http://upload.orthobullets.com/topic/7055/images/tib ant rupture.jpg
  • Partial or complete discontinuity of the tibialis anterior tendon
  • Epidemiology
    • demographics
      • attritional rupture more common in older patients
      • strong eccentric contraction more common in younger patients
    • body location
      • at the level of the ankle joint with varying degrees of retraction of the proximal stump
    • risk factors
      • older age
      • diabetes
      • fluoroquinolone use
      • local steroid injection
      • inflammatory arthritis
  • Pathophysiology
    • mechanism of injury
      • result of either laceration of the tendon or closed rupture
      • may also result from strong eccentric contraction in young individual
  • Medical conditions & comorbidities
    • diabetes
    • inflammatory arthritis
  • Prognosis
    • Good with treatment
  • Ankle dorsiflexion
    • primary ankle dorsiflexor (80%)
      •  tibialis anterior
    • secondary ankle dorsiflexors
      •  extensor hallucis longus
      •  extensor digitorum longus
  • History
    • acute
      • patient reports a 'pop' followed by anterior ankle swelling
    • chronic
      • patient reports difficulty clearing foot during gait
  • Symtpoms:
    • acute
      • pain
    • chronic
      • may be painless
  • Physical exam
    • acute injury
      • pain swelling anterior to ankle
      • weakness in dorsiflexion of the ankle
        • 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
    • chronic injury
      • inspection and palpation
        • swelling may be minimal
        • painless mass at the anteromedial aspect of the ankle
        • loss of the contour of the tibialis anterior tendon over the ankle (tendon not palpable during resisted dorsiflexion)
      • weakness
        • use of the extensor hallucis longus and extensor digitorum communis to dorsiflex the ankle
      • gait
        • steppage gait (hip flexed more than normal in swing phase to prevent toes from catching)
        • foot slaps down after heel strike
  • Radiographs
    • three views of foot and ankle helpful to exclude any associated osseous injury
  • CT
    • not indicated
  • MRI
    • helpful to diagnose complete versus partial tear but not to determine if interposition graft is necessary
  • Lumbar radiculopathy (L4)
    • can be differentiated from TA rupture by
      • intact tendon palpable
      • no ankle mass
      • may have dermatomal sensory abnormality
      • positive lumbar spine MRI
  • Common peroneal nerve compression neuropathy
    • EDL, EHL also affected
    • sensory abormalities
    • history of compression to common peroneal nerve
  • Nonoperative
    • ankle-foot orthosis
      • indications
        • low demand patient
    • casting
      • indications
        • partial ruptures
  • Operative 
    • direct repair
      • indications
        • acute injury (<6 week) injuries
        • should be attempted up to 3 months out
      • outcomes 
        • surgical repair leads to improved AOFAS scores and improved levels of activity
        • some residual weakness of dorsiflexion is expected
    • reconstruction 
      • indications
        • most often required in chronic (>6 week)  old injuries
  • Direct repair
    • approach
      • open laceration: incorporate laceration
      • closed rupture: longitudinal incision centered over palpable defect
    • repair technique
      • distal end usually accessible through laceration, proximal end may retract ~3cm
      • place hemostat in wound under extensor retinaculum and pull tendon into wound
      • primary end-to-end non-absorbable suture with Krackow, Bunnell or Kessler technique
      • ends oversewn with small monofilament if frayed to create smoother gliding surface
      • in cases of avulsion, suture anchors or bone tunnels may be used for reattachment
  • Tendon reconstruction
    • approach 
      • curvilinear incision over course of tibialis tendon, may need to be extensile depending needs of reconstruction
      • EHL can be divided through separate small incision and tunneled proximally
    • sliding tendon graft
      • harvest one half width of tibialis anterior tendon proximally and turn down to span gap
      • repair can be strengthened by securing tibialis anterior tendon to medial cuneiform or dorsal navicular distal to extensor retinaculum
    • free tendon graft
      • interposition of autograft (hamstring, plantaris) or allograft  
    • EHL tenodesis or EHL transfer
      • distal EHL stump tenodesed to EHB
      • proximal EHL stump used as tendon graft to repair tibialis anterior insertion
      • proximal tibialis anterior placed under tension prior to suturing to proximal EHL stump
  • Failure of reconstruction/repair
  • Weakness of dorsiflexion
  • Adhesion formation
  • Neuroma formation

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Questions (1)

(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? Review Topic


Surgical reconstruction with posterior tibial tendon transfer and gastrocnemius recession




MRI of the proximal tibiofibular joint for evaluation of ganglion cyst and EMG of the peroneal nerve




Primary surgical repair with gastrocnemius recession




Chest CT, skeletal survey, hematology profile, and referral to an orthopaedic oncologist for biopsy of the mass




Surgical reconstruction with plantaris tendon interposition augmentation



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This patient's history, examination, and images are consistent with chronic anterior tibialis rupture. This injury most often occurs in middle-aged patients following an eccentric loading of a degenerated tibialis anterior tendon against a plantar flexed foot. The classic triad for anterior tibialis ruptures include: (1) a pseudotumor at the anterior part of the ankle that corresponded with the ruptured tendon end, (2) loss of the normal contour of the tendon, and (3) weak dorsiflexion of the ankle accompanied by hyperextension of all of the toes can help to make the diagnosis.

Sammarco et al present a Level 4 review of 19 patients with traumatic or atraumatic ruptures that were surgically treated in an early (<6 weeks) or late (>7 weeks) manner. Patients who were managed surgically both early and late had improvements in dorsiflexion strength and gait pattern and had a significant improvement in the AOFAS hindfoot score as compared with the preoperative value. The authors advocate repair or reconstruction of the tendon to restore dorsiflexion and inversion of the ankle in order to approximate a normal gait pattern and theoretically to avoid the late development of foot deformity

Ouzounian et al present a Level 4 review of 12 patients with chronic anterior tibialis ruptures. Two types of ruptures were identified on the basis of clinical presentation: (1) atraumatic ruptures, which occurred in low-demand older patients who presented late with minimal dysfunction and (2) traumatic ruptures, which occurred in higher-demand younger patients who presented earlier with more disability. The authors concluded (1) that patients with traumatic ruptures, regardless of the time of presentation, demonstrated better function after operative intervention and (2) that patients with atraumatic ruptures who present early should be managed surgically, whereas those with delayed presentation could be managed with bracing.

Illustration A demonstrates a loss of normal contour of the anterior tibialis tendon of the right ankle associated with a rupture of the anterior tibialis tendon.


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