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Flashcards in Tendon injuries Deck (96):

What is plantar fascitis?

  • Inflammation of the aponeurosis at its origin on the calcaneus


What is the epidemiology of plantar fascitis?

  • men = women
  • effects POSTEROMEDIAL Heel
  • Risk factors
    • Obesity
    • decreased ankle DORSIFLEXION in an non- athelete population ( tightness of foot/calf muscl)
    • weight bearing endurance activity- running


What is the pathophysiology of  plantar fascitis?

  • chronic overuse leads to microtears in origin of plantar fascitis
  • repititive trauma-> recurrent inflammation and periostitis
  • Abductor hallucis, flexor digitorium brevis & quadratus plantae- same origin on medial calcaneal tubercle- may become inflammed


What are the associated conditions of plantar fascitis?

  • Calcaneal apophysitis- inflamation of heel pad growth plate= Sever's disease- affects children
  • gastronemius soleus contracture
  • heel pad triad
    • plantar fascitis
    • post tibital tendon dysfunction
    • tarsal tunnel syndrome


What is the anatomy of  plantar fascitis?

  • is a thin layer of connective tissue supporting arch of foot


What are the signs and symptoms of planar fascitis?

  • Symptoms
    • SHARP heel pain, often when first getting out of bed
    • may prefer to walk on toes initially
    • worse at end of day after prolonged standing
    • relieved by amputation
    • common bilateral symptoms
  • Signs
    • tender to palpation over medial tuberosity of calcaneus
    • dorsiflexion of toes and foot increases tenderness with palpation
    • limited ankle dorsiflexion due to tight achilles tendon
    • tenderness at origin of abductor hallucis- entrapment /irriation of 1st branch of lateral plantar nerve = baxter's


What imaging is useful in  plantar fascitis?


  • may show plantar heel spur
  • ap and lateral standing may show structural changes


  • useful for surgical planning

Bone scan

  • can quantify inflammation and quide management


What is the tx of  plantar fascitis?

Non operative

  • Pain control, splinting and stretching therapy regime
    • first line of tx
    • plantar fascia specific stretching and achilles tendon stretching
      • recreate windlass mechanism and achieve tissue tension thru controlled stretch of PF
    • anti-inflammatories
    • Foot orthosis
      • cushioned heel inserts, prefabricated shoes inserts,
      • If no relief 6wks think night splints, walking casts or steriod injection

        • steriod injection-> heel pad necrosis/planar fascia rupture
      • short leg casts 8-10 wks
      • Outcomes
      • prefab shoe inserts better than custom orthotics in relieving symptoms + stretching exercises
      • NWB plantar fascia specific strecthing programme better than WB achilles tednon stretching programme
      • Stretching programmes have equal satisifaction at 2 years
  • Shock wave Tx ( post 6 months of failed tx)
    • 2nd line
    • chronic pain lasting >6 months
    • painful for pts
    • efficacous at 6 months FU


  • Gastronemius recession
  • Surgical release w plantar fasciotomy
  • surigcal release w planter fasciotomy and distal tarsal tunnel decompression


what is the tier of t for plantar fascitis?

  1. Intial padding /strapping foot , therapeutic insoles , oral antiinflammatories & regular achilles/ plantar fascia stretching
  2. symptoms persist > 6 weeks
    • Shock wave therapy
    • corticosteriod injections
    • Night splints
  3. Symptoms > 6months
    • Surgical release

Non surgical tx is successful in 90% pts


Can you describe the indications for sugery?

  • Gastronemius recession- no clear indications established
  • Surgical release w planar fasciotomy
    • Pain persists > 9 months of failed consx 
    • complx common & recovery protracted
  • Surgical release w planar fasciotomy with distal tarsal tunnel release
    • concomitant compression neuropathy ( tibial n in tarsal tunnel)
    • success rate 70-90%


can you describe the surgical release of plantar fascia?

  • Open vs arthroscopic
  • open is indicated if tarsal tunnel symptoms is present
  • incision= anteropr border of weight bearing surface of calcaneum.superifical fascia over abductor hallucis is identified and incised to reveal plantar fascia inferior adn beneath. Incise abductor hallucis muscle to reveal  planar fascia beneath
  • release
    • medial 1/3rd to 2/3rds
    • avoid complete release can lead to
      • destabilisation of longitudinal arch
      • overload of lateral column
      • dorsolateral foot pain
    • consider stimulanteous release of abxter's nerve
      • ​release deep fascia of abductor hallucis
      • may improve outcomes


What are the complications of plantar fascitis?

  • Lateral plantar nerve injury
  • Complete release of the plantar fascia with destabilisation of medial longitudinal arch
  • increased stress on dorsolateral midfoot
  • chronic pain


What is FHl tendonitis?

  • Flexor hallucis longus impingment -> tendonitis- inflammation and even rupture can occur at level of posterior ankle


What is the epidemiology of FHL tendonitis?


  • Posterior ankle
  • great toe

risk factors

  • Excessive plantar-flexion
    • dancers/ on pointe position
    • gymnasts


What is the pathophysiology of FHL tendonitis?

  • Activties involving maximal planar-flexion
  • In chronic cases- nodule formation may lead to triggering


Can you name any associated conditions of FHL tendonitis?

  • Os trigonum ( posteriorlateral tubercle)
  • posterior ankle inpingement


Can you describe the anatomy of FHL?

What is its actions?

  • originates from posterior fibula
  • travels between posteriomedial/posteriolateral tubercles of talus
  • contained with fibro-osseous tunnel
  • passes beneath sustentaculum tali
  • crosses dorsal to FDL ( at knot of henry)
    • multiple connections exists between FDL /FHL
    • distally is stays dorsal to FDL and NV bundle
  • inserts onto distal phalanx of great toe


  • PLANTARFLEXION of hallux IP and MPJ
  • Supplied by tibial nerve


What are the signs and symptoms of FHL tendonitis?


  • Posteriomedial ankle pain
  • Great toe locking with active range of motion
  • Crepitus along posterior medial ankle


  • Pain with resisted flexion of IPJ 
  • Pain with forced plantarflexion of ankle
  • great toe triggering with active/passive motion but no tenderness at level of 1st MT head


What investigations would help woth dx of FHL tendonitis?

  • MRI
    • Find fluid around tendon at level of ankle joint
    • intra-substance tendinous signal


What is the tx for FHL tendonitis?

Non operative

  • Rest, activity modification, NSAIDS
    • first line of tx
    • arch supports
    • physical therapy


  • Release of FHL from fibro-ossoeus tunnel , tenosynovectomy +/- tendon repair
    •  in athletes when symptoms persist
    • arthroscopic/open-post medial 


Describe the surgical decompression of FHL for tendonitis?

  •  consider medial approach, made posterior to the medial malleolus at the the level of the superior border of calcaneus; 
    •  FHL is identified just anterior to the Achilles tendon; 
    • identify the N/V bundle and the underlying FHL tunnel; 
    • flex and extend the great toe to identify the tunnel, and attempt to palpate for a nodule; 
    •  release the posteromedial aspect of the tunnel down to the level of the sustentaculum tali; 
    •   ensure that there is unrestricted motion of the FHL; 
    • look for a longitudinal rent in the FHL tendon; 

      consider removal of an os trigonium is one is present


How is the FHL tendon injured?

  • laceration form direct trauma in acute setting


What signs of FHL laceration?

  • inablity to actively flex IPJ great toe


What are the most useful investigations to aid dx of FHL laceration?


  • tendon ends may retract


What is the tx of FHL laceration?

  • Acute repair when FHL and FHB lacerated
  • debateable depends on location
  • If the FHL is lacerated proximal to the Knot of Henry where FHL and FDL cross, then the intact FDL acts through the interconnection with the remaining FHL to allow plantarflexion of the great toe. If FHL is lacerated distal to the Knot of Henry then FHL will no longer function. This would then lead to an absence of hallux plantarflexion at the interphalangeal joint and possibly also to gait disturbances.


name the tendons in this axial view

no next card - keep guessing


name the tendons in this axial view 2?

Tendons are


Define Peroneal tendon injury ?

  • Tendon dislocation and repetitive subluxation from behind lateral malleolus


What is the epidemiology of peroneal tendon injuries?

What is the mechanism of peroneal tendon injuries?

  • Most injuries occur in young, active patients
  • Rapid dorsiflexion of an inverted foot inversion leading to rapid reflexive contraction of the PL and PB tendons
  • Rapid contraction can lead to injury to superior peroneal retinaculum
  • Longitudinal split tears more common than transverse


Pathophysiology of peroneal tendon injuries?

  • subluxation of the peroneal tendons lead to longitudinal tears over time which usually involves the peroneus brevis at fibular groove


Describe the anatomy of peroneus brevis and longus?

  • Peroneus brevis
    • Innervated by superificial peroneal n S1
    • Acts as primary EVERTOR of foot
    • tendinous about 2-4cm prox to tip of fibula
    • lies anterior and medial to peroneus longus at level of lateral malleolus
  • Peroneus Longus
    • Innervated by superficial peroneal nerve S1
    • Acts as primarly PLANTAR FLEXOR FOOT/1st MT ( longus want to make foot look long)
    • Can have ossicle- os peroneum in tendon body


Describe the space and compartment within which Peroneus longus and brevis are contained?

  • Peroneal tendons contained within common synovial sheath that splits at the level of the peroneal tubercle
  • the sheath runs in the RETROMALLEOLAR SULCUS on the fibula- see pic
    • Peroneus longus is POSTERIOR in sulcus (longest takes the longway round!!)
    • deepened by fibrocartilaginous rim ( 5mm deep)
      • orginates from posterolat ridge of fibula & inserts into lat calcaneus
      • Inf aspect of SPR blends w Inf peroneal retinaculum
      • It is the primary restraint the peroneal tendons within the retrimalleolar sulcus


Name the classification of superifical peroneal retinaculum tears?

  • Ogden  ( NB hilda ogden - nora battie- wrinkles aorunf ankles)
  • Grade 1- SPR- is partially elevated off the fibula allowing for subluxation of both tendons
  • Grade 2- SPR is separated from cartilofibrous ridge of lat malleolus , allowing tendons to sublux between SPR and cartiofibrous ridge
  • Grade 3 -cortical avulsion of SPR off fibula, allowing subluxed tendons to move underneath the cortical fragment
  • Grade 4- Spr is torn from calcaneous not fibula


What is the signs and symptoms of peroneal nerve disslocation/subluxation?


  • Pt reports they felt a POP with DORSIFLEXION ANKLE Injury


  • Clicking and popping and feeling of instability or pain on the LATERAL aspect of the ankle


  • swelling posterior to lateral malleolus
  • tenderness over tendons
  • 'pseudotumour' of peroneal tendons
  • Provocational test
    • Subuxation with active dorsiflexion and eversion against resistance -> subluxation/dislcation /apprehension
    • Compressive test- pain on active dorsiflexion and eversion


What investigations aid DX of peroneal tendon dislocation?

  • Xray
    • internal rotation view
    • may see distal tip of lateral malleolus- RIM FRACTURE
    • need to evaluate for varus hindfoot
  • MRI
    • axial views w slightly flexed ankle gd
    • demonstrate peroneus quartus muscle
    • low lying peroneus brevis muscle belly


What is the tx of peroneal tendon subluxation/dislocation?

Non operative

  • Short leg cast immobilisation & protected weight bearing 6 weeks
    • all acute injuries
    • tendons must be reduced at time of casting
    • success rates approx 50%


  • Acute repair of superior peroneal retinaculum and deeping of fibular groove
    • ​acute dislocations in serious athletes who desire QUICK return to sport/active lifestyle
    • presence of longitudinal tears
  • Groove deepening with soft tissue transfer adn or osteotomy
    • Chronic/recurrent dislocations
    • less able to reconstruct SPR
    • Deepening groove in addition to soft tissue transfer or one block techniques
    • Plantaris graft can be used to reinforce the SPR
    • Hindfoot varus must be corrected prior to any SPR reconstructive procedure


What is the signs and symptom of peroneus brevis tendon tears?

  • presentation & exam similar to peroneal tendon dislocation but there is no instability of the tendon  
  • MRI is required for diagnosis


What is the TX of peroneal tendon tears?

Non operative

  • NSAIDS activity restriction & walking boots
  • failure rate as much as 83%


  • Simple tear
    • Core repair and tubularization of tendon
    • Complex tears in which multiple longitudinal tears and significant tendinosis >50% tendon involved
      • debride tendon with tenodesis of distal and proximal ends to BREVIS tendon to peroneus longus or reconstruct with allograft


What is achilles tendonitis?

  • A family of conditions that include
    • Insertional achilles tendonitis
    • Retrocalcanceal bursitis and Haglund deformity
    • Achilles tendonitis


What is insertional achilles tendonitis?

  • Pain and tendon thickening at insertion of achilles tendon


What is the epidemiology of insertional achilles tendonitis?

  • Occurs in middle aged & elderly patients with a tight heel cord


What is the aetiology of achilles tendonitis?

  • Repetitive trauma leads to inflammation followed by cartilagenous then bony metaplasia


What are the signs and symptoms of achilles tendonitis?


  • Posterior heel pain, swelling, burning, stiffness
  • shoe wear due tio direct presure
  • progressive bony enlargement of calcaneus at insertion site


  • Midline tenderness at insertion of achilles tendon


What are the imaging useful for dx of insertional achilles tendonitis?

  • XRay
    • Lateral xray  foot may show spur nad intratendinous calcification
  • MRI/ultrasound
    • can show amount of degeneration


What is the histology of insertional achilles tendonitis?

  • Disorganised collagen with mucoid degeneration, although few inflammatory cells


What is the tx of insertional  achilles tendonitis?

Non operative

  • Activity modification, shoe modification, therapy
    • first line of tx
    • PT with eccentric training
    • gastronemius-soleus stretching
    • Shoe
      • Heel sleeves and pads
      • small heel lift
      • locked ankle afo 6-9 months ( if other nonop fail)
    • Injections- avoid steriods= risk of Achilles tendon rupture


  • Retrocalcaneal bursa excision, debridement of diseased tendonm calcaneal bony prominence resection
    • failure of nonop mx and <50% of achilles needs to be removed
    • midline, lateral or 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


What is retrocalcaneal bursitis?

  • Inflammation of bursa between the anterior aspect of the Achilles and posterior aspect of calcaneus


What is this?

  • Haglund deformity
  • Enlargement of posterosuperior tuberosity of the calcaneus


Describe the epidemiology, signs and symptoms of retrocalcaneal bursitis and Haglund deformity?

  • Young patients


  • Pain localised to anterior /2-3 cm proximal to achilles tendon insertion
  • Fullness and tendereness medial and lateral to tendon
  • Pain with dorsiflexion
  • Bony prominence at achilles insertion


What imaging is useful in dx of haglund defomrmity and retrocalcaneal bursitis?

  • Xrays
    • show haglund deformity
  • MRI- rarely required


What is the tx of haglund deformity and retrocalcaneal bursitis?

Non operative

  • Activity modification, shoe wear modification, PT, NSAIDS
    • first line
    • ice
    • shoewear- external padding of achillles tendon
    • Avoid steriod injections -> tendon rupture


  • Retrocalcaneal bursa excision adn resection of haglund deformity
    • Refractory to non op measures
    • Midline, lateral or medial J shaped incisions 


What is the aetiology of achilles tendonitis?

  • Overuse
  • imbalance of dorsiflexors & plantar flexors
  • poor tendon blood supply
  • Genetic redisposition
  • Fluoroquinolones antibiotics
  • inflammatory arthropathy


What is the pathoanatomy of achilles tendonitis?

  • Theorized to abnormal vascularity 2-6cm Proximal to achilles insertion in response to repetitive microscopic tearing of the tendon


What is the classification of achilles tendonitis?

  • Achilles tendinosis
    • Tendon thickening
    • thought to  be caused by anaerobic degeneration in portion of tendon with poor blood suply
  • Achilles peritendonitis
    • inflammation of tendon sheath
  • ​Inflammation of paratenon


What are the signs and symptoms of achilles tendonitis?


  • Pain, swelling,warmth
  • worse with activity
  • difficulty running


  • Tendon thickening and tenderness 2-6cm proximal to achilles insertion
  • pain throughout entire ROM


What imaging is useful in dx of achilles tendonitis?

  • MRI
    • disorganised tissue will show up as intrasubstance intermediate signal intensity
    • thicked tendon
    • chronic rupture will show hypoechoic region between tendon ends


What is the tx of achilles tendonitis?

Non operative

  • Activity modification, shoe wear modificiation, nsaids, PT
    • first line
    • PT with eccentric training- strengthen skeletal muscle- constant muscle tension whilst lengthening muscle- see pic
    • modalities- Ultrasound
    • shoewear
      • heel lifts
      • cast/removal boot ( severe disease)
    • Non op is 65-90% successful
    • Glyceryl trinitrate patches- evolving lack of evidence yet


  • Percutaneous Tentomies
    • Mild - moderate disease
    • longitudinal tenotomy made in degenerate area
    • strip the anterior achilles tendon with a large suture to free adhesions
  • Open excision of degenerative tendon with tubularisation
    • mod- severe disease
    • 70-100% successful
  • Tendon transfer= FHL/FDL/ PB
    • degeneration >50% of achilles tendon
    • >55yrs old
    • MRI evidence of diffuse tendon thickening without focal area of disease


What is the epidemiology of achilles tendon rupture?

  • 18:100,000 per year
  • more common in men
  • most common in ages 30-40

risk factors

  • episode athelete 'weekend warrior"
  • flouroquinolone antibiotics
  • steriod injections


What is the mechanism of achilles tendon rupture?

  • Usually traumatic during sporting event
  • may occur with
    • sudden forced plantar flexion
    • violent dorsiflexion in a plantar flexed foot


What is the pathoanatomy of achilles tendon ruptures?


  • Rupture normally 4-6cm above calcaneus in hypovascular location


Decribe the anatomy of achilles tendon ?


  • Longest tendon in bocy
  • formed from soleus -
    • post fibular- post medial tibial to achlles tendon post 3rd of calcaneus
    • plantarflxoe of ankle
    • Tibial nerve
  • 2 heads of medial and lateral gastronemius
    • Medial head -post medial femoral condyle
    • lateral head - post lat femoral condyle
    • insert into achilles- calcaneus
    • Tibial nerve


What are the symptoms and signs of achilles tendon rupture?


  • Hx- pt reports a 'pop'


  • weakness and difficulty walking
  • pain in heel


  • Incease ankle dorsiflexion in prone position with knees bent
  • calf atrophy- chronic cases
  • palpable gap
  • Weakness to plantarfelxion
  • Thompson/Symmons test- calf squeeze and no passive Dorsiflexion


What investigations are useful in dx of achllles tendon rupture?

  • Xray- rule out other pathology
  • USS- distinquish partial from full thickness tear
  • MRI- equivoical diagnosis, chronic tear will show retracted edges


What is the tx and indications of tx of achilles tendon rupture?

Non operative

  • Pt non op, medially frail,sedentry pt
  • Functional bracing/ equinus cast
    • 20 degrees of plantarflexion
    • re-repture lower in early Wb with protective rom cf NWB cast
    • decreased plantarflexion strength cf operative fixation
    • increased risk of re- rupture cf op fixation
    • fewer wound complications


  • End to end achilles tendon repair
    • <3/12 old ruptures
    • No diff in re-repture rates cf consx
    • No sig diff in plantarflexion strength cf non op - both level 1 evidence
  • percutaneous achilles tendon repair
    • concerns over comesis of scar
    • risk of sural nerve damage
  • Reconstruction with VY advancement
    • Chronic ruptures w 4cm defect
  • FHL transfer with VY advancement of gastronmenius
    • chronic defect with gap .4cm


Describe the technique for acute achilles tendon repair?


  • medial incision to achilles tendon- to avoid sural nerve
  • Incise paratenon
  • expose edges
  • reapir heavy non absorable suture
  • imobilise in 20o planarflexion- to reduce skin tension and protect tendon repair 4-6 weeks


 Describe the technique for v to y advancement for acute achilles tendon repair?


  • V shaped incision, apex of v at musculotendinoius border limbs divergent to edge
  • V incised only thru superifical tendinous portion leaving muscle fibres intact


Describe the techque for repairt of achilles tendon injury with >.4cm defect?


  • FHL transfer and n V turndown of gastronemius
  • Excise degenerative tendon edges
  • Take FHL prox to knot of henry and ransfer thru calcaneus
  • FHl used to proximiity and vascular supply
  • V of gastronemiu 6cm long at apex and thru superficial tendon


What are the complication of achilles tendon repair?


  • Re-repture
    • Generaly considered hiogher with non op 10-40% vs 2% but new level 1 evidence suggests no difference
  • Wound healing complications
    • 5-10%
    • Risk factors
      • smoking
      • female gender
      • steriod use
    • Tx of chronic infection
      • debridment, no try at repair
      • culture specific antibiotics 6 weeks
      • Soft tissue coverage and reconstruction
  • Sural nerve injury
    • higher when percutanoeus approach used


What is the mechanism for anterior tibilalis tendon rupture?

  • Result of either laceration of the tendon
  • Blunt trauma
  • Most common in middle aged pts following eccentric loading of a degenerative tibialis anterior tendon against plantar flexed foot


Why is there a delay in diagnosis?

  • intact dorsiflexion because of EHL and extensor digitorium longus muscles


Decribe the anatomy of tibialis anterior?

  • origin- lateral condyle of tibia
  • inserts- medial and planar surfaces of 1st cuneiform on base of 1st MT
  • Action= dorsiflexion of ankle and INVERTOR of foot
  • Deep Peroneal Nerve L4/5


Name the secondary ankle dorsiflexors?

  • Extensor Hallucis longus
    • origin- anterior surface of fibula
    • inserts- base and dorsal centre of distal phalanx
    • Action= Extends Great Toe/ Dorsiflexes Ankle
    • Deep Peroneal nerve
  • Extensor Digitorium Longus ( Nb long attachement and tendons)- see pic
    • origin- lat condyle of fibula, 2/3-3/4 fibular shaft
    • inserts- splis into 4 tendon slips inserts into dorsum middle & distal phalnanges of toes
    • action= extends toes 2-5 and Dorsiflexes ankle
    • Deep peroneal Nerve


What are the signs of tibialis anterior tendon rupture?

  • Traumatic injury
    • associated ossous or soft tissue injury
    • Pain and weakness on ankle dorsiflexion
  • Atraumatic injury
    • Pseudotumour at anteriomedial aspect of ankle
    • loss of ocntour of tibilalis anterior tenson over the ankle- see pic
    • use of EHL and EDC to dorsiflex ankle 


What investigaitons are helpful in tibialis anterior tendon tears?

  • Xrays
    • exclude bony injury
  • MRI
    • Helful to dx patial from incomplete tears


What is the tx of tibialis anterior tendon ruptures?

Non operative

  • Ankle- foot Orthosis
    • tx individualised ot pt


  • Direct repair
    • More acute <6 wks post injury
  • Reconstruction with interposition of EDL or Plantaris
    • more in chronic injuries >6weeks


What is the most common cause of flatfoot?

Posterior Tibial tendon insufficiency


What is the epidemiology of Posterior Tibial tendon insufficiency?

  • More common females
  • often present 6th decade
  • Risk factors
    • obesity
    • older athletes
    • inflammatory disorders


What is the mechanism of Posterior Tibial tendon insufficiency?

  • Exact aetiology unknown
  • Assumed to be MULTIFACTORAL
  • 20% report acute injury


Describe the pathoanatomy of Posterior Tibial tendon insufficiency?

  • Tendon degeneration occurs in the watershed region distal to medial malleolus
  • Begins as tenosynovitis and progresses to significant tendinosis with an incompetent, painful tendon that lacks exercusion
  • Medial longitudinal arch collapses, subtalar joint everts and heel goes into valgus
  • Achilles tendon is then held lateral to axis of rotation of subtalar joint and begins to act as an evertor of calcaneus. loss of longitudinal arc->fixed eqinus of hindfoot and contracture of achilles-> equinus mechanically disadvantage-> worsens collapse
  • fixed bony deformities occur later


What conditions are associated with Posterior Tibial tendon insufficiency?

  • Young males with Posterior Tibial tendon insufficiency may have
    • Seronegative spondyloarthropathy
    • inflammatory arthropathy


What is the anatomy of tibialis posterior?

  • origin: posterior aspect of interosseous membrane, superior medial posterior of tibia
  • inserts- spits into 3 after passing INFERIOR to plantar calcaneonavicular ligament and behind Medial malleolus
    • ​anterior slip inserts onto tuberosty of navicular/ medial cuneiform (sometimes)
    • middle slip inserts 2nd 3rd cuneiforms, cuboid and 2-5 MT
    • post slip- inserts sustenaculum tali
  • ​Action- INVERTOR of FOOT- primary
    • ​Adducts foot
    • plantar flexes ankle
    • supinates foot
  • ​TIBIAL Nerve L4/L5


What is the blood supply of tibialis posterior?

  • Branches of posterior tibial artery
  • A watershed area of poor intrinsic blood supply exisits between navicular and distal medial malleolus ( 2-6cm proximal to navicular insertion)


Decribe the biomechanics of tibialis posterior tendon?

  • Lies in axis posterior to tibiotalar joint  and medial to aaxis of subtalar joint
  • Primary dynamic support of arch
  • Hindfoot INVERTOR
  • ADDUCTS and SUPINATES the forefoot suring stance phase of gait
  • acts as secondary plantar flexor of ankle


Descirbe the classification system of Posterior Tibial tendon insufficiency?

  • Johnstone and Stromm


Describe stage 1  of Posterior tibial insufficiency?



  • Tenosynovitis
  • No deformity


  • Single leg raise


  • Normal 


Describe stage 2 of PTT insufficiency?

  • STAGE 2A
    • Flatfloot deformity
    • flexible hindfoot
    • Normal forefoot
    • unable to do SINGLE heel raise
    • mild sinus tarsi pain
    • xray- arch collapse deformity
  • Stage 2B
    • Flatfoot deformity
    • Flexible HIndfoot
    • Forefoot abduction too many toes >40% Talonavicular coverage- important in tx
    • unable to do SINGLE heel raise

    • mild sinus tarsi pain


    • xray- arch collapse deformity




Descirbe stage 3 PTT insufficiency?

  • Flatfoot deformity
  • Rigid forefoot abduction
  • Rigid hindfoot valgus
  • Severe sinus tarsi pain
  • unable to do single leg stance


  • arch collapse
  • subtalar arthritis



Describe stage IV PTT insufficiency?

  • Flatfoot deformity
  • Rigid forefoot abduction
  • rigid Hindfoot valgus
  • Deltoid ligament compromise


  • Ankle pain
  • severe sinus tarsi pain
  • Unable to single heel raise


  • arch collapse deformity
  • subtalar arthritis
  • talar tilt ankle mortise


What are the signs and symptoms of PTT insuficiency?


  • medial ankle/foot pain and weakness is seen early
  • progressive loss of arch
  • lateral ankle pain due to subfibular impingment is a late symptom


  • Pes planus- collapse of medial arch
  • hindfoot valgus deformity 
    • flexible stage 2
    • rigid stage 3,4
  • Forefoot abduction
    • ​stage 2B- 'too many toes sign'


  • ROM
    • Single limb heel rise
      • unable to preform stage 2,3,4
    • Fixed or flexible deformity
      • ​flexible stage 2
      • fixed stage 3/4


What is seen on plain radiographs with PTT insufficiency?

Ap foot

  • Increased talonavicular uncoverage
  • increased talo- first metatarsal angle ( Simmons angle)
    • stage 2-4


  • Increased talo-forst MT ankle = meary angle normal 0
  • decreased calcaneal pitch
    • normal 17=30 
    • inidcates loss of arch height
  • decreased medial cuneform- floor height
    • Loss of arch height
  • Subtalar arthritis
    • stage 3 & 4
  • talar tilt due to deltoid insufficiency
    • stage 4


Can you describe Meary's angle?

The angle formed between the talus and 1st metatarsal 

normal is 0

Angles <4o = Ped planus


What are the other differentials of pes planus?

  • Midfoot pathology
    • OA
    • Lis Franc Injury
  • Incompetent of Spring ligament
    • primary static stabiliser of the talonavicular joint
    • Tx with adjunctive spring ligament reconstruction in addition to standard flatfoot reconstruction


What are the tx for PTT insufficiency?

non operative

  • Immobilisation in walking cast/boot 3-4 months
    • first line in stage 1
  • Custom moulded shoe orthosis= medial heel lift & longitudinal arch support
    • stage 1 post immobilisation
    • Stage 2
  • Ankle foot orthosis
    • stage 2-4 in low, sedentary pts
    • AFO most effectivewant medial orthotic post to support valgus collapse


  • Stage 1= Tensosynovectomy
  • Stage 2= FDL transfer, calcaneal osteotomy. TAL +/- forefoot correction osteotomy +/- spring ligament repair+/- PTT debridement
    • Stage 2B= forefoot correction will needed to be done
    • ​CI= hypermobility, neuromuscular conditions. severe subtalar arthritis, obesity, age 60-70
  • Stage 3= Triple arthrodesis +TAL
  • Stage 4= Triple arthrodesis +TAL + deltoid ligament reconstruction
  • Stage 4 w rigid hindfoot, valgus talus, tibiotalar and subtalar arthritis= Tibiotalocalcaneal arthrodes


Why is FDL used in stage 2 disease?

  • FDL is Synergistic with tibialis posterior 
  • can augment function of deficient PT
  • Insert FDL into navicular near insertion of PT
  • FDL cf FHL - FHL more complicated to mobilise & not shown improved results
  • In midfoot FHL runs under FDL


What are the techniques for correcting hindfoot valgus?


Name the joints involved in a triple arthrodesis?

  • Calcaneocuboid
  • Talonavicular
  • Subtalaar