Posterior ankle tendinopathies

INTRODUCTION — Posterior ankle tendinopathies usually result from cumulative movement disorders or repetitive strain injuries. In some cases, subtle skeletal structural faults (such as limb length discrepancy) predispose to such disorders or injuries. It is therefore important to conduct a careful examination to detect these defects. (See "Evaluation for subtle structural defects of the lower limb").

Other factors can contribute to recurrent or perplexing lower limb distress. These include osteoporosis, spondyloarthritis and enthesitis of lower limb structures, improper footwear, prolonged standing on concrete floors, and structural disorders such as joint laxity or malalignment of the lower limbs.

This topic review will discuss tendinitis of the posterior ankle. Ankle sprains and other soft tissue disorders of the foot are discussed separately. (See "Ankle sprain" and see "Plantar fasciitis and other causes of heel and sole pain").

TENDINITIS OF THE ANKLE — Eleven muscles have tendons crossing the ankle (show figure 1 and show figure 2). Inflammation and degeneration of a tendon sheath (often referred to as peritendinitis and tendinosis, respectively) may result from repetitive activity or unaccustomed extraordinary work. In addition, improper footwear often causes injury to the extensor hallucis longus or Achilles tendon.

A chronic nonspecific tendinitis similar to that seen in de Quervain's tenosynovitis can affect several tendons of the ankle. Tenosynovitis involving the tibialis anterior, tibialis posterior, extensor digitorum longus, or fibularis (peroneal) tendons can occur where the tendons become angulated at the ankle; friction can then cause inflammation of the tendon sheath. A bulbous swelling often occurs distally to areas of constriction and is helpful in demonstrating points of constriction. Occasionally, there is an underlying systemic disorder such as rheumatoid arthritis, spondyloarthritis, and rarely oxalosis, xanthomas, giant cell tumors, or tuberculosis. (See "de Quervain's tenosynovitis" and see "Clinical features and management of ankle pain in the young athlete", section on peroneal tendon injuries).

The posterior tibial tendon typically is involved in a patient with a pronated flatfoot. The presenting complaints include an aching mild to moderate pain over the medial ankle and longitudinal arch with weightbearing. Several weeks of persistent pain often have passed before the patient decides to seek help. Tendinitis of the other tendons of the ankle may also develop slowly. Calcific tendinitis is the exception; onset of pain with this disorder is acute.

Physical examination in the patient with tendinitis often reveals a tubular swelling of the tendon sheath, tenderness, pain on passive stretching of the tendon, pain on active ankle movement, and normal findings with palpation of the ankle joint. Comparison with the uninvolved side is helpful.

Radiographic abnormalities in tendinitis are usually absent in plain x-rays. New bone formation over the posterior aspect of the medial malleolus can occur in some cases. Magnetic resonance imaging with a low-field-strength instrument gives excellent definition of tendinopathy with or without rupture, but may not provide a cost benefit. In a randomized controlled study of 500 persons with acute injury of the wrist, knee, or ankle, MRI did not expedite the workup or change treatment of wrist or ankle injuries when compared to plain radiography [2]. Ultrasound may be helpful in determining the extent of tendon injury [1].

Most cases of tendinitis can be treated by partial immobilization of the ankle with bandaging or an elastic support for three to six weeks, and home exercise therapy. Foot/ankle circles is a simple exercise to maintain range of motion and strength (show picture 1). These can be performed several times daily with increasing repetitions and intensity as healing progresses. Stretching and lengthening of the calf muscles and plantar fascia begin gently and continue as activity increases. Strengthening exercises are added as pain subsides. Massage of the involved tendon can improve tissue flexibility.

Complete immobilization in a walking cast boot for a brief period of time may be necessary in severe cases; nonsteroidal antiinflammatory drugs (NSAID) can be used for pain relief. Tendon sheath injection with a corticosteroid and anesthetic mixture may be used in select cases. When injections are performed, the needle must be kept parallel to the tendon in order to minimize the risk of injecting steroid directly into the tendon. Injection is only performed in nonathletes with palpable swelling at the site of injury. The risk of post injection tendon rupture is significant in young athletes. Following injection the patient gradully begins strengthening and stretching exercises.

To perform intralesional injection, prepare the area with soap and alcohol. Using the shortest needle that can reach the required depth, use the needle as a probe. A 1 inch No. 23 or No. 25 needle is inserted 1/4 to 1/2 inch deep parallel to the tendon and into the tendon sheath for deposition of the mixture of corticosteroid and local anesthetic (1 mL 1 percent lidocaine hydrochloride and 20 to 40 mg methylprednisolone or equivalent). The mixture will flocculate within the syringe. Repeated injections around the ankle should not be made, since this can result in tendon rupture.

POSTERIOR TIBIAL TENDINITIS — Researchers no longer describe posterior tibial tendinitis as an inflammatory condition but rather as a degenerative condition with a nonspecific reparative response to tissue injury characterized by mucinous degeneration, fibroblast hypercellularity, chondroid metaplasia, and neovascularization in some patients [3,4]. These pathologic changes result in marked disruption in collagen bundle structure and orientation, creating weakened tendons susceptible to injury.

Inflammation and dysfunction of the posterior tibial tendon presents with gradually increasing pain and swelling over the medial ankle and longitudinal arch. This disorder is important to recognize since longstanding inflammation can lead to tendon disruption and progressive flatfoot deformity if left untreated. Complete rupture of the posterior tibial tendon may be suspected by x-ray if a sag of the naviculocuneiform joint or mild subluxation of the talonavicular joint is evident.

Numerous risk factors have been identified including increasing age, pes planus, hypertension, diabetes mellitus, peritendinous injections and inflammatory arthropathies [5]. Middle aged women are commonly affected. The pathogenesis of idiopathic tibialis posterior tendinopathy remains unclear. Areas of the tendon with relatively poor vascularization are more vulnerable, particularly if they are close to the medial malleolus. Forces acting through this tendon are high and may be influenced by adverse biomechanics (eg, excessively pronation).

Treatment is similar to other forms of tendinitis and begins with rest, ice, compression, elevation, and gentle stretching. Nonsteroidal antiinflammatory medications (NSAID) may reduce pain and swelling. If symptoms have not resolved in ten to fourteen days and NSAIDs do not provide adequate pain relief, treatment with a tendon sheath injection, and possibly casting for a short time, followed by use of an orthosis, may be helpful. Passive stretching is performed with the forefoot rotated externally (ie, outward) from the neutral position, or in a circular manner. Walking in a figure eight can begin when tenderness and swelling have subsided. Surgical intervention is sometimes necessary [6].

ACHILLES TENDINITIS

Pathophysiology and risk factors — As with posterior tibial tendinitis, Achilles tendinitis appears to be a degenerative condition, rather than inflammatory [5,7]. Histopathological evaluation of Achilles tendon biopsies, obtained from regions showing pathology at surgery, reveals altered fiber structure and arrangement, focal variations in cellularity, extracellular glycosaminoglycans, neovascularization, and hyalinization, but no evidence of inflammatory cell infiltration [7]. Doppler studies have confirmed the presence of increased vascularity in symptomatic tendons [8].

Plantar flexor muscle weakness and increased dorsiflexion excursion appear to be intrinsic risk factors for the development of Achilles tendinitis [9]. A tight Achilles tendon may result from disuse, from complex factors associated with growth, or more often as a problem occurring in women who wear high-heeled shoes or individuals who wear boots with high heels. In addition, runners may develop microtearing due to accumulated impact loading, and local inflammation can be induced by calcific tendinitis, spondyloarthropathies, and use of fluoroquinolones [10].

Support for an association between fluoroquinolone use and Achilles tendinitis is provided by a population study of approximately 250,000 individuals [11]. The adjusted relative risk of tendinitis with the administration of a fluoroquinolone was 3.7, with the risk being particularly high with ofloxacin (relative risk of 10.1).

Affected patients present with pain over the heel. Dorsiflexion of the ankle increases the pain and tenderness and a tendon friction rub may be palpable. Bilateral involvement, in the absence of fluoroquinolone use, suggests a systemic rheumatic disease such as ankylosing spondylitis with peripheral arthritis, reactive arthritis (formerly Reiter's syndrome), or calcium apatite deposition disease.

Inflammation involving the Achilles tendon insertion can occur in association with spondyloarthritides (eg, ankylosing spondylitis, undifferentiated spondyloarthritis, reactive arthritis, and psoriatic arthritis). (See appropriate topics). A tendon xanthoma, from hypercholesterolemia, can cause pain in the Achilles tendon without swelling.

Management — Gentle progressive stretching and lengthening exercises for the lower leg muscles are helpful, including the posterior leg stretch-wall (show picture 2), the posterior leg stretch-doorway (show picture 3), and the calf-plantar fascia stretch (show picture 4). Deep friction massage to the involved tendon may provide relief of pain and facilitate stretching. Achilles tendinitis in runners may respond to use of viscoelastic or other heel inserts to cushion and raise the heel, and a reduction in training level, especially on hills. If the disorder occurs in association with fluoroquinolone use, the antibiotic should be discontinued and another class of antimicrobial administered.

Several small randomized trials suggest eccentric exercise can reduce pain and improve function in patients with Achilles tendinitis, and many sports medicine specialists incorporate eccentric exercises into their treatment plan [5,12-15]. Eccentric loading exercises involve active lengthening (ie, the muscle is working while elongating) of the muscle tendon unit. A graded progressive program is recommended and is best supervised by an experienced therapist. The exercises may provide less benefit to sedentary patients [16].

Glyceryl trinitrate ointment applied to the skin overlying the Achilles tendon may be of some benefit. This was suggested in a randomized, placebo-controlled study in which 65 patients with noninsertional Achilles tendinopathy were randomly assigned to either apply the nitrate-containing patch (at a dosage of 1.25 mg per 24 hours) or an inert placebo [17]. Those who received the nitrate-containing patch had significantly less pain with activity.

Studies of chronic Achilles tendinopathy treatment using extracorporeal shock wave therapy have shown mixed results [18,19].

Corticosteroid injection for treatment of Achilles tendonitis is controversial [20]. It should only be considered in patients with ongoing symptoms despite rest, the use of corrective orthotics, and physical therapy. If local glucocorticoids are necessary, fluoroscopically guided peritendinous injection may offer an additional measure of safety. This was illustrated in a retrospective study of 43 patients who were injected with fluoroscopic guidance and were followed for at least two years [21]. Improvement occurred in 40 percent of patients; no major complications were noted.

In selected cases, refractory to other approaches, surgery such as percutaneous longitudinal tenotomy may be helpful [22]. Surgery may yield worse results in sedentary patients [23].

ACHILLES TENDON RUPTURE

History and examination — Rupture of the Achilles tendon may occur after abrupt calf muscle contraction. This typically occurs in men over the age of 30 who sporadically engage in sports and do not do a regular leg conditioning program. Fluoroquinolone antibiotic use has also been reported as a predisposing factor, particularly when combined with use of corticosteroids in people older than 60 years [10,24,25]. Genetic predisposition may also play a role [26].

The patient may note an audible snap, followed by pain in the calf as if struck with a baseball. Partial rupture, in contrast, may not have a well defined inciting event.

On physical examination, the patient may be unable to stand up on the toes. A positive Thompson test is further evidence of rupture (show figure 3). This test is performed with the patient kneeling on a chair and the feet hanging over the edge. When the examiner squeezes the calf muscle on the normal side, the foot responds with plantar flexion; on the side with a rupture, there is no foot response.

With partial rupture of the tendon there may still be substantial strength. A crescent sign due to blood tracking into the soft tissues may be seen beneath the malleolus or even into the foot or toes.

Management — Imaging is unnecessary in the case of obvious complete rupture. Discontinuity of tendon fibers and hypoechoic areas may be demonstrated by ultrasound in partial ruptures [27]. In one study, ultrasound was highly accurate in differentiating full from partial thickness tears [28].

Orthopedic consultation for immobilization or repair is necessary for patients with tendon rupture. Surgical end-to-end repair performed soon after the injury allows patients to return to their preinjury level of activity in over 90 percent of cases [29]. However, in one study of 25 elderly patients, only 9 had a complete recovery [30].

Nonoperative treatment appears to be associated with a higher risk of rerupture. This was illustrated in a 2004 systematic review that included 4 trials and a total of 356 patients in which operative and nonoperative treatment were compared [31]. Achilles tendon repair using an open operative technique had a significantly lower risk of subsequent rupture (relative risk 0.27, 95% CI 0.11-0.64). Infection, adhesions, and local nerve damage were more frequent in those who were operated upon. Patients have a more rapid rehabilitation when a functional brace is used rather than a cast for post operative immobilization.

The success of delayed surgery is less clear [32,33]. Extensive postoperative exercise rehabilitation may be needed.


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