0363-5465/101/2929-0656$02.00/0 THE AMERICAN JOURNAL OF SPORTS MEDICINE, Vol. 29, No.

5 2001 American Orthopaedic Society for Sports Medicine

Dislocation of the Posterior Tibial Tendon without Disruption of the Flexor Retinaculum
A Case Report and Review of the Literature
Stephen L. Nuccion, MD, D. Monte Hunter,* MD, and John DiFiori, MD From the Department of Orthopaedic Surgery, University of California, Los Angeles, School of Medicine, Los Angeles, California
Dislocation of the posterior tibial tendon is a very rare injury. Most accounts in the literature are of one or two cases,15 with only one report of an experience with seven patients.6 Acute traumatic dislocation appears to be more common than chronic dislocation.3 The mechanism for traumatic dislocation is forced dorsiflexion with some degree of foot inversion.5 Diagnosis is often delayed and may be confused with that of complex ankle sprain. Nonoperative management has not been found to be successful.1 6 On operative exploration of the posterior tibial tendon, a variety of pathologic lesions have been found.1 6 Most lesions involve a tearing or absence of the flexor retinaculum. We describe the case of a 31-year-old man with an acute traumatic irreducible dislocation of the posterior tibial tendon and an intact flexor retinaculum. legged heel raise. The patient was able to actively plantarflex the affected extremity, but he was unable to invert the foot. Dysfunction of the posterior tibial tendon was suspected and an MRI was ordered. An elastic wrap was placed around the ankle for compression, the patient was instructed not to bear weight on the injured extremity, and he was referred to the orthopaedic clinic. The patient was seen at our office 10 days after his initial injury. He continued to have medial ankle swelling and a vague discomfort medially. He was unable to bear weight on his affected extremity. On physical examination, the patient was found to have a palpable posterior tibial tendon medial to the medial malleolus. The tendon appeared to be intact. Active ankle dorsiflexion and plantar flexion were painless, but attempts at active inversion or eversion were painful. Radiographs demonstrated soft tissue swelling medially and an ankle effusion, but no fracture. The MRI demonstrated an anteriorly dislocated posterior tibial tendon medial to the medial malleolus with moderate edema surrounding the tendon (Fig. 1). On our recommendation, the patient elected to undergo operative exploration. Procedure The patient was taken to the operating room approximately 2 weeks after his initial injury. A 10-cm curvilinear incision was made just posterior to the medial malleolus, along the course of the posterior tibial tendon and extending distally to the approximate area of the tarsal navicular bone. The retinaculum was noted to be intact, and the posterior tibial tendon was both visible and easily palpable, dislocated medial to the medial malleolus, but still underneath the lax retinaculum (Fig. 2). The tendon could not be reduced manually. The retinaculum was incised sharply along its posterior one-third margin both proximally and distally, leaving approximately a 1-cm cuff of retinaculum intact anteriorly (Fig. 3). There was no obvious tearing of the retinaculum, but it was indeed lax and
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CASE REPORT
A 31-year-old man was seen with a chief complaint of medial ankle pain. The patient had been playing soccer, a frequent activity for him, when he noted a sudden sharp pain along the medial aspect of his left ankle while running straight ahead at near full speed. He did not recall any specific malposition of his foot or trauma. He was unable to continue playing and had difficulty bearing weight. His ankle swelled and he had generalized discomfort along the medial aspect of his ankle. He had not experienced any prior episodes of a similar nature. When initially seen by his primary care physician 3 days after the injury, the patient was found to have marked edema and tenderness to palpation around the medial malleolus. He had difficulty bearing weight on the extremity and was unable to perform a single- or double-

*Address correspondence and reprint requests to Stephen L. Nuccion, MD, UCLA Medical Center CHS 10833 LeConte Avenue, Room 16-155, Los Angeles, CA 90095. No author or related institution has received any financial benefit from research in this study.

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Figure 3. Incision of the retinaculum along its posterior onethird, leaving approximately a 1-cm cuff of retinaculum intact anteriorly. did not provide a mechanical restraint to keep the tendon within the groove. There was one small area of the tendon that was minimally ecchymotic. It corresponded to the area that had subluxated over the medial malleolus. The entire posterior tibial groove could be visualized, and there was no evidence of injury or soft tissue blockage. The groove was normal in shape and depth. The tendon could be reduced and maintained with the foot in inversion and slight plantar flexion. Since the tendon could be held within the groove and the retinaculum appeared lax, a reefing of the retinaculum was thought to be the most appropriate procedure. Two mini Mitek suture anchors (Mitek Products, Westwood, Massachusetts) were placed right at the anterior ridge of the posterior tibial tendon groove (Fig. 4). The retinaculum was then advanced and secured back to this area of the posterior medial malleolus. The remaining retinaculum was advanced to the posterior aspect of the retinaculum in a pants-over-vest fashion with 3 0 Maxon suture (Davis & Geck, Danbury, Connecticut). This provided a more taut retinaculum (Fig. 5). The posterior tibial tendon maintained its reduction. The remaining sheath was closed proximally and distally as well. The wound was irrigated and closed. The patients foot and ankle were splinted in plantar flexion and inversion. Postoperative Course The patient was kept nonweightbearing with his foot casted in plantar flexion and inversion for a total of 6 weeks. After 6 weeks, he was advanced to weightbearing as tolerated in a fracture boot with the foot in a neutral position. After the cast was removed, he underwent physical therapy emphasizing passive and active range of motion exercises of the affected ankle. He then was released to full activities with the use of a lace-up ankle brace. At

Figure 1. Magnetic resonance image demonstrating the dislocated posterior tibial tendon (arrow) medial to the medial malleolus with moderate edema surrounding the tendon.

Figure 2. The intact retinaculum with the posterior tibial tendon visible underneath but dislocated medial to the medial malleolus.

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Figure 4. Two mini Mitek suture anchors placed at the ridge of the posterior tibial tendon tunnel.

Figure 5. The remaining retinaculum was advanced to the posterior aspect of the retinaculum. last follow-up, nearly 5 months after his surgery, the patient had no complaints of pain and had full active range of motion of the ankle. Clinically, the posterior tibial tendon had full motor strength and was reduced and stable within the groove.

DISCUSSION
The posterior tibial muscle originates along the lateral part of the posterior surface of the tibia, medial two-thirds of the fibula, interosseous membrane, intermuscular

septa, and deep fascia. It is located in the deep posterior compartment of the leg. The posterior tibial tendon courses directly behind the medial malleolus in a groove often referred to as the posterior tibial groove. The tendon is held in the groove by the flexor retinaculum, which is a strong fibrous band that extends from the medial malleolus proximally to the margin of the calcaneus distally. Traumatic dislocation of the posterior tibial tendon has been infrequently described in the literature. Nava5 reported a case of traumatic dislocation of the posterior tibial tendon in a 16-year-old boy after he was involved in a motorcycle accident. The tendon was found to be lying over the medial malleolus, the tendon tunnel was empty, and the flexor retinaculum was torn. The groove was reported to be normal in shape and depth. Nava primarily repaired the retinaculum after reduction of the tendon and applied a short-leg cast for 10 weeks. The results were reported to be excellent. Nava hypothesized that the mechanism of injury must involve forcible dorsiflexion of the ankle in slight inversion counteracted by a forcible contraction of the posterior tibialis muscle. Larsen and Lauridsen3 reported on the traumatic dislocation of the posterior tibial tendon in an 18-year-old man and a 36-year-old woman during running activities. Both patients appeared to have sustained dorsiflexion and inversion injuries to the affected foot. At surgery, the flexor retinaculum was found to be torn. Treatment consisted of primary repair of the retinaculum and immobilization for 6 weeks. Excellent results were again reported. The report of Ouzounian and Myerson6 on seven patients with dislocated posterior tibial tendons is the largest series in the literature. These patients ranged in age from 17 to 55 years. Six patients had experienced a traumatic event. All patients had a delayed diagnosis and were eventually treated operatively. At surgery, three patients were noted to have a completely torn or absent flexor retinaculum. In two patients the retinaculum had avulsed off with a fibrocartilaginous rim, and two patients had a redundant retinaculum. Reconstruction entailed reattaching the avulsed retinaculum through drill holes, imbricating the redundant retinaculum, and primarily repairing the torn retinaculum. All patients had postoperative immobilization in a short-leg cast followed by physical therapy. Results were reported as excellent. Biedert1 described an 18-year-old man who suffered a traumatic dislocation of the posterior tibial tendon. At surgery, the flexor retinaculum was completely disrupted and was reconstructed using bone-in-trough suturing through drill holes in the groove of the medial malleolus. The author suggested augmenting a weak flexor retinaculum with a periosteal sleeve or using the plantaris tendon to create a new retinaculum. Again, results were reported as excellent. The limited literature on dislocation of the posterior tibial tendon suggests that most such incidents are caused by a traumatic event in which inversion or eversion forces act on the dorsiflexed foot. These injuries are most often accompanied by a disruption of the flexor retinaculum and respond well to surgical reconstruction. Our patient did

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not have an apparent traumatic event and the flexor retinaculum was intact. The major question at surgery centered on defining an etiologic basis for the dislocation. Namely, was this a failure of the bony groove, the tendon itself, or the soft tissue restraints holding the tendon in position? The bony groove appeared normal and had not been a source of problems for the patient in the past. The tendon appeared grossly normal without elongation. However, the retinaculum was lax enough that it failed to provide a mechanical restraint to maintain the tendon within the groove. We believe that the lax retinaculum was the source of failure that led to the dislocation of the posterior tibial tendon. This probably occurred through a gradual increase in the laxity of the retinaculum. Once the retinaculum had reached a critical laxity where it no longer was able to maintain the tendon in the groove, the tendon was able to dislocate without significant trauma. Having established that this laxity was the basis for the dislocation, we therefore thought the problem could be addressed by advancing the retinaculum. Using suture

anchors placed into the edge of the medial malleolus, we were able to secure the retinaculum to the malleolus, thereby preventing the posterior tibial tendon from subluxating under the retinaculum. This provided a mechanical restraint and placed the retinaculum in optimal position to scar during healing. The retinaculum was then advanced in a pants-over-vest manner, further increasing its mechanical advantage. This technique has not been reported previously and appears to be a useful procedure for this unusual problem. REFERENCES
1. Biedert R: Dislocation of the tibialis posterior tendon. Am J Sports Med 20: 775776, 1992 2. Healy WA III, Starkweather KD, Gruber MA: Chronic dislocation of the posterior tibial tendon. A case report. Am J Sports Med 23: 776 777, 1995 3. Larsen E, Lauridsen F: Dislocation of the tibialis posterior tendon in two athletes. Am J Sports Med 12: 429 430, 1984 4. Loncarich DP, Clapper M: Dislocation of posterior tibial tendon. Foot Ankle Int 19: 821 824, 1998 5. Nava BE: Traumatic dislocation of the tibialis posterior tendon at the ankle. Report of a case. J Bone Joint Surg 50B: 150 151, 1968 6. Ouzounian TJ, Myerson MS: Dislocation of the posterior tibial tendon. Foot Ankle 13: 215219, 1992