Non-Achilles ankle tendinopathy
- Timothy Ryan Draper, DO, AAFP, CAQ Sports Medicine
Timothy Ryan Draper, DO, AAFP, CAQ Sports Medicine
- Assistant Professor of Family Medicine
- University of North Carolina School of Medicine
- Associate Program Director
- Cone Health Sports Medicine
- Section Editor
- Karl B Fields, MD
Karl B Fields, MD
- Editor-in-Chief — Primary Care Sports Medicine (Adolescents and Adults)
- Section Editor — Biomechanics, Rehabilitation, and Recovery; Sports-Related Injuries; Symptom Assessment and Physical Examination
- Professor of Family Medicine and Sports Medicine
- University of North Carolina at Chapel Hill
Approximately 50 percent of sports-related injuries are related to overuse. Of injuries seen in running clinics, the majority are due to overuse with about half involving the lower leg . Many such injuries involve a tendinopathy.
The clinical presentation and management of tendinopathies involving ankle tendons other than the Achilles is reviewed here. Achilles tendinopathy, as well as acute ankle injuries, are discussed separately. (See "Achilles tendinopathy and tendon rupture" and "Ankle sprain in adults" and "Overview of ankle fractures in adults".)
Tendinopathy, or tendinosis, is a clinical syndrome that often follows an initial period of inflammation (tendonitis). Some clinicians mistakenly use the terms tendinopathy, tendinosis, and tendonitis interchangeably. The histopathology and treatment of tendinopathy differs from that of acute tendonitis. An overview of tendinopathy is provided separately. (See "Overview of overuse (chronic) tendinopathy".)
EPIDEMIOLOGY AND RISK FACTORS
Fifteen percent of overuse injuries affect the ankle, most commonly the Achilles, posterior tibialis, peroneus longus, and peroneus brevis tendons . Tendinopathy can develop in both the athletic and sedentary patient but is uncommon in children. Extrinsic factors that can predispose to ankle tendinopathy include improper training, poor biomechanics (eg, running technique), and improper footwear. Intrinsic factors can include foot malalignment, leg length discrepancy, joint laxity, and obesity.
A number of medications have been associated with musculoskeletal injury, including nonsteroidal antiinflammatory drugs (NSAIDs) and statins. Although rare, fluoroquinolone use may be associated with tendinopathy and acute tendon rupture. The association of specific agents with tendon injury is discussed separately. (See "Nonselective NSAIDs: Overview of adverse effects", section on 'Healing of musculoskeletal injury' and "Statin myopathy" and "Achilles tendinopathy and tendon rupture", section on 'Measures for patients on fluoroquinolones'.)
- Wilder RP, Sethi S. Overuse injuries: tendinopathies, stress fractures, compartment syndrome, and shin splints. Clin Sports Med 2004; 23:55.
- Suzuki T, Tohda E, Ishihara K. Power Doppler ultrasonography of symptomatic rheumatoid arthritis ankles revealed a positive association between tenosynovitis and rheumatoid factor. Mod Rheumatol 2009; 19:235.
- Dalbeth N, Kalluru R, Aati O, et al. Tendon involvement in the feet of patients with gout: a dual-energy CT study. Ann Rheum Dis 2013; 72:1545.
- Heckman DS, Gluck GS, Parekh SG. Tendon disorders of the foot and ankle, part 1: peroneal tendon disorders. Am J Sports Med 2009; 37:614.
- Wang XT, Rosenberg ZS, Mechlin MB, Schweitzer ME. Normal variants and diseases of the peroneal tendons and superior peroneal retinaculum: MR imaging features. Radiographics 2005; 25:587.
- Simpson MR, Howard TM. Tendinopathies of the foot and ankle. Am Fam Physician 2009; 80:1107.
- Park HJ, Cha SD, Kim HS, et al. Reliability of MRI findings of peroneal tendinopathy in patients with lateral chronic ankle instability. Clin Orthop Surg 2010; 2:237.
- Wheeless CR. Peroneal tendon dislocation. In: Wheeless’ Textbook of Orthopaedics, 2011. www.wheelessonline.com/ortho/peroneal_tendon_dislocation (Accessed on November 16, 2013).
- Bianchi S, Delmi M, Molini L. Ultrasound of peroneal tendons. Semin Musculoskelet Radiol 2010; 14:292.
- Grant TH, Kelikian AS, Jereb SE, McCarthy RJ. Ultrasound diagnosis of peroneal tendon tears. A surgical correlation. J Bone Joint Surg Am 2005; 87:1788.
- Khoury V, Guillin R, Dhanju J, Cardinal E. Ultrasound of ankle and foot: overuse and sports injuries. Semin Musculoskelet Radiol 2007; 11:149.
- Jacobson JA. Fundamentals of Musculoskeletal Ultrasound, Saunders, Philadelphia 2007.
- Bianchi S, Martinoli C. Ultrasound of the Musculoskeletal System, Springer, New York 2007.
- Neustadter J, Raikin SM, Nazarian LN. Dynamic sonographic evaluation of peroneal tendon subluxation. AJR Am J Roentgenol 2004; 183:985.
- Raikin SM, Elias I, Nazarian LN. Intrasheath subluxation of the peroneal tendons. J Bone Joint Surg Am 2008; 90:992.
- Lee SJ, Jacobson JA, Kim SM, et al. Ultrasound and MRI of the peroneal tendons and associated pathology. Skeletal Radiol 2013; 42:1191.
- Rockett MS, Waitches G, Sudakoff G, Brage M. Use of ultrasonography versus magnetic resonance imaging for tendon abnormalities around the ankle. Foot Ankle Int 1998; 19:604.
- Park HJ, Lee SY, Park NH, et al. Accuracy of MR findings in characterizing peroneal tendons disorders in comparison with surgery. Acta Radiol 2012; 53:795.
- O'Neill PJ, Van Aman SE, Guyton GP. Is MRI adequate to detect lesions in patients with ankle instability? Clin Orthop Relat Res 2010; 468:1115.
- Kuwada GT. Surgical correlation of preoperative MRI findings of trauma to tendons and ligaments of the foot and ankle. J Am Podiatr Med Assoc 2008; 98:370.
- Lamm BM, Myers DT, Dombek M, et al. Magnetic resonance imaging and surgical correlation of peroneus brevis tears. J Foot Ankle Surg 2004; 43:30.
- Collins MS, Felmlee JP. 3T magnetic resonance imaging of ankle and hindfoot tendon pathology. Top Magn Reson Imaging 2009; 20:175.
- Stasko PM, McSpadden CK, Jung R, et al. Incidence of talar dome lesions with concomitant peroneal tendon pathologic features: a magnetic resonance imaging evaluation. J Foot Ankle Surg 2012; 51:579.
- Adams E, Madden C. Cuboid subluxation: a case study and review of the literature. Curr Sports Med Rep 2009; 8:300.
- Durall CJ. Examination and treatment of cuboid syndrome: a literature review. Sports Health 2011; 3:514.
- Macintyre J, Joy E. Foot and ankle injuries in dance. Clin Sports Med 2000; 19:351.
- Marshall P, Hamilton WG. Cuboid subluxation in ballet dancers. Am J Sports Med 1992; 20:169.
- Patterson SM. Cuboid syndrome: a review of the literature. J Sports Sci Med 2006; 5:597.
- Batt J, Neeki MM. Osteopathic manipulative treatment in tarsal somatic dysfunction: a case study. J Am Osteopath Assoc 2013; 113:857.
- Grasset W, Mercier N, Chaussard C, et al. The surgical treatment of peroneal tendinopathy (excluding subluxations): a series of 17 patients. J Foot Ankle Surg 2012; 51:13.
- Rees JD, Maffulli N, Cook J. Management of tendinopathy. Am J Sports Med 2009; 37:1855.
- Oliva F, Del Frate D, Ferran NA, Maffulli N. Peroneal tendons subluxation. Sports Med Arthrosc 2009; 17:105.
- Gluck GS, Heckman DS, Parekh SG. Tendon disorders of the foot and ankle, part 3: the posterior tibial tendon. Am J Sports Med 2010; 38:2133.
- Wheeless CR. Flexor digitorum longus. In: Wheeless’ Textbook of Orthopaedics, 2011. www.wheelessonline.com/ortho/flexor_digitorum_longus (Accessed on August 16, 2013).
- Saar WE, Bell J. Accessory flexor digitorum longus presenting as tarsal tunnel syndrome: a case report. Foot Ankle Spec 2011; 4:379.
- Abelson B. Medial ankle pain-dancer’s tendonitis. In: Release Your Pain, 2nd ed, Kinetic Health 2012. http://kinetichealthcalgary.blogspot.com/2012/02/medial-ankle-pain-dancers-tendonitis.html (Accessed on August 16, 2013).
- Michelson J, Dunn L. Tenosynovitis of the flexor hallucis longus: a clinical study of the spectrum of presentation and treatment. Foot Ankle Int 2005; 26:291.
- Luk P, Thordarson D, Charlton T. Evaluation and management of posterior ankle pain in dancers. J Dance Med Sci 2013; 17:79.
- Cooper ME, Wolin PM. Os trigonum syndrome with flexor hallucis longus tenosynovitis in a professional football referee. Med Sci Sports Exerc 1999; 31:S493.
- Lui TH, Chow FY. "Intersection syndrome" of the foot: treated by endoscopic release of master knot of Henry. Knee Surg Sports Traumatol Arthrosc 2011; 19:850.
- Eberle CF, Moran B, Gleason T. The accessory flexor digitorum longus as a cause of Flexor Hallucis Syndrome. Foot Ankle Int 2002; 23:51.
- Holzmann M, Almudallal N, Rohlck K, et al. Identification of a flexor digitorum accessorius longus muscle with unique distal attachments. Foot (Edinb) 2009; 19:224.
- Kong A, Van Der Vliet A. Imaging of tibialis posterior dysfunction. Br J Radiol 2008; 81:826.
- Premkumar A, Perry MB, Dwyer AJ, et al. Sonography and MR imaging of posterior tibial tendinopathy. AJR Am J Roentgenol 2002; 178:223.
- Shibuya N, Ramanujam CL, Garcia GM. Association of tibialis posterior tendon pathology with other radiographic findings in the foot: a case-control study. J Foot Ankle Surg 2008; 47:546.
- Schweitzer ME, Karasick D. MR imaging of disorders of the posterior tibialis tendon. AJR Am J Roentgenol 2000; 175:627.
- Ugolini PA, Raikin SM. The accessory navicular. Foot Ankle Clin 2004; 9:165.
- Koenig MD, Clanton TO. Neurologic injury: tarsal tunnel syndrome. Foot problems. In: Netter’s Sports Medicine, 1st ed, Madden C, Putakian M, McCarty E, Young C (Eds), Saunders, Philadelphia 2009. p.464.
- Petron DJ, Crist JC. Tibial nerve injury. Neurologic problems in the athlete. In: Netter’s Sports Medicine, 1st, Madden C, Putakian M, McCarty E, Young C (Eds), Saunders, Philadelphia 2010. p.252.
- Corte-Real NM, Moreira RM, Guerra-Pinto F. Arthroscopic treatment of tenosynovitis of the flexor hallucis longus tendon. Foot Ankle Int 2012; 33:1108.
- Ng JM, Rosenberg ZS, Bencardino JT, et al. US and MR imaging of the extensor compartment of the ankle. Radiographics 2013; 33:2047.
- Grassi W, Meenagh G, Pascual E, Filippucci E. "Crystal clear"-sonographic assessment of gout and calcium pyrophosphate deposition disease. Semin Arthritis Rheum 2006; 36:197.
- Murtaugh B, Ihm JM. Eccentric training for the treatment of tendinopathies. Curr Sports Med Rep 2013; 12:175.
- EPIDEMIOLOGY AND RISK FACTORS
- LATERAL ANKLE TENDINOPATHY
- Clinical presentation and physical examination
- Imaging studies
- Differential diagnosis of lateral ankle tendinopathy
- MEDIAL ANKLE TENDINOPATHY
- Clinical presentation and physical examination
- Imaging studies
- Differential diagnosis of medial ankle tendinopathy
- - Posterior tibialis tendinopathy
- - Flexor hallucis longus tendinopathy
- ANTERIOR ANKLE TENDINOPATHY
- Clinical presentation and physical exam
- Imaging studies
- Differential diagnosis of anterior ankle tendinopathy
- ADDITIONAL ULTRASOUND RESOURCES
- FOLLOW-UP AND RETURN TO WORK OR SPORT
- SUMMARY AND RECOMMENDATIONS
- Lateral ankle tendinopathy
- Medial ankle tendinopathy
- Anterior ankle tendinopathy
- Common elements of management