Tendon Disorders

of the Foot and

Ankle
1/2016
Qatar Board Review Course
Anish R. Kadakia MD
Associate Professor
Northwestern University - Department of Orthopedic
Surgery
Program Director – Foot and Ankle Fellowship
Editor in Chief – Journal of Orthopaedic Surgery and
Research
 Overview

 Achilles disorders
 Posterior Tibialis
 Peroneal disorders
 Anterior Tibialis
disorders
 FHL tendinitis
 Haglund’s Syndrome

• Prominent
superolateral
calcaneus
• Pain, pressure from
shoe
• Tendon nontender
• Xray – parallel
pitch
• MRI – tendon
normal
 Haglund’s Syndrome
Elsevier: Foot Ankle Clin N Am. 11: 439-446, 2006
• Non-operative
– NSAIDs
– Heel lift Original Image
– Gel cushion, felt pad
Original Image

• Operative
– Exostectomy
• Open – lateral
– Sural nerve at risk
• Endoscopic
– Sural nerve at risk

– >50% achilles detached

• Reattach with anchors
 Insertional Achilles
•
Tendinosis
Exam Original Image
– Pain, swelling Original Image
– Directly Posterior Original Image

• Etiology
– Degenerative
– Enthesopathy
– Overuse
– Steroid injections
– Fluoroquinolones
• Lateral Radiograph
– Calcification of Insertion
• MRI
– Intratendinous signal
change (Distinction from
Haglund’s and Retrocalc
Bursitis)
 CTQ
Insertional Achilles
Tendinosis Original Images

 Surgery
 <50% involved
 Calcaneal exostectomy

 Debridement with

reattachment
 >50% involved
 Calcaneal exosectomy
 Debridement w/ FHL
transfer
 Traumatic avulsion
 Calcaneal exosectomy
 Debridement w/ FHL
transfer
 Let’s pretend it looks
this bad – Just for Fun.
 Problems
 Excision of all diseased tissue will
leave very little to reconstruct
 Isolated FHL unlikely to return
sufficient function to perform
athletic activity.
 Turndowns/V-Y require large
exposures
 Higher risk of sural nerve compromise
 Wound complication risk
 Just tenodese to FHL?
 Why not suture remaining Achilles to
FHL
 Cannot achieve symmetrical tension of
both tendons (highly unlikely at the
least)
 Muscles are not moving independently
 Compromise the length-tension relationship
of one of the muscle groups more than we
already have by the reconstruction
 15 patients
 4.8mos (3.3) after index injury
 10 had no limitations of activity
Cut out way too much
tendon?
 Clearly I took a lot
 Why
 A minimial debridement
removing the calficied
tissue will result in
discontinuity
 I had no plans to VY or
Turndown
 Remove all tissue that is
non-viable
 Yellow/Brown
 Firm tissue
 Lack of normal parallel
fibers (disorganized)
 The center always looks
worse than the periphery
Flouroscopy
Different Patient – Same
Technique
Tension FHL first
 Non-insertional Disorders
Original Images

 Para-tendinitis
 Inflammation of the
paratenon
 MRI
 Tendon is normal
 Signal change adjacent to
tendon
 Tendinosis
 Intratendinous degeneration
 MRI
 Increased signal within
tendon
 Thickening of tendon
 Non-insertional Achilles
Original Images

• Surgery
– <50%
degeneration
• Debridement
• Tubularization
– >50%
degeneration
• Debridement
• FHL transfer
• Time to recover
– 12 months
Acute Achilles Rupture
 Nonsurgical
 Functional bracing
 Do NOT Cast
 Controlled motion, rehab
 New Data supports that rerupture rate
is NOT significantly different
 Multiple studies
 Historical – 10-20% rerupture rate
 Function superior with surgery
 Superior PF strength at maximum speed
 <45 y.o – higher satisfaction
 Technique

• Open Repair Original Images

– Earlier motion, rehab
– 1-2% rerupture rate
– Wound problems

• Percutaneous
– Fewer wound problems
– Rerupture ~ 5-8%
– Sural nerve injury may occur
– Minimized with sub
paratenon devices
Posterior Tibial Tendon Dysfunction

• Classification
– Stage I – tenosynovitis, no deformity
– Stage II – tenosynovitis or tear, flexible
flatfoot
– Stage IIB – Fixed forefoot supination
– Stage III – rigid flatfoot +/- arthritis
– Stage IV – ankle arthritis or valgus tilt
 CTQ
Posterior Tibialis OITE 2002

Dysfunction
 Etiology
 Degeneration – age
 Inflammatory
disease
 IF RA => Triple
 Diabetes, HTN
 Obesity
 Hypovascular
zone
 Tip of medial
malleolus to
navicular insertion
 Trauma
 Posterior Tibialis
Dysfunction
 Pathophysiology
 Tendon attenuation, tear
 Medial ligaments
weaken
 Spring Ligament
 Calcaneonavicular
 Heel valgus
 Arch collapse
 Midfoot supination,
abduction
 Gastrocemius/Achilles
contracture
CTQ
Posterior Tibial Tendon Dysfunction
Original Images
Elsevier: Foot Ankle Clin N Am. 6:341-369, 2001

• Nonoperative Treatment
– Stage I
• Immobilization – Cast/Boot WBAT
– Stage II – Initial Presentation
• Based on Current Literature!
– This is a change!
• AFO
• Physical Therapy
– Stage II – Recurrence Prevention
• Orthotic
– Medial Hindfoot Post/Inversion
– Arch Support
– Medial Forefoot Support
» Supports Forefoot Varus if present
– Stage III/IV
• AFO
• Arizona Brace
 Posterior Tibialis
Dysfunction
 Stage I
 Tenosynovectomy
 (+/-) medializing calcaneal osteotomy
 Indications – Joint
Sparing Surgery
 Physical Exam
 Passive Correction
to Neutral Required
 Radiographic
Exam
 No arthritic changes
in the hindfoot
 Preferred Technique –
Hindfoot Valgus
 Medial Displacement
Calcaneal Osteotomy
(MDCO)
 Corrects Hindfoot Valgus
 Reliable Union Rate

 Subtalar Fusion
 Obese Patient – BMI >30
(Clinical Judgment)
 Subluxated Subtalar Joint
 Preferred Technique –
FDL
 Transfer to Stump of PTT vs
Navicular
 Stump of PTT
 Simple and may give benefit of stabilization
through multiple plantar attachments of
PTT
 Navicular
 Reliable bone to bone healing
 Preferred Technique -
Abduction
 > 50% Talonavicular Uncovering
 Lateral Column Lengthening
 Most Reliable Radiographic Correction
 <50% Talonavicular Uncovering
 Spring Ligament Reconstruction
( Tan G, Kadakia AR, et al. Novel Reconstruction of a Static Medial Ligamentous
Complex in a Flatfoot Model. Foot Ankle Int. 2010. 31(8):695-700.)
Lateral Column is NOT Short!
 No difference in Lateral Column lengths
(Kang et. al. Foot Ankle Int. 2013)
 Flatfoot vs. Normal
 Preferred Technique –
Forefoot Varus
 Rigid
 Dorsal opening wedge
cuneiform osteotomy (Cotton)

 1st tarsometatarsal (TMT)

instability
 1st TMT plantarflexion
arthrodesis
 Preferred Technique –
Equinus
 Gastrocnemius Recession
 I reserve TAL for Stage III
patients
2 year PO s/p staged TAA
PTTD s/p Failed Kidner
(Flatfoot my whole life)
 Stage III
 Definition
 Fixed hindfoot valgus with
associated hindfoot abduction w/ or
w/o forefoot supination secondary to
chronic PTTD
 Stage III
 Simplified definition
 Rigid
Flatfoot (Just won’t
move)
 Long-standing PTTD
 Coalition
 Effectively functions as Stage III
 Arthrosis

 Failed prior correction

Stage III
Stage III
Stage III
Stage III
Surgical Intervention
 Arthrodesisof the CC joint is not
required to correct deformity
 Exception
 CC Arthritis
 Coalition
 Revision of Stiff / Failed Stage II

correction
 Inability to correct abduction
Lamina spreader – Lateral
process talus to anterior
process calcaneus
Stiff ST joint – Different
approach
Coalition Prime example
 Flat Cuts
• Persistently rigid subtalar
joint
• Tight lateral soft tissue
(peroneals)

• Calcaneus does not have

to translate distally
• Decreases lateral soft
tissue tension
?????
• Failed TN fusion
• Disruption of TN stability
• Nonunion Evans Calc Ost
 Posterior Tibialis
Dysfunction
 Stage III
 Rigid/Not
Correctable/DJD
 Surgical Rx
Original Images
 Triple arthrodesis
 “Medial Triple”
 Do NOT have to fuse CC
 Achilles Lengthening
Original Images
 Stage IV
 WB xrays ankle
 Rule out arthritis
 Rule out valgus tilt
 Stage IV
 Historically Correct
 Pantalar Arthrodesis
 Contemporary Option
 Triple Arthrodesis
 AND

 Ankle Replacement
 CTQ
Posterior Tibialis
Dysfunction
 How they trick you on Stage II
 Lateralizing osteotomy = WRONG
 Trying to confuse you with lateral column
lengthening
 Hindfoot arthrodesis = WRONG
 Stage III only
 Isolated
anything = WRONG
 Both medial slide and LCL????
 Yes- this is OK
 LCL – Corrects hindfoot abduction
 Medial Slide – Corrects Hindfoot Valgus
 CTQ
PTTD Summary
 Stage I – No deformity
 Synovectomy
 Stage II – Flat and Flexible
 FDL transfer
 Calcaneal osteotomy
 Medial slide
 Lateral column Lengthening
 Forefoot varus
 Cotton osteotomy
 Stage III – Flat and Rigid
 Fuse it- Triple
 Stage IV – Ankle valgus/arthritis
 Fuse it – TTC
 Heel Cord is Tight
 Cut it – Gastroc (stage II), TAL (stage III)
 Peroneal Tendon Pathology
 Peroneal Tendon Tear
 MRI – axial views
 Split, chevron or bilobed shape
 Intermediate signal intensity = disorganized
scar
 Fluid in sheath

Original Images
 Anatomy
 Peroneus
Brevis and
Longus

 Main evertors
of the hindfoot

 Dynamically
maintain
alignment of
hindfoot
 Anatomy
 Peroneus
Brevis
 Innervation
 Superficial
Peroneal
Nerve
 Action
 Eversion
 Location
 Deep and
anterior to the
longus.
 CTQ
Anatomy
 Peroneus
Longus
 Innervation
 Superficial
Peroneal Nerve
 Action
 Plantarflex 1st
ray
 Evert foot

 Location
 Posterior and
lateral to the
 Anatomy
 Os Peroneum
 8.5% of population
 Within substance of peroneus longus

 Can be a source of pain

 CTQ
Peroneal Tenosynovitis
 Etiology
 Hypertrophy of the peroneal tubercle
 Trauma

 Varus Hindfoot

 Chronic Ankle instability

 Inflammatory arthropathy

 Injury to the Os Peroneum

 H and P
 Pain
 Posterolateral hindfoot
 Worse with activity
 Cutting activity
 Exam
 TTP over peroneals
 Palpable thickening
 Pain with passive inversion
 Pain with resisted eversion
Peroneal Tendon Conservative Rx
 Immobilization
 Short leg cast vs. boot
 3-4 weeks
 Ankle stirrup orthosis
 Orthotic
 Lateral post
 PT
 Peroneal Strengthening
Peroneal Tendon Surgical Rx
Original Images
 Goals
 Synovectomy

 Tendon Repair - < 50%

torn
 Tenodesis - >50% torn

 Groove Deepening
 Decrease pressure within
the groove
 Peroneal Tubercle
excision
 If Prominent
 Imbricate Retinaculum
 Peroneal Instability
Original Images

 Forced dorsiflexion-eversion
 Strips retinaculum off fibula
 History
 Snapping/Popping
posterolaterally
 PE
 Resisted Eversion
 Pain
 Reproduce subluxation

 Snapping
 If Tendons Remain
posterior to fibula
 Intrasheath Peroneal Tendon
 Peroneal Instability
 Conservative Rx
 Immoblization – Original Images

Boot/Cast
 NOT in Athlete
 Avoid injection
 Success rates < 50%

 Operative Intervention
 Acute (Athlete)
 Acute repair of
retinaculum
 Chronic
 Repair tendon tears
 Groove Deepening
 Imbricate retinaculum
 Revision/Failed Prior
repair
 FHL transfer to the base of the
5th Metatarsal
 Recreates dynamic eversion of the
peroneals
 Does not recreate PF of the 1st Ray.

Original Images
 Anterior Tibial Tendon
Rupture Original Images

 Presentation
 Foot Drop
 Pseudotumor
 Anterior Ankle Mass
 Anterior Ankle Pain
 MRI
 (Tendon is Missing)
 Treatment
 AFO – Low demand only
 Surgery – Best Choice
 Rupture
 Auto/Allograft – reattach to distal stump or
midfoot
 Surgical repair has shown success
in elderly.
 New Data – Change from previous
 Flexor Hallucis Longus
Tendinitis
 History - DANCER Original Images

 PM pain with Ankle PF

 PM pain with MTP DF
 Locking of great toe

 PE
 PM TTP over FHL
 Crepitus at FHL with
Hallux DF
 PM pain with hallux
DF
 Worse with ankle DF
 MTP Nontender
 FHL TendinitisOriginal Images

 Xrays
 Os trigonum
 Pain with forced
plantarflexion
 MRI
 Os trigonum edema
 FHL tenosynovitis
 Patients can have
BOTH
 Symptomatic Os-
trigonum
 FHL tenosynovitis
 FHL Tendinitis
Original Images

 Non-op
 Rest/Activity Mod
 Immobilization
 Steroid Injection
 Immobilize to protect
against rupture
 Surgical Rx
 Posteromedial incision
 FHL tenosynovectomy
 Resection Os-
trigonum
 If present
 Lateral to FHL
Thank You