Classically, tendon injuries occur from an event of over-activity or repetitive micro-insults that culminate into a painful syndrome that can lead to a rupture of the tendon. The majority of these tendonopathies involve those tendons which perform under great stress. The tendo-Achilles and tibialis posterior tendons are the most commonly affected in this array of tendon disorders.

The tendo-Achilles is the largest tendon in the body. It is formed by three muscles, the Gastrocnemius, the soleus, and the plantaris. These muscles function to: provide heel lift during the gait cycle; plantar flex the lateral column of the foot to the ground; decelerate the forward momentum of the tibia (extending the knee); and cause external rotation of the leg. The tendo-Achilles inserts into the posterior (back) middle 1/3 of the calcaneus (heel bone). This insertion (attachment) can be the source of problems. Bursal sacs located in this area (between the bone and tendon, and between the tendon and the skin) can become inflamed, resulting in Bursitis. The tendon can then cause a spur formation secondary to the chronic inflammation.

The goal of treating this disorder is to arrest the inflammation and irritation to the tendon at its insertion. This can be achieved through the use of non-steroidal anti-inflammatory medications, rest, heel lifts, and protective measures, such as avoiding heel irritation with heel cups. Orthotic devices may help with some heel tendonitis, and non-injected steroids may also be utilized.

Another tendon ailment is the "water-shed" injury. This is usually a rupture at the least vascular area of the tendon. It is caused by the foot being forced into the dorsiflexed position due to resistance of the muscle. When this occurs, the patient will feel as if he were hit in the leg with a baseball bat. He will not be able to dorsiflex his foot, and his tendon will have an abnormal contour with bruising. This particular injury requires a mandatory surgical primary repair of the tendon. Some cases also require a harvest graft of tendinous material from the plantaris or the tensor fascia lata. Post op casting of 8-12 weeks is necessary to heel this major disaster.

The tibialis posterior tendon may also present with injury to its substance. This may lead to dysfunction of the tendon. This muscle function is to decelerate the pronation of the foot in the stance phase of the gait cycle. Therefore, the tibialis posterior causes the arch to rise as it supinates. It also decelerates the forward momentum of the leg, which produces knee extension and heel lift as the foot dorsiflexes at the ankle joint. The tibialis posterior tendon also rotates the leg externally. Its activity begins just after heel strike and continues after heel lift.

The patient will complain of medial malleolus (ankle) pain at one of three sites: behind, below, or at the insertion point of the medial (inside) arch. These complaints include burning, aching, pulling, or ripping sensations which are localized within the course of the tendon. Pain is felt during the contact and stance phase of the gait cycle. This pain, along with swelling, temperature, and redness, will increase with use of the foot.

During tibialis dysfunction the forefoot is abducted on the rearfoot, the heel is everted, and the arch is collapsed in comparison to the contra lateral limb. If the tendon is ruptured, the patient will be unable to invert his heel on a toe raise. Also, when viewing from the back of the heel, the examiner will see too many toes on the lateral side of the foot, thus indicating the forefoot abduction. This foot will have a collapsing arch that leads to other secondary complaints.

Assessing this problem involves the collective use of x-rays, MRIs, tenograms, and the clinical exam. Conservative care may render relief of tendonitis. These measures consist of taping (strapping) the foot to relieve the tendon, as well as the use of non-steroidal anti-inflammatory medication, ice, arch devices (orthotics), and possible cast immobilization. In the acute phase of this injury, avoiding activity (exercise) of this muscle and its tendon is mandatory. If these measures fail to arrest the problem, surgery is indicated.

The goal of this surgery is to improve the function of the foot and eliminate pain. The presence of an accessory ossicle (extra bone) in the tendon at its insertion may cause the tendon’s function to weaken. If this is the case, removal of the bone and advancement of the tendon onto the navicular is in order. Pain from this particular condition is usually located near the navicular bone.

If the pain is located behind the medial malleolus, remodeling of this bone is required due to the abnormal contour irritating the tendon. The pain is localized here and the surgery is performed at this location. As in the earlier case, a non-weight bearing cast is used 4-6 weeks post operatively.

If the problem of tibialis dysfunction is the case, then many procedures involving tendon and osseous structures will be performed. The goal is addressing the deforming forces of the tendon. The tibialis posterior tendon will have a primary repair, as well as an anastomosis (joining) of the flexor digitorum longus tendon. The calcaneus can either be lengthened with a bone graft or rotated to invert. The tendo-Achilles is usually lengthened. In the worst case scenario, fusion of joints, such as a triple arthrodesis, may be needed. Remember it is the foot’s inability to supinate that causes a strain on the tibialis posterior tendon. The tibialis posterior tendon is thus secondarily insulted. For 8-12 weeks post operatively, a non-weight bearing cast is used.

Severe ankle sprains involving inversion can disrupt the peroneal tendons and can rupture, or more likely, cause a longitudinal split. Pain is located both posterior and inferior to the fibular malleolus. Popping and snapping are felt in range of motion. In this instance, the peroneal longus is usually injured.

Diagnosis can be confirmed with an arthrogram (x-ray of the ankle joint with radiopaque dye). Spillage of the dye out of the joint on the lateral aspect indicates tearing of the peroneal sheath and ligaments. Primary surgical repair is in order, although conservative care should first be employed. MRI studies can likewise reveal pathology of the tendon, however, this is not 100% successful in visualizing the disorder.

Peroneal slippage over the fibula may also symptomatically occur. The peroneal brevis and longus tendons use the Fibula as a pulley to evert the forefoot. This slippage can cause localized irritation in this area (posterior fibular). Reconstruction of the Posterior lip of the fibula via several surgical approaches should be utilized. Post operatively, a non weight bearing cast for 4-6 weeks (minimum) is needed to protect the heeling.

An argument exists in the use of a steroid injection into the tendon sheath to help heal the tendon. This approach should be used with extreme caution. The limb is protected from the patient with the use of a cast or a posterior splint for 2-4 weeks. It is not the steroid itself, but the possible removal of protective pain by the steroid, that can lead to a rupture.

Any tendon injury can lead to either a partial or a total rupture of the substance. This can be problematic for the surgeon. Total ruptures are similar to a cable rupture, in that the ends are frayed. Grafting may help, but the results are dependent on the health of the tendon and the skill of the surgeon. Do not delay care for any tendinous injury. Your results are dependent upon early treatment.

Abduction- movement away from the midline of the body which divides into right and left sides (Out-toeing)

Dorsiflexion- movement of the top of the foot to the front of the tibia

Plantarflexion- movement of the top of the foot away from the tibia

Pronation- movement of lowering the arch to the ground

Supination- movement of raising the arch from the ground

Adduction- movement towards the midline of the body which divides into right and left sides (In-toeing)

Medial- Located near the midline of the body which divides into right and left sides

Lateral- Located away from the midline of the body which divides into right and left sides

Dr. Graham has been in private practice in Effingham since 1989 and is on staff at St. Anthony's Memorial Hospital and Effingham Ambulatory Surgical Treatment Center. He is Board Certified by the American Board of Podiatric Surgery and American Board of Podiatric Orthopaedics and Primary Podiatric Medicine. Dr. Graham is a Fellow of the American College of Foot and Ankle Surgeons, the American College of Foot and Ankle Orthopaedics and Medicine, and American Professional Wound Care Association. He is also a member of the American Podiatric Medical Association and the Illinois Podiatric Medical Association.

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