Posterior Tibial Tendon Insufficiency: Which Ligaments are Involved?

2005 ◽  
Vol 26 (6) ◽  
pp. 427-435 ◽  
Author(s):  
Jonathan T. Deland ◽  
Richard J. de Asla ◽  
Il-Hoon Sung ◽  
Lauren A. Ernberg ◽  
Hollis G. Potter
Keyword(s):  
Progressive Failure ◽  
Plantar Fascia ◽  
Control Group ◽  
Deltoid Ligament ◽  
Posterior Tibial Tendon ◽  
Cross Sectional ◽  
Interosseous Ligament ◽  
Posterior Tibial ◽  
Spring Ligament ◽  
Magnetic Resonance Imaging Mri

Background: The pathology manifested in posterior tibial tendon insufficiency (PTTI) is not limited to the posterior tibial tendon. The association of ligament failure with deformity has been discussed in numerous publications, but extensive documentation of the structures involved has not been performed. The purpose of this observational study was to identify the pattern of ligament involvement using standarized, high-resolution magnetic resonance imaging (MRI) in a series of 31 consecutive patients diagnosed with PTTI compared to an age matched control group without PTTI. Method: The structures evaluated by MRI were the posterior tibial tendon, superomedial and inferomedial components of the spring ligament complex, talocalcaneal interosseous ligament, long and short plantar ligaments, plantar fascia, deltoid ligament, plantar naviculocuneiform ligament, and tarsometatarsal ligaments. Structural derangement was graded on a five-part scale (0 to IV) with level 0 being normal and level IV indicating a tear of more than 50% of the cross-sectional area of the ligament. Standard flatfoot measurements taken from preoperative plain standing radiographs were correlated with the MRI grading system. Results: Statistically significant differences in frequency of pathology in the PTTI group and controls were found for the superomedial calcaneonavicular ligament ( p < 0.0001), inferomedial calcaneonavicular ligament ( p < 0.0001), interosseous ligament ( p = 0.0009), anterior component of the superficial deltoid ( p < 0.0001), plantar metatarsal ligaments ( p = 0.0002) and plantar naviculocuneiform ligament ( p = 0.0006). The ligaments with the most severe involvement were the spring ligament complex (superomedial and inferomedial calcaneonavicular ligaments) and the talocalcaneal interosseous ligament. Conclusion: Ligament involvement is extensive in PTTI, and the spring ligament complex is the most frequently affected. Because ligament pathology in PTTI is nearly as common as posterior tibial tendinopathy, treatment should seek to protect or prevent progressive failure of these ligaments.

Morphological Characteristics of Passive and Active Structures of the Foot Across Populations With Different Levels of Physical Activity

2021 ◽  
pp. 1-7
Author(s):  
Inmaculada Reina-Martin ◽  
Santiago Navarro-Ledesma ◽  
Ana Belen Ortega-Avila ◽  
Kevin Deschamps ◽  
Alfonso Martinez-Franco ◽  
...  
Keyword(s):  
Physical Activity ◽  
Achilles Tendon ◽  
Patellar Tendon ◽  
Morphological Characteristics ◽  
Plantar Fascia ◽  
Posterior Tibial Tendon ◽  
Cross Sectional ◽  
Posterior Tibial ◽  
Longitudinal Measurement ◽  
The Right

Background: Imaging diagnosis plays a fundamental role in the evaluation and management of injuries suffered in sports activities. Objective: To analyze the differences in the thickness of the Achilles tendon, patellar tendon, plantar fascia, and posterior tibial tendon in the following levels of physical activity: persons who run regularly, persons otherwise physically active, and persons with a sedentary lifestyle. Design: Cross-sectional and observational. Participants: The 91 volunteers recruited from students at the university and the Triathlon Club from December 2016 to June 2019. The data were obtained (age, body mass index, and visual analog scale for quality of life together with the ultrasound measurements). Results: Tendon and ligament thickness was greater in the runners group than in the sedentary and active groups with the exception of the posterior tibial tendon. The thickness of the Achilles tendon was greater in the runners than in the other groups for both limbs (P = .007 and P = .005). This was also the case for the cross-sectional area (P < .01) and the plantar fascia at the heel insertion in both limbs (P = .034 and P = .026) and for patellar tendon thickness for the longitudinal measurement (P < .01). At the transversal level, however, the differences were only significant in the right limb (P = .040). Conclusion: The thickness of the Achilles tendon, plantar fascia, and patellar tendon is greater in runners than in persons who are otherwise active or who are sedentary.

Combined Spring and Deltoid Ligament Repair in Adult-Acquired Flatfoot

2018 ◽  
Vol 39 (8) ◽  
pp. 903-907 ◽  
Author(s):  
Caio Nery ◽  
André Vitor Kerber C. Lemos ◽  
Fernando Raduan ◽  
Nacime Salomão B. Mansur ◽  
Daniel Baumfeld
Keyword(s):  
Case Series ◽  
Deltoid Ligament ◽  
Posterior Tibial Tendon ◽  
Retrospective Case ◽  
Level Of Evidence ◽  
Posterior Tibial ◽  
Novel Technique ◽  
Spring Ligament ◽  
Tissue Healing ◽  
Internal Brace

Background: Adult-acquired flatfoot deformity (AAFD) is usually due to a combination of mechanical failure of the osteoligamentous complex that maintains the medial longitudinal arch of the foot and attenuation or complete tear of the posterior tibial tendon. Magnetic resonance imaging studies in patients with flatfoot deformities have reported the posterior tibial tendon to be pathologic in up to 100% of patients, the spring ligament in up to 87%, and the deltoid ligament in 33%. Many studies in the literature describe reconstruction of the spring ligament or the deltoid ligament associated with AAFD, but there is no study in which both (spring and deltoid) ligaments are reconstructed at the same time. We describe a novel technique to reconstruct the deltoid ligament and the spring ligament at the same time. Methods: We described the technique and evaluated 10 consecutive patients with AAFD and insufficient ankle and midfoot ligaments. Results: We found no postoperative complications, stiffness, or loss of correction. Conclusion: We present a novel technique to reconstruct the failed deltoid and spring ligament during flatfoot correction. It is unique in that it uses internal brace augmentation with FiberTape® to help and protect the soft tissue healing. Level of Evidence: Level IV, retrospective case series.

Adult Acquired Flatfoot Deformity at the Talonavicular Joint: Reconstruction of the Spring Ligament in an in Vitro Model

Foot & Ankle ◽  
1992 ◽  
Vol 13 (6) ◽  
pp. 327-332 ◽  
Author(s):  
Jonathan T. Deland ◽  
Stephen P. Arnoczky ◽  
Francesca M. Thompson
Keyword(s):  
Deltoid Ligament ◽  
Posterior Tibial Tendon ◽  
Joint Reconstruction ◽  
Posterior Tibial ◽  
Spring Ligament ◽  
Fresh Frozen ◽  
Adult Acquired Flatfoot Deformity ◽  
Vitro Model ◽  
Bone Autograft

The mobile unilateral flatfoot deformity of chronic posterior tibial tendon insufficiency has been difficult to correct by soft tissue procedures. The procedures can decrease pain, but they do not always correct the longitudinal arch or relieve all the symptoms. Using 10 fresh frozen cadaveric specimens and a rig for stimulation of weightbearing, the deformity associated with chronic posterior tibial tendon insufficiency was produced by multiple ligamentous release and documented by AP and lateral radiographs. Reconstruction of the spring ligament using a ligament bone autograft from the superficial deltoid ligament was then performed and tested under load. The mean correction was within 2.5° of normal (over or undercorrection) on both the AP and lateral radiographs with the specimens under load. Clinical Relevance. In posterior tibial tendon insufficiency, it may be possible to address the ligament as well as tendon insufficiency to gain a corrected arch. The success of such a procedure will depend upon adequate tendon and ligament reconstruction in a fully mobile deformity. Questions remain as to the adequacy of this ligament graft, and a stronger free ligament graft, as well as correction of any bony malalignment, may be required.

scholarly journals Weightbearing CT and MRI findings of Stage II Flatfoot Deformity

2018 ◽  
Vol 3 (3) ◽  
pp. 2473011418S0020 ◽  
Author(s):  
Cesar de Cesar Netto ◽  
Lauren Roberts ◽  
Guilherme Saito ◽  
Andrew Roney ◽  
Daniel Sturnick ◽  
...  
Keyword(s):  
Soft Tissue ◽  
Stage Ii ◽  
Posterior Tibial Tendon ◽  
Mr Images ◽  
Mri Findings ◽  
Bone Deformity ◽  
Interosseous Ligament ◽  
Posterior Tibial ◽  
Spring Ligament ◽  
Weightbearing Ct

Category: Hindfoot Introduction/Purpose: Adult acquired flatfoot deformity (AAFD) is characterized by concurrent bony deformities, tendinous and ligamentous insufficiencies. Weightbearing CT (WBCT) is a new imaging technique that allows excellent evaluation of the relative three-dimensional positioning of the tarsal bones in dynamic deformities such as AAFD. MRI, on the other hand, provides an accurate evaluation of soft tissue integrity in the unloaded foot. The objective of this study was to evaluate the correlation between bone deformity and soft tissue insufficiency in patients with stage II AAFD, using WBCT and MR images. We hypothesized that a significant correlation would be found between WBCT measurements of increased longitudinal arch collapse, hindfoot valgus, peritalar subluxation and forefoot abduction, with MRI findings demonstrating degree of involvement of ligaments and posterior tibial tendon (PTT). Methods: This retrospective comparative study included 55 patients (56 feet) with stage II AAFD, 20 men and 35 women, mean age of 52.5 (range, 20 to 78) years. Multiple WBCT and MRI variables related to the severity of the deformity were evaluated by four blinded and independent readers (two radiologists and two foot and ankle surgeons), including: arch collapse (navicular-floor distance and forefoot arch angle), hindfoot alignment angle (HAA), forefoot abduction (talonavicular uncoverage angle), subtalar joint subluxation, sinus tarsi and subfibular impingement, and soft tissue insufficiency (posterior tibial tendon, spring and talocalcaneal ligaments). Tendinous and ligamentous involvement on MRI were graded from zero (normal) to four (complete tear). Intra- and interobserver reliabilities were assessed by Pearson/Spearman’s and intraclass correlation coefficient, respectively. A multiple regression analysis was used to evaluate the relationship between bone alignment (WBCT variables) and soft tissue injury (MRI variables). P-values of less than 0.05 were considered significant. Results: We found overall good to excellent intra (range, 0.83-0.99) and interobserver reliability (range, 0.71-0.97) for WBCT measurements and MRI readings. Spring ligament superomedial component involvement was the only finding to correlate with medial column collapse and decreased navicular-floor distance (p=0.03). Superomedial spring ligament and PTT degeneration were also significantly correlated with increased HAA (p<0.01). Involvement of the talocalcaneal interosseous ligament significantly correlated with increased forefoot abduction as measured by the talonavicular uncoverage angle. Spring ligament degeneration, of both superomedial and inferior components, and talocalcaneal interosseous ligaments significantly correlated to subtalar joint subluxation (p<0.001). Involvement of the talocalcaneal interosseous ligament was the only one to significantly correlate to the presence of subfibular impingement (p=0.02). Degeneration of the PTT was significantly associated with sinus tarsi impingement (p=0.04). Conclusion: This study is the first to evaluate correlation between bone, tendinous and ligamentous involvement in AAFD patients, using WBCT and MR images. Our results demonstrated that progressive bone deformity in WBCT is significantly correlated to MRI involvement of the PTT and other important restraints such as the spring and talocalcaneal ligaments. The implications are that WBCT can predict ligamentous injuries and that MRI can predict dynamic bone deformity in AAFD patients. Furthermore, the correlation of bone and soft tissue involvement could impact surgical planning of flatfoot patients, decreasing thresholds for additional soft tissue procedures such as a spring ligament reconstruction.

scholarly journals The Deltoid Ligament

2017 ◽  
Vol 2 (3) ◽  
pp. 2473011417S0000
Author(s):  
Neal Ormsby ◽  
Simon Platt ◽  
Gillian Jackson ◽  
Paul Evans
Keyword(s):  
Weight Bearing ◽  
Control Group ◽  
Deltoid Ligament ◽  
Posterior Tibial Tendon ◽  
Talonavicular Joint ◽  
Corrective Surgery ◽  
First Metatarsal ◽  
Posterior Tibial ◽  
Metatarsal Angle ◽  
The Mean

Category: Basic Sciences/Biologics, Hindfoot, Midfoot/Forefoot Introduction/Purpose: The medial ligaments are integral in stabalising the medial column. Failure of these structures causes adult acquired flatfoot deformity (AAFD). The superomedial-cancaneonavicular component of the spring ligament(SLC) includes the medial capsule of the talonavicular joint and merges with the anterior superficial component of the deltoid complex, stabilising the talonavicular joint. However, when disrupted, it does not cause planovalgus deformity until the foot is cyclically loaded. We hypothesise that the next structure in the sequential failure cascade is the tibionavicular component of the Deltoid complex(TN) . With the failure of the SLC and the secondary effect of the posterior tibial tendon this ligament is the gatekeeper to stability of the midfoot, preventing plantar subluxation of the talus, and maintaining the radiographic lateral talo-first metatarsal angle. Methods: A prospective case control study using a novel MRI technique to image the TN. We scanned 20 consecutive normal feet and 20 with clinical and radiological AFFD. The AFFD group was subdivided into normal or abnormal TN. We assessed for pathology in the SLC, deltoid ligament (with conventional sequences) and posterior tibial tendon (PT). Imaging of the TN was performed using a novel sequence, which was an oblique view in both T1 and T2 sequence in the plane of the TN ligament to identify the normal ligament in the control group, and compare it to the patients with clinical AAFD. All patients had weight bearing AP and lateral radiographs in order to measure the calcaneal pitch, lateral talo-first metatarsal angle, and talo-calcaneal angle. We followed up patients, the end point being surgery or definitive conservative management and discharge. Results: 2 distinct groups of patients were identified. Normal TN(11/20) A mixture of medial ligament pathology was associated with this. All were managed conservatively and discharged from follow-up. The mean Meary’s angle was 6.8°. Abnormal TN(9/20) The ligament was thickened proximally, with distal attenuation and intrasubstance oedema. On sagittal sequence it had the appearance of an omega(O), with dorsal bulging and high signal on T2. The mean Meary’s angle was 13.2°(p 0.013). All patients had PT dysfunction and 8 had SLC attenuation. 5 of these patients have undergone corrective surgery. None had been discharged. The prevalence of the omega in AFFD was 30%. We confirm that the prevalence of deltoid involvement in AFFD is high, particularly in patients with more severe disease. Conclusion: Imaging of the TN is valuable in AFFD, and adds no cost or risk. There is no doubt that sequential failure of the medial ligaments occurs in AFFD. We have shown that the deltoid is involved more often than previously reported. In those with normal TN, our preliminary findings suggest that management can focus on protecting the medial structures. When the TN is attenuated(‘O’ on MRI), this represents a foot transitioning to a more severe deformity, both clinically and structurally. From our experience, these patients are more likely to have a progressive, less flexible planovalgus deformity, often requiring corrective surgery.

Magnetic Resonance Imaging in the Diagnosis of Disruption of the Posterior Tibial Tendon

Foot & Ankle ◽  
1987 ◽  
Vol 8 (3) ◽  
pp. 144-147 ◽  
Author(s):  
Ian J. Alexander ◽  
Kenneth A. Johnson ◽  
Thomas H. Berquist
Keyword(s):  
Magnetic Resonance Imaging ◽  
Magnetic Resonance ◽  
Soft Tissues ◽  
Diagnostic Technique ◽  
Clinical Findings ◽  
The Body ◽  
Posterior Tibial Tendon ◽  
Resonance Imaging ◽  
Posterior Tibial ◽  
Magnetic Resonance Imaging Mri

Magnetic resonance imaging (MRI), a useful technique of studying soft tissues of the body, can be very effective in assessing the integrity of tendons. Usually a patient with a complete tear of the posterior tibial tendon has characteristic physical findings. In the patient presented, MRI demonstrated a complete disruption of the posterior tibial tendon, despite the absence of the commonly associated clinical findings. In view of the difficulties encountered with attempted tenography of the completely torn posterior tibial tendon, MRI provides a sensitive alternative diagnostic technique.

3D foot kinematic difference in Posterior Tibial Tendon Dysfunction stage II/III and control group

2016 ◽  
Vol 22 (2) ◽  
pp. 11
Author(s):  
S. Wuite ◽  
K. Deschamps ◽  
C. Roels ◽  
M. van de Velde ◽  
F. Staes ◽  
...  
Keyword(s):  
Stage Ii ◽  
Control Group ◽  
Posterior Tibial Tendon ◽  
Posterior Tibial Tendon Dysfunction ◽  
Posterior Tibial ◽  
And Control

Role of Tendoscopy in Treating Stage II Posterior Tibial Tendon Dysfunction

2018 ◽  
Vol 39 (4) ◽  
pp. 433-442 ◽  
Author(s):  
Alessio Bernasconi ◽  
Francesco Sadile ◽  
Matthew Welck ◽  
Nazim Mehdi ◽  
Julien Laborde ◽  
...  
Keyword(s):  
Invasive Surgery ◽  
Stage Ii ◽  
Preoperative Imaging ◽  
Tibialis Posterior ◽  
Posterior Tibial Tendon ◽  
Posterior Tibial ◽  
Spring Ligament ◽  
Sf 36

Background: Stage II tibialis posterior tendon dysfunction (PTTD) resistant to conservative therapies is usually treated with invasive surgery. Posterior tibial tendoscopy is a novel technique being used in the assessment and treatment of posterior tibial pathology. The aims of this study were (1) to clarify the role of posterior tibial tendon tendoscopy in treating stage II PTTD, (2) to arthroscopically classify spring ligament lesions, and (3) to compare the arthroscopic assessment of spring ligament lesions with magnetic resonance imaging (MRI) and ultrasonographic (US) data. Methods: We reviewed prospectively collected data on 16 patients affected by stage II PTTD and treated by tendoscopy. We report the reoperation rate and functional outcomes evaluated by comparing pre- and postoperative visual analogic scale for pain (VAS-pain) and the Short-Form Health Survey (SF-36; with its physical [PCS] and mental [MCS] components). Postoperative satisfaction was assessed using a VAS-satisfaction scale. One patient was lost to follow-up. Spring ligament lesions were arthroscopically classified in 3 stages. Discrepancies between preoperative imaging and intraoperative findings were evaluated. Results: At a mean of 25.6 months’ follow-up, VAS-pain ( P < .001), SF-36 PCS ( P = .039), and SF-36 MCS ( P < .001) significantly improved. The mean VAS-satisfaction score was 75.3/100. Patients were relieved from symptoms in 80% of cases, while 3 patients required further surgery. MRI and US were in agreement with intraoperative data in 92% and 67%, respectively, for the tendon assessment and in 78% and 42%, respectively, for the spring ligament. Conclusions: Tendoscopy may be considered a valid therapeutic tool in the treatment of stage II PTTD resistant to conservative treatment. It provided objective and subjective encouraging results that could allow continued conservative therapy while avoiding more invasive surgery in most cases. MRI and US were proven more useful in detecting PT lesions than spring ligament tears. Further studies on PT could use this tendoscopic classification to standardize its description. Level of Evidence: Level IV, therapeutic study, case series.

scholarly journals The Influence Of Obesity in Stage IIB Posterior Tibial Tendon Dysfunction Corrective Surgery

2018 ◽  
Vol 3 (3) ◽  
pp. 2473011418S0044
Author(s):  
Amila Silva ◽  
Inderjeet Rikhraj
Keyword(s):  
Clinical Outcomes ◽  
Statistical Significance ◽  
Obese Group ◽  
Control Group ◽  
Posterior Tibial Tendon ◽  
Corrective Surgery ◽  
Posterior Tibial Tendon Dysfunction ◽  
Repeat Surgery ◽  
Posterior Tibial ◽  
Hind Foot

Category: Hindfoot Introduction/Purpose: In the western population prevalence of posterior tibial tendon dysfunction (PTTD) is said to be 3.3% and it is one of the most commonly undiagnosed foot and ankle pathologies. Stage IIB disease according to Johnson and Strom criteria is managed surgically and there are literature demonstrating good clinical outcomes. Obesity being a global epidemic it affects the patient both biomechanically and biochemically. Aim of the study was to investigate the influence of obesity on functional outcome scores, incidence of postoperative surgical site infection (SSI), and repeat surgery after corrective surgery for stage IIB posterior tibial tendon dysfunction (PTTD). Methods: Between January 2007 and December 2013, 102 patients who underwent corrective surgery for stage IIB PTTD at a tertiary hospital were evaluated. We categorized the group with a BMI less than 30 kg/m as control and the group with BMI more than 30 kg/m as obese. The patients were prospectively followed for 2 years. AOFAS mid foot and hind foot scores, mid foot and hind foot VAS scores, SF36 physical and mental function scores were measured pre-operative, post-operative 6 months and post-operative 24 months. SPSS was used for statistical analysis. P value <0.05 was considered as a significant value. Results: 19.6 percent of our study population was obese, there were 38 males and 64 females. The average age of the population was 44.3years and the average BMI for the population was 28.78kg/m2. Clinical outcomes are as follows SF36 physical function score demonstrated statistical significance (p=0.0001, CI -22.20 to -9.80), AOFAS midfoot scores (p=0.82, CI -9.55 to 7.56), AOFAS hindfoot scores (p=0.23, CI -10.60 to 2.60), Midfoot Visual Analogue Scores (p=0.54, CI 0.31 to 0.76), Hindfoot Visual Analogue Scores (p=0.45, CI 0.21 to 0.68) and SF36 mental health scores (p=0.99, CI -5.76 to 7.74) did not demonstrate any significance (6%) in the control group and 10% in the obese group required repeated surgery for complications. Conclusion: Both groups of patients who underwent corrective surgery for stage IIB pttd demonstrated good functional outcomes but there was a significantly higher risk of repeat surgery in the obese group. Obese patients should not be excluded from stage IIB PTTD corrective surgery but patients should be counselled of the higher risk percentage.

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