Updated: 6/7/2021

Anterior Tibialis Tendon Rupture

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    • Anterior Tibialis Tendon Ruptures are traumatic anterior ankle injuries that can present with foot drop and impaired gait. 
    • Diagnosis is made clinically with presence of a painless mass at the anteromedial aspect of the ankle associated with weakness of dorsiflexion.
    • Treatment is generally direct surgical repair of the tendon to achieve optimal functional outcomes. 
  • Etiology
    • 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
  • 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
  • Anatomy
    • Ankle dorsiflexion
      • primary ankle dorsiflexor (80%)
        • tibialis anterior
      • secondary ankle dorsiflexors
        • extensor hallucis longus
        • extensor digitorum longus
  • Presentation
    • 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
  • Imaging
    • 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
  • Differential
    • 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
  • Treatment
    • Nonoperative
      • ankle-foot orthosis
        • indications
          • low demand patient
      • casting
        • indications
          • partial ruptures
    • Operative
      • direct repair
        • indications
          • acute injury (<6 week) injuries in an active, high demand patient
          • 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
  • Technique
    • 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
        • if less then 5 degrees of ankle dorsiflexion with the knee extended perform gastrocnemius recession prior to tensioning repair
        • 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
  • Complications
    • Failure of reconstruction/repair
    • Weakness of dorsiflexion
    • Adhesion formation
    • Neuroma formation
  • Prognosis
    • Good with treatment
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Questions (5)

(OBQ18.109) A 70-year-old high functioning female is referred to your office from her primary care for an acute "foot drop" and anterior ankle pain. She states this started one week prior after hearing a loud "pop" with pain in the front of her left ankle. Figure A shows her active dorsiflexion against gravity bilaterally. She is otherwise neurovascularly intact. An MRI of her left ankle is obtained and shown in Figure B. What associated procedure is most likely indicated at the time of surgical treatment of her condition?

QID: 213005




Posterior tibial tendon (PTT) transfer



Primary repair with possible gastrocnemius recession



Flexor hallucis longis (FHL) tendon transfer



Superior peroneal retinaculum (SPR) repair and fibular groove deepening



L 3 A

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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?

QID: 3478

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



L 4 C

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