Disorders of tendons

fascia and posture of foot

and ankle:

DR ALI MUQADDAS SHERAZI

PGR FCPS ORTHOPEDICS
Plantar fasciitis:
A condition caused by inflammation of the aponeurosis at its origin on
the calcaneus
affects men and women equally
affects the posteromedial heel
risk factors
obesity (high BMI)
decreased ankle dorsiflexion in a
non-athletic population
weight bearing endurance activity
(dancing, running)
 Pathophysiology
chronic overuse leads to micro tears in the origin of the plantar fascia
repetitive trauma leads to recurrent inflammation and periosteitis
abductor hallucis, flexor digitorum brevis, and quadratus plantae share
the origin on medial calcaneal tubercle and may be inflamed as well

Associated conditions
calcaneal apophysitis
gastrocnemius-soleus contracture
Heel pain triad
plantar fasciitis
posterior tibial tendon dysfunction
tarsal tunnel syndrome
 Presentation:
Sharp heel pain. often at first getting out of bed
May prefer to walk on toes initially
Common to have symptoms bilaterally
Physical exam
tender to palpation at medial tuberosity of calcaneus
dorsiflexion of the toes and foot increases tenderness with palpation

Radiographs
often normal
may show plantar heel spur
MRI
may be useful for surgical planning
Treatment:
Non-operative
pain control, splinting & therapy (stretching) program
first line of treatment
anti-inflammatories or cortisone injections
corticosteroid injections can lead to fat pad atrophy or plantar fascia rupture

foot orthosis
examples include cushioned heel inserts, pre-fabricated shoe inserts, night splints,
walking casts
short leg casts can be used for 8-10 weeks

shock wave treatment

second line of treatment
chronic heel pain lasting longer than 6 months when other treatments have failed

outcomes
efficacious at 6 month follow-up
 Operative
surgical release with plantar fasciotomy
perisistent pain after 9 months of failed conservative measures

outcomes
complications common and recovery can be protracted

surgical release with plantar fasciotomy and distal tarsal tunnel

decompression
concomitant compression neuropathy (tibial nerve in tarsal tunnel)

outcomes
success rates are 70-90% for dual plantar fascial release and distal tarsal tunnel
decompression
 approach
can be done open or arthroscopically
open procedure is indicated if tarsal tunnel syndrome is present as well
release
release medial one-third to two-thirds
avoid complete release as it may lead to
destabilization of the longitudinal arch
overload of the lateral column
dorsolateral foot pain

consider simultaneous release of Baxter's nerve

release the deep fascia of abductor halluces
May improve outcomes

gastrocnemius recession
Variable results
Complications:

Lateral plantar nerve injury

Complete release of the plantar fascia with destabilization of medial
longitudinal arch
Increased stress on the dorsolateral midfoot
Chronic pain
Plantar fascia rupture
risk factors = athletes, minimalist runners, corticosteriod injections
treat with cast immobilization
Achiles disorders

The Achilles tendon (gastro-soleus tendon) rotates 90 degree

laterally to attach on posterior aspect of calcaneul tuberosity

Accepts 2000-7000 N of stress,

depending on the load and
transfer forces 6 to 10 times
body weight during a running stride

Retrocalcaneum bursa :
lies between anterior surface of Achilles tendon and posterosuperior
surface of calcaneus tuberosity
Insertional Achilles tendinitis

Pain and tendon thickening at insertion of Achilles tendon

occurs in middle-aged and elderly patients with a tight heel cord

Mechanism
repetitive trauma leads to inflammation followed by cartilaginous then
bony metaplasia
symptoms
posterior heel pain, swelling, burning, and stiffness
shoe wear pain due to direct pressure
progressive bony enlargement of calcaneus at insertion site
 physical exam
midline tenderness at insertion site of Achilles tendon

radiographs
lateral foot shows bone spur and intratendinous calcification
MRI and ultrasound
can demonstrate amount of degeneration
histology
disorganized collagen with mucoid degeneration, although few
inflammatory cells
Treatment
nonoperative
activity modification, shoe wear modification, therapy
first line of treatment
therapy
physical therapy with eccentric training
gastrocnemius-soleus stretching
shoe wear
heel sleeves and pads (mainstay of nonoperative treatment)
small heel lift
locked ankle AFO for 6-9 months (if other nonoperative modalities fail)
injections
avoid steroid injections due to risk of Achilles tendon rupture
Operative
Retro calcaneal bursa excision, debridement of diseased tendon,
calcaneal bony prominence resection

failure of non-operative management and < 50% of Achilles needs to be

removed
midline, lateral, or medial J-shaped incisions

tendon augmentation or transfer (FDL, FHL, or PB) vs. suture anchor repair

when > 50% of Achilles tendon insertion must be removed during thorough
debridement
Non insertional Achilles
tendinopathy:
Mechanism
overuse
imbalance of dorsiflexors and plantar flexors
poor tendon blood supply
genetic predisposition
fluoroquinolone antibiotics
inflammatory arthropathy
Pathophysiology
theorized to be due to abnormal vascularity 2 to 6 cm proximal to
Achilles insertion in response to repetitive microscopic tearing of the
tendon
 symptoms
pain, swelling, warmth
worse symptoms with activity
difficulty running
physical exam
tendon thickening and tenderness 2 to 6 cm proximal to Achilles insertion
pain throughout entire range of motion
MRI
disorganized tissue will show up as intrasubstance intermediate signal intensity
thickened tendon
chronic rupture will show a hypoechoic region between tendon ends
Treatment
Nonoperative
activity modification, shoe wear modification, therapy, NSAIDs
first line of treatment
physical therapy with eccentric training
shoewear
heel lifts
cast or removable boot (severe disease)
nonoperative management is 65% to 90% successful

glyceryl trinitrate patches, prolotherapy, and aprotinin injections

evolving indications due to lack of evidence at this time
operative
percutaneous tenotomies
mild to moderate disease
techniques
longitudinal tenotomy made in the degenerative area
strip the anterior Achilles tendon with a large suture to free
any adhesions
open excision of degenerative tendon with tubularization
moderate to severe disease
70% to 100% successful
tendon transfer (FHL, FDL, or PB)
degeneration of >50% of the Achilles tendon
>55 years of age
MRI evidence of diffuse tendon thickening without a focal
area of disease
Achiles tendon rupture:
Acute rupture of the Achilles tendon
often misdiagnosed as an ankle sprain
may be missed in up to 25%
Epidemiology
18:100,000 per year
more common in men
most common in ages 30-40
risk factors
episodic athletes, "weekend warrior"
flouroquinolone antibiotics
steroid injections
 Mechanism
usually traumatic injury during a sporting event
may occur with
sudden forced plantar flexion
violent dorsiflexion in a plantar flexed foot

Pathoanatomy
rupture usually occurs 4-6 cm above the calcaneal insertion in
hypovascular region
Presentation:
History
patient usually reports a "pop"
weakness and difficulty walking
pain in heel
Physical exam
inspection
increased resting ankle dorsiflexion in prone position
with knees bent
calf atrophy may be apparent in chronic cases
palpation
palpable gap
motion
weakness to ankle plantar flexion
increased passive dorsiflexion
 provocative test
Thompson test
lack of plantar flexion when calf is squeezed

Radiographs
used to rule out other pathology

Ultrasound
may be useful to determine complete vs. partial ruptures

MRI
equivocal physical exam findings
chronic ruptures
findings
will show acute rupture with retracted tendon edges
Treatment:
Nonoperative
functional bracing/casting in resting equinus
cast/brace in 20 degrees of plantar flexion
acute injuries with surgeon or patient preference for non-operative management
sedentary patient
medically frail patients

outcomes
equivalent plantar flexion strength compared to operative management
increased risk of re-rupture (20 % )compared to operative management
fewer complications compared to operative treatment
 End-to-end achilles tendon repair
make incision just medial to achilles tendon to avoid sural nerve
incise paratenon
expose tendon edges
repair with heavy non-absorbable suture
postoperative care
immobilize in 20 of plantar flexion to
decrease tension on skin and protect tendon
repair for 4-6 weeks
 Reconstruction with VY advancement

make V cut with apex at musculotendinous junction with limbs

divergent to exit the tendon
V is incised through only the
superficial tendinous portion leaving
the muscle fibers intact

Flexor hallucis longus transfer VY advancement of gastrocnemius

excise degenerative tendon edges
release FHL tendon at the Knot of Henry and transfer through the calcaneus
Complications:
Re-rupture
higher with non-operative management (~10-40% vs 2%)
treatment
surgical repair
Wound healing complications
5-10%
risk factors
smoking (most common)
female gender
steroid use
open technique (versus percutaneous)
Sural nerve injury
Incidence higher when percutaneous approach is used
Infections:
Culture sensitivity
debridement
Flexor hallucis longus tendonitis:
Impingement of the flexor hallucis longus with resultant tendonitis
and even rupture can occur at the level of the posterior ankle joint
risk factors
excessive plantar-flexion

Pathophysiology
activities involving maximal plantar-flexion
pathoanatomy
posterior to the talus
within the fibro-osseous tunnel
in chronic cases nodule formation may lead to triggering
Anatomy:
Muscle
FHL
originates from posterior fibula
travels between posteromedial/posterolateral
tubercles of the talus
contained within fibro-osseous tunnel
passes beneath the sustentaculum tali
crosses dorsal to FDL (at the Knot of Henry)
FHL is "higher" at Knot of Henry
FDL is "down" at Knot of Henry

multiple connections exist between the FDL and FHL

distally it stays dorsal to the FDL and neurovascular bundle
inserts on the distal phalanx of the great toe
 Biomechanics
primary action
plantarflexion of the hallux IP and MP joints
secondary action
plantarflexion of the ankle
 Symptoms
posteromedial ankle pain
great toe locking with active range of motion
crepitus along the posterior medial ankle
Physical exam
pain with resisted flexion of the IP joint
pain with forced plantarflexion of the ankle
motion
great toe triggering with active or passive motion but no tenderness at the
level of the first MT head
Treatment:
Nonoperative
rest/activity modification, NSAID
first line of treatment

modalities
arch supports
physical therapy

Operative
release of the FHL from the fibro-osseous tunnel, tenosynovectomy,
recalcitrant symptoms
in athletes when symptoms persist despite rest and nonsurgical management
approach
arthroscopic
open, posteromedial
FHL laceration:

Introduction
direct trauma to the FHL tendon in an acute setting
acute laceration -most common form of injury
physical exam
range of motion
loss of active interphalangeal joint flexion

MRI
tendon ends may be retracted

Treatment
operative
acute surgical repair of the laceration
lacerations of both the FHL and the FHB
Peroneal tendons:
Peroneal tedon dislocation and repetitive subluxation from behind
lateral malleolus
young, active patients

Mechanism

rapid dorsiflexion of an inverted foot- inversion leading to rapid reflexive

contraction of PL, PB
rapid contraction can also lead to injury to the superior peroneal
retinaculum
 Pathophysiology
subluxation of the peroneal tendons leads to longitudinal tears over
time which usually involves peroneus brevis at fibular groove
subfibular impingement secondary to calcaneal malunion
Associated conditions
tears of the peroneus brevis and or longus
longitudinal split tears more common than transverse
lateral ankle ligament injuries (ATFL, CFL) in up to 75% of patients with SPR
injuries
 Muscles & innervation
Peroneus brevis
innervated by the superficial peroneal nerve, S1
acts as primary evertor of the foot
tendinous about 2-4cm proximal to the tip of the fibula
lies anterior and medial to the peroneus longus at the level of the lateral malleolus

Peroneus longus
innervated by
superficial peroneal nerve, S1
primarily a plantar flexor and foot and first metatarsal
can have an ossicle (os peroneum) located within the tendon body
 Space & compartment

peroneal tendons contained within a common synovial sheath that

splits at the level of the peroneal tubercle

the sheath runs in the retromalleolar sulcus on the fibula

peroneus longus is posterior in the sulcus (longus takes the long way around)
peroneus brevis is anterior in the sulcus (brevis is behind the bone)
deepened by a fibrocartilaginous rim (still only about 5 millimeters deep)
 covered by superior peroneal retinaculum (SPR)

originates from the posterolateral ridge of the fibula and inserts

onto the lateral calcaneus (peroneal tubercle)
the inferior aspect of the SPR blends with the inferior peroneal
retinaculum
is the primary restraint the peroneal tendons within the
retromalleolar sulcus

at the level of the peroneal tubercle of the calcaneus

peroneus longus is inferior
peroneus brevis is superior
both tendons covered by inferior peroneal retinaculum
Classification:
Ogden Classification of Superior Peroneal Retinaculum (SPR) Tears

Grade 1 The SPR is partially elevated off of the fibula allowing for subluxation of both
tendons

Grade 2 The SPR is separated from the cartilofibrous ridge of the lateral malleolus,
allowing the tendons to sublux between the SPR and the cartilofibrous ridge

Grade 3 There is a cortical avulsion of the SPR off of the fibula, allowing the subluxed
tendons to move underneath the cortical fragment

Grade 4 The SPR is torn from the calcaneous, not the fibula
 History
patients often report they felt a pop with a dorsiflexion ankle injury
clicking, popping and feelings of instability or pain on the lateral aspect
of the ankle
inspection
swelling posterior to the lateral malleolus
tenderness over the tendons
provocative tests
apprehension tests
the sensation of apprehension or subluxation with active
dorsiflexion and eversion against resistance
 Radiographs
best recognized on an internal rotation view
findings
may see a cortical avulsion off the distal tip of the lateral malleolus (fleck
sign, rim fracture)
needed to evaluate for varus hindfoot

MRI
best evaluated with axial views of a slightly flexed ankle
 Nonoperative
short leg cast immobilization and protected weight bearing for 6 weeks
all acute injuries in nonprofessional athletes
tendons must be reduced at the time of casting
success rates for nonsurgical management are only marginally better than 50%.

Operative
acute repair of superior peroneal retinaculum and deepening of the
fibular groove
acute tendon dislocations in serious athletes who desire a quick return to a
sport or active lifestyle
 groove-deepening with soft tissue transfer and/or
osteotomy
chronic/recurrent dislocation
Technique

less able to reconstruct SPR so treatment focuses on other aspects

of peroneal stability
typically involves groove-deepening in addition to soft tissue
transfers or bone block techniques (osteotomies to further contain
the tendons within the sulcus)
plantaris grafts can act to reinforce the SPR
hindfoot varus must be corrected prior to any SPR reconstructive
procedure
PERONEAL BREVIS TEARS
Introduction
presentation and physical exam is often very similar to peroneal tendon
dislocation, however there is no instability of the tendon
Imaging
MRI is requried for diagnosis
Treatment
nonoperative
NSAIDs, activity restriction and a walking boot are often the first line of treatment
failure rate may be as high as 83%
operative
core repair and tubularization of the tendon
simple tears
debridement of the tendon with tenodesis of distal and proximal ends of the brevis tendon
to the peroneus longus or reconstruction with allograft
complex tears with multiple longitudinal tears and significant tendinosis (>
50% of the tendon involved
Tibialis anterior tear:

Partial or complete discontinuity of the tibialis anterior tendon

attritional rupture more common in older patients
strong eccentric contraction more common
in younger patients
at the level of the ankle joint with varying
degrees of retraction of the proximal stump
risk factors
older age
diabetes
fluoroquinolone use
local steroid injection
inflammatory arthritis
 Ankle dorsiflexion
primary ankle dorsiflexor (80%)
tibialis anterior
secondary ankle dorsiflexors
extensor hallucis longus
extensor digitorum longus
delay in diagnosis is common because of intact ankle
dorsiflexion that occurs as a result of secondary function
of the extensor hallucis longus and extensor digitorum
longus muscles
 gait
High steppage gait (hip flexed more than
normal in swing phase to prevent toes from
catching)
foot slaps down after heel strike
Radiographs
threeviews of foot and ankle helpful to exclude any
associated osseous injury
MRI
helpful to diagnose complete versus partial tear
Treatment:
Nonoperative
ankle-foot orthosis
low demand patient

casting
partial ruptures

Operative
direct repair
acute injury (<6 week) injuries
should be attempted up to 3 months
 Reconstruction
most often required in chronic (>6 week) old injuries
harvest one half width of tibialis anterior tendon proximally and turn down to
span gap
repair can be strengthened by securing tibialis anterior tendon to medial
cuneiform or dorsal navicular distal to extensor retinaculum
interposition of autograft (hamstring, plantaris) or allograft
EHL tenodesis or EHL transfer
distal EHL stump tenodesed to EHB
proximal EHL stump used as tendon graft to repair tibialis anterior insertion
Adult acquired Pes Planus

Posterior tibial tendon insufficiency is the most common cause

of adult-acquired flatfoot deformity
Epidemiology
more common in women
often presents in the sixth decade
risk factors
obesity
hypertension
diabetes
increased age
corticosteroid use
seronegative inflammatory disorders
 Mechanism
exact etiology is unknown
acute injury (e.g., ankle fractures caused by pronation and external rotation)
vs. long-standing tendon degeneration

Pathoanatomy
early disease
early tenosynovitis progresses to PTTI
leads to loss of medial longitudinal arch dynamic stabilization
late disease
PTTI contributes to attritional failure of static hindfoot
stabilizers and collapse of the medial longitudinal arch
 foot deformity
pes planus
hindfoot valgus
forefoot varus
forefoot abduction
 Muscle
tibialis posterior
originates from posterior fibula, tibia, and interosseous membrane
innervated by tibial nerve (L4-5)
Tendon
posterior tibial tendon (PTT) lies posterior to the medial malleolus before
dividing into 3 limbs
anterior limb
inserts onto navicular tuberosity and first cuneiform
middle limb
inserts onto second and third cuneiforms, cuboid, and
metatarsals 2-4
posterior limb
inserts on sustentaculum tali anteriorly
 Blood supply
branches of the posterior tibial artery supply the tendon distally
a watershed area of poor intrinsic blood supply exists between the
navicular and distal medial malleolus (2-6 cm proximal to navicular
insertion)
Biomechanics
PTT lies in an axis posterior to the tibiotalar joint and medial to the axis of the
subtalar joint
functions as a primary dynamic support for the arch
acts as a hindfoot invertor
adducts and supinates the forefoot during stance phase of gait
acts as secondary plantar flexor of the ankle
major antagonist to PTT is peroneus brevis
activation of PTT allows locking of the transverse tarsal joints creating a
rigid lever arm for toe off phase of gait
Classification
Deformity Physical exam Radiographs

Stage I Tenosynovitis (+) single-heel raise Normal

No deformity
Stage IIA Flatfoot deformity (-) single-leg heel raise Arch collapse
Flexible hindfoot Mild sinus tarsi pain deformity
Normal forefoot
Stage IIB Flatfoot deformity
Flexible hindfoot
Forefoot abduction ("too
many toes", >40%
talonavicular uncoverage)
Stage III Flatfoot deformity (-) single-leg heel raise Arch collapse
Rigid forefoot abduction Severe sinus tarsi pain deformity
Rigid hindfoot valgus Subtalar arthritis
Stage IV Flatfoot deformity (-) single-leg heel raise Arch collapse
Rigid forefoot abduction Severe sinus tarsi pain deformity
Rigid hindfoot valgus Ankle pain Subtalar arthritis
Deltoid ligament Talar tilt in ankle
compromise mortise
 Symptoms
medial ankle/foot pain and weakness is seen early
progressive loss of arch
lateral ankle pain due to subfibular impingement is a late symptom
Physical exam
inspection & palpation
pes planus
collapse of the medial longitudinal arch
hindfoot valgus deformity
flexible stage II
rigid stage III, IV
forefoot abduction (Stage IIB disease)
"too many toes" sign
>40% talonavicular uncoverage
 FOREFOOT VARUS
place flexible heel in neutral position
observe the relationship of metatarsal heads
FLEXIBLE = MT heads perpendicular to long axis of tibia and
calcaneus
FIXED = lateral border of foot is more plantar flexed than
medial border
tenderness just posterior to tip of medial malleolus
often associated with an equinus contracture
RANGE OF MOTION
single-limb heel rise
unable to perform in stages II, III, and IV
 PTT power
foot positioned in plantar flexion and full inversion
unable to maintain foot position when examiner applies
eversion force
determine whether deformity is flexible or fixed
flexible deformities are passively correctable to a
plantigrade foot (stage II)
rigid deformities are not correctable (stages III and IV)
Imaging:
Radiographs
AP view
increased talonavicular uncoverage
increased talo-first metatarsal angle
(Simmon angle)
seen in stages II-IV

weight bearing lateral foot

increased talo-first metatarsal angle
(Meary angle)
angles >4 indicate pes planus
seen in stages II-IV
 DECREASED CALCANEAL PITCH
normal angle is between 17-32
indicates loss of arch height
DECREASED MEDIAL CUNEIFORM-FLOOR HEIGHT
indicates loss of arch height
SUBTALAR ARTHRITIS
seen in stages III and IV
ANKLE MORTISE
talar tilt due to deltoid insufficiency
seen in stage IV
 MRI
variable amounts of tendon degeneration and arthritic changes in the
talonavicular, subtalar joint
Ultrasound
increasing role in the evaluation of pathology within the PTT
Differntials:

Pes planus secondary to

MIDFOOT PATHOLOGY (OSTEOARTHRITIS OR CHRONIC LISFRANC
INJURY)
treat with midfoot fusion and a realignment procedure
INCOMPETENCE OF THE SPRING LIGAMENT
(primary
static stabilizer of the talonavicular joint) in the
absence of PTT pathology
treat with adjunctive spring ligament reconstruction in
addition to standard flatfoot reconstruction
Treatment:

Stage 1 :synovitis without deformity

Nonoperative
ankle foot orthosis
immobilization in walking cast/boot for 3-4 months
custom-molded in-shoe orthosis
Operative:
Synovectomy of PTT
Stage 2: flexible deformity is the key factor, PTT is
degenerated and functionaly incompetent

Non operative:
Physical therapy along with AFO
Full length orthotic with an arch support
Lace up ankle support
Operative:
Correction of all stage 2 deformities include
a tendon transfer FDL/FHL into navicular
to reconstruct the PTT
Gastrocnemius recession if present
Stafge 2A: hindfoot valgus without forefoot abduction
Medial side calcaneul osteotomy
Stage 2B: forefoot abduction in addition to hindfoot
valgus
Lateral column lenghthening
Medial calcaneul osteotomy

Stage 2 C: Fixed forefoot supination and varus

Stable medial column: cotton osteotomy:
dorsal opening wedge osteotomy of cuneiform to
plantar flex the first ray
Unstable medial column:
Medial column fusion
Isolated first TMT fusion
Isolated NC fusion
Combined NC and TMT fusion
Stage 3: fixed planovalgus

Non operative:
Rigid AFO/ Arizona brace
Dont try to correct deformity: increased pain
and ulceration

Operative
Triple arthrodesis
Medial column stabilization
TAL if equinus contracture
Stage 4 incompetence of deltoid
ligament:
Operative:
Deltoid ligament reconstruction:
If ankle valgus is correctable with
minimal degenerative changes
Hind foot reconstruction
Tibiotalocalcaneul arthrodesis:
Rigid deformity or progressive arthritis
Most reliable procedure for stage 4
Tibiotalocalcaneul arthrodesis:
Pes cavus deformity

Defined by high arch foot often with heel varus

Pathology:
Neuromuscular
Unilateral:
Rule out tethering of spinal cord
or spinal tumours
Bilateral:
charcot marie tooth disease
Idiopathic: usually subtle , bilateral
Traumatic:
Talus fracture malunion, compartment syndrome, crush injury
Diagnosis:
Complains of painful calluses under ist metatarsal, 5th metatarsal,
and medial heel
Secondary to plantar flexed fist ray and varus hind foot
Often associated with lateral ankle ligament instability, peroneal
tendon pathology
Coleman block test : used to assess flexibility of hind foot ( out of
varus) when ist metatarsal plantar flexion(forefoot valgus) is
eliminated
Wooden block placed just lateral to 1st ray; Ist MT head then lies off the
block, with remainder of block on the weight bearing foot.
If the hind foot passively corrects into valgus, the deformity is forefoot
driven( due to plantar flexed Ist ray)
Coleman block test:
Treatment:
Non operative:
Orthotics with lateral heel wedge, Decreased arch, and depressed ist
ray may be effective
Operative:
Forfoot driven pathology:
Ist metatarsal dorsiflexion osteotomyis indicated
Lateral calcaneul closing wedge osteotomy:
With no or incomplete correction of hind foot with coleman block test
Performed in addition to dorsiflexion osteotomy

Subtalar fusion or triple arthrodesis:

If arthritic symptoms are present