Tendon Disorders of Foot and Ankle

Achilles Tendon Disorders - Achilles' Agony

• Achilles Tendinopathy: Overuse injury; pain, swelling, morning stiffness.
  • Non-insertional: 2-6 cm proximal to insertion.
  • Insertional: At calcaneal insertion; Haglund's deformity.
  • Rx: Conservative (RICE, NSAIDs, eccentric exercises), PRP. Surgery rare.
• Achilles Tendon Rupture: Acute; audible "pop"/"snap" during push-off. Sudden pain, inability to tiptoe/bear weight.
  • Risk Factors: "Weekend warriors" (30-50 yrs), tendinopathy, fluoroquinolones, steroids.
  • Clinical Dx:
    • Palpable gap.
    • 📌 Thompson Test: Calf squeeze → no plantarflexion.
    • Simmonds' Triad: Altered rest angle, gap, +ve Thompson.
    • Matles Test: Prone, knee 90° flexed → foot neutral/dorsiflexed.
    • USG/MRI: Confirm, assess gap.

  ⭐ Fluoroquinolone use is a significant risk factor for Achilles tendon rupture.

-   Surgical goal: Restore tension/length. Gap > **1 cm** indicates surgery.

Posterior Tibial Tendon Dysfunction - Arch Anarchy

• Progressive degeneration of posterior tibial tendon (PTT), primary dynamic stabilizer of medial longitudinal arch.
• Leads to adult-acquired flatfoot deformity (pes planus).
• Clinical Features: Medial ankle pain/swelling, ↓ arch height, forefoot abduction, hindfoot valgus.
  • Difficulty/inability to perform single heel rise.
  • 📌 "Too many toes" sign: Increased toes visible laterally when viewing from behind.

⭐ The 'too many toes' sign is a classic clinical indicator of PTTD.

• Johnson and Strom Classification & Management:

• Management aims to relieve pain, restore alignment, and improve function based on stage.

Peroneal Tendon Disorders - Fibular Fighters

• Common Issues: Tendinopathy (Peroneus Brevis > Longus), longitudinal tears, subluxation/dislocation.
• Symptoms: Posterolateral ankle pain, swelling, snapping sensation (subluxation).
• Peroneal Tendinopathy/Tears:
  • Pain with resisted eversion/dorsiflexion.
  • MRI: Confirms tear, tenosynovitis;

Other Foot & Ankle Tendinopathies - Toe Tendon Troubles

• Flexor Hallucis Longus (FHL) Tendinopathy:
  • Pain: Posteromedial ankle, deep to FDL, near sustentaculum tali.
  • Aggravation: Great toe plantarflexion (push-off), passive dorsiflexion.
  • Associations: Dancers (repetitive relevé), os trigonum.
  • Test: Resisted great toe plantarflexion.

  ⭐ Flexor Hallucis Longus (FHL) tendinopathy is often termed 'Dancer's Tendinitis' due to repetitive plantarflexion.

• Tibialis Anterior Tendinopathy:
  • Pain: Anterior ankle, dorsomedial midfoot, over tendon sheath.
  • Aggravation: Active dorsiflexion, uphill running, tight footwear.
  • Associations: Runners, inflammatory arthropathy.
  • Risk: Tendon rupture → drop foot (uncommon).
• Flexor Digitorum Longus (FDL) Tendinopathy:
  • Pain: Posteromedial ankle, inferior to FHL, radiates to plantar foot.
  • Aggravation: Lesser toe flexion, push-off.
  • Associations: Often with posterior tibial tendon dysfunction (PTTD).
  • Less common in isolation.

High‑Yield Points - ⚡ Biggest Takeaways

• Achilles tendinopathy: Commonest overuse injury; pain 2-6 cm above insertion. Rupture: positive Thompson test.
• Plantar fasciitis: Inferior heel pain, worst with first steps; tenderness at medial calcaneal tuberosity.
• Tibialis posterior tendon dysfunction: Key cause of adult acquired flatfoot; "too many toes" sign.
• Peroneal tendinopathy: Lateral ankle pain post-inversion; may involve subluxation/dislocation.
• Flexor Hallucis Longus (FHL) tendinopathy: "Dancer's tendinitis"; posteromedial ankle pain with toe flexion.
• Initial management for most tendinopathies: Conservative (rest, NSAIDs, physiotherapy).