic (High) Ankle Sprains

• AP/LAT/OBLIQUE ankle x-rays
• Syndesmotic widening
• Medial joint space widening
• Presence of fibula FX
• External rotation stress x-rays
• Severe pain associated with normal x-rays
• Must get tib/fib x-rays to rule out high fibula
  fracture

40
Stress View

• SER-2
• Negative Stress view
• External rotation of foot with ankle in neutral
  flexion (00)
• Stable ? Treatment FWBAT

Stress View Widened Medial Clear Space
41
Classification Edwards and Delee

• Type I
• Lateral subluxation of talus
• gt5mm b/n lateral anterior tibial tubercle and
  medial fibula
• Type II
• Lateral subluxation of talus
• Plastic deformity of fibula
• Type III
• Posterior rotatory displacement of talus and
  fibula
• Type IV
• Complete ankle diastasis with superior talus
  subluxation
• Treatment temp fixation with syndesmosis screw
  followed by casting and non-weight bearing with
  gradual weight bearing

42
Syndesmosis Injury

• Treatment
• Non-displaced without fracture
• May consider casting for 6 weeks (high ankle
  sprain)
• Surgical treatment with syndesmotic screws
• Displaced
• Surgical treatment with syndesmotic screws

43
Syndesmosis Injury

• Maximally dorsiflex hindfoot
• Reduce the syndesmosis with a large clamp under
  fluoro by internally rotating the fibula and
  compressing it to the tibia
• Perform medial arthrotomy if unable to reduce in
  order to debride medial ankle joint

44
Fixation
Anterior

• 1 or 2 3.5 or 4.5 mm cortical screws
• Placed 1.5-2.0 cm superior to ankle joint line
  parallel to ankle joint from the posterolateral
  fibula to the anteromedial tibia
• Screws are not lagged!

Medial
Lateral
Posterior
45
Syndesmosis Controversies

• Number of Screws
• One vs. two, 3.5 mm screw vs. 4.5 mm screw
• Number of Cortices
• Three vs. four cortices
• Ankle position during placement
• Classically dorsiflexion was advocated
• Tornetta showed no difference with plantarflexion

46
New Techniques

• Thornes et al. CORR 2005 Describe in the use of
  heavy suture and endobuttons to reduce and fix
  the ankle syndesmosis.
• Potential Benefits flexible fixation, no need
  for implant removal, earlier weight bearing,
  improved functional outcomes.

47
Syndesmosis Post-Op

• Place in a cast or removable boot NWB
• May consider screw removal after 3 months
• Weight bearing will break screws, but does not
  cause clinical problems
• Premature weight bearing may break screws and
  lead to syndesmosis widening

48
Ankle Dislocations

• Isolated ankle dislocation is rare
• Mechanism is forced inversion that results in a
  posteromedial dislocation
• Anterolateral ligaments damaged
• Commonly open 30 - 90
• Rule out neurovascular injury

49
Tibiotalar Dislocations

• OTA classification
• Anterior
• posterior

50
Tibiotalar Dislocations

• Management closed injury
• Check neurovascular status
• Prompt closed reduction
• Cast for 6 weeks in plantigrade position
• Results generally good
• Results not improved with acute ligament repair
• Late instability rare

51
Tibiotalar Dislocations

• Management open injuries
• Check neurovascular status
• IV ABX and reduction in ER
• Emergent ID
• Ligament repair if they can be identified easily

52
Tibiotalar Dislocations

• Management open injuries
• Consider stabilization with ex-fix to facilitate
  care of soft tissues
• Prognosis worse than closed injuries
• Stabilize syndesmosis if disrupted
• Immediate wound closure if possible

53
Ankle Dislocations

• Post operative care
• Open reduction may require ex fix or cast to hold
  the repair in place
• Long term instability is rare
• May have development of arthosis over time

54
Achilles Tendon Ruptures

• Anatomy
• 10-12 cm long
• 0.5-1.0 cm diameter
• Avascular zone 2-6 cm proximal to insertion
• Fibers rotate 90 degrees at insertion

55
Achilles Tendon Rupture

• History
• Acute pain in the back of the ankle with
  contraction, no antecedent history of calf or
  heal pain
• Average age 35
• Steroids, fluorquinolones, and chronic overuse
  may predispose to rupture
• Pathology
• Rupture occurs 3-4 cm above the Achilles
  insertion in a watershed area

56
Achilles Tendon Rupture

• Physical Exam
• Tenderness over achilles tendon
• Palpable defect
• Positive Thompsons test
• Needle test- needle inserted midline 10cm
  proximal to the superior aspect of the calcaneous
  moves towards the foot when the calf is squeezed

57
Achilles Tendon Ruptures

• Surgical repair
• Younger active patients
• Nonoperative treatment
• Older sedentary patients
• Patients with increased risk of soft tissue
  complications
• IDDM
• Smokers
• Vascular disease

58
Achilles Tendon Ruptures

• Nonoperative treatment
• Weaker tendon
• Higher risk re-rupture
• Slower return to sport
• No surgical morbidity
• Lower cost

59
Indications of Non-Operative Versus Operative
Treatment

• Indications
• Non-Operative Tx may be indicated for older
  patients with minimally displaced ruptures
• Non-Operative may be indicated for patients who
  are at an increased operative risk due to age or
  medical problems
• Note that younger patients w/ expectations of
  participating in sports such as basketball may
  not be good candidates for non operative Tx

60
Management of Non-Operative Tx

• Short leg cast strategy (SLC)
• SLC is applied w/ ankle in plantarflexion
• Cast is brought out of equinus over 8-10 weeks
• Walking is allowed (in the cast) at 4-6 weeks
• Alternatively, consider using functional brace
  starting in 45 degrees of flexion
• Following casting, a 2 cm heel lift is worn for
  an additional 2-4 months
• Long leg cast (LLC)
• Initial LLC in gravity equinus for 6 weeks,
  followed by short leg cast for 4 weeks

61
Achilles Tendon Rupture

• Non-Operative
• Resistance exercises started at 8 weeks
• Return to sports in 4 6 months
• May take 12 months to regain maximal
  plantarflexion power

62
Clinical Evidence to Support Nonoperative
Treatment

• Benefits no wound complications, no scar,
  decreased patient cost.
• Disadvantage up to 39 re-rupture rate,
  increased patient dissatisfaction, decreased
  power, strength and endurance.
• Nistor and later Gilles and Chalmers-
  non-operative treatment preferred because
• No hospitalizations
• No wound complications
• No difference in functional strength
• Gillies and Chalmers-
• 80 vs. 84.3 return of strength compared to
  unaffected side, non-op and operative,
  respectively
• Wills, 775 patients the overall complication rate
  of surgically treated Achilles tendon ruptures
  was 20.
• skin necrosis, wound infection, sural neuromas,
  adhesions of the scar to the skin, and the usual
  anesthesia risks

63
Non-operative Protocol

• Nistor and by Lea and Smith
• 8 weeks in short led equinous cast- WBAT as soon
  as cast is dry followed by 4 weeks with 2.5cm
  shoe lift
• McComis et al.
• Functional brace WBAT, permitted active
  plantarflexion with dorsal block to maintain
  equinous.
• 5/15 patients had positive Thompson test at 2
  years

64
Achilles Tendon Ruptures

• Surgical repair
• Superior tendon strength
• Lower risk re-rupture (1-3)
• Quicker return to sport
• surgical morbidity
• Infection
• Dehiscence
• Superficial nerve injury
• Increased cost

65
Achilles Tendon Rupture

• Surgical treatment
• Preferred for athletes
• Medial incision avoids the sural nerve
• Percutaneous vs. Open treatments described
• Isolate the paratenon as a separate layer

66
Clinical Results Surgical Reconstruction

• Benefits 0-5 re-rupture rate, gt percentage
  patients return to sport, improved power,
  strength, and endurance.
• Disadvantages gt patient cost and wound
  complications
• Clinical series many techniques
• Most Bunnel or Modified Kessler suture
• Some with augmentation EHL vs. Gastrocnemius
  fascia vs. Plantaris tendon

Krackow
67
Operative Support

• Cetti et al. compared operative versus
  non-operative treatment in a prospective study
  with 111 patients
• In the operative group (56 patients), there were
  three re-ruptures (5) and two deep infections,
  as compared with eight re-ruptures (15) in the
  non-operative group (55 patients)
• The operative group had a significantly higher
  rate of resuming sports activities at same level
  prior to rupture (57.1 vs 29.1 of pts), a
  lesser degree of calf atrophy (1.6 cm vs 1.1 cm
  calf circum.), significantly fewer complaints at
  1 year (29 vs 49 of pts), and better ankle
  movement at 1 year (82 vs 53 of pts, op vs
  non-op, respectively)

68
Operative Support (cont.)

• In separate studies, Helgeland and Inglis
• showed that surgical treatment of Achilles tendon
  rupture resulted in increased strength
• Haggemark et al. compared the functional work
  capacity in patients managed by open repair or in
  a closed fashion
• significant deficits in the patients treated
  non-operatively
• Mandelbaum et al
• direct repair lost only 2.6 of their strength
• 92 of athletes were able to return to their
  respective sports at a similar level at 6 months
  postoperatively

69
Percutaneous Achilles Repair
70
Clinical Results Surgical Treatment

• Jessing and Hansen primary repair compared to
  direct technique combined with Gastroc fascia
  turn down. No diff re-rupture one in each group.
• Mortensen et al. 71 acute repairs ½ immobilized
  for 8 weeks versus ½ early motion in below the
  knee brace. Improved ROM and earlier return to
  sport/work in the early motion group.
• Suchak et al. Meta-analysis 315 patient ½ 6-8 wk
  post-op immob vs ½ early ROM.
• Increased excellent rate responses early ROM
• No diff complication rates
• No diff re-rupture
• Khan et al. Meta-analysis 800 patient acute
  operative repair vs. non-operative management
• Operative repair reduced re-rupture rate at the
  cost of increased complication rate.
  Complication rate was reduced with post operative
  functional bracing and use of percutaneous
  technique

71
Summary of Expected Outcome Non-Operative Versus
Operative

• Re-rupture rates between 10 and 35 have been
  reported in the literature after closed
  management of Achilles tendon ruptures rates of
  0-4 have been reported after operative
  treatment
• When major complications, including re-ruptures
  are compared, both forms of Tx have similar
  complication rates
• 83 of surgical patients vs 69 immobilization
  patients returned to the pre-injury level of
  activity
• 93 of surgical patients were satisfied with the
  results of treatment vs 66 of immobilized
  patients

72
Conclusion

• The current preferred treatment in young and
  other wise healthy patients is surgical repair
• Conservative treatment remains an acceptable
  alternative in older, sick or sedentary patients
  who have fewer physical demands with limited
  functional and athletic goals

73
Achilles Tendon Injury

• X-ray
• Lateral ankle X-ray to exclude avulsion from the
  calcaneus

• MRI
• - May be useful to diagnose partial
  rupture only

74
Achilles Tendon Avulsion

• Treatment includes ORIF of avulsion or
  reinsertion on the calcaneus with suture anchors

75
Chronic Achilles Tendon Rupture

• History
• Remote hx trauma, post pain, gradual improvement
  of symptoms, palpable tendon defect.
• No hx trauma, gradual thickening of tendon, AM
  startup pain, pain ascending/descending stairs.
• Physical Exam
• Hatchet posterior calf at site of defect at
  resolution of swelling
• Positive Thompson test
• Weakened plantar flexion

76
MRI

• lt3 cm gap, lt3 months oldprimary repair
• gt3cm gapscar tissue debridement and V-Y
  lengthening of proximal gastroc tendon granted
  that remaining tissue no evidence inflammation
• Evidence chronic inflammationaugmentation with
  FHL tendon

77
Chronic Achilles Rupture

• Chronic rupture may be reconstructed with FHL,
  FDL, or slip from gastrocnemius

78
Achilles Tendon Ruptures
Reconstruction of neglected rupture with peroneus
longus and plantaris weave
79
V-Y Lengthening gt3 cm
Debride necrotic tissue
Advance Tendon
Suture Repair
80
FHL Transfer gt3cm with tendinopathy

• Reflect abductor hallucis and flexor hallucis
  brevis

• FHL medial to FDL

81
FHL Transfer
Tag each end of tendon
82
FHL Transfer
Distal FHL sutured to FDL with ankle and toes in
neutral
Confirm full hallux MTP dorsiflexion, otherwise
retension and residual clawing
83
FHL Transfer
84
Clinical Results Delayed Reconstruction

• Wapner et al. First to describe FHL transfer
• Described in 7 patients with mean FU 17 months-
  satisfactory return of function in all patients
  despite persistent loss of ROM in ankle and great
  toe.
• No wound complications
• Miskulin et al. Repair of chronic ruptures
• Augmentation of repairs with local peroneus
  brevis and plantaris.
• 5 patients 4/5 improved plantar flexion strength
  at one year.
• No wound complications

85
Peroneal Tendon Dislocation

• Peroneal tendons course behind the distal fibula
• The peroneus brevis may have degenerative changes
  if the injury is not identified in a timely
  fashion

86
Peroneal Tendon Dislocation

• The peroneal retinaculum may be avulsed from the
  fibula or calcaneus or lifted up enough to allow
  tendon dislocation

87
Peroneal Tendon Dislocation

• Forceful contraction of peroneals during sudden
  dorsiflexion and inversion
• Usually cutting sport
• Frequently misdiagnosed as ankle sprain

88
Peroneal Tendon Dislocation

• Tenderness/swelling retromalleolar area
• Active eversion may demonstrate subluxing tendons
• X-rays may reveal a small avulsion FX off the
  posterior lateral malleolus
• MRI may reveal subluxed tendons

89
Peroneal Tendon Dislocation

• X-ray
• May show avulsion of retinaculum from fibula
• Conservative treatment
• Casting in slight plantarflexion and inversion
  for 6 weeks non weight bearing
• Allows the retinaculum to heal if the tendons can
  be reduced closed
• Successful if the injury is identified early

90
Peroneal Tendon Dislocation

• Surgery
• ORIF retinacular piece if possible
• Repair retinaculum if possible
• Soft tissue reconstruction with sling for
  retinaculum

91
Peroneal Tendon Dislocation

• Bone block surgeries such as Kellys or DuVries
  modification
• Debridement of peroneus brevis may be necessary
  if degenerative changes are present and tenodesis
  

92
Peroneal Tendon Dislocation

• Surgery
• Deepening of the groove has become more popular
• Post Operative Care
• NWB for 6 weeks
• Passive motion after 2 weeks
• Strengthening after 6 weeks

93
Posterior Tibial Tendon Rupture

• Anatomy
• Arises from posterior aspect intermuscular septum
• Inserts on tarsal bones
• Avascular zone posterior to medial malleolus
• High frictional load posterior to medial malleolus

94
Posterior Tibial Tendon Rupture

• Function
• Inverter of hindfoot
• Locks transverse tarsal joint
• Maintains height longitudinal arch
• Maintains neutral position of hindfoot at 7-10
  degrees

95
Posterior Tibial Tendon

• History
• More commonly an attritional rupture over time
  than an acute rupture
• Patient may complain of flat foot and midfoot
  pain
• Sports with quick changes of direction may put
  increased force on tendon
• X-ray
• Foot x-ray may show medial talar displacement

96
Posterior Tibial Tendon

• Physical Exam
• Hindfoot valgus and forefoot abduction that give
  the too many toes sign
• Pain in the midfoot and weakness in inversion
  from an everted position
• Late stages may demonstrate sinus tarsi pain from
  impingement
• Single heel rise - Lack of supination of the
  foot and inversion of the heel while rising on
  toes
• Flexible vs. rigid deformity

97
AP Radiograph

• Talonavicular coverage- as arch collapses the
  talarhead coverage by the navicular is lost

• Anterior talocalcaneal angle increases

• Talus-1st MT diverges or angle increases

98
Lateral Radiograph

• Increased Talus-forefoot angle
• B. Increased Talus Calcaneous angle
• - plantarflexed talus
• C. Decreased Calcaneal Pitch
• Negative Med Cun-5th MT
• normally the 5th MT is more plantar than the
  medial cuneiform

A
C
B
99
Talus-1st MT and Calcaneal Pitch
Colinear Talus-1st MT Normal calcaneal pitch
Divergent Talus-1st MT Loss of calcaneal pitch
100
Posterior Tibial Tendon
Lateral subtalar dislocation
101
Posterior Tibial Tendon

• Conservative Treatment
• UCBL orthosis for chronic problem or in the
  relatively inactive population
• Rest and NSAIDS
• Consider casting in recalcitrant cases
• Shoe modification
• Orthotics with medial wedges

102
Posterior Tibialis Reconstruction

• Surgery for the flexible deformity
• Reconstruction of the posterior tibial tendon
  with FDL or FHL
• Medial calcaneal wedge osteotomy or lateral
  column lengthening through the calcaneus
• Fig 14, page 1705 from Acquired adult flatfoot
  deformity in Orthopaedics, 2002

103
Posterior Tibial Tendon Rupture

• Chronic rupture
• Develop gradually
• Women over 40
• Tenderness/swelling over tendon
• Forefoot abduction
• too many toes sign
• Absent single heel raise

• Loss of height of arch

• Hindfoot valgus

104
Posterior Tibial Tendon Rupture

• Imaging
• Weightbearing radiographs
• Degree deformity
• Presence arthritis
• Assessment longitudinal arch
• MRI
• Method of choice in imaging posterior tibial
  tendon

105
Posterior Tibial Tendon Rupture

• Chronic rupture
• Stage I
• Pain, weakness, no deformity
• Stage II
• Flexible flatfoot deformity
• Stage III
• Rigid flatfoot deformity
• Radiographic subluxation/arthritis

106
Posterior Tibial Tendon Rupture

• Chronic rupture
• Stage I
• Pain, weakness, no deformity
• Stage II
• Flexible flatfoot deformity
• Stage III
• Rigid flatfoot deformity
• Radiographic subluxation/arthritis

107
Posterior Tibial Tendon Rupture

• Management
• Chronic rupture
• Stage I
• Nonop (NSAID, arch support, AFO)
• Tenosynovectomy if SXs persist
• Stage II
• nonop (medial wedge, arch support, or AFO)
• Surgical TX controversial
• Reconstruction utilizing FDL or split anterior
  tibial tendon
• Deformity frequently recurs
• Calcaneal osteotomies hold promise

tenosynovectomy
108
Posterior Tibial Tendon Rupture

• Management
• Chronic rupture
• Stage III
• Nonop AFO
• Surgical arthrodesis (type depends on deformity
  and site of arthritis)
• Subtalar
• Double
• Triple

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