Posterior tibial tendon dysfunction: secondary MR signs

Tibial Retro-Malleolar Groove Morphology in Patients With Posterior Tibialis Tendon Dysfunction

The posterior tibial tendon is a gliding tendon which courses around the medial malleolus and fails in posterior tibialis tendon dysfunction (PTTD) leading to a flat foot deformity. Distal tibial bone spurs have been identified as a secondary sign of PTTD although they have not been quantified in detail. The aim of this study was to assess the association of tendon dysfunction with the bony morphology of the tibial retro-malleolar groove. We performed a retrospective review of the clinical presentation, plain radiographs, and 103 magnetic resonance imaging (MRI) scans in 82 consecutive patients with PTTD compared with a non-PTTD group. We carried out a quantitative and qualitative assessment of the presence of plain radiographic bone spurs, stage of PTTD and MRI imaging of the morphology of the tibial bony malleolar groove. Plain radiographic bone spurs, as a secondary sign of PTTD, were present in 21.3% of ankle radiographs. MRI bone spurs were identified in 26/41 (63.4%) for all high-grade partial and complete tears and 7/41 (17.1%) for isolated complete tears compared with only 3.9% of the non-PTTD group. There was a significant association between the presence of bone spurs on MRI imaging and high-grade partial and complete tibialis posterior tears (p < .001; odds ratio of 4.98). Eleven of 103 (10.7%) of spurs were large and in 4/103 (3.9%) were substantial enough to create a tunnel-like hypertrophic groove not previously reported. There is variation in the bony structure of the malleolar groove in PTTD not observed in the non-PTTD group. Further investigation over time may elucidate whether the groove morphology may lead to mechanical attrition of the tibialis posterior tendon and contribute to failure of healing and progressive tendon degeneration.

Sinus tarsi and sinus tarsi syndrome: An imaging review

The sinus tarsi is a funnel-shaped region at the junction of mid-foot and hind-foot which contains fat, vessels, nerves and ligaments. The ligaments help stabilise the subtalar joint and maintain the longitudinal arch of the foot. The nerve endings contain proprioceptive fibres indicating a role for the sinus tarsi in movement of the foot. Sinus tarsi syndrome is a clinical entity characterised by lateral hind-foot pain with worsening on palpation and weight-bearing, and perceived instability. It is associated with both traumatic and non-traumatic causes. Magnetic resonance imaging is the imaging modality of choice for assessment of the sinus tarsi and sinus tarsi syndrome. In this review article, we review the anatomy and various aetiologies of sinus tarsi syndrome, along with the imaging appearances.

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.

Adult Acquired Flatfoot Deformity: Anatomy, Biomechanics, Staging, and Imaging Findings

Adult acquired flatfoot deformity (AAFD) is a common disorder that typically affects middle-aged and elderly women, resulting in foot pain, malalignment, and loss of function. The disorder is initiated most commonly by degeneration of the posterior tibialis tendon (PTT), which normally functions to maintain the talonavicular joint at the apex of the three arches of the foot. PTT degeneration encompasses tenosynovitis, tendinosis, tendon elongation, and tendon tearing. The malaligned foot is initially flexible but becomes rigid and constant as the disorder progresses. Tendon dysfunction commonly leads to secondary damage of the spring ligament and talocalcaneal ligaments and may be associated with injury to the deltoid ligament, plantar fascia, and other soft-tissue structures. Failure of multiple stabilizers appears to be necessary for development of the characteristic planovalgus deformity of AAFD, with a depressed plantar-flexed talus bone, hindfoot and/or midfoot valgus, and an everted flattened forefoot. AAFD also leads to gait dysfunction as the foot is unable to change shape and function adequately to accommodate the various phases of gait, which require multiple rapid transitions in foot position and tone for effective ambulation. The four-tier staging system for AAFD emphasizes physical examination findings and metrics of foot malalignment. Mild disease is managed conservatively, but surgical procedures directed at the soft tissues and/or bones become necessary and progressively more invasive as the disease progresses. Although much has been written about the imaging findings of AAFD, this article emphasizes the anatomy and function of the foot's stabilizing structures to help the radiologist better understand this disabling disorder. Online supplemental material is available for this article. ^©RSNA, 2019.

Sonographic and radiographic findings of posterior tibial tendon dysfunction: a practical step forward

The purpose of this article is to describe the sonographic and radiographic findings in the diagnosis and treatment of posterior tibial tendon dysfunction. Ultrasound and radiographs play a crucial role in the diagnosis of posterior tibial tendon dysfunction and in imaging the postoperative changes related to posterior tibial tendon dysfunction. Early detection and diagnosis of posterior tibial tendon dysfunction is important in helping to prevent further progression of disease, obviating the need for more invasive and complex procedures.

Self-reported social and activity restrictions accompany local impairments in posterior tibial tendon dysfunction: a systematic review

BACKGROUND

Posterior tibial tendon dysfunction (PTTD) is a painful, progressive tendinopathy that reportedly predominates in middle-age, overweight women. There is no evidence based guidelines that clinicians can use to guide treatment planning, which leaves clinicians to make decisions on the basis of presenting clinical impairments and self-reported pain and disability. The purpose of this systematic review was to quantify clinical impairments, pain and disability in individuals with PTTD compared with controls.

METHODS

Five databases were searched for terms referring to the posterior tibial tendon and flatfoot up to and including 11 March 2018. The systematic review was registered with PROSPERO (CRD: 42016046951). Studies were eligible if they were published in the English language and contained data on clinical impairments, pain or disability compared between participants diagnosed with PTTD and pain-free individuals. Standardised mean differences (SMDs) were calculated where possible and meta-analysis was performed when homogeneity of outcomes allowed.

RESULTS

Ten eligible studies were identified and pooled in the meta-analyses. Strong effects were revealed for poor heel rise endurance (SMD -1.52, 95% CI -2.05 to - 0.99), less forefoot adduction-inversion strength (SMD -1.19, 95% CI -1.68 to - 0.71) and lower arch height (SMD -1.76, 95% CI -2.29 to - 1.23). Compared to controls, individuals with PTTD also had more self-reported stiffness (SMD 1.45, 95% CI 0.91 to 1.99), difficulties caused by foot problems (SMD 1.42, 95% CI 0.52 to 2.33) and social restrictions (SMD1.26, 95% CI 0.25 to 2.27).

CONCLUSION

There is evidence of impaired tibialis posterior capacity and lowered arch height in individuals with PTTD compared to controls. Further to addressing the expected impairments in local tendon function and foot posture, pain, stiffness, functional limitations and social participation restrictions should be considered when managing PTTD.

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.

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.

Hindfoot motion following reconstruction for posterior tibial tendon dysfunction

INTRODUCTION

Due to advances in technology, segmental gait analysis of the foot is now possible and can elucidate hindfoot deformity in persons with posterior tibial tendon dysfunction (PTTD). This study evaluated the motion of the hindfoot and ankle power following surgical reconstruction for PTTD utilizing a segmental foot model during gait.

MATERIALS AND METHODS

Twenty patients who underwent posterior tibial tendon reconstruction for Stage 2 PTTD using transfer of the flexor digitorum longus tendon to the navicular tuberosity, reconstruction of the calcaneo-navicular ligament complex, and a medial displacement calcaneal osteotomy were evaluated at a minimum followup of 1 year. Three-dimensional gait analysis was performed utilizing a 4-segment foot model. Temporal-spatial parameters included walking velocity, cadence, step length, and single support time. Sagittal, coronal, and transverse hindfoot motion with respect to the tibia/fibula and ankle power was calculated throughout the gait cycle.

RESULTS

Walking velocity, cadence, and step length were not significantly different between the study subjects and the normal control group. Study patients did show a significantly smaller single support time on both the affected and unaffected limbs compared to controls. There was no statistical difference in plantarflexion-dorsiflexion, varus-valgus, or ankle push-off power between the affected and unaffected sides of the study subjects, or between the affected side and the controls.

CONCLUSION

In this preliminary postoperative study, surgical reconstruction for PTTD effects quantifiable objective improvement in walking velocity, hindfoot motion and power.

Magnetresonanztomographie des Sprunggelenkes

The ankle represents an anatomically complex region with a broad spectrum of pathologies. Magnetic resonance imaging (MRI) of the ankle offers detailed, high-resolution imaging of the bones, the ligaments and the surrounding soft tissue structures and therefore has a major role in the diagnostic evaluation of traumatic sequelae, infectious diseases or ankle pain of unknown origin. MRI is especially valuable in the detection of radiographically occult stress reactions or osteomyelitis because it can visualize bone marrow edema earlier than any other imaging method. MRI is superior to any other imaging method for visualizing the tendons and ligaments of the foot and is an important basis for further treatment planning.

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.

Preliminary gait analysis results after posterior tibial tendon reconstruction: a prospective study

The purpose of this study was to investigate the effect on gait in patients who underwent reconstruction for stage II posterior tibial tendon (PTT) dysfunction. Twelve patients with stage II PTT dysfunction underwent surgical reconstruction consisting of debridement of the posterior tibial tendon, flexor digitorum longus tendon transfer to the navicular tuberosity, medial displacement calcaneal osteotomy, and spring ligament reconstruction. Midfoot arthrodesis was performed in six patients and gastrocnemius recession in three. Gait analysis was performed 2 weeks prior to surgery and 1 year postoperatively. Preoperative and postoperative data were compared to determine differences in temporal-spatial parameters, lower limb kinematics, and ankle push-off power. Step length for the operated side increased from 52.6 +/- 9.6 cm before the surgery to 57.5 +/- 7.1 cm after the surgery (p =.048). Cadence improved from 100.2 +/- 10.7 steps/min to 109.1 +/- 8.5 steps/min (p =.05), thus increasing velocity from 87.6 +/- 22.6 cm/s to 103.4 +/- 15.9 cm/s (p =.042). Single support percentage was unchanged. Maximum sagittal ankle joint power at push-off increased from 0.79 +/- 0.35 W before surgery to 1.2 +/- 0.5 W after surgery (p =.042). There were statistically significant improvements in all radiographic parameters studied. This is the first prospective study to evaluate the in vivo effects on gait in patients undergoing this common surgical procedure. Analysis demonstrated statistically significant improvement in kinetic and kinematic parameters of gait function.

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.

Imaging sports injuries of the foot and ankle

The complexity of foot and ankle anatomy and function is unique in the musculoskeletal system. Understanding the complex anatomy alone is a daunting task, not to mention transferring that understanding to the two-dimensional planes encountered on imaging studies. When evaluating sports injuries in the foot and ankle, the interpreting radiologist must take into account the type of activity, vector of stress, and inherent characteristics of the involved structures. A strong working relationship with the health care providers managing patient care, ideally orthopedists, is essential. But in this age of decreasing specialization and increasing availability of imaging resources, the interpreting radiologist must use all available tools for clinical investigation. When interpreting an ankle or foot MR imaging, one finding should trigger a search for the next finding along a logical pathway of injury evolution. Bone marrow edema patterns are guides to tendon and ligament failure. And a clinical syndrome without correlative imaging diagnosis should call attention to potential alternative diagnoses. As the number of MR imaging studies performed continues to increase and MR technology continues to improve, we expect further advancements in MR evaluation of foot and ankle injury. We hope to continue to work closely with our referring orthopedists in this arena to improve our diagnostic skills and our understanding of foot and ankle injury.

Magnetic resonance imaging of sports injuries of the ankle

Basic sports-related injuries of the ankle include ligament tear, tendon degeneration and tear, bone bruise, fracture, impingement, osteochondral defect, and plantar fasciitis. This article discusses the magnetic resonance imaging appearance of these injuries.

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.

Partial interosseous ligament tears of the wrist: difficulty in utilizing either primary or secondary MRI signs

PURPOSE

Prior reports on scapholunate ligament (SLL) and lunotriquetral ligament (LTL) tears have evaluated complete tears. As these complete tears have markedly different biomechanical manifestations and surgical considerations than do partial tears, we evaluated the accuracy of MR and the usefulness of secondary MR signs to diagnose partial interosseous ligament tears.

METHOD

Fifty wrists in 50 patients underwent arthroscopy following 1.5 T MR. Images were evaluated by two independent blinded observers for normal or partially torn SLL and LTL and for three secondary signs potentially seen as mechanical sequelae of tears: osseous offset, arc disruption, or focal osteoarthritis.

RESULTS

Arthroscopically, there were 16 SLL and 14 LTL partial tears. Accuracy of primary MR signs of partial tears was lower than that described in the literature for complete tears [sensitivity/specificity (kappa) = 0.56/0.56 (0.12)-SLL, 0.31/0.76 (0.13)-LTL]. Secondary signs showed low sensitivity but high specificity, particularly for LTL tears: arc disruption [0.17/0.83 (0.43)-SLL, 0.0/1.00 (1.0)- LTL], focal osteoarthritis [0.32/0.78 (0.18)-SLL, 0.11/0.91 (0.12)-LTL], and focal osseous offset [0.39/0.75 (0.10)-SLL, 0.26/0.93 (0.39)-LTL]. Additionally, there was poor interobserver consistency for both primary and secondary signs.

CONCLUSION

The sensitivity of morphologic evaluation for diagnosing partial intercarpal ligament tears, particularly those of the LTL, is limited. Secondary signs increase specificity but have low sensitivity, and with the exception of arc disruption, all signs had poor interobserver agreement.

Association of posterior tibial tendon injury with spring ligament injury, sinus tarsi abnormality, and plantar fasciitis on MR imaging

OBJECTIVE

The purpose of this study was to investigate the frequency of abnormalities of the spring ligament, sinus tarsi, and plantar fascia revealed on MR imaging in a group of patients with advanced injury of the posterior tibial tendon. MATERIALS AND METHODS; MR images from 25 patients with advanced posterior tibial tendon injury were retrospectively examined for spring ligament, sinus tarsi, and plantar fascia abnormalities. These images were randomly compared with those obtained from 25 control patients with normal-appearing posterior tibial tendons.

RESULTS

The spring ligament was abnormal in 23 (92%) of 25 patients with a posterior tibial tendon injury and seven (28%) of 25 patients with a normal posterior tibial tendon (p < 0.0001). The sinus tarsi was abnormal in 18 (72%) of 25 patients with posterior tibial tendon injury and nine (36%) of 25 patients with a normal posterior tibial tendon (p < 0.0132). The plantar fascia was abnormal in seven (32%) of 22 patients with posterior tibial tendon injury and two (9%) of 22 patients with a normal posterior tibial tendon (p < 0.0768). Two or more associated abnormalities were present in 20 (80%) of 25 patients with posterior tibial tendon injury and four (16%) of 25 patients with a normal posterior tibial tendon (p < 0.0001).

CONCLUSION

Advanced posterior tibial tendon injury has a high association with spring ligament and sinus tarsi abnormalities on MR imaging. There was a low association between advanced posterior tibial tendon injury and plantar fascia abnormality. Patients with posterior tibial tendon injury often have abnormalities of two or more associated structures.

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.