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Given that many patients will present with tendon-related pain, this author offers key diagnostic tips, insights on conservative treatment and pearls on appropriate surgical options.
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Continuing Education Course #159
December 2007
| I am pleased to introduce the latest article, “How To Address Lower Extremity Tendon Injuries,” in our CE series. This series, brought to you by the North American Center for Continuing Medical Education (NACCME), consists of complimentary CE activities that qualify for one continuing education contact hour (.1 CEU). Readers will not be required to pay a processing fee for this course.
When it comes to tendon injuries, podiatrists see a variety of presentations in the lower extremity. Accordingly, William Fishco, DPM, emphasizes key questions in regard to the history of the complaint and pertinent diagnostic pointers. Dr. Fishco also reviews appropriate conservative therapies and when physicians should consider surgical repair.
At the end of this article, you’ll find a nine-question exam. Please mark your responses on the enclosed postcard and return it to NACCME. This course will be posted on Podiatry Today’s Web site (www.podiatrytoday.com) roughly one month after the publication date. I hope this CE series contributes to your clinical skills.
Sincerely,
Jeff A. Hall
Executive Editor
Podiatry Today
INSTRUCTIONS: Physicians may receive one continuing education contact hour (.1 CEU) by reading the article on pg. 54 and successfully answering the questions on pg. 58. Use the enclosed card provided to submit your answers or log on to www.podiatrytoday.com and respond via fax to (610) 560-0502.
ACCREDITATION: NACCME is approved by the Council on Podiatric Medical Education as a sponsor of continuing education in podiatric medicine.
DESIGNATION: This activity is approved for 1 continuing education contact hour or .1 CEU.
DISCLOSURE POLICY: All faculty participating in Continuing Education programs sponsored by NACCME are expected to disclose to the audience any real or apparent conflicts of interest related to the content of their presentation.
DISCLOSURE STATEMENTS: Dr. Fishco has disclosed that he has no significant financial relationship with any organization that could be perceived as a real or apparent conflict of interest in the context of the subject of his presentation.
GRADING: Answers to the CE exam will be graded by NACCME. Within 60 days, you will be advised that you have passed or failed the exam. A score of 70 percent or above will comprise a passing grade. A certificate will be awarded to participants who successfully complete the exam.
TARGET AUDIENCE: Podiatrists
RELEASE DATE: December 2007
EXPIRATION DATE: December 31, 2008
LEARNING OBJECTIVES: At the conclusion of this activity, participants should be able to:
• discuss the use of magnetic resonance imaging in diagnosing tendon injuries in the lower extremity;
• review conservative treatment for inflammatory tendon pathology;
• describe the diagnosis and treatment of posterior tibial tendon pain and peroneal tendon tears;
• discuss the intrinsic and extrinsic treatment options available to repair tendons; and
• review the benefits of reconstruction techniques for tendon repair.
Sponsored by the North American Center for Continuing Medical Education.
| The vast majority of patients we see on any given day have pain of some sort in the lower extremity. One would diagnose tendon injuries by obtaining a thorough history of the chief complaint and performing a clinical examination, which should emphasize range of motion analysis, muscle strength testing, palpation, gait examination and reviewing X-rays.
Physicians should always perform an examination of the contralateral extremity as one may not otherwise appreciate subtle swelling, muscle weakness and/or skin changes. Certainly, podiatrists should also do a cursory vascular and neurologic exam. When examination findings include pain with palpation along the course of a tendon, weakness of a tendon and pain with motion of a tendon, these findings are all consistent with tendon pathology.
After the patient has described the problem, podiatrists should hone in on key questions when obtaining the history of the complaint. The following are some examples of pertinent questions.
• “Do you have pain after periods of rest, such as getting out of bed in the morning?”
• “Does it get better or worse as you start walking?”
• “Do you have any weakness in your foot?”
• “Has your foot changed position when you walk?”
• “Does your foot slap or drop when you are walking?”
• “Has there been an injury to the foot?”
• “Have you had any recent cortisone injections?”
Understanding The Continuum Of Tendon Injuries
Tendon injuries for the most part are overuse injuries. Notable exceptions would be trauma or laceration of a tendon. One should explain to patients that an overuse injury does not mean the patient has just ran a marathon. It simply means that he or she has done an activity that may be aggravating to the foot or perhaps the patient did a normal activity wearing a shoe that was inappropriate. Patients can often remember doing something that might have been the culprit.
Tendon injuries present in a variety of ways and one should think of tendon disease as a continuum. For example, early inflammation would be consistent with tendinitis, inflammation of the tendon sheath and perhaps the tendon as well. If this goes untreated or if the aggravating factor is uncontrolled, then the patient might develop a partial rupture of the tendon such as an interstitial (longitudinal) tear. Some tendons (posterior tibial) are more likely to continue to deteriorate with complete rupture. Others may not rupture but may progress to a tendinosis (Achilles).
Histologically, tendinosis is more of a degenerative process as opposed to an inflammatory process. Now that a patient has presented to your office with pain and dysfunction of a tendon, it is your job is to figure out where he or she is in this continuum of tendon pathology and initiate appropriate treatment.
After making the diagnosis, use radiographs to rule out osseous pathology. Then the severity and chronicity of the problem will determine whether one should obtain magnetic resonance imaging (MRI). Magnetic resonance imaging is the gold standard for assessing soft tissue pathology such as tendinopathies. I am more likely to obtain a MRI with disorders of the peroneal and posterior tibial tendons.
When it comes to disorders of the Achilles tendon and extensor tendons, I am more likely to pursue early treatments before obtaining MRI. My experience with posterior tibial and peroneal tendons is that partial tears and chronic conditions do not fare well with conservative treatments.
|  | | Here one can see microdebridement of tendons. The device shown above essentially causes a controlled inflammatory reaction, which allows for revascularization of a relatively avascular tissue (tendon). |
In my practice, we find the most common tendon disorders include the large tendons that originate in the leg, cross the ankle and attach in the foot. We most frequently diagnose disorders of the Achilles, tibialis posterior and the peroneus brevis tendons. The long extensor tendons are rarely a problem with the exception of runners or hikers who have tibial stress syndrome. I see tibialis anterior tendon pathology on occasion. I generally will note certain tendon dysfunctions after an injury. For example, a turf toe injury can cause flexor tendon pathology to the great toe.
A Guide To Conservative Care For Inflammatory Tendon Pathology
Conservative treatments for inflammatory tendon pathology include a resting or immobilization phase with antiinflammatory medication. Generally, I will prescribe a nonsteroidal antiinflammatory drug (NSAID). In some cases, I have found a taper dose of prednisone to be beneficial, especially for retrocalcaneal pain.
I do not think medrol dose packs are strong enough so I prefer to prescribe prednisone 60 mg for three days and subsequently taper down to 40 mg, 20 mg, 10 mg and 5 mg, all for three days each. Then we emphasize the benefits of physical therapy modalities such as stretching, strengthening, contrasting heat and ice, ultrasound and muscle stimulation. I personally refer these patients to licensed physical therapists for these treatments.
I have found night splints to be helpful with Achilles and peroneal pathology, especially if there is a strong element of post-static dyskinesia in the morning. The final phase of treatment will involve prevention of tendinitis recurrence. This typically involves a daily stretching program and the use of supportive shoes and orthotic devices.
There are areas of pain with the Achilles tendon that one should differentiate on examination. There may be midsubstance pain in the body of the tendon. There may be pain in the retrocalcaneal bursa that one can palpate on the medial and lateral sides of the tendon superior to the attachment site. Patients may have pain on the attachment site of the calcaneus (enthesopathy).
For the most part, non-surgical treatment is the same for all three scenarios with the exception of being able to use cortisone in the retrocalcaneal bursa. Use extreme caution with cortisone injections near a tendon. I will only use a phosphate-based cortisone injection in the retrocalcaneal bursa.
What About Posterior Tibial Tendon Pain?
The posterior tibial tendon is a common source of pain and dysfunction in the foot. One could easily devote an entire manuscript to this tendon alone and the consequences of an adult-acquired flatfoot.
To be brief, just remember that this tendon can go through an early inflammatory phase (tendinitis) and can rapidly progress to a tendinosis (degenerative condition) that cannot be reversed easily with conservative treatments. Eventually, the posterior tibial tendon will tear if it goes untreated. I recommend being more aggressive in immobilization and bracing with disorders of the posterior tibial tendon.
For example, after making the diagnosis, I will generally prescribe a podiatric ankle foot orthosis (AFO) and immobilize the patient in a fracture boot until the device is ready. Often, the patient will only need the brace for a short period of time such as a month or two.
Once pain is resolving, then one can fit the patient for a custom foot orthotic. Otherwise, if one waits too long, partial tearing and posterior tibial tendon dysfunction may ensue. This combination is a difficult problem to manage conservatively. Most people do not want to have surgery or wear a brace for the rest of their lives.
Addressing Peroneal Tendon Tears And Pathology
We frequently see split interstitial tears with the peroneus brevis tendon and they are difficult to manage without surgery. Therefore, in my practice, I obtain a MRI sooner than later with suspected pathology. My experience with peroneal tendinitis is that one should be very cautious with cortisone injections on the lateral side of the foot in the region of the peroneus brevis tendon.
More often than not, I will see split tendon tears on MRI and there has been a history of cortisone injections. I less frequently see pathology of the peroneus longus tendon but there may be split tendon tears as well with this pathology. During the examination, having the patient press his or her first metatarsal head on your thumb is a good way to differentiate between peroneus longus and brevis pain.
One thing to consider with peroneal pathology would be osseous problems such as hypertrophy of the peroneal tubercle on the calcaneus and exostoses of the fibula near the sulcus. Also bear in mind that an os peroneum can be a source of pain in the cubital fossa. Additionally, be aware that stenosing peroneal tenosynovitis is more common in the cavus foot type. In this case, pain is palpable inferior to the tip of the lateral malleolus in the fibular groove.
Exploring The Options For Intrinsic Repair
When conservative treatments fail to resolve tendon pain, I consider surgical procedures. I look at surgical procedures in three categories: intrinsic repair, extrinsic repair or reconstruction. However, one may often employ a combination of techniques depending on the pathology at hand.
Intrinsic repair allows one’s own body to repair the tendon. To illustrate, extracorporeal shockwave therapy is a non-invasive procedure that causes a localized, controlled inflammatory process to increase regional blood flow through angioneogenesis. Despite the procedure being FDA approved only for plantar fasciitis and lateral epicondylitis, I have found it beneficial in treating other tendinopathies such as the Achilles tendon.
Physicians may utilize another technique called microdebridement for intrinsic repair. I use a device that offers radiofrequency coblation, which facilitates the microdebridement of a tendon. This essentially causes a controlled inflammatory reaction which allows for revascularization of a relatively avascular tissue (tendon).
After performing intrinsic repair, it is important for the physician to avoid using systemic antiinflammatory medication as one does not want to undermine the surgical effect of causing a controlled inflammatory response with the body’s natural ability to resolve inflammation.
What You Should Know About Extrinsic Repair
Extrinsic repair involves excising non-viable tendon (degenerative tendon), repairing split tendon tears using side-to-side suturing, and/or performing end-to-end repair as one would see in the case of a complete tendon rupture.
A good example of extrinsic repair is when there is advanced tendinosis with bulbous hypertrophy of the tendon of the Achilles tendon. In this case, I will generally cut out a section of the tendon to help tubularize it and repair it side to side.
Bear in mind that if one sends out tendon specimens such as the Achilles after debulking it, the pathology report rarely says anything about an inflammatory process. More often than not, it will describe degenerative changes of tendon such as mucoid degeneration.
|  | | Extrinsic repair involves excision of non-viable tendon (degenerative tendon), repair of split tendon tears with side to side suturing, and/or end to end repair in the case of a complete tendon rupture. A good example of extrinsic repair is of the Achilles tendon where there is advanced tendinosis with bulbous hypertrophy of the tendon. |
This is why conservative care will often fail with chronic degenerative changes of tendon as these changes do not represent an inflammatory process that would respond to antiinflammatory medication. When the tendon is bulbous, I explain to patients that the tendon will constantly aggravate the tendon sheath.
Can Reconstruction Techniques Facilitate Optimal Tendon Repair?
Reconstruction techniques with tendon repair include using tendon grafts for filling a defect, tendon augmentations and transfers such as the flexor digitorum longus tendon transfer for a dysfunctional posterior tibial tendon or a flexor hallucis longus transfer in Achilles tendinosis.
There are products such as collagen grafts that are available to augment reconstructions. These products can wrap around a primary repair or they can roll up to fill small defects. It is recommended that one suture these grafts on the tendon with non-absorbable suture to ensure the graft does not move after the sutures have dissolved. These grafts are not suitable for bridging a gap of tendon or for anchoring tendon to bone. In these cases, a tendon graft is preferable.
Depending on the situation, one may easily harvest a split peroneal graft for use as an autograft. I have found that fresh frozen tibialis anterior tendon is useful in repair for defects of the peroneals as well as the tibial tendons. When it comes to complete ruptures of the tibialis anterior tendon, the proximal stump will retract to the ankle, making it difficult to bring it back to the cuneiform without a graft.
|  | | Reconstruction techniques of tendon repair include using tendon grafts for filling a defect, tendon augmentations and transfers such as the flexor digitorum longus tendon transfer for a dysfunctional posterior tibial tendon or a flexor hallucis longus transfer in Achilles tendinosis. There are products such as collagen grafts that are available to augment reconstructions. |
Postoperative care following tendon surgery depends on the overall integrity of the tendon following surgery. For example, if one has to detach the Achilles tendon to excise a heel spur and remove intratendinous calcification, six weeks of immobilization is preferable. Physicians may subsequently allow progressive weightbearing in a fracture boot.
However, if one has performed an intrinsic repair of the Achilles tendon, then immediate fracture boot walking is acceptable. Physical therapy is recommended for rehabilitation of extrinsic repairs or reconstructions when weightbearing has commenced.
In Summary
Tendon pathology is a common source of lower extremity pain and dysfunction. Initial conservative treatments include immobilizing the tendon and prescribing antiinflammatory medications, progressing to physical therapy treatments and finally implementing controlling devices such as foot/ankle orthotics.
Magnetic resonance imaging is the gold standard test for assessing tendon pathology. Chronic degenerative changes of tendon (tendinosis), split tears and complete ruptures do not respond well to nonoperative interventions. When conservative care fails to resolve pain, surgery is recommended.
In the case of a complete tendon rupture, surgery is recommended to avoid future foot dysfunction. Certainly, one has to weigh the risks and benefits of surgery, considering the patient’s age, activity level and general medical conditions.
For related articles, see “Achilles Tendinopathy: What Are The Best Treatment Options?” in the October 2006 issue of Podiatry Today.
| CE Exam #159 | Choose the single best answer to the following questions.
1. Which of the following clinical exam findings is consistent with tendon pathology?
a) Pain with palpation along the course of a tendon
b) Weakness of a tendon
c) Pain with motion of a tendon
d) All of the above
2. What is the gold standard for assessing soft tissue pathology such as tendinopathies?
a) Radiographs
b) Magnetic resonance imaging
c) Ultrasound
d) None of the above
3. In the author’s experience with posterior tibial and peroneal tendons, partial tears and chronic conditions …
a) do not fare well with conservative treatments
b) are usually remedied with appropriate immobilization
c) are best treated with intrinsic surgical repair
d) none of the above
4. In regard to differentiating areas of pain with the Achilles tendon, patients may have …
a) pain in the retrocalcaneal bursa
b) pain on the attachment site of the calcaneus
c) midsubstance pain in the body of the tendon
d) all of the above
5. In regard to the posterior tibial tendon, which of the following statements is true?
a) The tendon may go through an early inflammatory phase (tendinosis) and rapidly progress to a tendonitis (degenerative condition).
b) The author recommends reserving bracing and immobilization only for severe disorders of the posterior tibial tendon.
c) It is a common source of pain and dysfunction in the foot.
d) None of the above
6. The author recommends being more aggressive with immobilization and bracing when it comes to …
a) peroneal pathology
b) disorders of the posterior tibial tendon
c) split interstitial tears of the peroneus brevis tendon
d) all of the above
7. In regard to the use of radiofrequency coblation in tendon repair …
a) it is an example of extrinsic repair that is ideal for excising non-viable tendon
b) it facilitates a localized, controlled inflammatory process to increase blood flow through angioneogenesis
c) it causes a controlled inflammatory reaction which allows for revascularization of a relatively avascular tissue (tendon)
d) none of the above
8. According to the author, when a physician sends out tendon specimens such as the Achilles after debulking it, the pathology report …
a) offers a detailed analysis of the inflammatory process
b) often describes degenerative changes of tendon such as mucoid degeneration
c) rarely says anything about an inflammatory process
d) b and c
9. Reconstruction techniques with tendon repair include …
a) repairing split tendon tears with side-to-side suturing
b) tendon transfers such as a flexor hallucis longus transfer in Achilles tendinosis
c) radiofrequency coblation for tendon microdebridement
d) none of the above
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Instructions for Submitting Exams
Fill out the enclosed card that appears on the following page or fax the form to the NACCME at (610) 560-0502. Within 60 days, you will be advised that you have passed or failed the exam. A score of 70 percent or above will comprise a passing grade. A certificate will be awarded to participants who successfully complete the exam. Responses will be accepted up to 12 months from the publication date.
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