Ankle Tendon Disorders

Dr. Samrood Akram (PT)

Assistant Professor
 Contents: Tendon Disorders
Ankle/Foot Pain Area Tendon Disorders of:
1.Ankle -Posterior Achilles Tendon
2.Ankle-Lateral Peroneus Tendon
3.Ankle-Medial Posterior Tibialis
4.Ankle-Anterior Anterior Tibialis
Terminologies related to Tendon Pathology
Tendinitis Inflammation of tendon
Tenosynovitis When a tendon is inflamed, it can cause swelling, pain, and discomfort. Another
problem called tenosynovitis is linked to tendinitis. This is the inflammation of the lining
of the tendon sheath around a tendon.
Tendinopathy Tendinopathy, also called tendinosis, refers to the breakdown of collagen in a tendon.
/Tendinosis
Rupture A tendon rupture is a partial or complete tear of tendon.
 TENDON HEALING

After a tendon injury there are three phases of healing:

• Phase 1: Acute inflammatory phase. This lasts for up to 1 week after injury. During this phase, inflammatory
cells remove the injured tissue.

• Phase 2: The proliferative phase. During this phase, type I collagen is produced by fibroblasts to increase
tendon strength. After about 4 weeks more than 50% of the tensile strength of the tissue may be restored.
The proliferative phase lasts up to about 4 weeks in most individuals.

• Phase 3: The remodelling phase. Here, healing occurs for up to 1.5 years after the original injury. During this
phase, the tensile strength, elasticity and structure of the tendon improve. However, there is currently no
evidence that the tendon will fully recover its properties, which indicates that there are permanent changes
in the tendon.
Posterior Ankle
1.Achilles Tendon
Description:
The Achilles tendon is the largest and strongest tendon in the human body. It
attaches the posterior calf muscles (the gastrocnemius and soleus) to the
calcaneus.
The Achilles tendon is subject to high forces with each step and therefore subject to
wear-and-tear damage.

Achilles tendon common Example

Condition
Acute condition Achilles Tendon Rupture (ATR)
Chronic condition Achilles tendonitis

The main causes of the rupture can be: overstretching of the heel during recreational
sports; a forceful plantar flexion of the heel; or a fall from a height
1a.Achilles tendonitis:
Tendon inflammation with strain of tendon fibres
Patient Presentation
Achilles tendonitis is a chronic condition characterized by pain and
swelling in the Achilles tendon.
Symptoms of tendonitis are produced by swelling and inflammation of the tissue that surrounds the
Achilles tendon - the paratendon. As such, the condition may be more appropriately described as an
Achilles tenosynovitis (inflammation of the lining surrounding the Achilles tendon). Inflammation
of the tendon can be caused either by direct pressure from shoewear or more commonly, as part of
the healing response to over-use and micro-trauma.

There are two types of Achilles tendonitis:

1.Non-insertional tendonitis and
2.Insertional tendonitis.
1.Non-insertional tendonitis 2.Insertional tendonitis
• The pathology is typically located 2 to 6 cm proximal The pathology is located at the insertion of the Achilles
to the insertion of the Achilles tendon to the tendon to the calcaneus (Figure right). Insertional
calcaneus. Achilles tendonitis is a product of wear and tear at the
• Often associated with a history of increased activity attachment ("insertion") of the tendon onto the
level (e.g., starting a new training regimen or calcaneus. This degeneration incites an inflammatory
attempting to resume a normal activity level after an response and produces pain at the back of the heel.
injury and enforced immobilization). Eventually, the inflamed Achilles tendon may become
calcified, forming bone-like fragments in the tendon.

Figure : Location of Symptoms: Non-insertional Achilles (Left) and Insertional Achilles (right)
Insertional Achilles Tendonitis:
The pathology associated with insertional Achilles tendonitis includes the "terrible
triad" (Figure):
1. Degeneration of the Achilles tendon near the insertion site,
2. An inflamed retrocalcaneal bursitis, and
3. A Haglund's deformity (a prominent bony lump on the heel)

A Haglund’s deformity is a bony prominence associated with the upper

part of the calcaneus.
This prominent bone tends to form gradually over many years, and can
eventually cause irritation by disrupting nearby structures, including the
retrocalcaneal bursa and the Achilles tendon.
The bony prominence also creates discomfort by rubbing up against the
back of footwear, the so-called "heel counter" of the shoe.
Figure: Location of pain in patients with
the “Terrible Triad”: insertional Achilles
tendonitis, retrocalcaneal bursitis, and a
prominent bony lump on the heel (known
as a Haglund’s deformity).
Objective Evidence
X-rays will usually be negative in cases of non-insertional Achilles tendonitis, unless there is
calcification of the Achilles tendon. (Calcification is relatively rare except in older patients.)
Cases of insertional Achilles tendonitis may reveal a calcaneal spur on x-ray.
An MRI can give a detailed view of the soft tissue . However, this test is not routinely indicated
in the initial assessment of Achilles tendonitis.
Ultrasound is usually less expensive than an MRI.
Figure : An x-ray showing both a Haglund’s deformity (red arrow) as well as calcification of the Achilles tendon insertion
(white arrow)
When a Haglund’s deformity is present, the retrocalcaneal bursa can become inflamed. This inflammation can result in
exquisite tenderness along the posterior aspect of the heel.
Figure: MRI of Achilles Tendonitis (non-insertional). Swelling associated with non-insertional Achilles
tendonitis as seen on MRI. The tendon is shown in continuity but is abnormally thickened.
Treatment Options and Outcomes
Non-operative Treatment of Achilles Tendonitis
Most patients with Achilles tendonitis can have their symptoms treated
effectively without surgery. Insertional Achilles tendonitis can be more
recalcitrant to treatment than non-insertional Achilles tendonitis. An initial
period of relative rest to allow the symptoms to settle is often beneficial.
This is followed by a gradual return to normal activities incorporating the
following non-operative treatment elements:
• Activity modification,
• Shoewear modification (a heel lift will unload the tendon),
• Weight Loss (if applicable)
• Anti-inflammatory medication (if not contra-indicated) and;
• A rehabilitation program including specific stretching and
strengthening exercises.
 1b. Achilles Tendon Rupture
Overstretch to Achilles tendon, it can tear (rupture) it.
Three categories of indirect injury that may result in rupture are:

1.Pushing off with a weight-bearing forefoot while also extending knee, as at beginning of a sprint, running
& jumping.
2.Sudden/unexpected dorsiflexion of ankle, occur when a person slips off a chair/ladder, when stumbling
into a hole, or suddenly falling forward.
3.Violent dorsiflexion of a plantar-flexed foot when one falls from a height.
A complete rupture of the Achilles Tendon will show the following characteristics:

•At the moment of rupture, the sharp pain will be felt as if the patient was stabbed in the
heel with a dagger.
•Often the rupture will coincide with a loud crack or pop sound.
•When palpating the tendon, a gap may be felt.
•The back of the heel will be swollen.
•Decreased active plantar flexion of the ankle.
•Increased passive dorsiflexion
•Inability to heel raise
•Impaired gait
•A positive outcome of the calf muscle squeeze test or Thompson Test.
•Some patients will have a history of tendinopathy in the heel or a prior cortisone injection.
Classification
Achilles tendon tears may be grouped into 4 types, according to the severity of the tear
and degree of retraction:

Classification Description
Type I: Partial ruptures ≤50% - typically treated with conservative management
Type II: Complete rupture with tendinous gap ≤3 cm - typically treated with end-end
anastomosis
Type III: Complete rupture with tendinous gap 3 to 6 cm - often requires tendon/synthetic
graft
Type IV: Complete rupture with a defect of >6 cm - often requires tendon/synthetic graft
and gastrocnemius recession (Lengthen muscle& tendon to allow heel to shift
downward in neutral position) .
 gap
gap

gap
 Examination

• Observation
For the inspection of an Achilles Tendon rupture, the therapist may observe the patient:

Standing -to look for fallen arches (flat feet) and other postural complications.
Lying - usually on the front. This can be used to observe the tendon more closely for
thickening, redness, swelling, and nodules.
Walking & -to look for overpronation.
Running
Swelling -a swollen ankle can point to a rupture of the Achilles Tendon.
• Palpation
The Achilles Tendon is easily palpable. When palpating along the entire length of the tendon, a gap
may be present.
Active Movements:
In this part of the examination, the therapist asks the patient to fulfil some active movements which can aid
in the diagnosis of a tendon rupture.

There are several active movements:

1.Observing the gait pattern can be an important indication for a possible rupture. A patient with an
Achilles Tendon rupture can possibly not make a plantar flexion of his ankle. So if the plantar flexion
movement in the walking phase is hindered and painful, it can be an indication of an Achilles rupture. A
patient with an Achilles rupture will show over-pronation of the injured ankle. The patient will also show a
lack of push-off at the end of the stance phase as a result of the dysfunction of
the Gastrocnemius and Soleus muscles.

2.Instructing the patient to stand on his/her toes for making a plantar flexion (Heel raise). This will be
impossible if the patient has an Achilles Tendon rupture.

3.Ask the patient to actively plantarflex the ankle.

4.Every active movement containing a plantar flexion of the heel will be almost, if totally not
impossible.
Special Tests:
Special tests for the observation of an Achilles Tendon rupture:
1.Thompson Test
2.Matles Test

Outcome Measure:
Achilles Tendon Total Rupture (ATR-score)
1. Thompson Test - this test is especially useful for diagnosing complete Achilles tendon ruptures and
less useful for the diagnosis of partial Achilles Tendon rupture.
The Thompson test examines the integrity of the Achilles tendon by squeezing the calf. It is performed as
a clinical test to identify the presence of a complete Achilles rupture.
The patient lies face down with feet hanging off the edge of the bed. If the test is positive, there is no
movement of the foot on squeezing the corresponding calf, signifying likely rupture of the Achilles
tendon.
Real-time Achilles ultrasound Thompson test –
This test is as the Thompson test, but under ultrasound visualization. It can be used by
surgeons with minimal training in ultrasonography. It provides improved diagnostic
characteristics compared with static ultrasound.
 1.Matles Test - The Matles Test is a visual diagnostic test for suspected rupture
of the Achilles tendon.

Description: The patient lies in prone, active or passively flexing the knee to
90° with both feet and ankles in a neutral position according to the patient.
The test is negative when the foot displays slight plantarflexion; the test is
positive if the footfalls into the neutral position or the movement result in
dorsiflexion. This is often referred to as 'the angle of dangle'.

This is an observation test, no further palpation or movement is required.

Maffulli reports a sensitivity of 0.88 and considered the most reliable test .
Outcome Measure:
Achilles Tendon rupture-score ATRS
The Achilles Tendon rupture-score is an important questionnaire that refers to the limitations/difficulties
a patient with a tendon rupture will face.

Intended Population: Patients with a total Achilles tendon rupture.

Questionnaire
Items asked:
•Are you limited because of decreased strength in the calf/ Achilles tendon/foot?
•Are you limited because of fatigue in the calf/Achilles tendon/foot?
•Are you limited due to stiffness in the calf/Achilles tendon/foot?
•Are you limited because of pain in the calf/Achilles tendon/foot?
•Are you limited during activities of daily living?
•Are you limited when walking on uneven surfaces?
•Are you limited when walking quickly upstairs or uphill?
•Are you limited during activities that include running?
•Are you limited during activities that include jumping?
•Are you limited in performing hard physical labor?

Subjects are asked to grade from 0 to 10 according to their level of limitations and/or difficulties.
 Case Study:
• A male patient of 45 years old experienced left Achilles tendon rupture while playing
basket ball. He had tendon repair surgery and now his pain is 5/10 with plantar fasciitis.
He is referred to physical therapy department for Post-op rehabilitation.
• Ankle & Subtalar AROM are WNL & no pain in RROM with 2finger resistance. Heel raises
feel loss of strength.
• In gait push off phase absent, bears weight on lateral aspect of foot, antalgic gait.
Objective Evidence
Article:
Accelerated rehabilitation following Achilles tendon repair after acute rupture - Development of an
evidence-based treatment protocol (systematic review)

The acute rupture of the Achilles tendon is a protracted injury. Surgery is only the beginning of a long rehabilitation period.
Therefore, the rehabilitation protocol is an integral aspect to restore the pre-injury activity level. Despite several trials
available comparing different treatment regimes, there is still no consensus regarding the optimal protocol. Consequently,
the aim of our study was to systematically search the evidence available and define a precise rehabilitation program after
operative repair of acute Achilles tendon rupture based on the trials with the highest level of evidence. We performed a
systematic literature search in Medline, Embase and Cochrane library. We identified 12 randomized controlled trials
comparing different treatment regimes after operative repair of the Achilles tendon.
• Five trials compared full to non weight bearing, all applying immobilization in equinus. Immediate full weight bearing led
to significant higher patient satisfaction, earlier ambulation and return to pre-injury activity.
• Four trials compared early ankle mobilization to immobilization. All trials found mobilization to be superior as it shortens
time to return to work and sports significantly.
• Three trials compared the combination of full weight bearing and early ankle mobilization to immobilization. This
combination was most beneficial. Patients showed significantly higher satisfaction, less use of rehabilitation resources,
earlier return to pre-injury activities and further demonstrated significantly increased calf muscle strength, reduced
atrophy and tendon elongation.
• No study found an increased re-rupture rate for the more progressive treatment.
• In conclusion, the rehabilitation protocol after Achilles tendon repair should allow immediate full weight bearing. After
the second postoperative week controlled ankle mobilization by free plantar flexion and limited dorsiflexion should be
applied.
 Physiotherapy interventions should be all avoided for the
first two weeks while the patient is asked to avoid any kind of
dorsiflexion and immobilise their foot in a boot or plaster of Paris in
30 ° plantar flexion. Weight-bearing is advised to be avoided in the
first two weeks.
After two weeks, the patients are encouraged to take their boot off for
five minutes every hour or two to do specific exercises.

Goals: The emphasis is on improving plantar flexion mobility and

gradually improving the strength into plantarflexion at this stage.
Dorsi-flexion stretches, and neutral position are still not allowed.
Week 4 to week 8: gradually lower the wedge of the boot inserted until the foot reaches neutral at
week 10 depending on the surgical technique and the presence of co-morbidities.

Ambulate with support device (eg, walker, crutches, rollabout) in hand at all times for safety.
After 4 weeks of weightbearing in boot, remove 1 wedge from heel lift each week.
•Gait re-education; looking through all the Lower limb joints and correcting any faulty pattern such as knee
hyperextension and reduced Gluteal activation.

•Plantar flexion Strengthening: by isometric and sustained heel raises starting on both legs then slowly
progressing on a single leg. Holding on one leg and lowering down on the other. Once the patient is able to
perform heel raises on one leg throughout the ROM in a controlled manner you can start working on
the endurance by doing four sets of six up to 24 repetitions or up to twenty repetitions in am minute. Progress
into eccentric loading by doing heel raises off the edge of a box. This can help to build up the tension and the
strength In the tendon.

• Running and fast walking can be introduced when the patient can comfortably do a single heel raise.
Tibialis Posterior work with Tibialis Anterior and the Peroneal muscles to maintain the foot core strength when
progressing into a single-leg stance during the gait. If they are not working properly, the Achilles tendon and the
calf muscle will be overloaded.

• Simpson H. Achilles Tendon Rupture Management. Physioplus Course 2020

• Brumann M, Baumbach SF, Mutschler W, Polzer H. Accelerated rehabilitation following Achilles tendon repair after acute rupture-Development of
an evidence-based treatment protocol. Injury. 2014; 45: 1782–1790 (level of evidence: 1a)
 Post op- after 2 weeks
Position Muscle Region/Joint Exercise Set* Reps. Hold Notes
work
Supine ly. FES L L.E - QUADS 10 min
Supine ly. Stretch L L.E Hamstring stretch 1*3 20 sec

Supine ly. Stretch L L.E Calf muscles 1*3 20 sec

Supine ly. AROM L L.E- hip Hip abd. 2*10
Supine ly. AROM L L.E- hip SLR 2*10
Supine ly. A-AROM L L.E- ankle PF,DF, INV & EVR 2*10 Each

Prone Ly Stretch L L.E Quads 1*3

Prone ly. AROM L L.E- knee flexion 2*10
Side ly. AROM L L.E clamshell 2*10
Standing AROM L.E Uni. WB 1*10 10 sec
Sitting on cycle Cardio. L.E PF & DF 5min
 Progression week: 8-10
Position Muscle work Region/Joint Exercise Set* Reps. Hold Notes
Standing Stretch PF’s Standing on 1*4 30 sec
wedge
Standing AROM L.E PF & DF on 1*10 ----- Initial ranges &
Balance board side to side
Standing AROM L.E Heel Raises 1*10
Standing AROM L.E Unilateral stance 1*5 20 sec With shoulder
flexion
Standing AROM L.E Unilateral 2*10 Vs. 2kg
Squat
Standing AROM L.E Step up & down 1*10 Focus on L foot
weight bearing
Standing AROM L.E Forward lunges 2*15
Standing Agility training L.E Step up & down 1*10 Front & sideways
(fast steeping)
Lying AR-ROM Ankle All ROM 1*20 Using theraband
Sitting AROM Foot toes Flex/Ext. 1*20
2.Lateral Ankle
Peroneal Tendon
 Peroneal Tendon
Clinically Relevant Anatomy:
The peroneus longus and brevis muscle bellies originate on the fibula
and the tendons course together along the bone, with the brevis medial
to the longus (Figure ). They cross the ankle behind the lateral
malleolus, in a groove covered by the superior peroneal retinaculum.
The peroneus longus tendon then continues in a plantar direction along
the sole of the foot to the base of the first metatarsal bone.
The peroneus brevis tendon inserts into a tuberosity at the base of the
fifth metatarsal bone, on its lateral side.
Action: The peroneus muscles everts foot and plantarflex.
Innervated by the superficial peroneal nerve.
The peroneal tendons receive their blood supply from the peroneal
artery and the tibialis anterior artery.
 Peroneal tendonitis
Peroneal tendinitis is a condition that can be acute or become
chronic (peroneal tendinopathy) whereby there is an irritation
to one or both peroneal tendons with subsequent degeneration
and inflammation.

The peroneus longus and peroneus brevis muscles reside in the lateral
compartment of the lower leg.
There are avascular zones that may contribute to tendonitis:
• in both the tendons at the turn around the lateral malleolus and
• in the peroneus longus tendon where the tendon curves around the
cuboid.
 Peroneal tendonitis
Epidemiology /Etiology
Peroneal tendonitis is common in running athletes, young dancers, ice skaters
and sports requiring frequent change of direction or jumping such as basketball,
skiing and even horse riding.
The lesion may be due to partial tears, complete ruptures, subluxation,
tenosynovitis, a fractured or damage to the peroneal retinacula.

Contributional factors for the development of peroneal tendonitis are tight

calf muscles, inappropriate training, poor foot biomechanics such as over-
pronation of the foot or excess eversion of the foot, inappropriate footwear and
muscle weakness.

Risk factors for peroneal tendonitis include:

• Overuse and a high arched foot.
 Peroneal tendonitis
Patient Presentation:
• Patients with peroneal tendonitis present with pain and, occasionally,
swelling near the poster-lateral ankle.
• Resisted eversion will produce pain.
•Peroneus brevis tendonitis is usually symptomatic from the lateral
malleolus distally to its insertion at the base of the fifth metatarsal.

•Peroneus longus tendonitis is characterized by tenderness over the lateral

calcaneus, often extending distally to the plantar aspect of the cuboid.

• Concomitant sural nerve irritation (by inflamed or damaged tendon) can

lead to either decreased sensation or a burning over the lateral or
outside aspect of the foot.
 Peroneal tendonitis

Examination

A thorough history should be taken prior to the examination.

Observation:
•Attention should be paid to the overall alignment of the leg and
posture of the hindfoot.
Patients with hindfoot varus may subject the peroneals to
increased forces that predispose to injury, or the varus might result
from peroneal weakness.
•Look for the presence of swelling over the poster-lateral aspect of
the ankle.

Palpation:
Feel for warmth and muscle guarding and tenderness along the
course of the tendons.
 Peroneal tendonitis
Tests:
•A provocative test for peroneal pathology has been described.
•The patient’s relaxed foot is examined hanging in a relaxed position with the
knee flexed 90°. Slight pressure is applied to the peroneal tendons posterior
to the fibula. The patient then is asked to dorsiflex and evert the foot
forcibly. Pain may be elicited, or subluxation of the tendons may be felt.
{Testing of lateral ankle ligaments: lateral ankle ligamentous stability should
be checked with the anterior drawer and ankle tilt test.(done in ankle sprain)}

ROM Testing: Passive inversion, Passive ankle plantarflexion, active-resisted eversion and active-resisted
ankle dorsiflexion provokes pain posterior of the lateral malleolus.
Muscle strength:
Muscle testing evaluation shows decreased peroneal muscle strength.

The peroneal muscles can be isolated from each other by the peroneus longus and brevis tests.
If the peroneus brevis tendon alone is affected, the pain is located posterior and distal to the lateral malleolus.
Peroneus longus tendonitis presents with pain along the lateral calcaneal wall extending to the cuboid.
Peroneal tendonitis
Outcome Measures
•LEFS (Lower Extremity Functional scale): the objective of the Lower Extremity Functional Scale (LEFS) is
to measure "patients' initial function, ongoing progress, and outcome" for a wide range of lower-
extremity conditions. It can be administered to determine the level of difficulty of various functional
tasks with a lower extremity disability and is scored from 0-80, with 80 indicating no limitations

•FAAM (The Foot and Ankle Ability Measure): it is a self-report outcome instrument consisting of 29
questions to evaluate the physical function of patients with foot or ankle disabilities. The questionnaire
is divided into two subscales: activities of daily living and sports.
Peroneal tendonitis

Diagnostic Procedures:
• A thorough subjective and objective examination from a physiotherapist can be sufficient to diagnose
peroneal tendonitis.
• Plain film radiographs do not reveal soft tissue abnormalities; however, they are useful for excluding
arthritis, bone abnormalities such as pes cavus, or fractures.
• Diagnosis may be confirmed with an MRI scan or ultrasound investigation showing
edema. Ultrasonography may be used for detecting all types of peroneal lesions.
• In chronic cases, or in cases which may be difficult to differentiate from lateral ankle ligamentous injury,
computed tomography or magnetic resonance imaging may be helpful.
 Peroneal tendonitis
Physical Therapy Management:
Treatment for peroneal tendonitis includes a program of stretching, strengthening, mobilisation and
manipulation, proprioceptive and balancing exercises, icing, ankle bracing or taping during contact
sports If symptoms are severe, a cast or ROM boot immobilization is prescribed for 10 days. After
symptoms resolve, the patient begins a progressive rehabilitation program along with a gradual increase
to full activity.
The use deep tissue friction massage, ultrasound electric stimulation can also be included in the physical
therapy
Also extracorporeal shock wave therapy (ESWT), acupuncture are used to treat tendinopathy. But there is
only limited evidence from studies for these treatments.
There is evidence for using manual therapy, specifically the
lateral calcaneal glide: To mobilize the left calcaneus, the
patient is in left side lying with the calcaneus hanging over the
table. The foot is held in a neutral position with the talus
stabilized while the therapist performs a medial to lateral glide
(in the transversal plane).
3. Medial Ankle
Tibialis Posterior Tendon
Medial Ankle
 Tibialis Posterior Tendon
Clinical Relevant Anatomy:
The tibialis posterior muscle belly originates on the posterior
aspects of the tibia and fibula and the tendon crosses behind
the medial malleolus (blood supply to the tendon is poorest in
this area and is the most common site for rupture) to insert
primarily on navicular.
Action: It actively inverts the foot and also plantar flexes the
ankle, but its primary role is to support the medial arch of
the foot.
Contraction of the tibialis posterior locks the joints of the
midfoot during gait progression to create a rigid lever in the
foot. Therefore, rupture or even stretching of this tendon can
lead to flat feet.
Tibialis Posterior tendonitis
 Tibialis Posterior tendonitis
Etiology:
• The most commonly the cause for PTT degeneration is credited to
a repetitive loading causing microtrauma and progressive failure.
• Posterior tibial tendon dysfunction (PTTD) insufficiency is the
most common cause of adult-acquired flatfoot deformity. Failure
of the tendon affects surrounding ligamentous structures and will
eventually lead to bony involvement and deformity.

• Rheumatoid conditions predispose to joint capsular laxity and

tendon attenuation and may cause posterior tendon dysfunction.

• Abnormal anatomy of the talus, degenerative changes associated with osteoarthritis, and pre-existing pes
planus
 Tibialis Posterior tendonitis
Patient Presentation:
• Tibialis Posterior tendonitis presents as medial ankle and arch pain, worsened with prolonged standing and
often in conjunction with a flat foot and prominent navicular bone on the medial aspect of the foot.
• Pain with resisted inversion and tenderness along the course of the tendon to its insertion on the navicular
are hallmarks of this condition. (If there is tenderness at the insertion but not along the course of the tendon,
a symptomatic accessory navicular may be present. This can be confirmed with a radiograph).
 Tibialis Posterior tendonitis

Stages of PTTD
As per Johnson and Strom:

1.Stage I: Posterior tibial tendon intact and inflamed, no deformity, mild swelling

2.Stage II: Posterior tibial tendon dysfunctional, acquired pes planus but passively correctable,
commonly unable to perform a heel raise

3.Stage III: Degenerative changes in the sub-talar joint and the deformity is fixed

4.Stage IV ( Myerson): Valgus tilt of talus leading to lateral tibiotalar degeneration

 Examination
The diagnosis of posterior tibial tendon dysfunction made clinically based on history and objective testing.

Subjective
The patient should be asked a series of questions to rule out other disorders. It is essential to diagnose
posterior tibial tendon dysfunction (PTTD) in an early phase to prevent permanent deformities of the
foot/ankle, a physical examination is therefore essential.

Objective
• The physiotherapist can palpate the posterior tibial tendon from above the medial malleolus to its
insertion at Navicular bone, to control the integrity and assess possible pain and swelling that are
common for the first stages of PTTD.
• In the later stages, the deformity can progress and pes planus may be visible. It is important to examine
the whole lower body and not just the foot, as valgus in the knees can accentuate the appearance of
pes planus.
• A healthy person has a 5° valgus in his hindfoot, in patients with PTTD the valgus is increased and the
abduction in the forefoot is also more pronounced The physiotherapist can determine the severity of
the pes planus by checking how many fingers can be passed underneath the midfoot.
Special tests for PTTD include:
Double leg heel rise: to go with both feet from a flatfoot stance to standing on the toes.
• Patients in stage I dysfunction can do this, but it's painful.
• Patients with stage II, III or IV dysfunction are unable to do a heel raise.
When a patient stands on tiptoes the heel of the affected foot will not bend inwards; the normal foot will
stay into inversion while the affected hindfoot will stay in valgus.

Single-leg heel raise:

The integrity of the Tibialis Posterior can be assessed with a single leg heel rise; having the patient stand up
on the ball of the foot, with the contralateral foot off the ground entirely (that is, in a stork position). When
viewed from behind, the intact tendon will be seen to invert the ankle and heel. A lack of this motion
suggests tendon dysfunction or failure.
patients can't do a single heel raise with the affected foot in severe condition. This can be related to pain,
weakness, or a combination of the two.

Test the power of the tibialis posterior:

Plantar flexion and inversion of the foot against resistance.
Outcome Measures:

•Foot Function Index (FFI)

•The Foot Functional Index (FFI) is comprised of 23 selfreport items divided into three subcategories
of pain (nine items), disability (nine items), and activity limitation (five items).

•5-Minute Walk Test

The 5-Minute Walk Test measured the total distance a participant walked in 5 minutes. Within symptom tolerance,
the participant was asked to walk at a brisk, self-selected pace. The participant walked back and forth in a 451 feet
long hallway to obtain an accurate measurement of distance.
This outcome measure has good day-to-day reliability of individuals with low back pain (ICC = 0.87) and moderate day-
to-day reliability in healthy individuals (ICC = 0.60).43
It has also been used in persons with PTTD

Reference: Nonsurgical Management of Posterior Tibial Tendon Dysfunction With Orthoses and Resistive Exercise: A
Randomized Controlled Trial (2008)
 Conservative management with physiotherapy and orthotics for Stage I and II:

Medications: non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, help reduce

the pain and inflammation.
• Immobilization: a short-leg cast or boot, it allows the tendon to heal, or avoid all weight-
bearing.
A walking cast or CAM boot can be used to immobilize the foot. If this brings relief, the patient
can have shoe inserts or modifications, orthotics or an ankle-foot orthosis (AFO) fitted.

• Orthotic devices or bracing: to support the arch.

• Achilles tendon stretching and tibialis posterior strengthening, concentric/eccentric training of the posterior
tibialis.
• Shoe modifications: advise changes such as special inserts designed to improve arch support.
• Toe Pick-Ups: The exercise consists of picking up small objects such as pebbles, marbles or tiny toys with
toes and depositing them in other container.
 Conservative management with physiotherapy

Arch Strengthening Caterpillar: the arch strengthening caterpillar exercise

begins by lying on your back with your knees bent and your feet flat on
the floor about two feet from your butt. Lift both foot arches and pull
toes back toward heels. Relax your arches and slide feet slightly back
toward butt.
Repeat the process, allowing your feet to inch closer and closer to your
glutes in a caterpillar motion. Once your feet are nearly touching your
butt, repeat the sequence in reverse, slowly moving your feet away from
your butt in the same caterpillar motion.

Arch Raises: Sit in a chair with your back straight, knees bent in a 90-
degree angle and your feet flat on the floor. Raise the arch of one foot off
the floor without curling your toes or lifting your heel. (It’s much harder
than it sounds!) When done properly, you should feel muscle strain in your
foot, lower leg and thigh.
Alphabet Writing: You can strengthen your entire foot by imagining a pencil in between your toes, pointing the
toes outward and “writing” the alphabet in the air in front of.

Up to 4 months of non-operative treatment should be trialled; if there is no improvement after this period, a
tendon synovectomy or debridement may be indicated.
4.Anterior Ankle-Tibialis Anterior Tendon
Tibialis Anterior tendonitis
 Tibialis Anterior Tendon
The tibialis anterior muscle is the most medial muscle of the
anterior compartment of the leg.
The tibialis anterior muscle is a muscle in humans that
originates along the upper two-thirds of the lateral (outside)
surface of the tibia and inserts into the medial cuneiform and
first metatarsal bones of the foot. It acts to dorsiflex and invert
the foot.
It stabilizes the ankle as the foot hits the ground during the
contact phase of walking and dorsiflexes the ankle to help the
foot clear the ground during the swing phase.
 Tibialis Anterior tendonitis
Patient Presentation
• Tibialis Anterior tendonitis leads to pain and often swelling in the front of the ankle and into the
medial midfoot.
• Symptoms typically occur in middle aged and older individuals. They often occur after prolonged
exercise or ankle injury, and can be related to change in activity levels or footwear.
• Symptoms are aggravated by standing and walking and alleviated by rest.

Examination will often reveal tenderness and sometimes swelling over the anterior aspect of the
ankle. Resisted dorsiflexion of the ankle against the examiner’s hand will often exacerbate
symptoms
Objective Evidence
Suspected tibialis anterior tendonitis can be evaluated with plain x-rays of the foot and ankle which
might reveal bone injury or arthrosis in the ankle or midfoot joints & also MRI,Ultrasound.
Contributing factors to the development of tibialis anterior tendonitis
There are several factors which can predispose patients to developing this condition. These need
to be assessed and corrected with direction from a physiotherapist and may include:

•muscle tightness (particularly of the tibialis anterior or calf)

•muscle weakness (particularly of the tibialis anterior and tibialis posterior)
•joint stiffness (particularly of the foot and ankle)
•inappropriate or excessive training
•poor foot biomechanics
•inappropriate running technique
•inappropriate footwear
•inadequate warm up
•inadequate rehabilitation following a previous ankle or lower limb injury
•neural tightness
•muscle imbalances
•being overweight
Physiotherapy for tibialis anterior tendonitis
Physiotherapy treatment for patients with tibialis anterior tendonitis is vital to hasten the healing
process, ensure an optimal outcome and reduce the likelihood of injury recurrence. Treatment may
comprise:
•soft tissue massage
•electrotherapy (e.g. ultrasound)
•anti-inflammatory advice
•stretches
•joint mobilization
•dry needling
•ankle taping
•bracing
•the use of crutches
•ice or heat treatment
•exercises to improve strength, flexibility and balance
•education
•activity modification advice
•biomechanical correction
•footwear advice
•a gradual return to activity program
Following is a general Taping that is commonly used by
physiotherapists to support the tibialis anterior tendon
 Initial Exercises

Foot and Ankle Up and Down

Move your foot and ankle up and down as far as possible and comfortable
without pain (figure ). Repeat 10 – 20 times provided there is no increase
in symptoms.

Figure – Foot and Ankle Up and Down (left leg)

 Foot and Ankle In and Out
Move your foot and ankle in and out as far as possible and comfortable without pain (figure ).
Repeat 10 -20 times provided there is no increase in symptoms.

Figure – Foot and Ankle In and Out (right leg)

Summary
Evidence suggests that posterior tibial and peroneal tendonitis are relatively common.
Whereas anterior tibial tendonitis is less common, except perhaps in younger athletes
who have just increased training regime or started running up and down hills (PMID:
19912714)
Risk factors for peroneal tendon problems include a high arch foot with an inward
(varus) heel and can occur at any age.
Tibialis posterior problems are associated with a flatfoot deformity and more commonly
occur in patients in their 40s and 50s
Tendon Its Muscle Action of Special test/ Characteristics
Pathology origin & muscle Testing of patient
insertion method
Achilles
Tendon
Peroneus
Tendon
Posterior
Tibialis
Anterior
Tibialis