Ultrasonographic examination of the posterior tibial tendon

Characteristics and Future Direction of Tibialis Posterior Tendinopathy Research: A Scoping Review

Background and Objectives: Tibialis posterior tendon pathologies have been traditionally categorized into different stages of posterior tibial tendon dysfunction (PTTD), or adult acquired flatfoot deformity (AAFD), and more recently to progressive collapsing foot deformity (PCFD). The purpose of this scoping review is to synthesize and characterize literature on early stages of PTTD (previously known as Stage I and II), which we will describe as tibialis posterior tendinopathy (TPT). We aim to identify what is known about TPT, identify gaps in knowledge on the topics of TPT, and propose future research direction. Materials and Methods: We included 44 studies and categorized them into epidemiology, diagnosis, evaluation, biomechanics outcome measure, imaging, and nonsurgical treatment. Results: A majority of studies (86.4%, 38 of 44 studies) recruited patients with mean or median ages greater than 40. For studies that reported body mass index (BMI) of the patients, 81.5% had mean or median BMI meeting criteria for being overweight. All but two papers described study populations as predominantly or entirely female gender. Biomechanical studies characterized findings associated with TPT to include increased forefoot abduction and rearfoot eversion during gait cycle, weak hip and ankle performance, and poor balance. Research on non-surgical treatment focused on orthotics with evidence mostly limited to observational studies. The optimal exercise regimen for the management of TPT remains unclear due to the limited number of high-quality studies. Conclusions: More epidemiological studies from diverse patient populations are necessary to better understand prevalence, incidence, and risk factors for TPT. The lack of high-quality studies investigating nonsurgical treatment options is concerning because, regardless of coexisting foot deformity, the initial treatment for TPT is typically conservative. Additional studies comparing various exercise programs may help identify optimal exercise therapy, and investigation into further nonsurgical treatments is needed to optimize the management for TPT.

Chronic adaptations of the long head of the biceps tendon and groove in professional baseball pitchers

BACKGROUND AND HYPOTHESIS

The long head of the biceps tendon (LHBT) plays a significant shoulder stabilizing role during pitching, with the large forces and repetitions involved in overhead throwing likely contributing to LHBT pathology. Determining whether the LHBT undergoes adaptive changes in baseball pitchers and how these changes relate to bicipital groove morphology can improve our understanding of the biceps function at the glenohumeral joint. Therefore, the purpose of this study was to determine the chronic adaptations of the bicipital groove morphology and the LHBT in professional baseball pitchers, with a secondary purpose of evaluating biceps integrity as it relates to torsional changes of the bicipital groove. We hypothesized that the throwing arm of professional baseball pitchers would exhibit chronic adaptations of the LHBT compared with their nonthrowing arm, and that these adaptations would be related to the bicipital groove morphology.

MATERIALS AND METHODS

Fifty-three professional baseball pitchers were enrolled at the beginning of the 2015 Major League Baseball spring training. Ultrasound was used to bilaterally measure humeral retroversion and to capture images of the bicipital groove and the LHBT. MATLAB software was used to calculate the area of the bicipital groove, and ImageJ software was used to quantify the area, echogenicity, and circularity of the LHBT.

RESULTS

The dominant arm LHBT cross-sectional area was significantly smaller than the nondominant arm (9 mm² vs. 10 mm²; P = .011), whereas the dominant arm LHBT echogenicity was significantly higher than the nondominant arm (65 optical density vs. 59 optical density; P = .002). Pitchers with more bicipital groove rotational adaptation (more retroversion) had significantly more LHBT echogenicity adaptation compared with pitchers with less bicipital groove rotational adaptation (12 vs. 2; P = .023).

CONCLUSION

There are significant bilateral differences in the LHBT of professional baseball pitchers. An adaptation in bony rotation was associated with a larger bilateral difference in LHBT echogenicity but was not related to bilateral differences in LHBT area or circularity. Therefore, the bilateral difference in echogenicity is impacted by bony morphology, whereas the bilateral difference in cross-sectional area may be independent of bony morphology in this healthy population.

Clinical Tests of Tibialis Posterior Tendinopathy: Are They Reliable, and How Well Are They Reflected in Structural Changes on Imaging?

OBJECTIVE

To determine the reliability of common clinical tests for tibialis posterior tendinopathy (TPT) and to investigate their relationship with grayscale ultrasound findings in individuals who have medial foot/ankle pain.

DESIGN

Prospective cohort.

METHODS

Fifty-two individuals reporting medial foot/ankle pain were clinically examined by 2 physical therapists using 4 clinical tests for TPT: pain on tendon palpation, swelling around the tendon, pain/weakness with tibialis posterior contraction, and pain during or inability to perform a single-leg heel raise (SLHR). Individuals also underwent an ultrasound examination by a sonographer. Physical therapists and the sonographer were blind to each other's findings. Positive ultrasound examination included at least 1 of the following grayscale changes: hypoechogenicity, fibrillar disruption, or thickening of the tendon. For reliability between the 2 physical therapists, we calculated kappa coefficients and 95% confidence intervals (CIs). To assess relationships between clinical and imaging findings, we calculated odds ratios and 95% CIs.

RESULTS

The SLHR was the most reliable test, with substantial agreement between physical therapists (κ = 0.74; 95% CI: 0.54, 0.93), while the other tests had moderate levels of reliability. Of all clinical tests, the SLHR was most related to grayscale findings on ultrasound (odds ratio = 5.8), but was imprecisely so, with a 95% CI of 1.7 to 20.4.

CONCLUSION

Of all tests, the SLHR was the most reliable between clinicians and best related to imaging findings in individuals presenting with TPT, aligning with contemporary thinking of tendinopathy as a load-related clinical presentation. There was a disconnect between clinical findings and ultrasound grayscale changes in the tibialis posterior tendon in individuals with TPT. J Orthop Sports Phys Ther 2021;51(5):253-260. Epub 28 Mar 2021. doi:10.2519/jospt.2021.9707.

Prevalence of Abnormal Ultrasound Findings in Asymptomatic Posterior Tibial Tendons

BACKGROUND

Posterior tibial tendon dysfunction (PTTD) is a pathological condition that can cause failure of the posterior tibial tendon (PTT). Initially, patients with PTTD are often asymptomatic, making early identification and treatment challenging. Certain ultrasound (US) characteristics have been implicated in the presence of tendinopathy, but their frequency has yet to be assessed in the PTT. The purpose of this study was to identify and report on the frequency of incidental, or potentially early subclinical, tendinopathic US characteristics in asymptomatic PTTs.

METHODS

Following institutional review board approval, 150 participants underwent a bilateral-comprehensive US assessment. The resulting images were reviewed and assessed to identify the presence of abnormalities demonstrated to represent tendinopathy.

RESULTS

Overall, 266 tendons were assessed and 128 (48.1%) were determined to have at least one tendinopathic trait. Specifically, 51 (19.2%) had circumferential fluid, 69 (25.9%) had noncircumferential fluid, 22 (8.3%) had thickening, 31 (11.7%) had heterogenicity, 19 (7.1%) had hyperemia, and 2 (0.8%) had calcification. Additionally, Caucasian participants were found to be nearly 3 times more likely to have tendinopathic findings when compared with African American participants.

CONCLUSION

Sixty-seven percent of participants and 48.1% of PTTs evaluated had at least one tendinopathic feature identified on US. The prevalence rates of these findings, observed in participants, were as follows: noncircumferential fluid, circumferential fluid, heterogenicity, and thickening. Knowing the frequency of these traits may help clinicians to identify subclinical tendinopathy in the PTT before it progresses to PTTD.

LEVEL OF EVIDENCE

Level IV, case series.

Normal Ultrasonographic Parameters of the Posterior Tibial, Peroneal, and Achilles Tendons

Tendinopathy of the foot and ankle is common and can lead to pain or functional limitations. The most frequently affected tendons in the foot and ankle are the posterior tibial, peroneal, and Achilles. We used ultrasound to determine normal values for these tendons. From 2015 to 2016, a prospective, standardized bilateral lower extremity ultrasound examination protocol was performed by a musculoskeletal ultrasonographer of the 4 tendons and above and below the malleoli as appropriate. A total of 199 patients with 398 extremities were identified, consented, and participated in the study. Most tendons were normally distributed. The average size of the tendons was as follows: Achilles 5.0 mm (range 2.8-11.2 mm); peroneus long above the malleolus 2.1 mm (range 0.7-3.6 mm), below the malleolus 2.9 mm (range 0.8-6.3 mm); peroneus brevis above the malleolus 1.2 cm (range 0.3-4.0 mm), below the malleolus 1.3 mm (range 0.5-4.8 mm); posterior tibial tendon above the malleoli 3.7 mm (range 1.9-8.1 mm), below the malleolus 4.6 cm (range 1.8-11.8 mm). Standard deviations and distribution curves were similarly calculated for each tendon. This baseline data can assist clinicians in their diagnostic ability with ultrasound. Given its low cost, lack of ionizing radiation and dynamic ability along with an improved understanding of normative data it may become an increasingly used diagnostic modality. Levels of Evidence: Level II: Diagnostic.

Surgical Considerations: Repair of Long Segment Defect Posterior Tibial Tendon Using Fresh Frozen Tibial Tendon Allograft

Tibialis posterior (TP) tendon ruptures are common after ankle injuries, degenerative processes, or biomechanical instability. The TP tendon decelerates the subtalar joint pronation and internal rotation of the leg during the contact phase. It also plantarflexes and inverts the foot on the leg during the static phase of gait. When this function is lost, the medial longitudinal arch collapses, increasing the length of time of rearfoot pronation, eventually rupturing the TP tendon. Conservative treatment includes immobilization, strapping, antiinflammatories, custom-fabricated orthotics, and physical therapy. If the TP tendon rupture is severe, conservative treatment will provide little relief and surgery is indicated. This case study presents 53-year-old female who presented with left TP tendon rupture with a defect of 6 cm after sustaining an ankle injury that was surgically repaired using a TP tendon fresh frozen allograft and flexor digitorum longus tenodesis. After a 16-month follow-up, the patient was healed without complications and returned to preinjury activity. We believe that surgically repairing a TP tendon rupture with a TP tendon allograft and flexor digitorum longus tenodesis can be 1 of the treatment options for patients with extensive disruption of the TP tendon.

Reported selection criteria for adult acquired flatfoot deformity and posterior tibial tendon dysfunction: Are they one and the same? A systematic review

BACKGROUND

Posterior tibial tendon dysfunction (PTTD) and adult acquired flatfoot deformity (AAFD) are used interchangeably, although both suggest quite different pathological processes.

OBJECTIVE

To investigate key differences in selection criteria used for inclusion into research studies.

METHODS

An electronic database search was performed from inception to June 2016. All primary research articles with clear inclusion/diagnostic criteria for PTTD or AAFD were included in the review. All criteria were extracted and synthesised into one aggregate list. Frequencies of recurring criteria were calculated and reported for each stage of the conditions.

RESULTS

Of the potentially eligible papers, 148 (65%) did not specify inclusion/selection criteria for PTTD or AAFD and were excluded. Eligibility criteria were reported 82 times in the 80 included papers, with 69 descriptions for PTTD and 13 for AAFD. After synthesis of criteria from all papers, there were 18 key signs and symptoms. Signs and symptoms were considered to be those relating to tendon pathology and those relating to structural deformity. The total number of individual inclusion/diagnostic criteria ranged from 2 to 9. The majority of articles required signs of both tendon dysfunction and structural deformity (84% for AAFD and 81% for PTTD). Across both groups, the most frequently reported criteria were abduction of the forefoot (11.5% of total criteria used), the presence of a flexible deformity (10.2%) and difficulty performing a single leg heel raise (10.0%). This was largely the case for the PTTD articles, whereas the AAFD articles were more focused on postural issues such as forefoot abduction, medial arch collapse, and hindfoot valgus (each 16.7%).

CONCLUSION

As well as synthesising the available literature and providing reporting recommendations, this review has identified that many papers investigating PTTD/AAFD do not state condition-specific selection criteria and that this limits their clinical applicability. Key signs and symptoms of PTTD and AAFD appear similar, except in early PTTD where no structural deformity is present. We recommend that PTTD is the preferred terminology for the condition associated with signs of local tendon dysfunction with pain and/or swelling along the tendon and difficulty with inversion and/or single leg heel raise characterising stage I and difficulty with single leg heel raise and a flexible flatfoot deformity characterizing stage II PTTD. While AAFD may be useful as an umbrella term for acquired flatfoot deformities, the specific associated aetiology should be reported in studies to aid consolidation and implementation of research into practice.

TRIAL REGISTRATION

Prospero ID: 42016046943.

Posterior Tibial Tendon Dysfunction: An Overview

BACKGROUND

Adult acquired flatfoot deformity is a commonly seen condition with a large clinical spectrum. It ranges from asymptomatic subjects to severely disabled arthritic patients. Posterior tibialis tendon dysfunction is a common cause of adult acquired flatfoot deformity.

METHODS

This article systematically reviews the published literature from books and journals that were either originally written or later translated into the English language regarding the subject of posterior tibialis tendon dysfunction.

RESULTS

Posterior tibialis tendon dysfunction is a primary soft tissue tendinopathy of the posterior tibialis that leads to altered foot biomechanics. Although the natural history of posterior tibialis tendon dysfunction is not fully known, it has mostly been agreed that it is a progressive disorder. While clinical examination is important in diagnosing adult acquired flat-feet; further investigation is often required to delineate the different aetiologies and stage of the disease. The literature describes many different management choices for the different stages of posterior tibialis tendon dysfunction.

CONCLUSION

Because of the wide range of symptom and deformity severity, surgical reconstruction is based on a-la-carte. The consensus is that a plethora of reconstructive options needs to be available and the list of procedures should be tailored to tackle the different symptoms, especially when managing complex multi-planar reconstructions.

Acute tear of tibialis posterior: case report

Tibialis posterior tendon injuries are commonly missed and can result in significant foot deformity. In the young athlete these are best diagnosed acutely with ultrasound and may be treated conservatively or operatively. We present the case of a young serviceman and describe the treatment plan that was successful in allowing an early return to exercise.

Prevalence of and factors associated with posterior tibial tendon pathology on sonographic assessment

OBJECTIVE

To assess the frequency of and factors associated with supramalleolar posterior tibial tendon (PTT) pathology that often may be missed on sonography because of the limited field of view of ultrasound.

DESIGN

Retrospective cross-sectional study.

SETTING

Large academic center.

PATIENTS

Patients with medial ankle pain and tenderness and with normal radiographs who presented for sonographic assessment (n = 217).

METHODS

Two experienced musculoskeletal radiologists interpreted the studies by consensus.

MAIN OUTCOME MEASUREMENT

PTT pathology.

RESULTS

Of the 217 patients, 33.2% had grade 1 PTT pathology (n = 72), 14.3% had grade 2 pathology (n = 31), and 2.8% had grade 3 pathology (n = 6). When stratified by location, 29.0% of patients (n = 63) had inframalleolar abnormalities, 11.5% had retromalleolar pathology (n = 25), and 11 patients had supramalleolar pathology (5.1%). Four patients had PTT subluxation or dislocation. Age was significantly associated with PTT pathology (P = .02). A higher proportion of patients with supramalleolar (81.8%) and retromalleolar (72.0%) PTT pathology were women compared with patients who had inframalleolar (57.1%) PTT pathology. A higher proportion of patients with supramalleolar and retromalleolar PTT pathology had grade 2 tears compared with those with inframalleolar PTT pathology (36.4% for supramalleolar, 44.0% for retromalleolar, and 22.2% for inframalleolar pathology).

CONCLUSIONS

We present one of the largest studies on PTT pathology. PTT pathology can occur in the supramalleolar area, a region that often is not assessed on imaging. Although data are unavailable with regard to whether the natural history of supramalleolar PTT is different from that of other regions, patients with supramalleolar PTT pathology had more severe grades of tear and increased prevalence of tenosynovitis and were more often women. It is essential to recognize supramalleolar PTT pathology so that consequences of nontreatment such as medial arch collapse can be prevented.

Tendon disorders of the foot and ankle, part 3: the posterior tibial tendon

This article provides a review of posterior tibial tendon pathology and the authors' preferred management. The tibialis posterior musculotendinous unit is the most powerful inverter of the foot and an important dynamic stabilizer of the arch. In the stance phase of the gait cycle, it serves as an initiator of both ankle plantar flexion and subtalar inversion. This creates a rigid midfoot by stabilizing the transverse tarsal joint, and allows for increased power generation by the gastrocsoleus complex through toe-off. Injuries to the posterior tibialis tendon include traumatic laceration and dislocation, as well as tenosynovitis and tendinopathy, which can lead to attenuation and rupture. If these injuries are not addressed, significant clinical deformity and disability can result.

Evaluation of posterior tibial pathology: comparison of sonography and MR imaging

OBJECTIVE

To compare the results of sonographic (US) and magnetic resonance (MR) imaging in detecting pathology of the posterior tibial tendon (PTT) in patients with PTT dysfunction.

DESIGN

Twenty-two ankles that were clinically suspected by the orthopedic surgeon to have PTT dysfunction were evaluated with US (10 MHz linear-array transducer) and 1.5 T MR examinations within the same day. The US and MR studies were conducted and interpreted by two sonologists and two musculoskeletal radiologists who were masked to the results of the other study. Four patients had bilateral studies. Classic clinical findings were utilized as a standard reference in staging PTT dysfunction.

PATIENTS

Eighteen women (mean age 61 years, age range 39-86 years).

RESULTS

Based on a commonly accepted staging system for PTT dysfunction, 6 ankles were classified as stage I, 11 ankles as stage II, and 5 ankles as stage III. All stage I ankles were interpreted as having an intact PTT by both MR imaging and US. In the stage II and III tendons, MR imaging demonstrated PTT tears in 12 of 22 examinations, including 11 partial tears and 1 complete tear. US demonstrated PTT tears in 8 of 22 examinations, including 8 partial tears and no complete tears. The findings of US and MR imaging were consistent in 17 of 22 cases (77%). The five inconsistencies were as follows: in 4 cases, US reported tendinosis when MR imaging interpreted partial tears (no change in management); in one case, US diagnosed a partial tear when MR reported a complete tear of the PTT (no change in management because the clinical findings were more consistent with a partial tear).

CONCLUSIONS

In this study, US and MR imaging of the PTT were concordant in the majority of cases. US was slightly less sensitive than MR imaging for PTT pathology, but these discrepancies did not affect clinical management.

Ultrasound visualization of central slip injuries of the finger extensor mechanism

PURPOSE

To evaluate the ability of ultrasound to detect a central tear of the finger extensor tendon mechanism.

METHODS

Twelve fresh-frozen and thawed cadaver fingers were used. All fingers had a midradial incision with exposure of the extensor mechanism over the proximal interphalangeal joint. Six fingers had a sharp transection of the central slip. The other 6 fingers were used as sham dissection controls. All fingers had the exposure closed by suture and then were examined by a musculoskeletal ultrasonographer.

RESULTS

All 12 fingers were identified correctly as either sham controls with intact central slips or as injury models that had a transected central slip. Thus there was a sensitivity of 100% a specificity of 100%, and a positive predictive value of 1.000, which were statistically significant.

CONCLUSIONS

Diagnostic ultrasound is a very accurate noninvasive study that can identify central slip injuries in the extensor mechanism of the finger. We recommend that clinically suspected cases of boutonniere injury be scanned by high-frequency ultrasound to confirm the diagnosis and allow either early initiation of splinting or eliminate the need for prolonged splinting required for this injury.

Adult acquired flat foot deformity: clinical and radiographic examination

Symptomatic adult acquired flat foot deformity is encountered in the orthopedic office on a frequent basis. Although many causes exist, a careful history and a stepwise approach to the physical examination will clue the examiner into making the correct diagnosis and provide appropriate treatment. Radiographs serve as an adjunct and assist in verifying the examination findings. CT, US, and MRI are helpful modalities for surgical planning or when the diagnosis remains questionable.

Ultrasound, magnetic resonance imaging, and posterior tibialis dysfunction

The authors studied posterior tibialis tendons in 31 subjects with posterior tibialis tendon pain to compare clinical findings with those of magnetic resonance imaging and ultrasound images. All subjects received clinical, ultrasound, and magnetic resonance imaging examinations using T1-weighted, T2-weighted, and enhanced magnetic resonance imaging, and high resolution ultrasound using power Doppler. Forty-four tendons in 25 women and six men with a mean age 43.3 years (range, 20-73 years) were studied. Magnetic resonance imaging tendon and peritendon enhancement are associated statistically with increasing pain intensity on resistance to testing. Ultrasound tendon and peritendon flow were associated with increasing pain intensity on resistance to testing. There is no statistically significant association between magnetic resonance imaging inhomogeneity and pain intensity on resistance to testing. Clinical and ultrasound examinations positively identify peritendinitis and tendonitis but not inhomogeneity (partial tear) of the posterior tibialis tendon. The magnetic resonance imaging is a more sensitive test for posterior tibialis tendon tear than either clinical or ultrasound evaluation.

Use of the Cobb procedure in the treatment of posterior tibial tendon dysfunction

Numerous surgical procedures have been described for the treatment of the adult acquired flatfoot deformity. The surgeon should review in detail all the clinical, radiographic and imaging tests and propose the best surgical procedure for the patient. Although flexor tendon transfer has shown excellent results, the split anterior tibial tendon transfer is a second option. If used properly, the Cobb procedure results in less functional loss, since only half of the anterior tibial tendon is transferred. Furthermore, the flexor tendon is not disrupted and continues its primary function in the foot and ankle. Ultimately, the goals of the surgical procedure are to alleviate the patient's symptoms and pain, restore a normal foot alignment, and limit the loss of foot and ankle function without causing any complications.

Introduction to ultrasonography of ankle tendons

Medical technology is constantly improving, giving the physician more options to aid in diagnosis and treatment of ailments. Ultrasound (US) technology is one area that has made great improvements. Increased resolution and availability are two reasons why ultrasound is now being used to image the musculoskeletal system. This article discusses ultrasound technology, instrumentation, basic exam of ankle tendons, and some of the recent uses. The objective is to make the physician aware of this modality and possibly add it to their diagnostic armementarian.

Sonography and MR imaging of posterior tibial tendinopathy

OBJECTIVE

The purpose of the study is to describe the appearance of the posterior tibialis tendon on MR imaging and high-resolution sonography with color and power Doppler imaging and to determine whether sonography is as accurate for diagnosing tendinosis as MR imaging.

SUBJECTS AND METHODS

Fifteen healthy volunteers and 31 patients (44 tendons) who were clinically suspected of having posterior tibial tendinopathy were prospectively evaluated with MR imaging and sonography.

RESULTS

On MR imaging, the normal tendon was elliptic on cross section and showed low signal intensity on all sequences. Minimal peritendinous enhancement and fluid were seen. On sonography, the tendon showed homogeneous longitudinal echogenic fibers. No flow was seen in or around the tendon. Tendinopathy was characterized by enhancement of the tendon on MR imaging (19/44 tendons); intratendinous flow on color Doppler sonography (16/44 tendons); increase in the anteroposterior diameter causing a rounding of the tendon (18/44 tendons); and inhomogeneity of the tendon (16/44 tendons on MR imaging and 21/44 tendons on sonography). Peritendinosis was characterized by peritendinous enhancement on MR imaging (29/44 tendons); flow on color Doppler sonography (20/44 tendons); and increased soft tissue (20/44 tendons on MR imaging and 27/44 tendons on sonography). When compared with MR imaging, the sensitivity and specificity of sonography for diagnosing tendinopathy were 80% and 90%, respectively, and for diagnosing peritendinosis were 90% and 80%. Addition of abnormal size to the structural abnormality criteria did not improve diagnostic ability.

CONCLUSION

Sonography can be useful as the initial imaging study in evaluating abnormalities caused by posterior tibial tendinopathy.

Ultrasound of the ankle

Because of their size and superficial location the ankle tendons can be well evaluated with ultrasound (US). The excellent definition of the modern high frequency probes allows us to consider US the technique of first choice in their assessment. Basic US appearances correlate well with the MRI findings. Since US can diagnose most tendon disorders including tendinopathies, tears, dislocations and enthesopathies MRI is less often utilized. US can easily depict the main ankle ligaments. The basic US appearance of ligament tears is well known. US can be considered an inexpensive and accurate technique in the evaluation of ankle sprains.

Tenosynovitis of the posterior tibial tendon

PTT tenosynovitis is a recognized entity no longer confused with an ankle sprain. Three possible causes are (1) overuse or age related (mechanical in cause, true stage I disease), (2) seronegative spondyloarthropathies (clinical suspicion, hematologic analysis), and (3) rheumatoid arthritis (deformity may be owing to ligamentous or capsular destruction). The PTT has a hypovascular zone 40 mm proximal to the insertion of the tendon and 14 mm in length. Pain often is localized to this portion of the tendon (primarily in stage I disease). Ultrasound is an inexpensive and accurate method to assist in the diagnosis of this condition and may replace MR imaging as more experienced ultrasonographers appear. The initial management of PTT tenosynovitis includes tendon rest and nonsteroidal anti-inflammatory medication and physical therapy. Surgical synovial débridement is performed early (6 weeks) in patients with enthesopathies (seronegative disease). This procedure may be delayed 3 months in patients with true stage I disease. At surgery, the undersurface of the tendon must be inspected for longitudinal split tears, and these must be repaired with nonabsorbable suture, burying the knots. The excursion of the tendon should be checked intraoperatively. Patients with stage I disease should be evaluated carefully for preoperative structural deformity to choose the appropriate surgical procedure and prevent failure of isolated tenosynovectomy.

Tibialis posterior myofascial tightness as a source of heel pain: diagnosis and treatment

STUDY DESIGN

We report 2 cases in which a novel tibialis posterior muscle stretch is used to treat heel pain and lower extremity impairment.

OBJECTIVES

To explore dysfunction of the tibialis posterior as a source of heel pain.

BACKGROUND

Heel pain is a common symptom of orthopaedic dysfunction of the lower extremity. Tibialis posterior tendon dysfunction is well documented in the medical and surgical literature, but its identification in its early or precursive stages has received little attention.

METHODS AND MEASURES

An examination and treatment outline, incorporating a novel assessment and stretching technique, is presented.

RESULTS

We identified a stage of dysfunction of the tibialis posterior ("Pre-Stage 1") without clinically identifiable tendon pathology. We refer to this as tibialis posterior myofascial tightness (TPMT).

CONCLUSION

Tibialis posterior myofascial tightness is a clinical entity that may be differentially diagnosed in cases of heel pain and specifically treated.

The use of magnetic resonance imaging in posterior tibial tendon dysfunction

The role of magnetic resonance imaging in the evaluation of the patient with posterior tibial tendon dysfunction is discussed. Considerations for the proper positioning of the patient and optimal technique to obtain appropriate images of the posterior tibial tendon and associated joint abnormalities are highlighted. Cases are presented to show the effectiveness of magnetic resonance imaging in different clinical situations. The treatment algorithm for posterior tibial tendon dysfunction should include magnetic resonance imaging as a diagnostic tool when appropriate.

Foot and ankle sonography

Sonography of the foot and ankle offers many advantages. Currently, sonographic evaluation rivals or exceeds MR imaging for evaluation of tendons, joint and bursal pathology, and specific soft tissue pathology. The advantages of sonographic evaluation provide a strong impetus for applying this modality to imaging of foot and ankle pathology. Those who accept the challenge will have an expanded repertoire to offer in the pursuit of efficient and effective patient care.