Posterior Tibial Tendon Dislocation
Other Names
- Posterior Tibial Tendon Dislocation
- Tibialis Posterior Dislocation
- Dislocation, Posterior Tibial Tendon
- Traumatic Subluxation of the Posterior Tibialis Tendon
Background
- This page refers to acute posterior tibial tendon dislocations (PTT Dislocation)
- Posterior Tibial Tendon Dysfunction and the more chronic manifestations are discussed separately
History
- First description is attributed to Martins in 1874[1]
Epidemiology
- Rare condition limited to case reports, case series
- One systematic review found[2]
- Mean age 33
- Male (39) > female (20)
Introduction
General
- Rare condition limited to case reports
- Diagnosis is often delayed due to co-occurring lesions and inconsistency in tendon dislocation
- Clinical suspicion should increase with pain and swelling around the medial malleolus following an inversion injury
- No history, physical exam or imaging has consistently detectable findings
Pathophysiology
- Occurs as an acute injury
- Thought to occur as a violent posterior tibial muscle contraction triggered by a forceful inversion[3]
- Greatest risk appears to be the ankle is inverted and then forced into dorsiflexion and eversion
- This creates a significant eccentric load and anteromedial force on the contracting tendon
- Can also occur from pronation-external rotation
Etiology
- Lohrer et al[2]
- 44 cases due to trauma, 17 were spontaneous
Diagnostic Delay
- One study found PTT Dislocation initially misdiagnosed as[2]
- Diagnostic delay mean is between 4 and 9 months depending on the cited study[4]
Associated Conditions
- Deltoid ligament partial tear
- Talar Osteochondral Lesion
- Tarsal Tunnel Syndrome
- Ankle meniscoid
- Flexor digitorum longus tendon sheath tear
- Medial Malleolar Fracture
Anatomy of the Tibialis Posterior
- Description[5]
- Originates in the Deep Posterior Compartment of the Leg
- Attaches along plantar surface of multiple tarsal, metatarsal bones
- Aids in plantarflexion, inversion and supports medial arch of foot
- Retromalleolar groove
- Often described as normal or shallow in patients with PTT dislocation
Risk Factors
- Previous posterior tibial tendon surgery
- Tarsal tunnel release
- Corticosteroid Injection
- Ankle Sprain
- General laxity
- Shallow posterior tibial tendon groove
- Tear of flexor retinaculum
Differential Diagnosis
Differential Diagnosis Ankle Pain
- Fractures & Dislocations
- Muscle and Tendon Injuries
- Ligament Injuries
- Bursopathies
- Nerve Injuries
- Arthropathies
- Pediatrics
- Fifth Metatarsal Apophysitis (Iselin's Disease)
- Calcaneal Apophysitis (Sever's Disease)
- Triplane Fracture
- Other
Clinical Features
History
- About half of patients report hearing or feeling a popping sensation
- Recurring snapping over the medial malleolus
- Patients complain of medial ankle pain
- Swelling and ecchymosis are often present
Physical Exam: Physical Exam Ankle
- More than half of cases identified a cord like structure passing over the medial malleolus[2]
- The presence of ankle edema may limit ability to palpate PTT
Special Tests
- Needs to be updated
Evaluation
Radiology
- Standard Radiographs Ankle
- Screening tool, typically normal
- Potential findings
- Medial malleolar chip fracture
- Fibular fracture
CT
- Potential findings
- Dislocated PTT
MRI
- Findings
- Dislocated or subluxed PTT
- Thickening of the PTT
- Peritendinous fluid
- Absence of tears
- Lohrer et al estimated specificity at 75%
Ultrasound
- Dynamic ultrasound is the diagnostic study of choice
- Lohrer et al estimated specificity at 66.7%
- Findings
- Tendon is subluxing or dislocation with forced inversion
- Typically surrounded by fluid without any tears
- Additional potential findings
- Stripping of the flexor retinaculum
- Small avulsion of the medial mal insertion of the retinaculum
Classification
- Type I: Flexor retinaculum is ruptured, thus allowing the PTT to freely move over the medial malleolus in the subcutaneous tissue
- Type II: Flexor retinaculum and periosteum are detached from the tibia, leading to the formation of a pseudopouch in which the PTT can settle
Management
Nonoperative
- Indications
- No clear guidelines
- Can be considered in appropriate compliant patients who are not great surgical candidates
- Need non operative protocol
Operative
- Indications
- Chronic cases
- Recurrent or permanent posterior tibial tendon dislocation
- Goals
- Correct PTT position
- Prevent subsequent tendon dislocations
- Technique
- Direct flexor retinaculum repair
- Reconstruction of the retinaculum combined with groove-deepening procedures
- Malleolar osteotomies
- Suture anchors
- Autogenous bone block grafting
- Buttress plate fixation
Rehab and Return to Play
Rehabilitation
- One post operative protocol
- 15 days of complete immobilization
- 15 days of protected weight bearing with crutches and boot
- Progression flexion and extension activities
- Followed by physical therapy
Return to Play/ Work
- Needs to be updated
Prognosis and Complications
Prognosis
- Patients tend to do better with surgical correction
Complications
- Posterior Tibial Tendon Dysfunction
- Chronic ankle pain
- Inability to return to work/ sport
See Also
References
- ↑ Martius CH: Notes on a case of posterior tibialis tendon luxation . Mem Acad Chir. 187423, 14:
- ↑ 2.0 2.1 2.2 2.3 Lohrer, Heinz, and Tanja Nauck. "Posterior tibial tendon dislocation: a systematic review of the literature and presentation of a case." British journal of sports medicine 44.6 (2010): 398-406.
- ↑ Soler RR, Gallart Castany FJ, Riba Ferret J, et al. Traumatic dislocation of the tibialis posterior tendon at the ankle level. J Trauma 1986;26:1049–52
- ↑ Perlman, M. D. "Dislocation of the posterior tibial tendon." Foot & Ankle 13.6 (1992): 364-364.
- ↑ Albano, Domenico, et al. "Posterior tibial tendon dysfunction: Clinical and magnetic resonance imaging findings having histology as reference standard." European Journal of Radiology 99 (2018): 55-61.
- ↑ 6.0 6.1 Zannoni, Stefania, et al. "Posterior tibial tendon dislocation: a case report." The Journal of Foot and Ankle Surgery 61.2 (2022): 417-420.
Created by:
John Kiel on 17 June 2024 12:42:55
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Last edited:
17 June 2024 13:57:27
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