Tendon/Soft tissue

Acute Achilles tendonitis

Acute Achilles tendonitis (also known as Albert's Disease) typically has a abrupt onset with moderate to severe pain found at either the insertion of the tendon in the back of the heel (insertional tendonitis) or in a location 2-3 cm proximal to the tendons' insertion. Many individuals who suffer from acute Achilles tendonitis can describe an injury or single event that initiated the pain. Symptoms of acute Achilles tendonitis occur at the beginning of an activity and are typically described as sharp pain. As the activity continues and the Achilles tendon 'warms up', the Achilles tendon pain begins to feel a bit better. With excessive use, the Achilles tendon again becomes painful at the end of activity. For example, runners with Achilles tendonitis experience pain as they begin their run. The pain subsides during their run only to recur near the end of their normal running distance.

Chronic Achilles tendonitis (tendonosis)

Chronic Achilles tendonitis is also called Achilles tendonosis. Chronic Achilles tendonitis can also cause hypertrophy (enlargement) of the posterior heel and distal Achilles tendon. When viewed on x-ray, this finding is called an increased Phillip-Fowler angle.

In cases of chronic Achilles tendonitis it's important to differentiate between pain strictly due to the pull of the Achilles tendon and pain due to the enlargement of the posterior heel rubbing against the shoe called a pump bump or Haglund's deformity. The difference between Achilles tendonitis and a pump bump can be understood by evaluating the pain while barefoot (suggestive of Achilles tendonitis) compared to pain while wearing shoes with an enclosed heel (pump bump).

Another way to differentiate a pump bump from insertional Achilles tendonitis is by the location of the pain. This picture shows the back of a right heel, the outside of the ankle and a few of the lesser toes. The red dotted line outlines the Achilles tendon. This is the area within the tendon where we are most likely to find an acute tear of the Achilles tendon or tendonitis. The red circle shows the area where the Achilles tendon inserts into the calcaneus and is the location of chronic insertional Achilles tendonitis. This area will often become hypertrophied (enlarged) as the result of spurring that forms on the posterior heel at the insertion of the tendon. The red circle is also the area where we would find pain associated with retrocalcaneal bursitis. The blue area is on the outside, or lateral aspect of the heel. The blue area is where we would find the symptoms of Haglund's Deformity or a pump bump. You can see that a Haglund's Deformity is usually found on the posterior lateral heel (blue) while insertional Achilles tendonitis is central to the Achilles tendon.

Treatment of acute and chronic Achilles tendonitis

Knowing that the single greatest contributing factor to acute and chronic Achilles tendonitis is equinus (see the biomechanics section below for more information on equinus), we know that we need to weaken the calf muscle to allow the Achilles tendon an opportunity to heal. This can be done by elevating the heel with heel lifts or by wearing a subtle high heeled pair of shoes. Inflammation of the tendon can be calmed by ice, both before and after activities. Anti-inflammatory medications, casting or ultrasound treatment can also be used. Steroid injections are typically not used to treat Achilles tendonitis since injecting the tendon has a tendency to weaken the tendon resulting in a possible rupture.

In cases of chronic Achilles tendonitis, patients who do not respond to heel lifts and anti-inflammatory medications require a lengthening procedure of the Achilles tendon with or without a partial resection of the posterior heel. In cases with minimal hypertrophy of the heel, lengthening of the tendon will suffice. Lengthening of the Achilles tendon may be performed through three 0.5cm incisions but does require a period of casting. Full recovery may take 6-18 months. Endoscopic techniques are also available in a limited number of cases, correcting equinus with a procedure called an endoscopic gastrocnemius recession.

Cases of insertional Achilles tendonitis that fail to respond to conservative care will require partial resection of the posterior heel and lengthening of the Achilles tendon.  The following images show a Z-plasty lengthening of the Achilles tendon and resection of the posterior heel with a mallet and osteotome.  A bone anchor with attached suture is placed in the posterior heel to affix the Achilles tendon.  This procedure is performed in a hospital or outpatient surgery center and is typically performed under a general anesthetic.  Casting for 6-8 weeks following the procedure is required.

A newer method of treating chronic Achilles tendonitis (tendonosis) is called Topaz Radiofrequency Ablation. Topaz is used to stimulate an acute inflammatory reaction within the tendon. The inflammatory reaction attracts cellular and chemical mediators of inflammation and is assumed to jump start the natural healing process. Topaz surgery uses a grid of small holes that are placed in the tendon using a radiofrequency wand. The depth of the holes are varied. The indications for Topaz surgery includes those individuals who are interested in an ambulatory solution for Achilles tendonosis or who may have co-morbidities that preclude them from having an Achilles tendon lengthening.

How do we develop plantar fasciitis? Plantar fasciitis is an overuse syndrome that is the result of excessive and repetitive loading of the plantar fascia. When we stand, load is applied to the arch of the foot causing the height of the arch to drop. This drop in the height of the arch places tension on the plantar fascia. If the tension (load) applied to the plantar fascia is greater than what the fascia can tolerate, the fascia will become inflamed.

Treatment of Plantar Fasciitis

Treatment of plantar fasciitis is based on four broad categories of care; biomechanical methods, anti-inflammatories methods, surgery and other methods. Let's take a closer look at each of these four categories and see how they can often work together.

The leg, ankle and foot functions as a lever. This lever is called the CT band. Levers consist of three parts; an effort arm, a fulcrum and a resistance arm. In the CT band, the leg is the effort arm or source of force coming primarily from the calf muscles. The ankle is the fulcrum or hinge of the lever. And the foot is the resistance arm of the lever. The resistance arm of the lever is where the force creates action. The lever action of the leg, ankle and foot is to deliver force from the strongest muscle in our body (the calf) to the ball-of-the-foot. The action created is what we know as walking. Plantar fasciitis is the result of an imbalance in the lever mechanics of the leg ankle and foot. This imbalance results in force from the effort arm (calf) that overwhelms the resistance arm (the foot).

The first step in treating plantar fasciitis is to try and restore the balance between the effort arm and the resistance arm of the CT band. To do so, there are three simple steps;

• Avoid going barefoot or wearing a shoe with a low heel.

• Wear a heel lift or shoe with an elevated heel.

• Begin a program of calf stretches. If you are unable to complete 6 stretches/day, begin the use of a night stretching splint.

Taping the arch, stretching splints, heel cushions and a host of other 'devices' have been used successfully to treat plantar fasciitis. All of these devices focus on changing the biomechanical properties of the CT band. Remember, the key to treating plantar fasciitis is addressing the entire CT Band and not just the plantar fascia. Stretches and heel lifts are quite often all that is needed to change the biomechanical properties of the CT band and for complete resolution of symptoms of plantar fasciitis. Arch supports can be used on a daily basis to maintain good support of the arch and help to decrease recurrence of plantar fasciitis.

The second category of care is the use of anti-inflammatories. Anti-inflammatories include steroid injections, oral anti-inflammatory medications such as aspirin, prescription strength medications called NSAID's, ultrasound, massage, topical medications and a host of other methods to reduce inflammation. When using anti-inflammatories, bear in mind that we are treating a problem that we know is mechanical in nature. Plantar fasciitis is caused by mechanical overuse or overloading of the CT band. Anti-inflammatories help with the dull ache common in cases of plantar fasciitis. Anti-inflammatories typically do not help with the sharp tearing pain found with that first step out of bed or when initially standing during the day. That's why it's important to combine mechanical methods of care (above) with the use of an anti-inflammatory. The two methods work in conjunction with each other to address the two different types of pain that are common in cases of plantar fasciitis.

The third category of care includes surgery and what we describe as other methods (below). Surgery becomes indicated when a course of conservative care has failed. Endoscopic surgical methods have become the standard of care for the treatment of plantar fasciitis. The surgical procedure used today to treat plantar fasciitis is called an endoscopic plantar fasciotomy. The older methods of surgical correction included resection of the heel spur or partial resection of the heel bone. With an endoscopic plantar fasciotomy, we release, or make a cut through the fascia, leaving any spur in place. It's important to recognize that we are treating a soft tissue problem (plantar fasciitis) and not a bone problem (heel spur).

The following video shows the steps used to perform an endoscopic plantar fasciotomy. This procedure is performed at a surgery center or hospital and is completed with sedation and local anesthesia. The procedure takes approximately 15 minutes to complete. Patients are able to walk the very same day on the foot and return to most activities within 3-4 weeks.

Heel spur surgery, whether performed endoscopically or with a traditional method, is not without problems. While 90% of EPF cases are completed without complication, 10% do have problems that can vary in severity. One complication specific to plantar fasciotomies, regardless of how they are performed, is later column syndrome (LCS). LCS is sometimes a very difficult complication to understand, diagnose and treat. The complications of LCS occur not in the first week or two after surgery but rather 2-4 month after a plantar fasciotomy. As a patient reaches status 4 weeks post surgery, they start to feel more able to return to their normal activities. As they progressively increase their activities they begin to add an increase of load to the foot. Although the surgical site no longer is sore from the surgery, the biomechanical impact, or change to the joint structure of the foot is not complete for 4-6 months following the surgery. Early symptoms of LCS are a dull ache of the lateral (outside) of the foot and the top of the arch. This ache is a stiffness that if left untreated will result in small stress fractures if the lateral and dorsal aspects of the foot. LCS is a manageable complication of this procedure and should be thoroughly discussed before surgery so that patients are aware of the symptoms of LCS and can make their doctor aware should they experience problems.

Other non-conservative methods of care include shock wave therapy, Topaz surgery growth factor injections and neuroablation. These methods of treating plantar fasciitis focus on the difference between the terms plantar fasciitis and plantar fasciosis. Plantar fasciitis is an acute inflammatory condition of the plantar fascia. But after several months, the inflammatory nature of plantar fasciitis changes. Studies that have used tissue biopsy of long term plantar fasciitis show that over time, there become less of an inflammatory response by the body within the plantar fascia. So the acute inflammatory condition of plantar fasciitis changes to a non-inflamed case of plantar fasciosis. This finding is the basis for several other techniques used to treat plantar fasciitis.

Extracorporeal shock wave therapy is used as a tool to break the re-injury cycle associated with plantar fasciitis. Shock wave therapy employs an acoustic wave that results in an explosion of energy at the point of focus. Shock waves differ in amplitude and are 'tuned' for a specific purpose based upon the desired amplitude and medium that is crossed to reach a target tissue. The effect of the shock wave in cases of plantar fasciitis is not fully understood. It is believed that the effect of the shock wave stimulates an intense focused inflammatory reaction that promotes healing at the insertion of the plantar fascia. Shock wave therapy can be painful to perform and therefore requires that the procedure be performed in an outpatient setting with deep sedation. The procedure takes about 15 minutes to complete and does not require a local anesthetic (only sedation). Patients are able to walk on the foot the same day. Complication are minimal. Most doctors will require continued stretching and limited activity for 4 weeks following shock wave therapy. The long term success or failure of shock wave therapy is yet to be seen, but recent studies have had short term success rates of 65-95%. For additional information on shock wave therapy refer to The International Society for Musculoskeletal Shock Wave Therapy.

Topaz surgery is used to treat plantar fasciosis. To complete Topaz surgery, a patient is taken to surgery, sedated and anesthetized. A Topaz wand is used to place a series of small holes or defects within the fascia. The Topaz wan creates this defect by using radio frequency ablation. Patients are able to bear weight and walk immediately following surgery.

Growth factor injections are also used to treat cases of plantar fasciitis/plantar fasciosis that have failed conservative care. Growth factor is isolated from the platelets in a patient's blood. This technique can be completed in the doctor's office. A 50cc sample of blood is drawn from the patient and spun down in a centrifuge. The platelets are then re-injected into the most symptomatic area of heel pain. Patients are able to walk immediately following this procedure.

Neuroablation is a technique used to treat heel pain that doesn't focus on treating inflammation, but instead focuses on deadening nerve pain in the plantar heel. Neuroablation doesn't actually treat the mechanical component of heel spur syndrome, but instead destroys nerve that supplies sensation to the bottom of the heel. Neuroablation can be performed with a cold probe (cryoablation, thermoablation) with a hot probe (radiofrequency surgery) or with injectable chemicals (alcohol, phenol). Neuroablation is an appropriate procedure for select patients who have not responded to conservative care.

What's the best method of care for you? That decision should be made by you and your doctor as a team. Consider conservative measures of care as a means to help your body heal itself. Surgery on the other hand is the physical change. The first consideration in determining a treatment plan is the duration of your symptoms of plantar fasciitis. How long has your plantar fasciitis been present? If your symptoms have been present for more than a year or if you've tried 4 months of conservative care with no change in your symptoms, you are probably a good candidate for surgery or other care.

Plantar Fascial Tears

Plantar fascial tears are a relatively uncommon injury. There are no precipitating factors (age, weight, smoker, etc) that would tend to make one patient more susceptible to a plantar fascial tears. Plantar fascial tears occur in men within the 20-50 year age range who are engaged in aggressive activities such as sports or physical labor. The onset of a plantar fascial tear is abrupt and typically secondary to a fall or sports injury. Sharp pain with weight bearing, along with bruising specific to the plantar heel and arch are found. Treatment include, rest, ice, compression and partial weight bearing to tolerance. Surgical repair of a torn plantar fascia is unnecessary. The fascia will heal over the course of 4-6 weeks to be fully functional. Plantar fascial tears should be evaluated with an x-ray to rule out a stress fracture of the heel.

The characteristic finding of posterior tibial tendon dysfunction include;

Loss of medial arch height.
Edema (swelling) of the medial ankle.
Loss of the ability to resist force to abduct or push the foot out from the midline of the body.
Pain on the medial ankle with weight bearing.
Inability to raise up on the toes without pain.
Too many toes sign.
Lateral subtalar joint (sinus tarsi) pain.

A common test to evaluate PTTD is the 'too many toes sign'. The 'too many toes sign' is a test used to measure abduction (deviation away from the midline of the body) of the forefoot. With damage to the posterior tibial tendon, the forefoot will abduct or move out in relationship to the rest of the foot. In cases of PTTD, when the foot is viewed from behind, the toes appear as 'too many' on the outside of the foot due to abduction of the forefoot.

In advanced cases of PTTD, in addition to the pain of the tendon itself, pain will also be noted in the subtalar joint and sinus tarsi. The sinus tarsi refers to a small tunnel or divot on the outside of the subtalar joint that can actually be felt. This tunnel is the entry to the subtalar joint. The subtalar joint is the joint that controls the side to side motion of the foot, motion that would occur with uneven surfaces or sloped hills. As PTTD progresses and the ability of the posterior tibial tendon to support the arch becomes diminished, the arch will collapse overloading the subtalar joint. As a result, there is increased pressure applied to the joint surfaces of the lateral aspect of the subtalar joint, resulting in pain.

There have been many proposed explanations for PTTD over the years since this condition was first described by Kulkowski in 1936. The most contemporary explanation refers to an area of hypovascularity (limited blood flow) in the tendon just below the ankle. Tendon derives most of its' nutritional support from synovial fluid produced by the outer lining of the tendon. Extremely small blood vessels also permeate the tendon sheath to reach tendon. This makes all tendon notoriously slow to heal. In the case of the posterior tibial tendon, this problem is exacerbated by a distinct area of poor blood flow (hypovascularity). This area is located in the posterior tibial tendon just below or distal to the inside ankle bone (medial malleolus).

Tendon is most susceptible to fatigue and failure at an area where the tendon changes direction. As the posterior tibial tendon descends the leg and comes to the inside of the ankle, the tendon follows a well defined groove in the back of the tibia (bone of the inside of the ankle). The tendon then takes a dramatic turn towards the arch of the foot. If the tendon is put into a situation where significant load is applied to the foot, the tendon responds by pulling up as the load of the body (in addition to gravity) pushes down. At the location where the tendon changes course, the tibia acts as a wedge and may apply enough force to actually damage or rupture the tendon.

Equinus is also a contributing factor in cases of posterior tibial tendon dysfunction. Equinus is the term used to describe the ability or lack of ability to dorsiflex the foot at the ankle (move the toes towards the shin). Equinus is usually due to tightness in the calf muscle, also known as the gastroc-soleal complex (a combination of the gastrocnemius and soleus muscles). Equinus may also be due to a bony block in the front of the ankle. The presence of equinus forces the posterior tibial tendon to accept additional load during gait.

Additional contributing factors that contribute to the onset of posterior tibial tendon dysfunction may include obesity, hypertension, diabetes, peripheral neuropathy, smoking or arthritis.

PTTD is a progressive condition, meaning to say, that if left untreated, PTTD will become worse over time. The progression of PTTD begins with focal tendonitis. If left untreated, tendonitis will progress to partial and then complete tears of the posterior tibial tendon. Several classifications have been developed to describe posterior tibial tendon dysfunction. The classification as described by Johnson and Strom is most commonly used today.

Stage I Posterior tibial tendonitis without tendon tear

Tendon status - Attenuated (lengthened) with tendonitis but no rupture.
Clinical findings - Palpable pain in the medial arch. Foot is supple, flexible. Too many toes sign may be positive or negative.
X-ray/MRI - Mild to moderate tenosynovitis on MRI, no X-ray changes found.

Stage II Posterior tibial tendonitis with partial tendon tear
Tendon status - Attenuated with possible partial or complete rupture.
Clinical findings - Pain in arch. Unable to raise on toes. Too many toes sign positive.
X-ray/MRI - MRI notes tear in tendon. X-ray noting abduction of forefoot, collapse of talo-navicular joint.

Stage III Posterior tibial tendonitis with partial to complete tendon tear.
Tendon status - Severe degeneration of the tendon with likely rupture.
Clinical findings - Rigid flatfoot with inability to raise up on toes. Too many toes sign positive.
X-ray/MRI - MRI shows tear in tendon. X-ray noting abduction of forefoot, collapse of talo-navicular joint

An additional consideration in diagnosing PTTD pain is the presence of an accessory bone called an os tibiale externum. The os tibiale externum, or what is frequently called and accessory navicular, is a small bone that resides within the body of the PT tendon. The os tibiale externum functions to facilitate motion around the navicular. The os tibiale externum functions much in the same way that the knee cap (patella) works to guide the quadraceps tendon around the knee as it bends. The os tibiale externum can undergo degenerative wear called chondromalacia. The os tibiale externum also can fracture. Therefore, the os tibiale externum must also be considered when diagnosing PT tendon pain.

Treatment of posterior tibial tendon dysfunction

Treatment for PTTD is dependant upon the clinical stage and the health status of the patient. It is important to recognize that PTTD is a mechanical problem that requires a mechanical solution. This means that treating PTTD with medication alone is fraught with failure. Prompt introduction of some form of mechanical support is imperative.

PTTD is a condition that increases in frequency with age and the prevalence of poor health indicators such as diabetes and obesity. As a result, many patients with PTTD are poor surgical candidates for correction of PTTD. Prosthetics such as an ankle foot orthotic (AFO), Arizona Brace or other bracing may be very helpful to control the symptoms of PTTD.

Surgical procedures which focus on primary repair of the posterior tibial tendon have been very unsuccessful. This is due to the fact that tendon heals slowly following injury and cannot be relied upon as a sole solution for PTTD cases. Surgical success is usually achieved by stabilization of the rearfoot (subtalar joint) which significantly reduces the work performed by the posterior tibial tendon.

Stage I PTTD may respond to treatment that includes variations of rest. Variations in rest include an ankle brace, walking cast with an elevated heel or a hard, below the knee non-weight bearing cast. Pain and inflammation may be controlled with anti-inflammatory medications. It is important to be sure that Stage I patients realize that the use of shoes with additional arch support and heel elevation is imperative. Arch support and heel elevation should be continued indefinitely. Arch support, whether built into the shoe or added as an orthotic, helps support the posterior tibial tendon and decrease the amount of mechanical load applied to the posterior tibial tendon. Elevation of the heel, reduces equinus, one of the most significant contributing factors to PTTD. If Stage I patients return to low heels without arch support, PTTD will recur.

Stage II patients typically require surgical correction to stabilize the subtalar joint prior to further damage to the posterior tibial tendon. Subtalar arthroeresis is a procedure used to stabilize the subtalar joint. Subtalar arthroeresis may only be used in flexible feet. Arthroeresis is a term that means the motion of the joint is blocked without fusion. Subtalar arthroeresis can only be used in cases of Stage II posterior tibial tendonitis where mild to moderate deformation of the arch has occurred and MRI findings show the tendon to be only partially ruptured. Subtalar arthroeresis is typically performed in conjunction with an Achilles tendon lengthening procedure or endoscopic gastrocnemius recession to correct equinus. These procedures require casting for a period of weeks following the procedure.

The following video shows placement of a subtalar joint implant for control of pronation in a flexible foot with PTTD. The sinus tarsi is dissected free of capsule and ligament and the implant is placed in the sinus tarsi. This procedure is completed in a hospital or out-patient surgery center using a general anesthetic. Patients can walk immediately following subtalar arthroeresis if an Achilles tendon lengthening is not performed. If an Achilles tendon lengthening is performed, a 6 week period of non-weight bearing casting is required. 

 

When an os tibiale externum is present, a modified Kidner procedure is typically performed. The following images show excision of the os tibiale externum and transposition of the posterior tibial tendon. This procedure is performed in a hospital or out-patient surgery center using a general anesthetic. Weight bering following the surgery is dependent upon the integrity of the tendon following excision of the os tibiale externum. Most modified Kidner procedures do require a period of non-weight bearing.

Stage III patients require stabilization of the rearfoot with procedures that fuse the primary joints of the arch and foot. Rearfoot stabilization is used to correct rigid deformities of the foot. These procedures are salvage procedures and require prolonged casting and disability following surgery. A common procedure for Stage III is called triple arthrodesis which is a technique used to fuse the subtalar joint, the talo-navicular joint and the calcaneal cuboid joint (picture at left).

Anterior Shin Splints -

Anterior shin splints are the most common cause of anterior shin pain. Anterior shin splints are also called medial tibial stress syndrome (MTSS), exertional shin pain, medial periostalgia, medial tibial periostitis and traction periostitis. Anterior shin splints are caused by overuse of the tibialis anterior muscle and tendon. The function of the tibialis anterior is to decelerate the foot at heel strike during the gait cycle.

The symptoms of anterior shin splints occur at the origin of the tibialis anterior muscle and tendon on the leading edge of the tibia. Anterior shin splint pain is the result of the tibialis anterior muscle pulling the periosteum (surface lining of the bone) from the bone.

Diagnosis of anterior shin splints is usually based upon the location and character of the symptoms. Diagnostic testing may include x-rays, bone scans or MRI studies to rule out tibial stress fractures.

Treatment of anterior shin splints

The key to treating anterior shin splints is to change the functional length of the tibialis anterior muscle and tendon, thereby weakening the pull of the muscle on the tibia. Pain and inflammation may also be treated concurrently, but if the mechanical component of anterior shin splints is not treated, recurrence of symptoms are likely with any increase in activities.

Biomechanical changes and changes in your training that may effect the tibialis anterior muscle are simple and include the following;

1. Decrease the length of stride - Taking shorter steps decreases the functional length of the tibialis anterior and subsequently reduces the pull of the muscle on the tibia.

2. Avoid running downhill - Running downhill will increase stride length. Also, the excursion of the tibialis anterior increases with downhill running.

3. Modified arch support to decrease the functional length of the tibialis anterior - This can be accomplished by extending the arch of an arch support or orthotic distally to reach under the first metatarsal and big toe joint. This modification is often called a Morton's extension. Changes should be made slowly and incrementally. As you build up and extend the arch, you are decreasing the functional length of the tibialis anterior.

4. Calf stretches - The tibialis anterior is the antagonist muscle to the calf (gastroc-soleal complex). A tight calf will increase the work load applied to the tibialis anterior. Calf stretching is a simple and effective way to regain balance between the tibialis anterior muscle (anterior leg) and calf (posterior leg).

5. Cross train - Vary your activities to decrease load applied to the tibialis anterior. Alternate running with biking or swimming.

6. Range of motion exercise - Warming the tibialis anterior with range of motion exercise helps to improve strength and flexibility. Use the ankle as the pivot point and write the alphabet with the foot, tracing an A, B, C, etc.

In addition to treating the mechanical aspects of anterior shin splints, inflammation of the tibia and tibialis anterior muscle can be address with these simple steps.

• Ice before and after activity helps to reduce the swelling of the muscle.

• Oral or topical anti-inflammatories will also reduce muscle swelling.

• Compression of the lower leg with an adjustable wrap can control swelling and ease pain.

• Physical therapy to include range of motion exercises, deep tissue massage and ultrasound.

• As a last resort, rest is helpful but never a final solution. Rest can be as simple as a decrease in activity, a walking cast or even a cast with crutches.

Posterior Shin Splints -

Posterior shin splints describes the less common form of shin splints of the lower leg. Posterior shin splints describes pain in the tibialis posterior tendon. The role of the tibialis posterior is to support the arch as the body moves over the foot during the gait cycle. Posterior shin splint pain is specific to the medial ankle, just behind the medial malleolus.

Interestingly, in non-athletic circles, posterior shin splints is known as posterior tibial tendon dysfunction or PTTD. PTTD describes a progressive weakening of the tibialis posterior tendon. Severe cases of PTTD may result in a rupture of the tibialis posterior tendon. Knowing that the two conditions are synonymous, we can consider posterior shin splints stage 1 PTTD.

Treatment of posterior tibial shin splints

One of the keys to treating any form of tendonitis is to recognize that tendonitis is an overuse syndrome. Therefore, effective treatment lies either in modifying the way the tendon functions (biomechanical changes) or changing the activity that contributes to overuse. We know that the function of the tibialis poster tendon is to support the arch. Subsequently we can support the function of the tibialis posterior tendon by supporting the arch with a firm arch support. The tibialis posterior can also be helped by elevating the heel with a firm heel lift and by performing calf stretches to weaken the calf muscle.

• Ice before and after activity helps to reduce swelling of the muscle.

• Oral or topical anti-inflammatories will also reduce muscle swelling.

• Support of the tibialis posterior can be accomplished with elastic bracing.

• Physical therapy to include range of motion exercises, deep tissue massage and ultrasound if possible.

• As a last resort, rest is helpful but never a final solution. Rest can be as simple as a decrease in activity, a walking cast or even a cast with crutches.

The peroneal retinaculum is a small fibrous band that acts to restrain the peroneal tendons in a deep groove on the back of the fibula. Peroneal tendon subluxation occurs when the peroneal retinaculum is damaged or injured. The peroneal retinaculum is often injured in a lateral ankle sprain. Other causes of subluxation include anatomical variations of the fibular groove that may make the groove shallow and less able to inhibit the peroneal tendons from subluxation during ankle motion.

Another interesting injury in the region of the fibular groove is a compression injury to the peroneus brevis tendon resulting in a longitudinal peroneal tendon tear. Several authors have described a mechanism by which the peroneus longus tendon actually cuts into the brevis tendon, effectively splitting the brevis tendon. There appears to be a statistical relationship between peroneal tendon ruptures and recurrent peroneal tendon subluxation.

Treatment of recurrent subluxating peroneal tendons

A period of conservative care should be observed following an acute injury to the peroneal tendons. A walking cast, ice and a compression wrap may help to enable healing of the peroneal retinaculum. A lateral sole wedge can be used to limit load to the peroneal tendons by inhibiting supination of the foot (rolling out).  Lateral sole wedges can be placed in the shoe, on specialized orthotics or applied to the outer sole of the shoe by a shoe repair shop or O&P facility.  In cases of chronic peroneal tendon subluxation, surgical repair will be required to prevent subluxation and long term damage to the peroneal tendons. Treatment of peroneal tendon subluxation involves deepening the peroneal groove of the fibula and retinacular repair. A number of different methods have been described in the surgical literature to add depth to the peroneal groove, thereby limiting peroneal tendon subluxation. Those methods include drilling, tamping and creating rotating osseous (bone) shelves. Repair of the peroneal retinaculum may be accomplished by direct suture repair or by a supplemental graft from the Achilles tendon.

When surgically treating peroneal tendon subluxation, it's important to remember to treat any biomechanical factors that may contribute to lateral instability and ankle sprains. It's important to recognize that these biomechanical factors may be the contributing causes of what caused the peroneal tendon subluxation in the first place. If these biomechanical co-morbidities are not addressed, surgical repair of peroneal subluxation may be doomed to failure. Two common biomechanical faults found in conjunction with peroneal tendon subluxation include lateral ankle ligament instability and uncompensated rearfoot varus.

Lateral ankle ligament instability and ligament tears contribute to ankle instability and recurrent ankle sprains. If ligament laxity is not addresses and lateral ankle sprains continue, surgery to correct peroneal tendon subluxation is likely to fail. It is not unusual to perform a Brostrom lateral ankle stabilization in conjunction with a repair of peroneal tendon subluxation.

Uncompensated rearfoot varus is a structural deformity of the heel. Rearfoot varus is an often overlooked contributing factor in recurrent lateral ankle sprains. Uncompensated rearfoot varus is another biomechanical issue that is often corrected in conjunction with correction of peroneal tendon subluxation. Correction of uncompensated rearfoot varus is accomplished by a Dwyer osteotomy of the heel.