Blake Spindler, Dr. Nikki German, Bobby Knodel, Dr. Kara Gange North Dakota State University

Department of Health, Nutrition and Exercise Sciences, Fargo, ND

Abstract Background Uniqueness

Diagnosis and Treatment

Clinical Significance

•  Dislocation of the tibialis posterior tendon is a rare injury that requires proper evaluation for correct diagnosis.

•  On physical examination, careful attention should be focused on the athlete’s ability to actively planterflex and invert the ankle joint

•  A palpable deformity on the anterior aspect of the medial malleolus should be noted.

•  A MRI should also be used to verify the injury and to establish if other structures are affected.

•  Surgical reconstruction treatment displays a good outcome and therefore should be performed on tibialis posterior dislocations.

Background: A 19-year-old male collegiate football player reported to the sideline during practice complaining of pain on the medial aspect of his left ankle. The athlete was hit on the medial side of his knee, but his foot stayed planted and was forced into dorsiflexion and eversion. A pop was heard and the athlete was in obvious pain. An evaluation revealed deformity over the medial malleolus. The athlete was extremely sensitive to palpation directly beneath the medial malleolus and posterior ankle joint. The athlete was not able to perform active inversion and planterflexion was graded two out of five when compared bilaterally. Through further palpation, the tendon was guided back below the medial malleolus, which greatly diminished the athlete’s pain. The athlete then tried to walk, which resulted in the tendon dislocating again and a subsequent relocation was performed. The athletic trainer diagnosed the injury as a tibialis posterior tendon dislocation/subluxation. The athlete was referred to a team physician for further evaluation. Differential Diagnosis: Differential diagnosis includes; medial ankle sprain or high ankle sprain, tendonitis, and subtalar fracture. Treatment: The athlete was placed in a walking cam-boot with crutches and scheduled to see a podiatrist the following day. A MRI was order and showed the following: a tibialis posterior tendon subluxation; the retinaculum obviously torn, although present; and the posterior tibial groove not too shallow, although notably present. Treatment options were discussed with the athlete, with surgical reconstruction strongly encouraged. Surgical reconstruction was chosen to relocate the tibialis posterior tendon, repair the torn flexor retinaculum, and to deepen the posterior tibial groove. Athlete expected to make full recovery. Uniqueness: Dislocations of the tibialis posterior tendon are extremely rare and have few documented/reported cases; especially when not associated with a fracture. There have only been 32 other cases reported in the English literature from 1874-2006. There are fewer than 40 reported cases before the year of 2011 and most of the reports are case reports of chronic tibialis posterior tendon dislocations that were neglected. Tendon dislocations on the medial side of the ankle are very rare when compared to the dislocation of the peroneal tendons on the lateral aspect of the ankle. This injury is often diagnosed and treated as a medial ankle sprain or high ankle sprain, tendonitis, or a subtalar dislocation. However, in this case the injury was diagnosed correctly upon initial evaluation by the athletic trainer. Conclusions: Posterior tibialis tendon dislocations are very rare injury. The MOI with was similar to other reported cases. Unlike other cases, surgical treatment was performed as soon as possible to relocate the tendon, repair the flexor retinaculum and deepen groove. The athlete was placed in splint for the first week, and then placed in a walking boot with non-weight bearing status. Passive dorsiflexion/planterflexion ROM began two weeks post-op followed by strengthening and proprioception exercises. Two months post-repair the athlete was advised to return to activities as tolerated with no restrictions. Word Count: 490

•  19-year-old male; Division 1 football player; during practice was hit on the medial side of his knee, but foot stayed planted and was forced into dorsiflexion and eversion; a pop was heard; reported to sideline and was in obvious pain

• Signs, Symptoms, & Positive Special Tests: 1. Deformity over medial malleolus 4. MMT for inversion (1/5) 7. Not able to walk normally

2. Sensitive to palpation 5. MMT for planterflexion (2/5) 8. Obvious pain 3. Not able to perform active inversion 6. Bump Test (+) for pain

• Referred athlete to team physician for further evaluation

Differential Diagnosis

Conclusions

•  Bruising was present the next day following the injury (figure 1). •  Athlete was placed in a walking cam-boot with crutches and scheduled to see a podiatrist. •  A MRI was order and showed the following: a tibialis posterior tendon subluxation; the retinaculum obviously torn, although present;

and the posterior tibial groove not too shallow, although notably present (figure 2). •  Tibialis Posterior Tendon dislocation was the diagnosis •  Treatment:

• Treatment options were discussed with surgical reconstruction strongly encouraged. • Surgical reconstruction was chosen to relocate the tibialis posterior tendon, repair the torn flexor retinaculum, and to deepen the

posterior tibial groove (figure 3 & 4). • Athlete placed in a cam-boot with crutches and non-weight bearing (NWB) status.

•  Outcome: • 1 week post-repair: athlete in cam-boot and NWB; PROM DF/PF • 3 weeks post-repair: athlete WB in cam-boot; ROM and theraband strengthening • 8 weeks post-repair: athlete out of cam-boot and WB as tolerated; proprioception , ROM, strengthening, biking, and elliptical • 9 weeks post-repair: athlete full WB; progress lower body lifts, jogging progression, strengthening, ROM, and proprioception • 10 weeks post repair: line jumping and agility progression • 12 weeks post repair: athlete advised to progress into full activity with no restrictions • 16 weeks post repair: athlete returned to full activity with no complications

•  Dislocations of the tibialis posterior tendon are extremely rare and have few documented/reported cases1-4; especially when not associated with a fracture.5

•  Martius described the first case in the year 1874.2 •  There have only been 32 other cases reported in the English literature

from 1874-2006.2

•  Up until the year of 2011 there were fewer than 40 reported cases in the English literature.4

•  Tendon dislocations on the medial side of the ankle are very rare when compared to the dislocation of the peroneal tendons on the lateral aspect of the ankle.

•  Diagnosing an injury such as a posterior tibialis dislocation can be a difficult thing to do. Due to the rarity of a posterior tibialis tendon dislocation, this injury is often times misdiagnosed.

1.  Mittal RL, Jain NC. Traumatic dislocation of the tibialis posterior tendon. Int Orthop. 1988; 12:259–260.

2.  Goucher NC, Coughlin, MJ, Kristensen RM. Dislocation of the posterior tibial tendon: a literature review and presentation of two cases. Iowa Orthop J. 2006; 26:122–126.

3.  Chu, Chung J. Spontaneous dislocation of the posterior tibial tendon. J Orthop. 2007; 4:15

4.  Mitchell K, Mencia MM, Hoford R. Tibialis posterior tendon dislocation: A case report. The Foot. 2011; 21:154-156.

5.  Larsen E, Lauridsen F. Dislocation of the tibialis posterior tendon in two athletes. Am J Sports Med. 1984; 12:429-430.

•  Syndesmotic Ankle Sprain •  Tendonitis •  Subtalar dislocation

References

•  Thorough evaluation is important when evaluating an injury to the medial side of the ankle so proper diagnosis and care can be administered.

•  This case study shows the importance of surgical reconstruction should be the chosen treatment method. Also, shows the possitive outcome from surgical treatment.

•  Other ATC’s can learn proper treatment and a rehabilitation protocol to follow.

•  This case report could help change clinical practice by showing the importance of a proper and thorough evaluation. Also, that surgical treatment is the best plan of action for the athlete to fully return to activity.

Traumatic Dislocation of the Posterior Tibialis Tendon: A Case Report

NDSU

Figure 1

Figure 2

Athletic Training

Figure 3

Figure 4