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Tibialis posterior tendon dislocation: A case report
The Foot 21 (2011) 154–156
Contents lists available at ScienceDirect
The Foot journal homepage: www.elsevier.com/locate/foot
Case report
Tibialis posterior tendon dislocation: A case report Karlene Mitchell, Marlon M. Mencia ∗ , Richard Hoford The Orthopaedic Department, Port of Spain General Hospital, Port of Spain, Trinidad and Tobago
a r t i c l e
i n f o
Article history: Received 25 August 2010 Received in revised form 24 October 2010 Accepted 25 October 2010 Keywords: Tibialis posterior tendon Dislocation Flexor retinaculum
a b s t r a c t Dislocation of the posterior tibial tendon is a rare event, which may occur after trauma particularly sporting accidents. These injuries are frequently misdiagnosed at the initial presentation leading to a delay in treatment. We describe a case of delayed presentation of an atraumatic dislocation of the posterior tibial tendon which was diagnosed accurately and managed with primary repair of the flexor retinaculum. © 2010 Elsevier Ltd. All rights reserved.
1. Introduction Sports injuries in athletes or motor vehicular accidents [1,2] often account for tendon dislocations around the ankle joint [3]. Dislocation of the tibialis posterior tendon however is a very rarely reported occurrence with fewer than 40 cases reported and most reports being cases of neglected chronic dislocation [1,3]. The tibialis posterior tendon courses under the flexor retinaculum of the ankle, immediately posterior to the medial malleolus [1,4,6]. Dislocation of the tibialis posterior tendon usually involves a failure of the retromalleolar groove or flexor retinaculum to retain the tendon in its anatomical position. The causes have sometimes been found to be related to trauma with an inversion and dorsiflexion of the ankle and retinaculum. In this report, we address a case of non traumatic dislocation of the tibialis posterior tendon in a 56 year old female. 2. Case report A 56 year old female, with nil known medical conditions presented to a specialist with complaints of pain over the medial malleolus of her right ankle for three weeks. She denied any previous episode of ankle injury or instability. She had no history of neuromuscular disorders. Three weeks prior to presentation, the patient had been squatting on the floor, when she shifted her weight forward and to the right, to reach an object. This was done without elevating her heels from the floor. She then immediately felt a snap, and began experiencing sudden onset, severe pain on
the medial aspect of her right ankle. The pain was associated with swelling over the medial malleolus and ecchymoses posterior to the medial malleolus. She was unable to ambulate due to pain. She presented to her physician the next day, who after history, examination and a negative X-ray scan, diagnosed her with a medial collateral ligament sprain of the right ankle. She was then treated conservatively with RICE therapy and analgesics. The patient continued to experience pain and swelling of the right ankle over the next three weeks despite compliance with RICE therapy. These symptoms continued to prevent ambulation, so the patients presented to an orthopaedic surgeon. During this examination, the tibialis posterior tendon was seen dislocating anteriorly over the medial malleolus (Fig. 1). X-rays were normal; nil associated fractures were seen. An MRI was ordered which confirmed the clinical diagnosis. The patient agreed to undergo surgical treatment. Upon surgical examination, an anteriorly dislocated, normal tibialis posterior tendon was encountered. It was lying within a flexor “retinacular-periosteal” sleeve on the medial malleolus (Fig. 2). The flexor retinaculum was normal, except for the avulsion and the retromalleolar groove was of normal depth. The tibialis posterior tendon was reduced to anatomical position within the retromalleolar groove and the flexor retinaculum was repaired (Fig. 3). Postoperatively, the patient was placed in a below knee cast for six weeks. The patients returned to full physical activity at 12 weeks postoperatively. At the most recent follow up at 18 months, the patients had no symptoms related to the ankle with normal range of motion and returned to pre-injury levels without recurrence of dislocation. 3. Discussion
∗ Corresponding author at: 10 E Starboard Drive, Admiral Court, Westmoorings by the Sea, Trinidad and Tobago. Tel.: +868 632 4824; fax: +868 632 4824. E-mail address: [email protected] (M.M. Mencia). 0958-2592/$ – see front matter © 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.foot.2010.10.005
To date, there is limited information on the incidence and prevalence of the dislocation of the tibialis posterior tendon injuries [1].
K. Mitchell et al. / The Foot 21 (2011) 154–156
Fig. 1. Anterior dislocation of tibialis posterior tendon (arrow and parallel lines) and the position of the medial malleolus (dotted line) after dorsiflexion and inversion of the ankle.
Fig. 2. Tibialis posterior tendon placed anteriorly in retinacular periosteal sleeve (cut ends) with artery forceps delineating the retromalleolar groove, which is of normal depth.
Fig. 3. Figure showing simple repair of the flexor retinaculum after reduction of the tendon.
155
Athletes and high trauma accidents e.g. MVA [1,2] account for the majority of cases of tibialis posterior tendon injury. A recent review of the literature, conducted by Lohrer and Nauck, noted 61 cases of dislocation and showed that 58.5% of the initial injuries were induced by sport [2]. There have been, however, some isolated case reports of non traumatic dislocation of the tibialis posteriortendon [1,3]. In this case of our patient with no history of ankle injury, upon surgical exploration, we encountered non traumatic tibialis posterior tendon dislocation. The usual mechanism of injury is dorsiflexion/plantarflexion and inversion of the ankle [1,6]. This patient was in squatting position when she shifted her weight forward. This was done without lifting her heels. When she leaned forward, she most likely caused forceful contraction of the already taut tibialis posterior, while the ankle was forced into dorsiflexion. In the case of our patient, there was also a delay in presentation with this condition, as has been observed in other case reports. This patient was diagnosed three weeks after initial presentation. According to the study by Ouzanian and Myerson the average length of time to diagnosis was nine months [5]. Similar to other cases in the literature, in the case of our patient there was also the likelihood of misdiagnoses. This patient also was misdiagnosed on initial presentation as an ankle sprain. In the literature review by Lohrer and Nauck, 53.1% of cases were initially mis diagnosed [2], and the condition considered refractory to conservative management [1,2,6,7]. A recent review of the literature reports that patients often undergo prior treatments for ankle sprains, tendinitis, or subtalar dislocation [4]. Conservative treatment of the dislocation of the tibialis posterior tendon is often unsuccessful [1,2,6,7]. Treatment with RICE therapy results in persistent pain and swelling, as was also the case with our patient. As with other observed cases, a proper history and examination are integral to the diagnosis of tibialis posterior tendon dislocation as the examination of the affected limb may be difficult in the acute setting. X-rays are usually non contributory to the diagnosis, unless to rule out an associated fracture of the medial malleolus [7] and the GOLD standard for radiological investigation is magnetic resonance imaging (MRI) [2,7]. As with other cases our patients had normal Xrays [7]. In this case, MRI was used to confirm the clinical diagnosis of tibialis posterior tendon dislocation. Recent studies suggest that MRI detected specific findings in 75% of cases [2]. This compared to the 66.7%, and 14.7%, detected by ultrasonography and X-ray, respectively [2]. It should be noted however that MRI may miss a dynamic tibialis posterior tendon dislocation that may be relocated at the time of the exam [7]. Tenography may also be used to delineate the course of a tendon, however it does not allow direct visualization of the tendon and it is also an invasive procedure [7]. CT may be used in the detection of the dislocation; however its usefulness is limited by its soft tissue contrast resolution and lack of multiplanar capabilities [7]. Treatment of dislocation of the tibialis posterior tendon involves surgical intervention and in recent reports, 83.1% were treated surgically [2]. However, there is no strong agreement in the literature on what is the best method of treatment. In the case of our patient, surgical exploration revealed that the flexor retinaculum was elevated off the tibia by a retinacula-periosteal sleeve. The tendon was displaced anteriorly into the pocket formed by the periosteal attachment. Her retromalleolar groove was normal so suturing of the sleeve only was performed. Surgical treatment, usually involves repair of the flexor retinaculum with or without a groove deepening procedure [1,2,4,8]. Alternative techniques include simple flexor retinaculum repair, reconstruction with a periosteal sleeve or suture anchor repair [1,2,8]. A recent study showed a medial Achilles tendon flap was utilized to support the repositioned tendon [4].
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K. Mitchell et al. / The Foot 21 (2011) 154–156
Surgical findings usually include a tear or avulsion of the flexor retinaculum, a lax retinaculum or elevation of the retinaculum in a “retinacular-periosteal” sleeve [1,9]. In some patients the retinaculum is torn, which requires repair, or completely avulsed and requires reattachment to the tibia or reconstruction. Another surgical finding may be a shallow retromalleolar groove. It is then necessary to perform a groove-deepening procedure to prevent recurrence. This can be done by placing a cortical bone slot graft posteriorly, to hold the relocated tendon in place [1,10]. In the case of our patient reduction of the tendon and simple repair of the flexor retinaculum was performed, which was an effective treatment for this patient. No groove deepening procedure was necessary. The patient had a full recovery subsequent to surgical treatment. 4. Summary and conclusion The tibialis posterior tendon may have been dislocated spontaneously by further dorsiflexion of the ankle with an already taut tibialis posterior tendon. The mechanism of injury in this patient is consistent with that of other case reports. MRI is an appropriate modality for the investigation of this injury and refractory STI injuries. Simple flexor retinaculum repair after reduction of
a dislocated tendon, is a reliable and effective procedure to treat dislocation in the setting of a normal retromalleolar groove. References [1] Goucher NR, Coughlin MJ, Kristensen RM. Dislocation of the posterior tibial tendon: a literature review and presentation of two cases. Iowa Orthop J 2006;26:122–6. [2] Lohrer H, Nauck T. Posterior tibial tendon dislocation. A systematic review of the literature and presentation of a case. Br J Sports Med 2010;44(6):398–406. Epub 2008 Jan 16. [3] Chu I, Chung J. Spontaneous dislocation of the posterior tibial tendon. J Orthop 2007;4(4):e15. [4] Rolf C, Gutner P, Ekenman I, Turan I. Dislocation of the tibialis posterior tendon: diagnosis and treatment. J Foot Ankle Surg 1997;36(1):63–5. [5] Ouzanian TJ, Myerson MS. Dislocation of the posterior tibial tendon. Foot Ankle 1992;13:215–9. [6] Aguiar ROC, Cabral MVG, Moura BB, Marchiori E. Dislocation of the flexor digitorum longus and posterior tibial tendons without fracture dislocation of the ankle. Foot Ankle Int 2007;28(1):1187–9. [7] Bencardino J, Rosenberg ZS, Beltran J, Broker M, Cheung Y, Rosemberg LA, Schweitzer M, Hamilton W. MR Imaging of dislocation of posterior tibial tendon. AJR 1997;169:1109–12. [8] Nava BE. Traumatic dislocation of the tibialis posterior tendon at the ankle: report of a case. J Bone Joint Surg 1968;50B:150–1. [9] Wong YS. Recurrent dislocation of the posterior tibial tendon secondary to detachment of a retinacular-periosteal sleeve: a case report. Foot Ankle Int 2004;25:602–4. [10] Perlman MD, Wertheimer SJ, Leveille DW. Traumatic dislocation of the tibialis posterior tendon: a review of the literature and two case reports. J Foot Surg 1990;29:253–9.
Contents lists available at ScienceDirect
The Foot journal homepage: www.elsevier.com/locate/foot
Case report
Tibialis posterior tendon dislocation: A case report Karlene Mitchell, Marlon M. Mencia ∗ , Richard Hoford The Orthopaedic Department, Port of Spain General Hospital, Port of Spain, Trinidad and Tobago
a r t i c l e
i n f o
Article history: Received 25 August 2010 Received in revised form 24 October 2010 Accepted 25 October 2010 Keywords: Tibialis posterior tendon Dislocation Flexor retinaculum
a b s t r a c t Dislocation of the posterior tibial tendon is a rare event, which may occur after trauma particularly sporting accidents. These injuries are frequently misdiagnosed at the initial presentation leading to a delay in treatment. We describe a case of delayed presentation of an atraumatic dislocation of the posterior tibial tendon which was diagnosed accurately and managed with primary repair of the flexor retinaculum. © 2010 Elsevier Ltd. All rights reserved.
1. Introduction Sports injuries in athletes or motor vehicular accidents [1,2] often account for tendon dislocations around the ankle joint [3]. Dislocation of the tibialis posterior tendon however is a very rarely reported occurrence with fewer than 40 cases reported and most reports being cases of neglected chronic dislocation [1,3]. The tibialis posterior tendon courses under the flexor retinaculum of the ankle, immediately posterior to the medial malleolus [1,4,6]. Dislocation of the tibialis posterior tendon usually involves a failure of the retromalleolar groove or flexor retinaculum to retain the tendon in its anatomical position. The causes have sometimes been found to be related to trauma with an inversion and dorsiflexion of the ankle and retinaculum. In this report, we address a case of non traumatic dislocation of the tibialis posterior tendon in a 56 year old female. 2. Case report A 56 year old female, with nil known medical conditions presented to a specialist with complaints of pain over the medial malleolus of her right ankle for three weeks. She denied any previous episode of ankle injury or instability. She had no history of neuromuscular disorders. Three weeks prior to presentation, the patient had been squatting on the floor, when she shifted her weight forward and to the right, to reach an object. This was done without elevating her heels from the floor. She then immediately felt a snap, and began experiencing sudden onset, severe pain on
the medial aspect of her right ankle. The pain was associated with swelling over the medial malleolus and ecchymoses posterior to the medial malleolus. She was unable to ambulate due to pain. She presented to her physician the next day, who after history, examination and a negative X-ray scan, diagnosed her with a medial collateral ligament sprain of the right ankle. She was then treated conservatively with RICE therapy and analgesics. The patient continued to experience pain and swelling of the right ankle over the next three weeks despite compliance with RICE therapy. These symptoms continued to prevent ambulation, so the patients presented to an orthopaedic surgeon. During this examination, the tibialis posterior tendon was seen dislocating anteriorly over the medial malleolus (Fig. 1). X-rays were normal; nil associated fractures were seen. An MRI was ordered which confirmed the clinical diagnosis. The patient agreed to undergo surgical treatment. Upon surgical examination, an anteriorly dislocated, normal tibialis posterior tendon was encountered. It was lying within a flexor “retinacular-periosteal” sleeve on the medial malleolus (Fig. 2). The flexor retinaculum was normal, except for the avulsion and the retromalleolar groove was of normal depth. The tibialis posterior tendon was reduced to anatomical position within the retromalleolar groove and the flexor retinaculum was repaired (Fig. 3). Postoperatively, the patient was placed in a below knee cast for six weeks. The patients returned to full physical activity at 12 weeks postoperatively. At the most recent follow up at 18 months, the patients had no symptoms related to the ankle with normal range of motion and returned to pre-injury levels without recurrence of dislocation. 3. Discussion
∗ Corresponding author at: 10 E Starboard Drive, Admiral Court, Westmoorings by the Sea, Trinidad and Tobago. Tel.: +868 632 4824; fax: +868 632 4824. E-mail address: [email protected] (M.M. Mencia). 0958-2592/$ – see front matter © 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.foot.2010.10.005
To date, there is limited information on the incidence and prevalence of the dislocation of the tibialis posterior tendon injuries [1].
K. Mitchell et al. / The Foot 21 (2011) 154–156
Fig. 1. Anterior dislocation of tibialis posterior tendon (arrow and parallel lines) and the position of the medial malleolus (dotted line) after dorsiflexion and inversion of the ankle.
Fig. 2. Tibialis posterior tendon placed anteriorly in retinacular periosteal sleeve (cut ends) with artery forceps delineating the retromalleolar groove, which is of normal depth.
Fig. 3. Figure showing simple repair of the flexor retinaculum after reduction of the tendon.
155
Athletes and high trauma accidents e.g. MVA [1,2] account for the majority of cases of tibialis posterior tendon injury. A recent review of the literature, conducted by Lohrer and Nauck, noted 61 cases of dislocation and showed that 58.5% of the initial injuries were induced by sport [2]. There have been, however, some isolated case reports of non traumatic dislocation of the tibialis posteriortendon [1,3]. In this case of our patient with no history of ankle injury, upon surgical exploration, we encountered non traumatic tibialis posterior tendon dislocation. The usual mechanism of injury is dorsiflexion/plantarflexion and inversion of the ankle [1,6]. This patient was in squatting position when she shifted her weight forward. This was done without lifting her heels. When she leaned forward, she most likely caused forceful contraction of the already taut tibialis posterior, while the ankle was forced into dorsiflexion. In the case of our patient, there was also a delay in presentation with this condition, as has been observed in other case reports. This patient was diagnosed three weeks after initial presentation. According to the study by Ouzanian and Myerson the average length of time to diagnosis was nine months [5]. Similar to other cases in the literature, in the case of our patient there was also the likelihood of misdiagnoses. This patient also was misdiagnosed on initial presentation as an ankle sprain. In the literature review by Lohrer and Nauck, 53.1% of cases were initially mis diagnosed [2], and the condition considered refractory to conservative management [1,2,6,7]. A recent review of the literature reports that patients often undergo prior treatments for ankle sprains, tendinitis, or subtalar dislocation [4]. Conservative treatment of the dislocation of the tibialis posterior tendon is often unsuccessful [1,2,6,7]. Treatment with RICE therapy results in persistent pain and swelling, as was also the case with our patient. As with other observed cases, a proper history and examination are integral to the diagnosis of tibialis posterior tendon dislocation as the examination of the affected limb may be difficult in the acute setting. X-rays are usually non contributory to the diagnosis, unless to rule out an associated fracture of the medial malleolus [7] and the GOLD standard for radiological investigation is magnetic resonance imaging (MRI) [2,7]. As with other cases our patients had normal Xrays [7]. In this case, MRI was used to confirm the clinical diagnosis of tibialis posterior tendon dislocation. Recent studies suggest that MRI detected specific findings in 75% of cases [2]. This compared to the 66.7%, and 14.7%, detected by ultrasonography and X-ray, respectively [2]. It should be noted however that MRI may miss a dynamic tibialis posterior tendon dislocation that may be relocated at the time of the exam [7]. Tenography may also be used to delineate the course of a tendon, however it does not allow direct visualization of the tendon and it is also an invasive procedure [7]. CT may be used in the detection of the dislocation; however its usefulness is limited by its soft tissue contrast resolution and lack of multiplanar capabilities [7]. Treatment of dislocation of the tibialis posterior tendon involves surgical intervention and in recent reports, 83.1% were treated surgically [2]. However, there is no strong agreement in the literature on what is the best method of treatment. In the case of our patient, surgical exploration revealed that the flexor retinaculum was elevated off the tibia by a retinacula-periosteal sleeve. The tendon was displaced anteriorly into the pocket formed by the periosteal attachment. Her retromalleolar groove was normal so suturing of the sleeve only was performed. Surgical treatment, usually involves repair of the flexor retinaculum with or without a groove deepening procedure [1,2,4,8]. Alternative techniques include simple flexor retinaculum repair, reconstruction with a periosteal sleeve or suture anchor repair [1,2,8]. A recent study showed a medial Achilles tendon flap was utilized to support the repositioned tendon [4].
156
K. Mitchell et al. / The Foot 21 (2011) 154–156
Surgical findings usually include a tear or avulsion of the flexor retinaculum, a lax retinaculum or elevation of the retinaculum in a “retinacular-periosteal” sleeve [1,9]. In some patients the retinaculum is torn, which requires repair, or completely avulsed and requires reattachment to the tibia or reconstruction. Another surgical finding may be a shallow retromalleolar groove. It is then necessary to perform a groove-deepening procedure to prevent recurrence. This can be done by placing a cortical bone slot graft posteriorly, to hold the relocated tendon in place [1,10]. In the case of our patient reduction of the tendon and simple repair of the flexor retinaculum was performed, which was an effective treatment for this patient. No groove deepening procedure was necessary. The patient had a full recovery subsequent to surgical treatment. 4. Summary and conclusion The tibialis posterior tendon may have been dislocated spontaneously by further dorsiflexion of the ankle with an already taut tibialis posterior tendon. The mechanism of injury in this patient is consistent with that of other case reports. MRI is an appropriate modality for the investigation of this injury and refractory STI injuries. Simple flexor retinaculum repair after reduction of
a dislocated tendon, is a reliable and effective procedure to treat dislocation in the setting of a normal retromalleolar groove. References [1] Goucher NR, Coughlin MJ, Kristensen RM. Dislocation of the posterior tibial tendon: a literature review and presentation of two cases. Iowa Orthop J 2006;26:122–6. [2] Lohrer H, Nauck T. Posterior tibial tendon dislocation. A systematic review of the literature and presentation of a case. Br J Sports Med 2010;44(6):398–406. Epub 2008 Jan 16. [3] Chu I, Chung J. Spontaneous dislocation of the posterior tibial tendon. J Orthop 2007;4(4):e15. [4] Rolf C, Gutner P, Ekenman I, Turan I. Dislocation of the tibialis posterior tendon: diagnosis and treatment. J Foot Ankle Surg 1997;36(1):63–5. [5] Ouzanian TJ, Myerson MS. Dislocation of the posterior tibial tendon. Foot Ankle 1992;13:215–9. [6] Aguiar ROC, Cabral MVG, Moura BB, Marchiori E. Dislocation of the flexor digitorum longus and posterior tibial tendons without fracture dislocation of the ankle. Foot Ankle Int 2007;28(1):1187–9. [7] Bencardino J, Rosenberg ZS, Beltran J, Broker M, Cheung Y, Rosemberg LA, Schweitzer M, Hamilton W. MR Imaging of dislocation of posterior tibial tendon. AJR 1997;169:1109–12. [8] Nava BE. Traumatic dislocation of the tibialis posterior tendon at the ankle: report of a case. J Bone Joint Surg 1968;50B:150–1. [9] Wong YS. Recurrent dislocation of the posterior tibial tendon secondary to detachment of a retinacular-periosteal sleeve: a case report. Foot Ankle Int 2004;25:602–4. [10] Perlman MD, Wertheimer SJ, Leveille DW. Traumatic dislocation of the tibialis posterior tendon: a review of the literature and two case reports. J Foot Surg 1990;29:253–9.