Ankle Tendons in Athletes Laura W. Bancroft, M.D.
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
Protocols Conventional MRI Sagittal T1 and FSE PD FS Axial FSE PD and FSE T2 FS Coronal DESS FOV 14 cm
Protocols Conventional MRI Sagittal T1 and FSE PD FS Axial FSE PD and FSE T2 FS Coronal DESS FOV 14 cm
Protocols Conventional MRI Sagittal T1 and FSE PD FS Axial FSE PD and FSE T2 FS Coronal DESS FOV 14 cm
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
Normal Anatomy
Posterior tibial t. Flexor digitorum t. Flexor hallucis longus t. FSE T2 FS
Anterior tibialis t. Extensor hallucis longus t. Extensor digitorum longus t. FSE T2 FS
Peroneal longus t. Peroneal brevis t. FSE T2 FS
Plantaris t. Achilles t. FSE T2 FS
Deltoid l. Anterior tibiofibular l. Posterior tibiofibular l. FSE T2 FS
Anterior talofibular l. Posterior talofibular l. FSE T2 FS
PTT FSE T2 FS
Sustentaculum talus FHL FSE T2 FS
FSE T2 FS Peroneus brevis t.
Deltoid ligament Spring ligament (dorsal calcaneonavicular)
PTT FDL T1W
Spring ligament ST FHL T1W
Achilles t. T1W Plantar fascia
Sinus tarsi T1W
Cervical and interosseous l. T1W
Root of extensor retinaculum Posterior talofibular l. T1W
Peroneus longus t. Peroneus brevis t. T1W
Anterior tibiofibular l. Posterior tibiofibular l. Anterior talofibular l. Posterior talofibular l. Calcaneofibular l.
Posterior intermalleolar l. Posterior inferior tibiofibular l. Transverse tibiofibular l. Deltoid l. Posterior talofibular l. Calcaneofibular l.
Posterior inferior tibiofibular l. Transverse tibiofibular l. Posterior talofibular l. T1W
Plantar fascia T1W
* Deltoid l. PTT FDL FHL T1W
Posterior Tibial Tendon Origin tibia and fibula (posteromedial borders) Attachment navicular, medial cuneiform Function inversion and plantar flexion of foot
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: 1045-8. PD
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: 1045-8. T1
* * * T1W T1W Accessory navicular and PTT tendinopathy
* * * T1W T1W Accessory navicular and PTT tendinopathy
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: 1045-8. PD
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: 1045-8. PDT2
PD PTT thinning and tibial spurring
PTT split tear and tenosynovitis FSE T2 FS
T1W PTT split tear FSE T2 FS
PTT split tear FSE PD FS
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
Flexor Hallucis Longus Tenosynovitis Os Trigonum Syndrome Tenosynovitis in ballerinas dancing on point Posterior impingement due to os trigonum syndrome PD
Flexor Hallucis Longus Tenosynovitis Os Trigonum Syndrome Tenosynovitis in ballerinas dancing on point Posterior impingement due to os trigonum syndrome PD
Flexor Hallucis Longus Tenosynovitis Os Trigonum Syndrome PD T2
Flexor Hallucis Longus Rupture DS PD
Achilles Tendon Origin gastrocnemius, soleus and plantaris muscles Attachment calcaneus Function plantar flexes foot
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, 1223-35. PD
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, 1223-35. T1
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, 1223-35.
T1W FSE PD FS Achilles near complete rupture
T1W FSE PD FS Achilles rupture
T1W FSE PD FS Achilles rupture
T1W FSE T2 FS Achilles rupture
T1W Achilles rupture
T1W FSE PD FS Achilles rupture
T1W FSE T2 FS Achilles rupture
Peroneal Brevis Tendon Origin fibula (lateral lower 2/3) and intermuscular septa Attachment 5 th metatarsal base Function plantar flexion, eversion of foot
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; 14:299-312.
T1W Peroneus brevis split tear
T1W Peroneus brevis split tear and peroneus longus tendinopathy
T1W Peroneus brevis split tear and peroneus longus tendinopathy
T1W Partial thickness Achilles tendon and peroneus brevis split tear
Partial thickness Achilles tendon and peroneus brevis split tear PD
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; 25:587 602.
Retinacular stripping, peroneal split tear and subluxation PD Cerrato RA et al. Peroneal tendon tears, surgical management and its complications. Foot Ankle Clin. 2009; 14:299-312. Want XT el al. Normal variants and diseases of the peroneal tendons and superior peroneal retinaculum: MR imaging features. RadioGraphics. 2005; 25:587 602.
PD Retinacular rupture and peroneal subluxation
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
Fragmented os peroneum
T1W Fragmented os peroneum
T1W FSE PD FS Peroneus longus tear
T1W FSE PD FS Peroneus longus tear
FSE PD FS Peroneus longus tear and edema in tubercle
Anterior Tibial Tendon Origin body of tibia Attachment medial cuneiform and 1 st metatarsal Function dorsiflexion and inversion of foot
* T1W Anterior tibialis tendon tear
T1W Anterior tibialis tendon tear FSE T2 FS
Anterior tibialis tendon tear
Postsurgical
T1W FSE PD FS Achilles rupture after reattachment
T1W Achilles rerupture
T1W FSE PD FS Achilles rerupture
Achilles rerupture FSE PD FS
T1W Achilles repair - ulceration
T1W FSE T2 FS Achilles repair - ulceration
FSE PD FS Achilles FSE T2 FS Failed FHL transfer for Achilles rupture
FHL FSE T2 FS FSE PD FS Failed FHL transfer for Achilles rupture
FHL FSE T2 FS FSE PD FS Achilles Failed FHL transfer for Achilles rupture
FSE T2 FS FSE PD FS Failed FHL transfer for Achilles rupture
T1W Calcaneal osteotomy with FDL transfer
T1W Calcaneal osteotomy with FDL transfer
T1W FSE PD FS ATT Retear
T1W T1 FS +Gd Infected ATT graft
T1W T1 FS +Gd Infected ATT graft
* T1 FS +Gd T1 FS +Gd Infected ATT graft
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
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