OrthopaedicPrinciples.com

Integrating Principles and Evidence

Integrating Principles and Evidence

  • Home
  • Editorial Board
  • Our Books
    • Evidence Based Orthopaedic Principles
  • Courses
  • Exams
  • Reviews
  • Live Program
  • Contact

Anterior Tibial Tendon Tears

Courtesy: NIcholas Strasser MD
Vanderbilt Unviersity, Nashville, Tennessee, US

 

Overview and Background

  • Anterior tibial tendon ruptures are rare and not well documented.

  • Treatment strategies can be tricky due to the limited literature.

  • The speaker has experience with external ankle bracing, which is used in rehabilitation.

Anatomy Review

  • The anterior tibial tendon originates from the lateral tibia and runs under the extensor retinaculum.

  • It inserts into the medial cuneiform and base of the first metatarsal.

  • Innervated by the deep fibular (peroneal) nerve.

  • Blood supply includes the anterior tibial artery (proximal) and medial tarsal artery (distal).

  • The rupture often occurs in a “watershed” area with less vascular supply.

Function of the Tendon

  • Main function is during about 1/3 of the gait cycle.

  • In swing phase: helps dorsiflex the foot for toe clearance.

  • In stance phase: eccentrically lowers the foot to the ground during heel strike.

  • Provides dorsiflexion and inversion.

  • Dysfunction may mimic foot drop and lead to tripping or foot slapping.

Pathophysiology and Biomechanics

  • Ruptures often occur in tendons with pre-existing tendinopathy.

  • Tendon behaves like a spring during gait, storing and releasing energy.

  • Muscle fibers don’t change length as much—tendon stretch accounts for motion.

Epidemiology and Presentation

  • Much less common than Achilles tendon ruptures.

  • Typical patient: active male in 60s–70s, sometimes linked to sports like pickleball.

  • Common patient remarks:

    • “My foot slaps when I walk.”

    • “I trip over my foot.”

    • “It’s weak, not painful.”

    • “Feels unstable.”

    • “I catch my toe when barefoot.”

Clinical Diagnosis

  • Often misdiagnosed as an ankle sprain.

  • Important to test ankle dorsiflexion in all “ankle sprain” patients.

  • Must check contralateral side for comparison.

  • EHL (extensor hallucis longus) may compensate, masking the rupture.

  • Gait may show compensatory big toe lift (steppage gait).

Imaging

  • MRI is useful—look for distal rupture signs (e.g., “Slytherin sign” or snake-head shape).

  • May show associated arthritis or osteophytes irritating the tendon.

Treatment Options

  • Non-operative treatment:

    • Best for elderly or non-surgical candidates.

    • Use of drop foot braces can be surprisingly effective.

    • No need to operate on all patients.

    • Concern exists about delaying surgery: may lead to muscle atrophy or worsen function.

  • Surgical repair:

    • Preferred for acute traumatic ruptures.

    • Timing and patient selection are key.

    • Tendon transfers may be needed in some cases.

  • Key Points Summary:

    Early Repair (<6 weeks):

    • Not always ideal — tendon may be too diseased to heal well.

    • Even early, tendon reapproximation can be difficult.

    • Standard approach: Anteromedial incision; repair with a Krackow stitch technique.

    • If the tendon quality is good, early repair is reasonable.

    Techniques for Primary Repair:

    • Insertional ruptures can use:

      • Suture anchors

      • Teno-deses screws

      • Endobuttons (looped through the medial cuneiform)

    • Goal: regain tendon length — often challenging.

    Outcomes & Expectations:

    • Only small case series available; no large comparative studies.

    • Patients generally do well but rarely regain full strength.

    • Residual weakness common — especially in toe extension (EHL still firing).

    • Important to counsel patients pre-op: “never quite normal”.

    Case Example (Traumatic Laceration):

    • Female in her 50s with ATT laceration and retraction.

    • Successful acute repair after separate incision for proximal stump.

    • Also repaired EHL, EDL.

    • Result: functional recovery, but minor imbalance/clawing of toes — typical due to altered length-tension relationship.

    If You Can’t Reapproximate Tendon:

    • Z-lengthening or free sliding tendon graft using the patient’s own tendon.

    • Maintains native anatomy and avoids donor site morbidity.

    • Downside: altered tendon biomechanics.

    • Gait analysis: good function but not symmetrical — about 50% dorsiflexion compared to the unaffected side.

    Chronic Cases: Tendon Transfer Options:

    • Most use EHL or EDL transfers.

    • EHL transfer:

      • In-phase transfer.

      • Weak (ATT provides ~80% of dorsiflexion strength).

      • Risks: big toe droop.

      • May require IP joint fusion to stabilize toe.

      • Fixation methods: interference screw, drill hole + loop back.

      • Set repair in 10° dorsiflexion.

      • Often combined with gastrocnemius recession to reduce posterior tension.

    • EDL transfer:

      • Weaves EDL into ATT.

      • Distal slips tenodesed to EDB.

      • Rarely used; mostly case reports.

    Allograft/Autograft Reconstruction:

    • Often used when:

      • Large gaps or chronic ruptures.

      • Extensor tendons not available.

    • Needs viable ATT muscle for function.

      • Consider MRI of proximal leg to evaluate muscle quality.

      • Similar approach to rotator cuff tear evaluation.

    • May also achieve tenodesis effect (passive support) even with minimal muscle contraction.

      Surgical Technique Overview:

      1. Graft Options:

      • Allografts are usually preferred due to availability and avoidance of donor site morbidity.

      • Hamstring autografts may be used in revisions or when allografts aren’t viable.

      2. Graft Fixation Strategy:

      • Use of Pulvertaft weave and distal bio-tenodesis for strong fixation.

      • If using a longer graft (allograft/autograft), a drill hole in the medial cuneiform can help anchor it.

      3. Graft Material:

      • Preference for Arthrex FlexBand Twist (5mm x 30mm).

        • Benefits: strong suture-holding capacity, spring-like behavior, durable under tension.

      4. Incision and Tissue Management:

      • Two-incision approach:

        • Distal incision to identify and tag the ATT stump.

        • Proximal incision above the extensor retinaculum, preserving overlying soft tissue to reduce wound complications.

      • Avoid disruption of the extensor retinaculum, which improves healing and lowers morbidity.

      5. Surgical Steps:

      • Secure graft distally into medial cuneiform.

      • Attach native ATT to graft at distal end.

      • Pass graft under retinaculum to proximal ATT stump.

      • Max dorsiflex the ankle and tension graft proximally before fixation.

      • Reinforce with tendon-to-tendon suture repair, potentially with a Z-lengthening if tension is too high.


      Post-Op Rehab Protocol:

      0–4 Weeks:

      • Splint or cast in maximum dorsiflexion.

      • Emphasis on no plantar flexion or stretch—staff instructed not to let foot hang.

      4–8 Weeks:

      • Transition to a CAM boot.

      • Begin passive dorsiflexion, active plantarflexion, progressive weight-bearing.

      8+ Weeks:

      • Transition to brace or similar:

        • Can be locked in dorsiflexion.

        • Avoids limb length discrepancy.

      • Continue physical therapy to regain strength and function.


      Clinical Outcomes:

      • Early results show good dorsiflexion strength return.

      • Incisions heal well; tendon glides appropriately.

      • Avoids drawbacks of autografts (donor site issues), while achieving strong functional restoration.

Post Views: 411

Related Posts

  • Pectoralis Major Tendon Tears

    Courtesy: Dr Krishnakumar, NorthCumbria University Hospitals, UK

  • Gluteus Medius Tendon Tears

    Courtesy: Prof Nabil Ebraheim, University of Toledo, Ohio, USA

  • All about Subscapularis Tendon Tears

    Courtesy: Jae Chul Hoo, MD, Professor, Samsung Medical Centre, Seoul, South Korea

Leave a Reply Cancel reply

Your email address will not be published. Required fields are marked *

Follow Us

instagram slideshare

Categories

  • -Applied Anatomy
  • -Approaches
  • -Basic Sciences
  • -Cartilage & Meniscus
  • -Classifications
  • -Examination
  • -Foot and Ankle
  • -Foot and Ankle Trauma
  • -FRCS(Tr and Orth) tutorials
  • -Gait
  • -Hand and Wrist
  • -Hand and Wrist Trauma
  • -Hand Infections
  • -Hip and Knee
  • -Hip Preservation
  • -Infections
  • -Joint Reconstruction
  • -Knee Arthroplasty
  • -Knee Preservation
  • -Metabolic Disorders
  • -Oncology
  • -OrthoBiologics
  • -OrthoPlastic
  • -Paediatric Orthopaedics
  • -Paediatric Trauma
  • -Patellofemoral Joint
  • -Pelvis
  • -Peripheral Nerves
  • -Principles
  • -Principles of Surgery
  • -Radiology
  • -Rheumatology
  • -Shoulder and Elbow
  • -Shoulder and Elbow Arthroplasty
  • -Spine Deformity
  • -Spine Oncology
  • -Spine Trauma
  • -Spine, Pelvis & Neurology
  • -Sports Ankle and Foot
  • -Sports Elbow
  • -Sports Knee
  • -Sports Medicine
  • -Sports Medicine Hip
  • -Sports Shoulder
  • -Sports Wrist
  • -Statistics
  • -Technical Tip
  • -Technology in Orth
  • -Trauma
  • -Trauma (Upper Limb)
  • -Trauma Life Support
  • -Trauma Reconstruction
  • Book Shelf
  • Book Shelf Medical
  • Careers
  • Case Studies and Free Papers
  • DNB Ortho
  • Evidence Based Orthopaedic Principles
  • Evidence Based Orthopaedics
  • Exam Corner
  • Fellowships
  • Guest Editor
  • Guest Reviews
  • Image Quiz
  • Instructional Course Lectures
  • Journal Club
  • MCQs
  • Meetings and Courses
  • Multimedia
  • News and Blog
  • Plaster Techniques
  • Podcasts
  • Public Health
  • Rehabilitation
  • Research
  • Shorts and Reels

Book Shelf

Kendall’s Muscle Testing and Function 6th Edition

Kendall’s Muscle Testing and Function 6th Edition

By admin Leave a Comment

Get Book Kendall’s Muscles: Testing and Function, with Posture and Pain, 6th Edition, transforms this landmark Physical Therapy classic to prepare you for unparalleled clinical success in today’s practice. Timeless coverage of manual muscle testing, evaluation, and treatment meets the latest evidence-based practices, engaging imagery, and dynamic digital resources to create a powerful resource you […]

Popular Posts

  • Bone Screws in Orthopaedic Surgery
  • Silverskold Test
  • Piriformis Syndrome
  • Blood Supply of Long Bone
  • Movements of the Thumb

Recent Comments

  • RAJATABHA BISWAS on NUH Fellowship in Singapore
  • Runj on ESSKA Congress 2026
  • OT Hand Therapist on Interosseous Muscles Of The Hand
  • Badreddine on Rockwood and Green Fractures in Adults and Children- 10th Edition
  • Prof Dr P.sridhar MS Ortho,D Ortho on Rockwood and Green Fractures in Adults and Children- 10th Edition

Exam Corner

FRCS Orth Exam- Knee Arthroplasty

Courtesy: Zaid al Rab, FOunder, OrthoPass

MCQ Exam for the FRCS Orth 1

Courtesy: Zaid al Rub, Founder, OrthoPass

Postgraduate Entrance Exam Set 3

Get explanatory answers from our book

Postgraduate Entrance Exam Set 2

Get explanatory answers from our book

Main Menu

  • Orthopaedic Principles
  • Editorial Board
  • Orthopaedic Principles-A Review

Recent Posts

  • Anterior Tibial Tendon Tears
  • Endoscopic Lumbar Microdiscectomy
  • RAMP Lesion of the Knee
  • Osteochondritis Dissecans of the Knee
  • Dual Mobility Cups in Total Hip Replacement

Links

  • Join Our Editorial Board
  • Journals
  • Weblinks
  • Submit Your Conference
  • Disclaimer
Copyright@orthopaedicprinciples.com. All right rerserved.