Physio Charlie

http://www.trauma.org/index.php/main/case/705/

Biomechanics of tendon injury and repair

Tony W. Lin, Luis Cardenas, Louis J. Soslowsky, Journal of Biomechanics 37 (2004) 865–877

http://www.sciencedirect.com/science?_ob=ArticleURL&_...

Many clinical and experimental studies have investigated how tendons repair in response to an injury. This body of work has led to a greater understanding of tendon healing mechanisms and subsequently to an improvement in their treatment. In this review paper, characterization of normal and healing tendons is first covered. In addition, the debate between intrinsic and extrinsic healing is examined, and the cellular and extracellular matrix response following a tendon injury is detailed. Next, clinical and experimental injury and repair methods utilizing animal models are discussed. Animal models have been utilized to study the effect of various activity levels, motions, injury methods, and injury locations on tendon injury and repair. Finally, current and future treatment modalities for improving tendon healing, such as tissue engineering, cell therapy, and gene therapy, are reviewed.

Tibialis posterior dysfunction: a common and treatable cause of adult acquired flatfoot, Kohls-Gatzoulis et al, BMJ 2004;329:1328–33

http://cms.interactivecsp.org.uk/uploads/documents/Tib%20...

http://www.bmj.com/cgi/content/full/329/7478/1328/DC1

"Adults with an acquired flatfoot deformity may present not with foot deformity but almost uniformly with medial foot pain and decreased function of the affected foot.  The most common cause of an acquired flatfoot deformity in an otherwise healthy adult is dysfunction of the tibialis posterior tendon, and this review provides an outline to its diagnosis and treatment".

Causes of an adult acquired flatfoot

• Neuropathic foot (Charcot foot) secondary to:  Diabetes mellitus, Leprosy, Profound peripheral neuritis of any cause

• Degenerative changes in the ankle, talonavicular or tarsometatarsal joints, or both, secondary to: Inflammatory arthropathy, Osteoarthropathy, Fractures

• Acquired flatfoot resulting from loss of the supporting structures of the medial longitudinal arch: Dysfunction of the tibialis posterior tendon, Tear of the spring (calcaneoanvicular) ligament (rare), Tibialis anterior rupture (rare)

Symptoms suggesting tibialis posterior dysfunction

• Pain and/or swelling behind the medial malleolus and along the instep

• Change in foot shape

• Decrease in walking ability and balance

• Ache on walking long distances

How to examine for tibialis posterior dysfunction

(1) Both of patient’s legs visible from knee down

(2) Observe heel alignment with patient standing with feet shoulder width apart, feet parallel. (Heel becomes valgus, arch collapses, and forefoot adducts in cases of tibialis posterior dysfunction)  Also visible is the “too many toes sign,” which results from abduction of the left forefoot.

(3) Inspect for swelling behind medial malleolus

(4) Ask patient to stand on tiptoes. Normally the heel should bend inwards. A patient with tibialis posterior dysfunction will have great difficulty standing on tiptoes, and the heel will not bend inwards

(5) Ask the patient to perform 10 unsupported heel rises on each leg. A patient with tibialis posterior dysfunction will not be able to do this

(6) Palpate along the tibialis posterior tendon for tenderness

(7) Test tibialis posterior tendon for power. Ask the patient to bring foot into an inverted and plantar flexed position from an everted and dorsiflexed position against your resistance

(8) Examine for hindfoot movement. In stages I and II, the foot is supple and the flatfoot deformity can be corrected by rotating the heel inwards (the arch of the foot will be reconstituted). In stage III and IV subtalar arthritis is present, and movement of the subtalar joint will be lessened and painful. Additionally in stage IV, ankle arthritis has set in and the ankle becomes stiff and painful

Stages of tibialis posterior dysfunction and treatment options

Stage I

Tendon inflamed, No change in foot shape, Acute: 4-8 weeks’ immobilisation; rest, ice, compression, and elevation (RICE); non-steroidal anti-inflammatory drugs (NSAIDs), Chronic lace-up, flat footwear and corrective orthosis or ankle foot orthosis (AFO), surgery; Tendon debridement combined with corrective osteotomy

Stage II

Tendon elongated, Acquired flatfoot deformity, Acute: 4-8 weeks’ immobilisation, RICE, NSAIDS, Chronic: lace-up, flat footwear and corrective orthosis, Surgery; Tendon transfer and corrective osteotomy

Stage III

Fixed deformity, Degenerative changes at subtalar joint, Lace-up, semirigid shoes or customised footwear and accommodative orthosis (AFO), Surgery; Triple arthrodesis (subtalar, calcaneo-cuboid. and talonavicular articulations)

Stage IV

Fixed deformity, Degenerative changes at subtalar and ankle joints, Lace-up, semirigid shoes or customised footwear and accommodative orthosis (AFO), Surgery; Pantalar arthrodesis (subtalar, calcaneo-cuboid, talonavicular, and ankle articulations)

Resources for patients and doctors

www.bofss.org.uk Designed for both patients and doctors and is run by the British Orthopaedic Foot Surgery Society and gives good general advice about foot care

www.orthoteers.co.uk good site for doctors. Click on flatfeet (in the paediatrics section) and then on tibialis posterior insufficiency

http://www.foothyperbook.com/elective/aaff/aaffIntro.htm  website for the Blackburn Foot and Ankle Hyperbook.