Ankle Tendons in Athletes. Laura W. Bancroft, M.D.

Transcription

1 Ankle Tendons in Athletes Laura W. Bancroft, M.D.

2 Outline Protocols Normal Anatomy Tendinopathy, partial and complete tears Posterior tibial, Flexor Hallucis Longus, Achilles, Peroneal and Anterior Tibial Tendons Post-surgical change of tendons

3 Protocols Conventional MRI Sagittal T1 and FSE PD FS Axial FSE PD and FSE T2 FS Coronal DESS FOV 14 cm

4 Protocols Conventional MRI Sagittal T1 and FSE PD FS Axial FSE PD and FSE T2 FS Coronal DESS FOV 14 cm

5 Protocols Conventional MRI Sagittal T1 and FSE PD FS Axial FSE PD and FSE T2 FS Coronal DESS FOV 14 cm

6 Protocols MR Arthrogram 0.1 cc Gad in 20 cc saline/lidocaine/contrast Sagittal, coronal and axial T1 FS Sagittal FSE T2 FS FOV 14 cm

7 Normal Anatomy

8 Posterior tibial t. Flexor digitorum t. Flexor hallucis longus t. FSE T2 FS

9 Anterior tibialis t. Extensor hallucis longus t. Extensor digitorum longus t. FSE T2 FS

10 Peroneal longus t. Peroneal brevis t. FSE T2 FS

11 Plantaris t. Achilles t. FSE T2 FS

12 Deltoid l. Anterior tibiofibular l. Posterior tibiofibular l. FSE T2 FS

13 Anterior talofibular l. Posterior talofibular l. FSE T2 FS

14 PTT FSE T2 FS

15 Sustentaculum talus FHL FSE T2 FS

16 FSE T2 FS Peroneus brevis t.

17 Deltoid ligament Spring ligament (dorsal calcaneonavicular)

18 PTT FDL T1W

19 Spring ligament ST FHL T1W

20 Achilles t. T1W Plantar fascia

21 Sinus tarsi T1W

22 Cervical and interosseous l. T1W

23 Root of extensor retinaculum Posterior talofibular l. T1W

24 Peroneus longus t. Peroneus brevis t. T1W

25 Anterior tibiofibular l. Posterior tibiofibular l. Anterior talofibular l. Posterior talofibular l. Calcaneofibular l.

26 Posterior intermalleolar l. Posterior inferior tibiofibular l. Transverse tibiofibular l. Deltoid l. Posterior talofibular l. Calcaneofibular l.

27 Posterior inferior tibiofibular l. Transverse tibiofibular l. Posterior talofibular l. T1W

28 Plantar fascia T1W

29 * Deltoid l. PTT FDL FHL T1W

30 Posterior Tibial Tendon Origin tibia and fibula (posteromedial borders) Attachment navicular, medial cuneiform Function inversion and plantar flexion of foot

31 Posterior Tibial Tendon Pathology Usually degenerative tendinopathy leads to tears Rare injury in athletes Sports with rapid change of direction / cutting sports PTT is subject to great stress after heel strike as hindfoot moves from loaded eversion to increasing inversion Jacoby SM.et al. Acute posterior tibial tendon tear in an ice-hockey player. Foot Ankle Intern 2008; 29: PD

32 Posterior Tibial Tendon Pathology Usually degenerative tendinopathy leads to tears Rare injury in athletes Sports with rapid change of direction / cutting sports PTT is subject to great stress after heel strike as hindfoot moves from loaded eversion to increasing inversion Jacoby SM.et al. Acute posterior tibial tendon tear in an ice-hockey player. Foot Ankle Intern 2008; 29: T1

33 * * * T1W T1W Accessory navicular and PTT tendinopathy

34 * * * T1W T1W Accessory navicular and PTT tendinopathy

35 Posterior Tibial Tendon Pathology Tenosynovitis precipitated by training errors Pronated feet Direct medial ankle trauma Systematic metabolic diseases Jacoby SM.et al. Acute posterior tibial tendon tear in an ice-hockey player. Foot Ankle Intern 2008; 29: PD

36 Posterior Tibial Tendon Pathology Tenosynovitis precipitated by training errors Pronated feet Direct medial ankle trauma Systematic metabolic diseases Jacoby SM.et al. Acute posterior tibial tendon tear in an ice-hockey player. Foot Ankle Intern 2008; 29: PDT2

37 PD PTT thinning and tibial spurring

38 PTT split tear and tenosynovitis FSE T2 FS

39 T1W PTT split tear FSE T2 FS

40 PTT split tear FSE PD FS

41 Flexor Hallucis Longus Tendon Origin posteromedial 1/3 of fibula Attachment base of distal phalanx of hallux Function flexes all joints of hallux, plantar flexes ankle

42 Flexor Hallucis Longus Tenosynovitis Os Trigonum Syndrome Tenosynovitis in ballerinas dancing on point Posterior impingement due to os trigonum syndrome PD

43 Flexor Hallucis Longus Tenosynovitis Os Trigonum Syndrome Tenosynovitis in ballerinas dancing on point Posterior impingement due to os trigonum syndrome PD

44 Flexor Hallucis Longus Tenosynovitis Os Trigonum Syndrome PD T2

45 Flexor Hallucis Longus Rupture DS PD

46 Achilles Tendon Origin gastrocnemius, soleus and plantaris muscles Attachment calcaneus Function plantar flexes foot

47 Achilles Tendon Disorders 7-9% annual incidence of Achilles disorders in top-level runners Most common cause of Achilles tendon injury - training errors Sudden increase in intensity Changes of terrain or surface Changes in training schedules Inappropriate footwear DS Heckman. Tendon Disorders of the Foot and Ankle, Part 2 Achilles Tendon Disorders. Am J Sports Medicine. 2009; 37, PD

48 Achilles Tendon Disorders 7-9% annual incidence of Achilles disorders in top-level runners Most common cause of Achilles tendon injury - training errors Sudden increase in intensity Changes of terrain or surface Changes in training schedules Inappropriate footwear DS Heckman. Tendon Disorders of the Foot and Ankle, Part 2 Achilles Tendon Disorders. Am J Sports Medicine. 2009; 37, T1

49 Achilles Tendon Tears Lower extremity malalignment Hyperpronated or cavus foot Forefoot varus FSE PD FS DS Heckman. Tendon Disorders of the Foot and Ankle, Part 2 Achilles Tendon Disorders. Am J Sports Medicine. 2009; 37,

50 T1W FSE PD FS Achilles near complete rupture

51 T1W FSE PD FS Achilles rupture

52 T1W FSE PD FS Achilles rupture

53 T1W FSE T2 FS Achilles rupture

54 T1W Achilles rupture

55 T1W FSE PD FS Achilles rupture

56 T1W FSE T2 FS Achilles rupture

57 Peroneal Brevis Tendon Origin fibula (lateral lower 2/3) and intermuscular septa Attachment 5 th metatarsal base Function plantar flexion, eversion of foot

58 Peroneal Tendon Pathology Persistent lateral ankle symptoms after "typical" ankle sprain Acute tears of peroneus brevis >> longus Often coexistent with peroneal instability Subluxation Foot is dorsiflexed and peroneal muscles strongly contract = eversion force Peroneal instability and tearing Ballet dancing, skiing, soccer, tennis, American football, running, basketball and ice skating Cerrato RA et al. Peroneal tendon tears, surgical management and its complications. Foot Ankle Clin. 2009; 14:

59 T1W Peroneus brevis split tear

60 T1W Peroneus brevis split tear and peroneus longus tendinopathy

61 T1W Peroneus brevis split tear and peroneus longus tendinopathy

62 T1W Partial thickness Achilles tendon and peroneus brevis split tear

63 Partial thickness Achilles tendon and peroneus brevis split tear PD

64 Peroneal Tendon Pathology Persistent lateral ankle symptoms after "typical" ankle sprain Acute tears of peroneus brevis >> longus Often coexistent with peroneal instability Subluxation Foot is dorsiflexed and peroneal muscles strongly contract = eversion force Peroneal instability and tearing Ballet dancing, skiing, soccer, tennis, American football, running, basketball and ice skating Want XT el al. Normal variants and diseases of the peroneal tendons and superior peroneal retinaculum: MR imaging features. RadioGraphics. 2005; 25:

65 Retinacular stripping, peroneal split tear and subluxation PD Cerrato RA et al. Peroneal tendon tears, surgical management and its complications. Foot Ankle Clin. 2009; 14: Want XT el al. Normal variants and diseases of the peroneal tendons and superior peroneal retinaculum: MR imaging features. RadioGraphics. 2005; 25:

66 PD Retinacular rupture and peroneal subluxation

67 Peroneal Longus Tendon Origin lateral condyle of tibia, head and proximal 2/3 of fibula, intermuscular septum Attachment lateral/plantar medial cuneiform and 1 st metatarsal base Function plantar flex hallux, plantar flex and evert the foot

68 Fragmented os peroneum

69 T1W Fragmented os peroneum

70 T1W FSE PD FS Peroneus longus tear

71 T1W FSE PD FS Peroneus longus tear

72 FSE PD FS Peroneus longus tear and edema in tubercle

73 Anterior Tibial Tendon Origin body of tibia Attachment medial cuneiform and 1 st metatarsal Function dorsiflexion and inversion of foot

74 * T1W Anterior tibialis tendon tear

75 T1W Anterior tibialis tendon tear FSE T2 FS

76 Anterior tibialis tendon tear

77 Postsurgical

78 T1W FSE PD FS Achilles rupture after reattachment

79 T1W Achilles rerupture

80 T1W FSE PD FS Achilles rerupture

81 Achilles rerupture FSE PD FS

82 T1W Achilles repair - ulceration

83 T1W FSE T2 FS Achilles repair - ulceration

84 FSE PD FS Achilles FSE T2 FS Failed FHL transfer for Achilles rupture

85 FHL FSE T2 FS FSE PD FS Failed FHL transfer for Achilles rupture

86 FHL FSE T2 FS FSE PD FS Achilles Failed FHL transfer for Achilles rupture

87 FSE T2 FS FSE PD FS Failed FHL transfer for Achilles rupture

88 T1W Calcaneal osteotomy with FDL transfer

89 T1W Calcaneal osteotomy with FDL transfer

90 T1W FSE PD FS ATT Retear

91 T1W T1 FS +Gd Infected ATT graft

92 T1W T1 FS +Gd Infected ATT graft

93 * T1 FS +Gd T1 FS +Gd Infected ATT graft

94 Conclusion Posterior tibial tendon injuries are rare injury in athletes, and are most common in sports involving rapid change of direction Flexor hallucis longus tenosynovitis can be seen in ballerinas on point, due to posterior impingement Achilles tendinopathy and tears are relatively common in top-level runners, and are most often due to training errors

95 Conclusion Peroneal tendon tears are most often peroneus brevis split tears, but subluxations or dislocations can occur with flexor retinacular disruption Anterior tibial tendon tears most often occur at the level of the extensor retinaculum, and less commonly at the myotendinous junction