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