Medical

Posterior and medial ankle tendinopathies not involving the Achilles tendon

Posterior and medial ankle tendinopathies not involving the Achilles tendon

INTRODUCTION — Posterior ankle tendinopathies often result from repetitive strain injuries. In some cases, subtle skeletal structural faults (such as limb length discrepancy, joint laxity, pes planus, and malalignment of the lower limb) predispose to such disorders or injuries. It is therefore important to look for such defects. Other factors that can contribute to ankle tendinopathy include chronic rheumatologic disease, such as osteoporosis or spondyloarthritis, enthesitis of lower limb structures, and improper footwear.

Tendinopathies of the posterior ankle other than Achilles tendinopathy are discussed here. Achilles tendinopathy and tendon rupture, ankle sprains, and other soft tissue disorders of the foot are reviewed separately. (See “Achilles tendinopathy and tendon rupture” and “Ankle sprain” and “Plantar fasciitis and other causes of heel and sole pain” and “Clinical features and management of ankle pain in the young athlete”.)

TENDINOPATHIES OF THE POSTEROMEDIAL ANKLE

Mechanism and clinical presentation — Eleven muscles have tendons crossing the ankle, while four major ligaments provide ankle stability (figure 1 and figure 2). Acute inflammation or chronic degeneration of a tendon or tendon sheath may result from repetitive activity or unaccustomed heavy workloads (eg, new or more intense athletic workout).

A chronic nonspecific tendinopathy can affect any of several ankle tendons. Tendons at the posteromedial ankle that may be affected include the posterior tibial and flexor hallucis longus.

Some researchers suspect that an acute tenosynovitis precedes the development of chronic tendinopathy, but patients frequently cannot recall the acute injury or episode [1]. Occasionally, an underlying systemic disorder predisposes to tenosynovitis. These may include rheumatoid arthritis, spondyloarthritis, or more rarely oxalosis, xanthomas, giant cell tumors, or tuberculosis.

Acute tenosynovitis can occur where the tendons curve around the medial malleolus when friction at such sites causes inflammation. A bulbous swelling can occur distal to areas of constriction. Mild to moderate pain may be felt but often increases gradually over several weeks. Calcific tendinitis is an exception; onset of pain with this disorder is acute.

However, in most cases of tendinopathy of the posteromedial ankle, the patient does not recall any acute event and the initial complaint is of chronic, worsening pain. Depending upon the time elapsed and the severity of tendon degeneration, the patient may also complain of weakness or foot deformity.

Clinical and radiologic evaluation — Physical examination of the patient with tendinopathy may reveal tubular swelling of the tendon sheath if acute tenosynovitis is present. In patients with chronic pain, findings generally include tenderness along the involved tendon, pain with passive stretching of the tendon, and pain with active ankle movement, while palpation of the ankle joint is unremarkable. Comparison with the uninvolved side is often helpful. In patients with long-standing symptoms (several months or longer) and significant tendon degeneration, weakness and structural deformities may be apparent.

Plain x-rays in patients with posteromedial ankle tendinopathy are usually unrevealing. New bone formation over the posterior aspect of the medial malleolus may occur in some cases. Magnetic resonance imaging (MRI) provides excellent definition of tendinopathy with or without rupture, but may not provide a cost benefit. In a randomized controlled study of 500 persons with acute injury of the wrist, knee, or ankle, MRI did not expedite the workup or change treatment of wrist or ankle injuries when compared with plain radiography [2].

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Improving transducer technology and portability make high-resolution, musculoskeletal ultrasound (US) a useful tool for evaluating tendinopathies. US enables knowledgeable clinicians to obtain high-resolution imaging of tendons, ligaments, and nerve structures at the bedside without exposing the patient to ionizing radiation [3,4]. US also allows tendons and muscles to be visualized while examination maneuvers are performed.

Treatment — Most cases of mild to moderate posteromedial ankle tendinopathy can be treated by partial immobilization and support of the ankle with bandaging or an elastic support for three to six weeks, depending upon severity, and home exercise therapy. Acetaminophen or nonsteroidal antiinflammatory drugs (NSAID) can be used for pain relief. The treatment of tendinopathy and the effect of NSAIDs on tendon healing are reviewed separately. (See “Overview of the management of overuse (chronic) tendinopathy” and “Nonselective NSAIDs: Overview of adverse effects”, section on ‘Possible effect on tendon injury’.)

This nonsurgical approach to initial treatment is supported by a randomized controlled trial of 36 patients with posterior tibial tendon dysfunction assigned to treatment with orthoses wear and stretching (O group); orthoses wear, stretching, and concentric progressive resistive exercise (OC group); or orthoses wear, stretching, and eccentric progressive resistive exercise (OE group) [5]. Foot Functional Index scores (a validated measure of total pain and disability) decreased in all groups following treatment. The OE group demonstrated the greatest improvement in each subcategory; the O group demonstrated the least improvement.

A number of exercises can be used to help patients regain ankle mobility and strength. Foot-ankle circles are a simple exercise to maintain range of motion and strength (picture 1). These can be performed several times daily with increasing repetitions and intensity as healing progresses. Stretching and lengthening of the calf muscles and plantar fascia begin gently and progress as activity increases. Strengthening exercises are added as pain subsides. As with Achilles tendinopathy, preliminary studies suggest that a strength program emphasizing eccentric exercises may be useful [5,6]. Massage of the involved muscle and tendon can improve tissue flexibility. (See “Achilles tendinopathy and tendon rupture”, section on ‘Eccentric exercise rehabilitation’.)

Complete immobilization in a walking cast boot for a brief period of time may be necessary in severe cases of tendinopathy. Referral to a clinician with experience managing tendinopathy of ankle tendons is best in such cases. Patients with severe weakness, suggestive of tendon rupture, or foot or ankle deformity should be referred to a foot and ankle surgeon.

Injection of the tendon sheath with a glucocorticoid has been associated with posterior tibial tendon rupture and is best avoided [1,7-9]. The effect of glucocorticoid injection on tendon healing is reviewed separately. (See “Overview of the management of overuse (chronic) tendinopathy”, section on ‘Glucocorticoids’.)

POSTERIOR TIBIAL TENDINOPATHY — The posterior tibial muscle and tendon are involved in plantar flexion, subtalar joint (foot) inversion, and stabilization of the medial foot arch and hindfoot. The tendon travels behind the medial malleolus and ultimately divides into several branches, which insert on the navicular, cuneiforms, cuboid, and the second, third, and fourth metatarsals. Tendinopathy of the posterior tibial tendon is important to recognize because chronic degeneration can lead to tendon disruption and progressive flatfoot deformity if left untreated (figure 3) [1,9,10].

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Researchers no longer describe posterior tibialis tendinitis as an inflammatory condition but rather as a degenerative condition with a nonspecific reparative response to tissue injury (tendinopathy) [11]. The pathologic changes characteristic of tendinopathy are discussed separately. (See “Overview of overuse (chronic) tendinopathy”.)

Numerous risk factors for posterior tibial tendinopathy have been identified, including increasing age, pes planus, hypertension, diabetes mellitus, peritendinous glucocorticoid injections, and inflammatory arthropathies [1,9,10]. Middle aged women are commonly affected. Areas of the tendon with relatively poor vascularization are more vulnerable, particularly if they are close to the medial malleolus. The forces acting on this tendon can be high and, particularly when combined with adverse biomechanics (eg, excessively pronation), likely play a role in the pathogenesis of this tendinopathy.

The presentation of posterior tibial tendinopathy depends upon the severity of tendon degeneration [1,9]. In the early stages, patients usually present with gradually increasing pain and possibly swelling at the posteromedial ankle and longitudinal arch. Pain is worse with walking or other weight-bearing activity and can radiate toward the tendon insertions. Several weeks of persistent pain often have passed before the patient decides to seek help.

As tendon degeneration worsens, patients generally complain of weakness with plantar flexion (toe raise) in addition to pain. With severe disease, patients cannot perform a toe raise and deformities may be present, such as collapse of the arch (pes planus), foot eversion, or heel valgus [9]. Examination may reveal the “too many toes” sign, in which the clinician sees more toes of the involved foot when looking from directly behind the patient.

Treatment for acute tendinopathy or tenosynovitis begins with protection, rest, ice, compression, elevation, and gentle stretching as tolerated. Acetaminophen or nonsteroidal antiinflammatory medications (NSAID) help to reduce pain. Passive stretching is performed with the forefoot rotated externally (ie, outward) from the neutral position, or in a circular manner. Walking in a figure-eight pattern can begin when tenderness and swelling have subsided. If symptoms have not resolved in ten to fourteen days and medications do not provide adequate pain relief, treatment with a rigid orthosis, and possibly casting for a short time, may be necessary [1]. Referral to a clinician with experience managing posterior tibial tendinopathy is suggested in such cases.

Physical therapy is likely to be helpful for injuries without severe degeneration. As with Achilles tendinopathy, preliminary studies suggest that a strength program emphasizing eccentric exercises may be useful [6]. Discussions of eccentric exercise and other general noninvasive therapeutic measures for tendinopathy are under investigation and are reviewed separately. (See “Achilles tendinopathy and tendon rupture”, section on ‘Eccentric exercise rehabilitation’ and “Overview of overuse (chronic) tendinopathy”, section on ‘Natural history and treatment’.)

In cases of persistent severe tendinopathy, significant weakness suggestive of complete tendon rupture, or deformity, surgical consultation should be obtained [12].

ACHILLES TENDINOPATHY AND TENDON RUPTURE — These topics are discussed separately. (See “Achilles tendinopathy and tendon rupture”.)

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SUMMARY AND RECOMMENDATIONS

  • Acute inflammation or chronic degeneration of a tendon or tendon sheath may result from repetitive activity or unaccustomed heavy workloads (eg, new or more intense athletic workout). Tendons at the posteromedial ankle that may be affected include the posterior tibial and flexor hallucis longus.
  • Clinical findings in patients with chronic tendinopathy generally include tenderness along the involved tendon, pain with passive stretching of the tendon, and pain with active ankle movement. In the early stages, there are no palpable abnormalities of the foot or ankle joint.
  • Patients with severe degeneration of the posterior tibial tendon manifest weakness (limited or no ability to perform a toe raise) and often deformities of the foot or ankle, such as collapse of the arch (pes planus), foot eversion, or heel valgus.
  • Most cases of mild posteromedial ankle tendinopathy can be treated by partial immobilization and support of the ankle with bandaging or an elastic support for three to six weeks, depending upon severity, and home exercise therapy, including an eccentric strengthening program.
  • Complete immobilization in a walking cast boot for a brief period may be necessary in severe cases of posteromedial ankle tendinopathy. Referral to a clinician with experience managing tendinopathy of ankle tendons is best in such cases.
  • In cases of persistent, severe posteromedial ankle tendinopathy, significant weakness suggestive of complete tendon rupture, or deformity, surgical consultation should be obtained.
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REFERENCES

  1. Simpson MR, Howard TM. Tendinopathies of the foot and ankle. Am Fam Physician 2009; 80:1107.
  2. Nikken JJ, Oei EH, Ginai AZ, et al. Acute peripheral joint injury: cost and effectiveness of low-field-strength MR imaging–results of randomized controlled trial. Radiology 2005; 236:958.
  3. Nallamshetty L, Nazarian LN, Schweitzer ME, et al. Evaluation of posterior tibial pathology: comparison of sonography and MR imaging. Skeletal Radiol 2005; 34:375.
  4. Lee KS, Rosas HG, Craig JG. Musculoskeletal ultrasound: elbow imaging and procedures. Semin Musculoskelet Radiol 2010; 14:449.
  5. Kulig K, Reischl SF, Pomrantz AB, et al. Nonsurgical management of posterior tibial tendon dysfunction with orthoses and resistive exercise: a randomized controlled trial. Phys Ther 2009; 89:26.
  6. Kulig K, Lederhaus ES, Reischl S, et al. Effect of eccentric exercise program for early tibialis posterior tendinopathy. Foot Ankle Int 2009; 30:877.
  7. Jahss MH. Spontaneous rupture of the tibialis posterior tendon: clinical findings, tenographic studies, and a new technique of repair. Foot Ankle 1982; 3:158.
  8. Holmes GB Jr, Mann RA. Possible epidemiological factors associated with rupture of the posterior tibial tendon. Foot Ankle 1992; 13:70.
  9. Gluck GS, Heckman DS, Parekh SG. Tendon disorders of the foot and ankle, part 3: the posterior tibial tendon. Am J Sports Med 2010; 38:2133.
  10. Rees JD, Wilson AM, Wolman RL. Current concepts in the management of tendon disorders. Rheumatology (Oxford) 2006; 45:508.
  11. Mosier SM, Pomeroy G, Manoli A 2nd. Pathoanatomy and etiology of posterior tibial tendon dysfunction. Clin Orthop Relat Res 1999; :12.
  12. Supple KM, Hanft JR, Murphy BJ, et al. Posterior tibial tendon dysfunction. Semin Arthritis Rheum 1992; 22:106.


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