Chapter 27: Muscle and

Tendon Pathology
Muscle Physiology
Principles of Tendon Repair
Tendon Lengthening and Tenotomy
Tendon Transfers
Tendon Grafts
Posterior Tibial Tendon Rupture
Posterior Tibial Tendon Dysfunction (Acquired
Adult Flatfoot Syndrome)
Peroneal Tendon Pathology
Achilles Tendon Rupture
Lateral Ankle Stabilization Procedures
Postoperative Care and Training Following Tendon
Transfer
Tenosynovitis
 MUSCLE AND TENDON PATHOLOGY
Tendon repair and tenoplasty are integral parts of many podiatric
procedures, thus it is imperative that the podiatric surgeon be familiar with
the principles of tendon healing and repair. Knowledge about tendon healing
will allow the surgeon to make appropriate decisions concerning the
procedure performed, materials used, postoperative care, and potential
complications

Muscle Physiology
1. Anatomy:
a. Connective tissue surrounding the muscle
i. Intact muscle enclosed by the epimysium
ii. Muscle fascicles enclosed by perimysium
iii. Individual muscle fiber enclosed by endomysium
b. Muscle's structural and functional subunits:
i. Fasciculus
ii. Muscle fiber
iii. Myofibril: The myofibrils complex protein structure is the basic contractile
unit:
 Actin: Thin protein filament containing contractile proteins tropomysin and
troponin
 Myosin: Thick protein filament
iv. Sarcomere: the smallest functional unit of the muscle fiber extending from
one "Z" line to the next
 The myofibril is composed of alternating "A" bands corresponding to the
thick myosin filaments and "I" bands corresponding to the thin actin units
 The "A" band encloses the "H" band (where cross bridges are absent) and
in the middle of the "I" band is the "Z" line
 T-tubules are invaginations of the sarcolemma which form an
interconnected network
 The sarcoplasmic reticulum extends from one T-tubule to the next forming
the terminal cisternae
v. Myoneural junction:
 The axon gives rise to several terminal twigs, the end of each is dilated
and unmyelinated
vi. Organelles:
 Mitrochondria are found between the myofibrils and appear in varying
amounts depending upon the type of muscle fiber
 Cytochromes for oxidation, and glycogen appear in varying amounts
c. Tendons:
i. Dense connective tissue between connective tissue in muscle, and insertion
area
ii. Golgi tendon organs transmit information concerning tendon tension

2. Physiology of muscle fiber:

a. Muscles function according to the Sliding Filament Theory of Muscular
contraction: rest, excitation coupling), contraction, recharging, and relaxation
b. Initiation of contraction:
i. The axons released acetylcholine which initiates an action potential
along the sarcolemma
ii. The action potential is propagated into the depths of the myofibril via
the T-tubule system
iii. This in turn mediates a release of calcium from the sarcoplasmic
reticulum (the sarcoplasmic reticulum has an active pump to recover
calcium once it is released)
iv. In the presence of repeated neural stimulation calcium will remain in
the sarcoplasm
v. Following the action potential is an absolute refractory period, during
which no action potential may be initiated
vi. Next follows a relative refractory period during which a greater than
normal neural stimulus may initiate another action potential in the
sarcolemma

c. Myofibril contraction (the ratchet mechanism):

i. In the absence of calcium, tropomycin blocks the myosin-binding sites on
the F-actin
ii. When calcium is released by the sarcoplasmic reticulum into the
sarcoplasm, it bonds to the Tn-C portion of the troponin, which mediates a
conformational change in tropomyosin which uncovers the myosin binding
sites
iii. ATP binds to heavy meromycin (form of myosin), which releases it from
the actin. The ATP-ase activity of the heavy meromysin then cleaves the
phosphate, and the myosin can once again bind to actin
iv. Upon binding with actin, the heavy meromysin changes conformation,
thereby pulling the actin along
v. As calcium is reabsorbed by the sarcoplasmic reticulum, the myofibrils
again relax

NOTE* Motor unit response is an all or nothing

d. Fast twitch vs. slow twitch muscle

Feature Fast Twitch Slow Twitch

# of type 1 fibers + +++
# of type 2 fibers +++ +
Speed of response +++ +
Strength + +++
Stamina + +++
Major energy source anaerobic aerobic

e. Type 1 vs. Type 2 muscle

Feature Type 1 Type 2

Color RED WHITE
Myoglobin content +++ +
Mitochondrial content +++ +
Glycolytic enzymes + +++
Glycogen content + +++
Complexity of T-tubules + +++
Speed to respond to stimulus + +++

f. Energy system function:

i. Phosphagen system (anaerobic)
 ATP and phosphocreatine
 Availability of energy is rapid
 Small amounts of energy available for a few seconds (30 seconds)
 Utilized in sprinting, jumping, swimming etc.
 Primary source of energy muscle storage
ii. Glycolytic system (anaerobic)
 For activities 30 seconds to 1.5 minutes
 No oxygen required
 Formation of lactate takes place
 Lactate accumulation results in oxygen debt and muscle fatigue
iii. Aerobic phosphorylation
 For activities greater than 1.5 minutes
 Carbohydrates, proteins and fats utilized through the Krebs cycle and
electron transport system (oxidative phosphorylation)
 Site of energy formation is the mitochondria -No lactate formation

NOTE* Sport activities require all 3 sources of energy but in different

proportions depending
NOTE* Rigor
on themortis
sport occurs
characteristics
due to exhaustion of A TP in the presence of
calcium (in the absence of ATP, myosin becomes tightly bound to
actin)

3. Training programs:
a. Most training programs are an adaptation of sprinting and endurance
training
i. Endurance training results in hypertrophy of type 1 fibers
ii. Sprint training results in hypertrophy of type 2 fibers

NOTE* Fiber type can change in response to training programs, but there is
no proof that one fiber can transform to another fiber type

iii. Training results in cardiac hypertrophy, increase in cardiac stroke volume,

and decrease in heart rate

4. Types of training:
a. Isometric excercises:
i. Contraction in which a muscle maintains a constant length
ii. Contraction against stationary objects
iii. Maximal isotonic contraction increases strength to a greater extent than
submaximal contractions
iv. Isotonic training does not require a long time of excercising
v. Maximal strength gained is very specific for the joint angle at which the
training is performed
vi. Motor performance is not increased by isotonic exercise
vii. Isometrics are static excercise
viii. Strength gained by isometrics decrease the maximal speed of a limb

b. Isotonic excercises (concentric): Implies constant tension

i. During isotonic excercise the amount of force exerted on a weight being
lifted depends on the acceleration of that weight (Newton's 2nd law:
F+W+MA)
ii. In case of isotonic training, voluntary maximal contraction (VMC) takes
place somewhere during training
iii. The maximal lift is really the weakest point in the ROM of the joint. If the
weight could be lifted quickly on each repetition, the VMC would be possible
to perform through the entire ROM
iv. Motor performance is increased
v. There is an increase in lean body mass and a decrease in body fats
c. Eccentric excercises: Negative weight training
i. A contraction in which the muscle lengthens upon contraction
ii. Strength gained is not different than in concentric or isotonic contraction
iii. Less effort is required to gain the same strength as in concentric training
iv. Tension developed in the muscle during eccentric contractions (as
compared to concentric contraction) utilizing equal weights indicates that
more tension is developed during concentric contraction
v. To cause equal tension as that during concentric training, more weight has
to be used during eccentric training
vi. Eccentric training has the following disadvantages:
 Muscular soreness
 Trainer is necessary to use heavier weights
 Weight handled can be hazardous
 Training time is longer than with other training methods

d. Isokinetic excercises: Constant velocity excercise

i. The machine is set at a constant velocity but the resistance is not set;
whatever force the trainee applies to the machine set at a certain velocity, is
offered as a resistance to the trainee by the machine
ii. The above allows the VMC throughout the entire ROM
iii. To be strong at fast speed of movement, the athlete should be training at
fast speed of movement
iv. Isokinetics increases motor performance
v. Motor performance is increased to a greater extent at fast speed than at
slow speed
vi. Muscular soreness is minimal
vii. No weight is lifted
vii. Length of the workout is decreased

e. Variable resistance exercises:

i. Percentage of increase in resistance that an individual can tolerate and
complete a particular movement depends upon the following variables:
 Limb length
 Muscle length
 Point of attachment of the tendons on the bone
 Bony position
ii. Motor performance increases with variable resistance machinery (high
cost)

f. Comparisons
i. Isotonic vs. isokinetics:
 Strength increase is greater in isokinetic as compared to isotonics
 Isokinetic contractions are preferred over isotonics
 Isokinetic training increases isokinetic and isotonic strength more than
isotonics
 Isokinetic training (at fast speeds) increases motor performance more
than isotonics
 Isokinetics is as effective as isotonics in decreasing fat and increasing lean
body mass
 Less muscle soreness with isokinetics over isotonics
ii. Isokinetics vs. isometrics:
 Isokinetics causes a greater increase in isometric and isokinetic strength
than does isometrics
iii. Isotonics vs. Isometrics:
 Motor performance is Improved to a greater extent with isotonics than
isometrics
iv. Variable resistance vs. isometrics:
 Probably better motor performance with variable resistance

NOTE* The strength training choice will depend upon the cost of the
equipment, amount of strength gains, and motor performance
increase
Principles of Tendon Repair
1. Histology:
a. Tropocollagen: The most basic molecular unit of tendon

NOTE* Successive molecules of tropocollagen are assembled and eventually

form collagen fibers. These longitudinally anastomosed fibers constitute a
tendon

b. Tendons are composed of 3 anatomical coverings:

i. Endotenon: Surrounds groups of collagen fibers and forms units called
fascicles
ii. Epitenon: This covers groups of fascicles. It is also the visceral layer and is
responsible for the intrinsic repair response
iii. Paratenon: A loose filmy structure that covers the entire tendon and has a
rich vascular supply that communicates with the, tendon itself. The
paratenon allows the tendon to glide

NOTE* Without the paratenon, the tendon would stick to the surrounding
tissue, so care must be made during surgery not to damage this
structure
2. Tendon healing:
a. 4 stages each taking approx. one week
i. Stage 1: The severed ends being joined by a fibroblastic splint. At the end
of this stage the repair site is in its weakest state consisting of serous
material and granulation tissue (termed zone of degeneration)
ii. Stage 2: Shows an increase in paratenon vascularity and collagen
proliferation. Immobilization is still necessary.
iii. Stage 3: Collagen fibers begin to form longitudinally and give the tendon a
moderate degree of strength. At this time controlled passive motion is
beneficial to decrease the formation of fibrous adhesions (CPM)
iv. Stage 4: Exhibits fiber alignment which imparts increased strength to the
tendon. At this point active mobilization can be initiated

b. Tendon lengthenings will often result is a loss of muscle strength roughly

equal to one grade of manual examination once healed

3. Suture selection: Plays a vital role in uneventful tendon surgery

a. Surgilon®: This non-absorbable non inflammatory suture allows for
increased strength during the end of stage 1 when the tendon is the weakest
b. Stainless steel: Excellent to anchor tendon to bone and then removed
when healing occurs. It is the strongest and least reactive, and best in
contaminated wounds. Its drawbacks are it can "kink" up and "saw" through a
tendon.
c. Silk: Was used for years but has been replaced with less reactive
nonabsorbable and absorbable sutures.
d. Tevdek®/Ticron®: Nonabsorbable braided polyester that retains greater
ability to resist gap-producing forces at 3 weeks than either nylon or
polypropylene
e. Vicryl®/Dexon®: Absorbable polygalactic acid and polyglycolic acid
usually provide strength long enough for the repair

4. Methods of tendon repair: tendon to tendon suture techniques

(see following diagrams)
a. Bunnell end-to-end: Excellent technique but can cause tissue restriction
b. Double right angle: Good for quick repair of small tendons
c. Lateral trap: Firmly grips the outside of the tendon without constricting
the microcirculation in the center. The central mattress suture acts as a
temporary anchor.
d. Chicago: A simple x-stitch described by Mason and Allen
e. Robertson: An excellent method of anastamosing tendons of unequal
diameter
f. Interlace: Another method for attaching smaller to larger tendons as in
tendon grafting
g. Herringbone stitch and insertion: A method of grafting one tendon
into the center of another
h. Bunnell pull-out suture: A pull-out stitch is a non-absorbable suture
that anchors a deep stitch to the outside of the skin so it can be removed
once healing it complete. Anchored to the outside with a button.
 NOTE* Side-to-Side anastamosis of a transferred tendon provides the most
physiological pull, the greatest danger is that of slippage, so the adjoining
surfaces should be roughened and the epitenon scraped free (encourages
fibrous union) and then sutured

NOTE* When suturing a tendon it is important to preserve the

microcirculation and therefore not encircle or strangle large
amounts of tendon tissue. Close apposition is important but 5.
the tendon ends must not bunch or overlap excessively. Securing
Tendon-to-tendon approximation must be equal otherwise tendon to
fibrous tissue extrusions will bind to the surrounding tissues. bone:
Necrotic ends must be debrided Most
secure
form of fixation
a. Trephine plug: Using a Michele vertebral trephine a hole is drilled into the
bone with the tendon pressed inside and the resultant plug is later tapped
into place securing the tendon
b. Three hole suture (see diagram prior page): Anchoring the transposed
tendon with a double armed suture and placing it in a drill hole. The sutures
(a nonabsorbable polyester suture is recommended) are then tied into 2
adjacent small drill holes.
c. Buttress and button anchor: For tenodesis using a nonabsorbable suture
(stainless steel) that is removed once the healing is complete
d. Tunnel with sling: Can only be used with a tendon with sufficient length.
Made via a tunnel in a bone with the tendon passed through and sutured on
itself. Used with a Jones suspension of the EHL
e. Screw and washer (cleated polyacetyl): Useful where there is little soft
tissue for the transferred tendon can be sutured.
f. STATAC Device (Zimmer® Inc.): Titanium implant that is drilled into the
bone with non-absorbable sutures attached that can be threaded to Keith
needles and sewn through a tendon.

6. Objectives of tendon transfer:

a. To improve motor function where weakness and imbalance exist and
thereby prevent contractures and further deformity
b. To eliminate deforming forces
c. To provide active motor power
d. To provide better stability
e. To eliminate the need for bracing
f. To improve cosmesis

7. Principles of tendon transfers:

a. Select suitable cases, do not create a new imbalance
b. Understand the anatomy and physiology
c. Correct the fixed or structural deformities first
d. Select the proper timing (age of patient)
e. Select a suitable tendon for the transfer (adequate length and strength)
f. Provide a direct or mechanically efficient line of pull
g. Perform stabilizing procedures first (if needed)
h. Preserve the gliding mechanism
i. Use atraumatic technique
j. Preserve blood supply and innervation
k. Provide adequate muscle-tendon tension on fixation
l. Use secure fixation techniques
m. Provide detailed postoperative management

8. Grading system of manual muscle testing:

5 Normal Full resistance at end range of motion
4 Good Some resistance at end ROM
4+ Moderate resistance at end ROM
4- Mild resistance at end ROM
3 Fair Able to move against gravity alone
2 Poor Able to move with gravity eliminated
1 Trace Can palpate or visualize muscle contraction
0 Zero No evidence of muscle contraction

Tendon Lengthening and Tenotomy

Tendon lengthening and tenotomy have limited indications when abnormal
contracture of a musculotendinous unit compromises normal function.
Absolute tenotomy has few applications in reconstructive foot surgery
(severing the adductor tendon in HAV surgery, the FDL for mallet toe, and
tenotomy for lengthening of the Achilles tendon)
1. Common procedures:
a. Strayer technique (distal recession): Modification of the Volpius-Stoffel
procedure. Lengthening the gastrocnemius ms., requiring the complete
severence of the aponeurosis, suturing the retracted proximal aponeurosis to
the underlying soleus, and casting the foot in neutral to allow for healing at
the new length
b. Silverskiold procedure (proximal recession): Release of the muscular
heads of the spastic gastrocnemius from the femoral condyles and
reinsertion to the proximal tibial area (a 3 joint muscle is converted to a 2
joint muscle)
c. Fulp and McGlamry tongue-in-groove procedure (distal recession):
Modified Baker procedure. The tongue-in-groove cuts are inverted in the
gastrocnemius
NOTE* These procedures are utilized for the correction of non-spastic ankle
equinus secondary to gastroc. shortening. If a spastic gastroc. equinus
is present then you must also perform a concomitant excision of the
central soleus aponeurosis
d. White tenotomy: Tenotomy of the anterior 2/3 of the distal end of the
Achilles tendon and the medial 2/3 of the tendon, performed 5-7.5 cm
proximal to the insertion (presumption of torque)
e. Hoke's tenotomy: A triple tenotomy of the Achilles tendon starting 2.5
cm from the insertion and the others at 2.5 cm intervals extending proximally
f. Hibbs procedure: Tendo Achilles lengthening via a lateral skin incision,
with the medial 2/3 of the tendon divided proximally and then split
longitudinally in the distal direction at the lateral end of the incision. The
lateral 2/3 of the tendon is then divided near the point insertion and it is split
longitudinally in the proximal direction at the medial end of the incision
g. Sliding Z-plasty: Can be used for the Achilles (Hauser or White
procedures) or extensor tendons
h. Abductor hallucis tenotomy: Tenotomy of the abductor hallucis in the
treatment of congenital hallux varus and metatarsus adductus.

NOTE* Tendon lengthenings (once healed) will often result in a loss of muscle
strength roughly equal to one grade of manual examination

Tendon Transfers
1. Common procedures:
a. Murphy modification (for advancement of the tendo Achilles): Is
utilized in young patients with CP where the spasticity of the triceps is
causing ankle equinus. This procedure is performed by transecting and
rerouting the achilles tendon into the calcaneus distally just proximal to the
subtalar joint
b. Peroneus brevis tendon transfer: This muscle is transferred to aid in
dorsiflexion via rerouting the tendon medially into the 3rd cunieform.
c. Peroneus longus tendon transfer: This muscle is transferred when
additional dorsiflexory power is needed via rerouting the tendon medially into
the 3rd cuneiform. It can also be rerouted into the posterior calcaneus when
paralytic calcaneal deformities are present

NOTE* The peroneus longus tendon transfer to the cuneiform is utilized with
a drop foot deformity and weakness or paralysis of the anterior muscle
group

d. Tibialis posterior tendon transfer: Has the potential to be a good

dorsiflexor when replacement is needed via rerouting the tendon laterally,
and inserting it into the 3rd cuneiform

NOTE* The tibialis posterior tendon transfer is indicated when a weak or

paralyzed anterior muscle group is present, equinovarus deformity,
drop foot, Charcot-Marie-Tooth deformity, and permanent peroneal
nerve palsy
e. Tibialis anterior tendon transfer: To reduce the supinatory forces in
the foot via detaching the tibialis anterior over the navicular and rerouting it
laterally into the 3rd cuneiform.

NOTE* Tibialis anterior tendon transfer can be used for recurrent clubfoot,
flexible forefoot equinus, drop foot, and Charcot-Marie-Tooth deformity

f. Split tibialis anterior tendon transfer (STATT): Its goal is to increase

true dorsiflexion of the foot by balancing its power laterally via splitting the
tibialis anterior and suturing the lateral portion to the peroneus tertius (see
chapter 21, Surgery of the Congenital Foot)

NOTE* The STATT is recommended for spastic rearfoot varus, fixed

equinovarus, excessive invertor power, forefoot equinus with swing phase
extensor substitution and claw toes, flexible cavovarus deformity, and
dorsiflexory, weakness

NOTE* EDL slips 4 and 5 must be attached to EDB tendon 4

h. Hibbs tenosuspension: Is performed to release the retrograde bucking
at the MPJ's causing the flexible forefoot equinus, is done via detaching all 4
tendons of the EDL distally enough and fused at the base of the 3rd
metatarsal to the. corresponding EDB

i. Jones suspension: Used for treatment of a cocked-up hallux by

transecting the EHL at the IPJ of the hallux and rerouting it through a medial
to lateral drill hole in the head of the 1st metatarsal
 NOTE* The Jones suspension has been utilized for flexible cavus foot flexible
plantarflexed 1st ray (with or without hammered hallux), and prophylaxis
when both hallucal sesamoids are removed

j. Young procedure: A tendon transposition (rerouted through a "keyhole"

in the navicular) for flatfoot (see chapter 21, Surgery of the Congenital Foot)
k. Kidner procedure: Advancement of the tibialis posterior either inferior to
the navicular bone or modified by attachment to the medial cuneiform to
increase its adductory influence on the forefoot (see chapter 21, Surgery of
the Congenital Foot)
l. Lowman procedure: For flatfoot, a rerouting of the a medial band of the
tibialis anterior tendon under. the navicular and sutured to the spring
ligament and transfer of a section of tendo Achilles (see chapter 21)
m. Heyman procedure: A panmetatarsal suspension for equinus foot via
suturing the EDL to their respective metatarsal heads (see chapter 21,
Surgery of the Congenital Foot)
n. Flexor digitorum longus transfer: Transferring the FDL to the proximal
phalanx of the involved digit will convert it into a strong plantarflexor of the
MPJ
o. Peroneal anastomosis: Involves securing the peroneus longus to the
peroneus brevis at the level of the midcalf (for pes cavus deformity to
decrease the plantarflexory force on the 1st ray and to increase the eversion
force to the foot)
p. Joplin sling procedure: To narrow the forefoot (used with children where
you do not want to do an osseous procedure). It is done via cutting the EDL
tendon 5 and passing it through and underneath the 5th MPJ joint capsule to
the abductor hallucis and back around and over the EHL suturing it to the 1st
MPJ joint capsule. The EDL tendon 4 is sutured to stump of the EDL 5. The
adductor is transected.
2. Healing for tendon transfers:
a. Casting for 4 weeks (foot in neutral position and at right angles to the leg)
b. Early passive ROM at about 3 weeks by bivalving the cast
c. Later, progressive weight-bearing excercise (isometrics)

Tendon Grafts
1. Donor tendons: Are usually from the plantaris, peroneus tertius, strips of
the Achilles, and slips of the EDL or EDB

2. Carbon Implants: The carbon acts as a scaffold on which new tendon can
develop, which makes it appropriate for filling large gaps as can be present in
the Achilles tendon (experimental as of now)

3. Silastic sheets: Used to protect a tendon anastomosis in one study

4. Silicone rod Implant: Used in staged gliding tendon transplant in

patients where the gliding bed has been damaged. This creates a
pseudosheath for delayed tendon grafting
5. Tendon xenografts: Bovine grafts are experimental at this point
6. Dacron mesh (Dacron Cooley graft): The dacron vascular graft is split
to provide a band of material of the desired length that can be woven
through or around a ruptured Achilles tendon as a lattice for further healing,
In the same manner as the plantaris tendon is used

Posterior Tibial Tendon Rupture

1. Anatomic considerations:
a. Deep posterior compartment muscle
b. Originates from the tibia, fibula and interosseous membrane
c. Extrinsic insertions into all bones of the midfoot except the talus, 1st and
5th metatarsal
d. Passes retromalleolarly with the flexor retinaculum and functions as a two
pulley system (medial malleolus and navicular) providing a mechanical
advantage to the tendon

2. Functional considerations:
a. Open kinetic chain:
i. Supination (plantarflexion-,adduction-inversion)
b. Closed kinetic chain:
i. Deceleration of STJ pronation
ii. Acceleration of STJ and oblique MTJ supination in midstance phase of gait
iii. Rigid lever for gastro-soleus function

3. Etiology:
a. Traumatic forces and injuries
b. Progressive degeneration due to excessive demand (severe forefoot varus,
equinus, obesity)
c. Severe degeneration secondary to systemic disease (RA, mixed connective
disease, DM, etc.)
d. Neoplasms

4. Subjective findings:
a. Medial arch and/or ankle pain
b. Diffuse swelling and tenderness along the course of the TP tendon
c. Symptoms aggravated by proloned weightbearing and ambulation
d. May be more painful on initial arising in the AM (post-static dyskinesia)
e. Progressive flatfoot deformity
f. Sedentary/decreased activity

5. Clinical findings:
a. Edema and increased warmth of the medial aspect of the foot and ankle
b. Palpable tenderness along the course of the tibialis posterior tendon
c. Tenosynovitis may be present
d. Collapse of the medial arch
e. Palpable defect with complete ruptures
f. Increased heel valgus and midfoot abduction
g. Decreased muscle strength with guarding
h. Positive single heel rise test
i. Apropulsive/antalgic gait without resupination
j. Flexible to rigid depending upon the duration

6. Radiographic findings:
a. DP view:
i. Increased T-C angle (angle of Kite)
ii. Increased calcaneocuboid angle (cuboid abduction angle)
iii. Degenerative arthritic changes
b. Lateral view:
i. Decreased calcaneal inclination angle (can be normal)
ii. Increased T-C angle
iii. Increased talar declination angle
iv. Significant medial column faulting
v. Forefoot supinatus
vi. Degenerative arthritic changes
c. Special studies:
i. MRI: T1-weighted images provide images about the tendon itself, T2
weighted images are useful to highlight fluid within the tendon sheath or
adjacent edema

NOTE* MRI is most revealing. Three patterns of rupture have been

reported:
a. Type 1: Intrasubstance tears noted on MRI with longitudinal splits and
hypertrophy of the tendon (increased signal on T1)
b. Type 2: Progression of intrasubstance tears noted on MRI as decreased
girth and attenuation of the tendon
c. Type 3: Complete rupture (noted as discontinuity of the tendon on MRI)

ii. CT
iii. Tenogram

7. Conservative treatment: Not usually helpful

a. NWB cast 4-6 weeks
b. Shoe modifications/orthotic devices
c. NSAIDS

8. Surgical treatment: Depends upon the time since the rupture,

degenerative changes taken place, rigidity of the deformity, and expected
functional demands
a. Soft tissue procedures:
i. Early tendon repair:
 Excision of all scar tissue
 Excision of inflamed synovium
 Z-plasty shortening repair technique or transfer of tibialis anterior
 Primary reattachment to the navicular tuberosity
ii. Delayed primary repair with tendon free graft and desmoplasty
iii. Delayed primary repair with tendon transfer and desmoplasty
iv. Evans type procedure

NOTE* The indications for primary soft tissue repair alone are limited

b. Osseous procedures:
i. Isolated STJ arthrodesis
ii. Evans calcaneal osteotomy
iii. Talonavicular arthrodesis
iv. Combinations of above
v. Triple arthrodesis
vi. Ankle arthrodesis
vii. Pantalar arthrodesis
viii. Talonavicular arthrodesis with lateral column lengthening
c. Ancillary procedures:
i. TAL
ii. Gastrocnemius recession
iii. Medial column suspension procedures iv. Bone grafting
v. Subtalar joint arthroereisis

Posterior Tibial Tendon Dysfunction (acquired adult

flatfoot syndrome)
1. Etiology:
a. Tenosynovitis of tendon
b. Shallow or absence of malleolar groove
c. Attenuation of tendon
d. Rupture

2. Differential diagnosis:
a. Residual calcaneal valgus
b. Torsional abnormalities
c. Limb length discrepancy
d. Post-traumatic arthritis
e. Charcot arthropathy
f. Lisfranc dislocation

3. Signs and symptoms:

a. Pain
b. Edema
c. Abducted forefoot
d. Apropulsive gait
e. Loss of inversion power
f. Progressive flatfoot
g. Antalgic gait
h. Difficulty on toe raising
i. Heel not inverting with standing on toes
4. Diagnostic studies:
a. Tenogram
b. CT
c. MRI

5. Treatment (conservative)
a. BK cast immobilization in equinovarus x 4 weeks
b. Orthoses
c. NSAIDS

6. Treatment (Surgery):
a. Tendon repair
b. FHL tendon transposition
c. Secondary stabilization:
i. Medial column fusion
ii. Modified Young procedure
iii. STJ arthroereisis
iv. Evans calcaneal osteotomy
v. Triple arthrodesis

NOTE* Posterior tibial inflammation can be divided into peritendonitis,

chronic tenosynovitis, and stenosing tenosynovitis.
a. Peritendonitis: elicits pain at the musculotendinous junction, and is
consistant with an overuse syndrome. Treatment is physical therapy and
orthoses
b. Chronic tenosynovitis: elicits pain around the tendon between the tip of
the malleoli and the navicular (seen with rheumatic disease patients),
requiring orthoses and steroid injections
c. Stenosing tenosynovitis: elicits pain around the malleoli, and requires
surgical intervention

Peroneal Tendon Pathology

1. Types of pathology:
a. Dislocation:
i. Etiology:
 Eversion/dorsiflexion trauma
 Congenital absence of groove in the lateral malleolus
 Direct blow to the lateral ankle with the ankle inverted
ii. Signs and symptoms:
 Ankle edema
 Tendonitis
 Pain
 “Clicking” sound
 Avulsion flake from the fibula noted on x-ray
i. Treatment:
 Strapping (acute and chronic cases)
 Cast immobilization 3--6 weeks (acute)
 Surgical repair (acute and chronic) followed by BK cast x 4 weeks and
physical therapy

b. Stenosing Tenosynovitis:
i. Etiology:
 Direct trauma
 Lowgrade/chronic trauma
 Enlarged peroneal tubercle
 Calcaneal fracture
 Arthritis
ii. Signs and symptoms:
 Pain
 Trigger point pain
 Thickened tendon sheath
 Pain with ankle inversion
 Chronic edema
iii.Diagnostic studies:
 X-ray (calcaneal axial view)
 CT
 MRI
 Peroneal tenogram
iv. Treatment:
 Surgical repair of osseous pathology
 Surgical repair of the tendon sheath
 Iontophoresis
 Physical therapy

c. Tendon rupture:
i. Etiology:
 Laceration
Chronic degeneration
ii. Signs and symptoms
 Pain
 Edema
 Loss of eversion strength
 Inability to plantarflex the 1st ray
 Increased soft tissue mass
iii. Diagnostic studies:
 Peroneal tenogram
 MRI
 CT
iv. Treatment:
 Cast x 6 weeks
 Surgical repair (either primary repair or secondary with a graft)

Achilles Tendon Rupture

In most cases rupture results in longitudinal tearing of the tendon tissue into
irregular strips either at the musculotendonous junction (younger patient) or
at the point of insertion into the calcaneus (middle-aged people), the 2 most
common sites of rupture. The areas most susceptible to rupture are areas of
decreased circulation, myotendonous junctions, and the area 4-6 cm
proximal to the tendo Achilles insertion

1. Etiology:
a. Direct blow
b. Laceration
c. Abnormal muscle pull

2. Clinical diagnosis:
a. Pain at the site
b. Palpable tendon gap
c. Increased soft tissue mass
d. Loss of plantarflexory strength
e. Inability to walk on toes
f. Doherty-Thompson Test (+) (or just Thompson Test): The patient attempts
to plantarflex the foot while the calf is being squeezed. The inability to
perform this plantarflexion is a strong indication of Achilles tendon rupture
 NOTE* Plantaris rupture often mimics tendo Achilles rupture but with this the
Thompson test is normal, and the pain is usually located along the course of
the ruptured plantaris tendon

3. Radiographic findings:
a. Obliteration of Kager's triangle
b. Increased soft tissue density
c. Toyger's angle (130-150°)
d. CT scan
e. MRI

4. Treatment: Partial rupture

a. BK cast x 3-4 weeks in plantarflexion
b. Followed by another BK cast with less plantarflexion x 4 weeks

5. Treatment : Complete rupture (24 hours-5 days)

a. Full equinus BK cast x 3 weeks, followed by
b. Gravity equinus BK cast x 3 weeks, followed by
c. Heel lifts

6. Treatment: Complete rupture (5 days or longer)

a. Surgical repair
b. BK NWB cast x 3 weeks, followed by
c. BK weight-bearing cast x 3 weeks, followed by
d. Heel lifts (19 mm to 13 mm to 6 mm)

NOTE* If a diagnosis of a distal rupture is made within 10 days, the Lynn

procedure is ideal. NOTE* If a diagnosis of a proximal rupture is made within 10 days, a
McLaughlin procedure is preferred.
Lynn procedure: A 7 inch medial/longitudinal incision parallel to the medial
border of the TA. The paratenon is opened in the midline and with the foot
held in 20° plantarflexion, and without excising the irregular ends, the TA is
sutured using an absorbable suture. If the plantaris is intact, its insertion at
the calcaneus is divided and the tendon is fanned out to form a membrane,
which is then placed over the TA repair and sutured into place (covering the
TA 1 inch above and below the repair). The TA paratenon and skin are
closed. Cast applied
McLaughlin's procedure: A midline incision curving laterally is made. The
frayed tendon edges are trimmed back to healthy tissue. A drill hole is
made medially to laterally through the calcaneus, and a stab wound is
made at its point of emergence. A long screw is passed through the drill
hole in the calcaneus. A wire suture is inserted into the proximal tendon
fragment, which is then pulled into position by the 2 ends of the wire suture
which are fastened to the projecting ends of the screw. With retraction thus
counteracted, the trimmed tendon ends are sutured together. The
superfluous portion of the screw is cut free and removed. A twisted wire
with a split lead shot (for palpable localization of the mattress suture) is
attached to the proximal portion of the wire suture. Cast applied.

NOTE* The Bosworth procedure or the Lindholm procedure is used for late
repair of a rupture.
Bosworth procedure: Ruptured tendon exposed through a posterior
longitudinal midline incision from the calcaneus to the proximal 1/3 of
the calf. Excision of scar tissue at the ruptured ends. Free up from the
medial raphe of the gastrocnemius a strip of tendon 1/2 inch wide
and 7 inches long, leaving this strip attached just proximal to the
rupture site. The strip is turned down and passed transversely
through the proximal tendon and then passed transversely through
the distal tendon, and then passing the tendon through the distal end
from anterior to posterior, while holding the knee at 90° and the
ankle in plantarflexion. Once again the strip is brought proximally and
passed through transversely and sutured onto itself. Cast applied
Lindholm procedure: A posterior curvilinear incision is made from the
midcalf to the calcaneus. The rupture is exposed, the ragged ends are
debrided and apposed with a box-type mattress of heavy silk or other
non-absorbable suture. From the proximal tendon and gastrocnemius
aponeurosis, 2 flaps are fashioned, each approx. 1 cm wide and 7-8 cm
long. These flaps are left attached at a point 3 cm proximal to the site
of rupture,- and each flap is twisted 1800 on itself so that its smooth
external surface lies next to the subcutaneous tissues as it is turned
distally over the rupture. Each flap is sutured to the distal stump of the
tendon and to the other flap, completely covering the site of the
rupture. Wound closed. Cast applied.
5. General surgical principles:
a. Functional length restoration
b. Approximation of clean ends
c. Avoid the sural nerve
d. Preserve the tendon sheath
e. Evacuate the hematoma
f. Use proper anchoring sutures for the tendon
g. Tendon graft as necessary

6. Complications:
a. Nonoperative
i. Occurs from long term cast immobilization in equinus (needs aggressive
isokinetic rehabilitation). At the 10-15 week mark atrophy of the triceps
occurs
b. Operative:
i. Intratendinous hemorrhage and irreparable damage to the paratenon
ii. Every attempt must be made to cover the newly repaired tendon with the
paratenon complex, because if not, this will become immobile and nongliding
iii. Rerupture
iv. Infection, wound dehiscence, sinus tarsitis, and STJ damage

Lateral Ankle Stabilization Procedures (tendon

transfers)
Single ligament rupture:
Watson-Jones*: This uses the peroneus brevis, which passes through the
fibula from posterior to anterior, through the neck of the talus from plantar
to dorsal, back through the fibula, from anterior to posterior, and sutured
back onto itself.
Lee Procedure (modified Watson-Jones)*: This uses the peroneus brevis
tendon, which is then passed through the fibula, from posterior to anterior,
and then sutured back onto itself.
Evans*: This utilizes the peroneus brevis through an oblique hole through
the fibula sutured back onto the belly of the peroneus brevis. Storren
Nilsonne
Pouzet
Haig
Castaing and Meunier
Dockery and Suppan

Double ligament rupture:

Elmslie*: Originally described as using the fascia lata and passed through a
drill hole in the lower aspect of the fibula, through the calcaneus, back
through the same drill hole, and tied onto itself, after passing through the
neck of the talus.
Chrisman and Snook*: This uses the split peroneus brevis, which is passed
through the fibula from anterior to posterior through a flap in the calcaneus,
and is then sutured back to the peroneus brevis tendon.
Stroren Hambly
Winfield
Gschwend-Francillon

Triple ligament rupture:

Spotoff
Rosendahl and Jansen
 NOTE* In the case of lateral instability, both the Watson-Jones and
the Evans procedures are utilized.
a. The Watson-Jones restores the function of the calcaneofibular
c. The
and Chrisman
talofibular and Snook
ligaments procedurethe
by rerouting wasperoneus
designedbrevis
to repair the
anterior talofibular and inferior calcaneofibular ligaments,
tendon. The chief drawback of this procedure is that it involves with
preservation
drilling of the peroneus
a hole through the neckbrevis
of thetendon
talus (difficult to accurately
accomplish). A second problem can arise with this technique if the
peroneus brevis is too short to be threaded through the tunnels
fashioned to receive it.
b. The Evans technique, which was designed to obviate the
potential difficulties of the Watson-Jones, has the disadvantage of
involving reconstruction of only the calcaneofibular ligament.
Postoperative Care and Training Following
Tendon Transfer
1. Age of the patient at the time of the transfer:
a. Should be old enough to cooperate in training (>4 years old)
b. Earlier transfer is indicated when delay would result in structural deformity

2. Support In overcorrected position:

a. Until full function is restored and no tendency for reccurrence
b. Bivalved cast will help hold tendon in relaxed position during this period

3. Preoperative training to localize contracture In muscle to be

transferred

4. Instruct patient to contract transferred muscle:

a. Voluntary contracture through the original arc while guiding the part in the
direction provided by the transfer
b. Initially palpate the belly of the ms. and tendon to ensure proper
contraction
c. Initially excercises are performed in the bivalved cast
d. Mild gentle tension on the transferred tendon may be used to assist
patient in "finding" the transfer
e. Electrical stimulation may also be used to assist patient in "finding"
transfer

5. Establish motion in the new function provided

6. Development of motor strength:

a. Once motor strength becomes fair, the bivalve cast is gradually
discontinued during the day
b. Controlled activities are permitted to develop function
c. Resistance excercises are begun to develop strength when a normal ROM
and fair strength are established
d. Important to excercise antagonistic muscles also
7. Incorporation of the transfer into the new functional pattern:
a. Action of the transfer may be good through full range and moderate
resistance and yet during walking, voluntary control is lost
b. Use of crutches during this period is helpful
c. Careful supervision is required
d. Walking periods are gradually increased until gait pattern becomes a
conditioned reflex

8. Use of bracing:
a. Should be judicious and for specific reasons
b. Standing and walking excercises must also be performed without a brace
to stimulate function in the transfer

9. Bivalved casts:
a. Prolonged use is very important
b. Continue until the muscle has developed full strength and balanced
function with no tendency for reccurrence of the original deformity

10. Triple arthrodesis:

a. If dynamic balance can be established prior to the development of
structural deformity, arthrodesis can be avoided
b. Perform the osseous correction/stabilization and then perform tendon
transfer and muscle reeducation after bone union has taken place

Tenosynovitis
An inflammation of the synovial lining of the tendon sheath
1. Etiology:
a. Acute infectious tenosynovitis: Caused by a pyogenic organism. The
bacterial invasion and the resultant purulent exudate can involve the entire
length of the tendon sheath. Treatment with antibiotics must be prompt, I
and D may be necessary when the purulent material organizes
b. Chronic infectious tenosynovitis: Caused by diseases such as syphilis and
TB. The synovial wall becomes thickened and there is a fibrinous exudate
which affects the peroneal and extensor tendons most frequently.
c. Acute simple synovitis: Results from overuse most commonly affecting the
EHL, TA, and tendo Achilles
d. Chronic simple tenosynovitis: Caused by continuous shoe friction on the
extensors or Achilles tendon
e. Stenosing tenosynovitis: Usually affects the anterior and posterior tibial,
EDL, and the peroneals below the lateral malleolus and in the inferior
retinaculum. Caused by friction with-in the "pulley system" of the ankle
within the fibrous sheath. In digits, "trigger toe" occurs.
f. Hemorrhagic tenosynovitis: Caused by trauma in which the epithelial lining
of the sheath is ruptured followed by hemorrhage and clot formation
(excision of the hematoma is recommended)
g. Paratendonitis: Results from excessive friction between the tendon and the
paratenon caused by overuse, crepitation can occur
h. Acute tenosynovitis caused by rheumatoid arthritis: Nodular masses can
form within the tendon sheath, which may be rheumatoid nodules.