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Anterior Tibialis Tendon Rupture

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Topic updated on 02/18/14 6:43pm
Introduction
  • Mechanism
    • result of either laceration of the tendon or blunt trauma
    • most often occurs in middle-aged patients following an eccentric loading of a degenerated tibialis anterior tendon against a plantar flexed foot 
  • Delay in diagnosis is common because of intact ankle dorsiflexion that occurs as a result of secondary function of the extensor hallucis longus and extensor digitorum longus muscles
Anatomy
  • Ankle dorsiflexion
    • primary ankle dorsiflexor
      •  tibialis anterior
        • located in anterior compartment
        • innervated by deep peroneal nerve
        • originates on tibia and IOM
        • inserts on medial cuneiform and 1st metatarsal
        • dorsiflexes and inverts the foot
    • secondary ankle dorsiflexors
      •  extensor hallucis longus
      •  extensor digitorum longus
Presentation
  • Physical exam
    • traumatic injury
      • accompanied by associated osseous or soft-tissue injury in addition to 
      • pain and weakness in dorsiflexion of the ankle
    • atraumatic injury
      • pseudotumor at the anteromedial aspect of the ankle
      • loss of the contour of the tibialis anterior tendon over the ankle
      • use of the extensor hallucis longus and extensor digitorum communis to dorsiflex the ankle
Imaging
  • Radiographs
    • helpful to exclude any associated osseous injury
  • MRI
    • helpful to diagnose complete versus partial tear but not to determine if interposition graft is necessary
Treatment
  • Nonoperative
    • ankle-foot orthosis
      • indications
        • treatment must be individualized to patient
  • Operative
    • direct repair
      • indications
        • more common in acute (<6 week) injuries
    • reconstruction with interposition of EDL or plantaris 
      • indications
        • most often required in chronic (>6 week)  old injuries

 

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Qbank (1 Questions)

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(OBQ11.55) A 45-year-old male presents with complaints that his left foot "slaps" on the floor when he tries to ambulate. He reports a remote history of playing rugby 7 months ago when an opposing player fell on his plantarflexed left ankle. He denies constitutional symptoms. On physical examination he has weak dorsiflexion and increased fatigue with walking. He is able to achieve 15 degrees of passive dorsiflexion with the knee in full extension and 20 degrees of dorsiflexion with his knee in 90 degrees of flexion. A sagittal T2 MRI is shown in Figure A and axial MRI images are shown in Figures B and C. Which of the following is the MOST appropriate next step in management? Topic Review Topic
FIGURES: A   B   C      

1. Surgical reconstruction with posterior tibial tendon transfer and gastrocnemius recession
2. MRI of the proximal tibiofibular joint for evaluation of ganglion cyst and EMG of the peroneal nerve
3. Primary surgical repair with gastrocnemius recession
4. Chest CT, skeletal survey, hematology profile, and referral to an orthopaedic oncologist for biopsy of the mass
5. Surgical reconstruction with plantaris tendon interposition augmentation

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