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Tendons & Ligaments

PTT dysfunction & Lisfranc injuries: diagnosis, acute vs chronic management, and reconstructive options for medial ankle instability.

Overview

Tendon and ligament management requires precise indication selection based on patient demand and tissue status. For posterior tibial tendon rupture, determining spring ligament status is essential [4]. In chronic distal biceps tendon ruptures, direct repair is preferred when possible, while autologous tendon graft reconstruction provides predictably good outcomes when direct repair is not feasible [12]. Reinsertion of the distal biceps tendon on the brachialis tendon is a safe, effective procedure with low complication rates and satisfactory long-term results [10]. Proximal hamstring tendon ruptures warrant acute repair in patients desiring a return to sports, whereas nonoperative management with delayed reconstruction is an option for low-demand patients [14]. Surgical treatment is the choice for active patients with Achilles tendon ruptures due to superior functional results and lower rerupture rates compared to non-surgical management [27].

Graft selection and technique vary by application. Bone-patellar tendon-bone grafts are the strongest ligament reconstruction tissue, with mean strength of 159 to 168 per cent of anterior cruciate ligaments, whereas some other graft tissues are markedly weak and prone to elongation at low forces [5]. Both open and arthroscopic biceps tenodesis provide satisfactory outcomes with no identifiable differences, leaving selection to surgeon preference [48]. Tendon lengthening and transfer are indicated for neuromuscular disorders, nerve injuries, and congenital or traumatic lesions [26]. Follow-up studies on eleven of eighteen tendons treated with plantaris tendon reinforcement as a membrane revealed excellent results [1].

Combined procedures and cartilage treatments require cautious indication. Smaller studies including second-look arthroscopy provide the most convincing evidence for combined procedure efficacy [15]. The benefit of high tibial osteotomy augmentation with cartilage treatment is far from proven, warranting caution until more evidence weighs risks and benefits [21]. Advanced microfracture techniques show promise, but indications and technique variability need elucidation in higher-level studies [28].

Anatomy & Pathophysiology

General Considerations

Magnetic resonance imaging plays an increasingly important role in the diagnosis of foot and ankle abnormalities and the planning for their surgical treatment [2]. Heel pain is the most common foot-related symptom [9], with plantar fasciitis being the most common cause [9]. Tarsal-tunnel syndrome is an entity that is probably more common than the literature suggests and is frequently misdiagnosed as acute foot strain or plantar fasciitis [47].

Ligamentous & Tendon Pathology

The posterior fibulotalocalcaneal ligament complex is part of the normal anatomy of the hindfoot [6]. There is little histopathologic evidence to support an inflammatory etiology to the posterior tibial tendons in acquired-adult flatfoot deformity [20]. Gender differences exist in the architectural and mechanical properties of the medial gastrocnemius–Achilles tendon unit in vivo [31]. Males demonstrate better physical fitness, speed, and performance in power-based sports events from a morphology and biomechanics perspective regarding the medial gastrocnemius–Achilles tendon unit [31]. Females have a greater degree of deficit in heel-rise height as compared to males irrespective of treatment for acute Achilles tendon rupture [45].

Kinematics & Deformity

Severe deformities with large amounts of midfoot pronation and hindfoot valgus may be better treated with nonanatomic spring ligament reconstruction methods [32]. Hallux valgus deformity and its severity are positively associated with the magnitude of the anteroposterior postural sway [34]. The anterolateral ligament shows no isometric behavior during the range of motion of the knee [37].

Surgical Implications

New surgical techniques have been developed to expose, inspect, and reliably repair the plantar plate in cases of metatarsophalangeal joint instability of the lesser toes and plantar plate deficiency [38]. Tendon transfer arrests the progression of flat-foot deformity, relieves pain, and restores inversion power of the hind part of the foot, but does not create a normal medial part of the arch in most patients [41]. Pain may be relieved and the ability to stand on the toes may be restored in most patients with acquired adult flat foot secondary to posterior tibial-tendon pathology, despite the position and appearance of the flat foot remaining unchanged [43]. Fascial transplants can close gaps in the kinetic chain to restore stability, prevent deformity, and improve function by transmitting force between muscle groups or to bone [52].

Classification

Imaging and Diagnostic Classification: Magnetic resonance imaging plays an increasingly important role in diagnosing foot and ankle abnormalities and planning surgical treatment [2]. In the hindfoot, the posterior fibulotalcaneal ligament complex is part of the normal anatomy and should be routinely recognized and partly released to access posterior ankle pathology for hindfoot endoscopy [6]. For medial knee anatomy, evidence delineates a consistent three-layered pattern, suggesting specific nomenclature for the superficial medial ligament and posteromedial capsule rather than the term 'posterior oblique ligament' [33].

Tendon and Ligament Morphology: The 'tendon unit' is proposed as a morpho-functional unit influenced by mechanical, hormonal, and pathological stimuli, with restoration of its homeostatic balance as a therapeutic target [22]. Normal tendons do not rupture except at the musculotendinous junction or tendon insertion, typically due to excessive weight application when the muscle is holding at maximum power [17]. Tendon fatigue damage progression from accumulation to fiber rupture illustrates the progression from tendinopathy to full-thickness tearing [8]. The anterior bundle, posterior bundle, and common tendon of the ulnar collateral ligament of the elbow and common flexor-pronator tendon can each be classified into an independent form and an unclear form [23].

Graft and Structural Classification: The bone-patellar tendon-bone graft was the strongest graft tissue, with a mean strength of 159 to 168 percent of that of anterior cruciate ligaments [5]. Some graft tissues used in ligament reconstructions are markedly weak and at risk for elongation and failure at low forces [5]. The LARS Ligament is the only ligament recognized and reimbursed by the Haute Autorité de Santé Française and is useful in 7% of ligament injuries [25]. Human muscle-derived cells contribute to structural and functional repair of injured tendons and are a potential cell source for the repair process after tendon injury [49].

Anatomical Zone Classification: Zone 2 of the flexor hallucis longus tendon sheath can be subdivided into a proximal fibrous zone (2A) and a distal fascial zone (2B) [44].

Other Considerations: Follow-up studies on eleven of eighteen Achilles tendons treated with plantaris tendon reinforcement revealed excellent results [1]. Further exploration during tendon harvest may reveal that a tendon continues past an obstruction level and remains usable [3]. It is essential to determine the status of the spring ligament when managing patients with posterior tibial tendon rupture [4].

Clinical Presentation

Heel pain is the most common foot-related symptom, with plantar fasciitis being the primary etiology [9]. In the hindfoot, the posterior fibulotalcaneal ligament complex constitutes normal anatomy [6]. Os trigonum syndrome typically presents with symptoms managed initially by nonsurgical measures, though symptomatic athletes may require surgical excision of the os trigonum [19].

Posterior tibial tendon disorders encompass traumatic lacerations, dislocations, and tendinopathy, which can lead to significant deformity and disability [35]. When managing posterior tibial tendon rupture, it is essential to determine the status of the spring ligament [4]. Notably, there is little histopathologic evidence to support an inflammatory etiology for posterior tibial tendons in acquired-adult flatfoot deformity [20]. Flexor hallucis tendinitis may present as surgically demonstrated erosive tendinitis with partial tendon rupture [7].

The progression from tendinopathy to full-thickness tearing illustrates damage accumulation leading to fiber rupture [8]. Normal tendons do not rupture except at the musculotendinous junction or insertion, typically due to excessive weight application while the muscle holds maximum power [17]. The 'tendon unit' is proposed as a morpho-functional unit influenced by mechanical, hormonal, and pathological stimuli [22]. Estrogen decreases stiffness in tendons and ligaments, which can decrease power and increase the risk of catastrophic ligament injury [24].

Magnetic resonance imaging plays an increasingly important role in diagnosing a wide range of foot and ankle abnormalities [2]. For Lisfranc ligament injuries, the oblique cross-section is the most important imaging plane as it clearly displays the entire ligament and its attachment points [18]. Ligamentous laxity is clinically significant in the context of patellofemoral instability [16].

Surgical exploration during tendon harvest may reveal that a tendon continues past an obstruction and remains usable [3]. Follow-up studies on Achilles tendons repaired using the plantaris tendon as a reinforcing membrane revealed excellent results in eleven of eighteen cases [1]. Conversely, harvesting the central third of the patellar tendon with the defect left open results in the tendon failing to regain a normal ultrastructure in either the central or peripheral part six years post-operatively [11].

Investigations

MRI: Magnetic resonance imaging plays an increasingly important role in the diagnosis of a wide range of foot and ankle abnormalities and the planning for their surgical treatment [2]. For Lisfranc ligament injuries, the oblique cross-section is the most important section for diagnosis as it clearly displays the entire ligament and its attachment points [18]. In patients managed with a Platelet-Rich Plasma Scaffold for Hepple Stage V Osteochondral Lesion of the Talus, MRI demonstrated complete regeneration of subchondral bone and cartilage in all patients [53]. Following autologous osteochondral mosaicplasty, MRI indicates that the donor site is resurfaced with fibrous tissue [61]. An MRI is justified at three months, one year, two years and five years after third-generation ACI surgery, unless the clinical symptomatology and individual patient needs dictate otherwise [64].

Treatment

Achilles Tendon

Surgical repair is the treatment of choice for Achilles tendon ruptures and should be recommended for more active patients, as it yields significantly better functional results and a lower incidence of reruptures compared to non-surgical treatment [27]. For defects in the tendo achillis, repair using the tendo achillis itself has been suggested [36]. Follow-up studies on eleven of eighteen tendons treated with repair using the plantaris tendon as a reinforcing membrane revealed excellent results [1]. Further exploration during plantaris tendon harvest may reveal that the tendon continues past the level of obstruction and will be usable [3].

Distal Biceps Tendon

Reinsertion of the distal biceps tendon on the brachialis tendon is a safe and effective procedure with a low complication rate, providing satisfactory subjective and objective results at long-term follow-up [10]. When possible, direct repair is preferred for chronic distal biceps tendon ruptures; if not possible, reconstruction with an autologous tendon graft results in predictably good outcomes [12]. Musculotendinous injuries of the distal biceps have a better outcome with a nonoperative approach [40].

Proximal Hamstring Tendons

Acute repair is recommended for patients desiring return to sports following proximal hamstring tendon ruptures [14]. Nonoperative management with delayed reconstruction is an option for low-demand patients with proximal hamstring tendon ruptures [14].

Posterior Tibial Tendon & Spring Ligament

It is essential to determine the status of the spring ligament when managing patients for rupture of the posterior tibial tendon [4].

Flexor Hallucis Tendons

Surgical release is suggested sooner in chronic recurrent cases of flexor hallucis tendinitis rather than waiting for incapacity [7].

Biceps Tenodesis

Both open and arthroscopic biceps tenodesis provided satisfactory outcomes in most patients, with no identifiable differences between the two approaches [42].

Ligament Reconstruction & Grafts

Some graft tissues used in ligament reconstructions are markedly weak and at risk for elongation and failure at low forces [5]. The bone-patellar tendon-bone graft was the strongest ligament reconstruction graft, with a mean strength of 159 to 168 per cent of that of anterior cruciate ligaments [5]. The LARS Ligament is useful and efficient in very specific cases, accounting for 7% of ligament injuries [25].

Tendon Lengthening and Transfer

Tendon lengthening and transfer are indicated for neuromuscular disorders, nerve injuries, and congenital or traumatic lesions [26].

Os Trigonum Syndrome

Treatment for os trigonum syndrome begins with nonsurgical measures [19]. Symptomatic athletes with os trigonum syndrome may require surgical excision of the os trigonum [19].

Heel Pain

Heel pain is the most common foot-related symptom, with plantar fasciitis being the most common cause [9].

Cartilage Restoration

Advanced microfracture techniques for isolated patellar chondral defects showed promise, but indications and variability in techniques need to be elucidated in higher-level studies [28]. The benefit of high tibial osteotomy (HTO) augmentation with cartilage treatment is far from being proven, and caution should be used in giving indications for combined HTO-cartilage treatment until more evidence is available to prove efficacy and weigh risks and benefits [21].

Tendon-Bone Interface Healing

Synthesizing studies on biomechanics, cellular mechanics, and tissue engineering provides an in-depth understanding of tendon-bone healing, offering new directions for clinical treatments to achieve better therapeutic outcomes and rehabilitation for patients with sports injuries [29].

Tendon Fatigue and Damage

The progression of damage accumulation leading to fiber rupture and eventual tendon tearing with higher loading illustrates the progression from tendinopathy to full-thickness tearing [8].

Surgical Efficacy Evidence

Smaller studies that include second-look arthroscopy provide the most convincing evidence for the efficacy of combined procedures [15].

Complications

Graft and Reconstruction Failure: Graft tissues used in ligament reconstructions can be markedly weak, carrying a risk of elongation and failure at low forces [5]. The bone-patellar tendon-bone graft demonstrates superior strength, with a mean strength of 159 to 168 per cent of that of anterior cruciate ligaments [5]. However, harvesting the central third of the patellar tendon leaves a defect that does not regain normal ultrastructure in either the central or peripheral part even six years post-harvest [11]. In challenging anterior cruciate ligament tears with large chondral defects, concurrent reconstruction and autologous chondrocyte implantation may lead to moderately improved pain and function at long-term follow-up [13].

Tendon Repair Outcomes and Morphology: Direct repair of chronic distal biceps tendon ruptures is often not possible; in these cases, reconstruction with an autologous tendon graft yields predictably good outcomes [12]. Reinsertion of the distal biceps tendon on the brachialis tendon is safe and effective, providing satisfactory subjective and objective results with a low complication rate at long-term follow-up [10]. All patients undergoing distal biceps tendon repair experience significant lengthening after surgery, with the greatest amount noted in the early post-operative period [55]. For Achilles tendon tears, repair using the plantaris tendon as a reinforcing membrane resulted in excellent outcomes in follow-up studies of eleven of eighteen tendons [1]. Variant plantaris anatomy during harvest may require further exploration to determine if the tendon continues past an obstruction and remains usable [3].

Tendinopathy and Rupture Progression: The progression of damage accumulation leading to fiber rupture and eventual tendon tearing illustrates the transition from tendinopathy to full-thickness tearing [8]. Surgically demonstrated erosive tendinitis with a partial rupture of the flexor hallucis tendon has been reported in ballet dancers, suggesting surgical release sooner in chronic recurrent cases rather than waiting for incapacity [7].

Ligament Integrity and Classification: Estrogen decreases stiffness in tendons and ligaments, which can decrease power and increase the risk of catastrophic ligament injury [24]. The anterior bundle, posterior bundle, and common tendon of the ulnar collateral ligament of the elbow can each be classified into an independent form and an unclear form [23]. When managing patients with rupture of the posterior tibial tendon, it is essential to determine the status of the spring ligament [4].

Surgical Access and Adjacent Pathology: The posterior fibulotalcaneal ligament complex is part of normal hindfoot anatomy and should be routinely recognized and partly released to achieve access to posterior ankle anatomical pathology relevant for hindfoot endoscopy [6]. Magnetic resonance imaging plays an increasingly important role in the diagnosis of foot and ankle abnormalities and the planning for their surgical treatment [2]. Heel pain is the most common foot-related symptom, with plantar fasciitis being the most common cause [9].

Other Considerations: Both open and endoscopic techniques are effective for treating gluteus medius tears at short- and long-term follow-up, though endoscopic techniques result in fewer postoperative complications such as retear [46]. Forty-seven (96 per cent) of forty-nine shoulders had a good clinical result after distal release of deltoid muscle contracture [30].

Recovery

Light activity (weeks): Evidence does not specify a week range for light activity or desk work in the provided data.

Full activity (months): Evidence does not specify a month range for full activity, manual work, or sport return in the provided data.

Complete recovery / outcome plateau (months): Long-term follow-up data indicates that structural and functional outcomes may not stabilize within standard short-term windows. Ten years after reharvesting the central third of the patellar tendon for anterior cruciate ligament revision surgery, the tendon had not normalized in terms of histological and ultrastructural appearance [59]. Similarly, six years after harvesting the central third of the patellar tendon with the defect left open, the tendon did not regain a normal ultrastructure in either the central or peripheral part [11]. Further studies with long-term follow-up are needed to determine whether the grafted area maintains structural and functional integrity over time following autologous matrix-induced chondrogenesis for focal cartilage defects in the knee [51].

Rehabilitation protocol: Specific rehabilitation protocols, including physical therapy phasing, immobilization duration, or weight-bearing progression, are not detailed in the provided evidence.

Functional milestones: Validated patient-reported outcome measures are not explicitly cited in the provided data. However, clinical results are reported as "excellent" in follow-up studies on eleven of eighteen tendons treated with repair using the plantaris tendon as a reinforcing membrane [1]. Reinsertion of the distal biceps tendon on the brachialis tendon provides satisfactory subjective and objective results at long-term follow-up [10]. Concurrent anterior cruciate ligament reconstruction and autologous chondrocyte implantation for challenging cases with large chondral defects can lead to moderately improved pain and function at long-term follow-up [13]. Forty-seven of forty-nine shoulders (96 per cent) had a good clinical result after distal release of deltoid muscle contracture [30]. The presence of chondrosis at the time of surgery is an important prognosticator of functional outcome at intermediate follow-up in late multiple ligament and posterolateral corner-reconstructed knees [57].

Other Considerations: Surgical decision-making and recovery trajectories are influenced by specific anatomical and pathological factors. Magnetic resonance imaging plays an increasingly important role in the diagnosis of foot and ankle abnormalities and the planning for their surgical treatment [2]. Further exploration during tendon harvest may reveal that a tendon continues past an obstruction level and remains usable [3]. Surgical release is suggested sooner in chronic recurrent cases of flexor hallucis tendinitis with partial rupture rather than waiting for incapacity [7]. When direct repair is not possible for chronic distal biceps tendon ruptures, reconstruction with an autologous tendon graft results in predictably good outcomes [12], whereas direct repair is preferred when possible [12]. Acute repair is recommended for proximal hamstring tendon ruptures in patients desiring a return to sports [14], while nonoperative management with delayed reconstruction is an option for low-demand patients with proximal hamstring tendon ruptures [14]. Bone-patellar tendon-bone grafts are the strongest graft tissues used in ligament reconstructions, with a mean strength of 159 to 168 per cent of that of anterior cruciate ligaments [5]. Some graft tissues used in ligament reconstructions are markedly weak and at risk for elongation and failure at low forces [5]. The posterior fibulotalocalcaneal ligament complex is part of the normal hindfoot anatomy and should be routinely recognized and partly released to achieve access to posterior ankle anatomical pathology relevant for hindfoot endoscopy [6]. Apoptosis in healing tendons peaks at day 3, followed about 10 days later by the peak proliferation period [63]. Frozen articular cartilage at one year showed biochemical and morphological changes typical of degenerative joint disease [62].

Key Evidence

  • [L4] Follow-up studies on eleven of eighteen tendons so treated revealed excellent results. (10.2106/00004623-196648020-00005)
  • [L5] Magnetic resonance imaging of the foot and ankle is playing an increasingly important role in the diagnosis of a wide range of foot and ankle abnormalities and the planning for their surgical treatment. (10.5435/00124635-200105000-00005)
  • [L4] Further exploration may reveal that the tendon continues past the level of obstruction and will be usable. (10.1016/j.jhsa.2021.01.004)
  • [L4] It is essential to determine the status of the spring ligament when patients are managed for rupture of the posterior tibial tendon. (10.2106/00004623-199705000-00006)
  • [L5] Some graft tissues used in ligament reconstructions are markedly weak and at risk for elongation and failure at low forces, whereas the bone-patellar tendon-bone graft was the strongest with a mean strength of 159 to 168 per cent of that of anterior cruciate ligaments. (10.2106/00004623-198466030-00005)
  • [L5] The PFTCLC is part of the normal anatomy of the hindfoot and should be routinely recognized and partly released to achieve access to the posterior ankle anatomical pathology relevant for hindfoot endoscopy. (10.1007/s00167-020-06431-5)
  • [Case_report] The author reports a surgically demonstrated erosive tendinitis with a partial rupture of the tendon, distinct from other described conditions, and suggests surgical release sooner in chronic recurrent cases rather than waiting for incapacity. (10.2106/00004623-198163090-00018)
  • [L5] The progression of damage accumulation leading to fiber rupture and eventual tendon tearing seen with higher loading illustrates the progression from tendinopathy to fullthickness tearing. (10.1016/j.jse.2011.11.014)
  • [L4] Reinsertion of the distal biceps tendon on the brachialis tendon can be considered a safe and effective procedure with low complication rate, providing satisfactory subjective and objective results at long-term follow-up. (10.1007/s00167-008-0705-9)
  • [L3] Six years after the central third of the patellar tendon is harvested and the defect is left open in humans, the tendon did not regain a normal ultrastructure either in the central or in the peripheral part, as seen using transmission electron microscopy. (10.1177/0363546506293898)
  • [L3] This suggests that when possible direct repair is preferred, however, if not possible, reconstruction with an autologous tendon graft results in predictably good outcomes. (10.1016/j.jse.2019.01.006)
  • [L4] Challenging cases of ACL tears with large chondral defects treated with concurrent ACL reconstruction and ACI can lead to moderately improved pain and function at long-term follow-up. (10.1177/2325967117693591)
  • [L3] Acute repair is recommended for patients desiring return to sports, while nonoperative management with delayed reconstruction is an option for low-demand patients. (10.1177/2325967113s00061)
  • [L5] The authors believe that smaller studies that include second-look arthroscopy provide the most convincing evidence for the efficacy of these combined procedures. (10.1016/j.arthro.2017.01.005)
  • [L3] LAX, which is clinically significant. (10.1177/2325967116s00127)
  • [L4] The oblique cross-section is the most important section for the diagnosis of Lisfranc ligament injuries as it clearly displays the entire ligament and its attachment points. (10.1186/s13018-018-0968-x)
  • [L5] Treatment begins with nonsurgical measures, but symptomatic athletes may require surgical excision of the os trigonum. (10.5435/jaaos-22-09-545)
  • [L4] There is little histopathologic evidence to support an inflammatory etiology to the posterior tibial tendons in acquired-adult flatfoot deformity. (10.1097/01.blo.0000218759.42805.43)
  • [Letter] The benefit of an HTO augmentation with a cartilage treatment is far from being proven, and caution should be used in giving indications for a combined HTO-cartilage treatment until more evidence is available to prove their efficacy and to weigh their risks and benefits. (10.1016/j.arthro.2017.01.006)
  • [L5] The authors propose the concept of the 'tendon unit' as a morpho-functional unit influenced by mechanical, hormonal, and pathological stimuli, hypothesizing that restoration of its homeostatic balance should be a therapeutic target. (10.1186/s13018-023-03796-4)
  • [L5] These results suggest that the anterior bundle, posterior bundle, and common tendon each can be classified into an independent form and an unclear form. (10.1177/2325967120952415)
  • [L5] Estrogen improves muscle mass and strength and increases collagen content in connective tissues, but decreases stiffness in tendons and ligaments, which can decrease power and increase the risk of catastrophic ligament injury. (10.3389/fphys.2018.01834)
  • [L5] The LARS Ligament has never been banned and is the only ligament recognized and reimbursed by the Haute Autorité de Santé Française; it is useful and efficient in very specific cases (7% of ligament injuries). (10.1016/j.arthro.2016.02.003)
  • [L5] Tendon lengthening and transfer are indicated for neuromuscular disorders, nerve injuries, and congenital or traumatic lesions. (10.1016/j.otsr.2014.07.033)
  • [L3] Surgical treatment is the treatment of choice and should be recommended for more active patients due to significantly better functional results and a lower incidence of reruptures compared to non-surgical treatment. (10.2106/00004623-197658070-00015)
  • [L4] Advanced microfracture techniques showed promise, but indications and variability in techniques need to be elucidated in higher-level studies. (10.1177/23259671231153422)
  • [L5] Synthesizing studies on biomechanics, cellular mechanics, and tissue engineering provides an in-depth understanding of tendon-bone healing, offering new directions for clinical treatments to achieve better therapeutic outcomes and rehabilitation for patients with sports injuries. (10.1186/s13018-024-05304-8)
  • [L3] Forty-seven (96 per cent) of the forty-nine shoulders had a good clinical result after distal release of the contracture. (10.2106/00004623-199802000-00010)
  • [L4] Gender differences exist in the architectural and mechanical properties of the medial gastrocnemius–Achilles tendon unit in vivo, with males demonstrating better physical fitness, speed, and performance in power-based sports events from a morphology and biomechanics perspective. (10.3390/life11060569)
  • [L5] Severe deformities with large amounts of midfoot pronation and hindfoot valgus may be better treated with nonanatomic reconstruction methods. (10.1186/s13018-019-1154-5)
  • [L5] The study delineated a consistent three-layered anatomical pattern of the medial knee, suggesting the use of specific nomenclature for the superficial medial ligament and posteromedial capsule rather than the term 'posterior oblique ligament'. (10.2106/00004623-197961010-00011)
  • [L4] Hallux valgus deformity and its severity were positively associated with the magnitude of the anteroposterior postural sway. (10.1186/s12891-021-04385-4)
  • [L5] This article provides a review of posterior tibial tendon pathology and the authors' preferred management, covering traumatic lacerations, dislocations, and tendinopathy leading to deformity and disability. (10.1177/0363546509359492)
  • [L4] A repair using the tendo achillis itself has been suggested. (10.2106/00004623-195638010-00011)
  • [L5] The ALL shows no isometric behavior during the range of motion of the knee. (10.1177/2325967114562205)
  • [L5] New surgical techniques have been developed to expose, inspect, and reliably repair the plantar plate, if necessary. (10.5435/jaaos-22-04-235)
  • [L4] Musculotendinous injuries of the distal biceps have a better outcome with a nonoperative approach, although this report does not compare surgical intervention with nonsurgical treatment. (10.1016/j.jse.2006.06.009)
  • [L4] Tendon transfer does not create a normal medial part of the arch in most patients, but our method arrests the progression of the flat-foot deformity, relieves pain, and restores inversion power of the hind part of the foot. (10.2106/00004623-198567090-00027)
  • [L4] Both open and arthroscopic biceps tenodesis provided satisfactory outcomes in most patients, and there were no identifiable differences in this review. (10.1016/j.arthro.2015.07.028)
  • [L4] Pain may be relieved and the ability to stand on the toes may be restored in most patients, despite the fact that the position and appearance of the flat foot are unchanged. (10.2106/00004623-198668010-00012)
  • [L5] The zone 2 FHL tendon sheath can be subdivided into a proximal fibrous zone (2A) and a distal fascial zone (2B). (10.1016/j.arthro.2009.11.007)
  • [L2] Females have a greater degree of deficit in heel-rise height as compared to males irrespective of treatment. (10.1177/2325967114s00055)
  • [L5] Both open and endoscopic techniques are effective for treating gluteus medius tears at short- and long-term follow-up, though endoscopic techniques result in fewer postoperative complications such as retear. (10.1016/j.arthro.2022.05.002)
  • [L4] The tarsal-tunnel syndrome is an entity that is probably more common than the literature suggests and is frequently misdiagnosed as acute foot strain or plantar fasciitis. (10.2106/00004623-196244010-00015)
  • [L4] Both techniques provide satisfactory outcomes in most patients with no identifiable differences, suggesting surgeon preference may dictate technique selection. (10.1016/j.arthro.2015.12.017)
  • [L5] Human MDCs contribute to structural and functional repair for the injured tendon and are a potential cell source to participate in the repair process after tendon injury. (10.1177/03635465221147486)
  • [L4] However, further studies with long-term follow-up are needed to determine whether the grafted area will maintain structural and functional integrity over time. (10.1007/s00167-010-1042-3)
  • [L4] Fascial transplants can close gaps in the kinetic chain to restore stability, prevent deformity, and improve function by transmitting force between muscle groups or to bone. (10.2106/00004623-196345010-00021)
  • [L4] MRI demonstrated complete regeneration of subchondral bone and cartilage in all patients with significant improvement in functional scores. (10.1155/2017/6525373)
  • [L4] All patients undergoing distal biceps tendon repair have significant lengthening after surgery, with the greatest amount noted in the early post-operative period. (10.1177/2325967117s00400)
  • [L4] The presence of chondrosis at the time of surgery is an important prognosticator of functional outcome at intermediate follow-up. (10.1177/0363546507311091)
  • [L3] Ten years after its central third was reharvested for anterior cruciate ligament revision surgery, the patellar tendon had not normalized in terms of its histological and ultrastructural appearance. (10.1177/0363546507311092)
  • [L4] However, magnetic resonance imaging indicates that the donor site is resurfaced with fibrous tissue. (10.1177/0363546507306465)
  • [L5] Frozen articular cartilage at one year showed biochemical and morphological changes typical of degenerative joint disease. (10.2106/00004623-197658040-00015)
  • [L5] Apoptosis in the healing tendons peaks at day 3, followed about 10 days later by the peak proliferation period. (10.1016/j.jhsa.2009.10.021)
  • [L2] An MRI is justified at three months, one year, two years and five years after surgery, unless the clinical symptomatology and individual patient needs dictate otherwise. (10.1177/2325967121s00183)

See Also

References

[1] Repair of the Torn Achilles Tendon, Using the Plantaris Tendon as a Reinforcing Membrane. The Journal of Bone & Joint Surgery. 1966. DOI: 10.2106/00004623-196648020-00005

[2] Magnetic Resonance Imaging of the Foot and Ankle. Journal of the American Academy of Orthopaedic Surgeons. 2001. DOI: 10.5435/00124635-200105000-00005

[3] Variant Plantaris Anatomy During Tendon Harvest. The Journal of Hand Surgery. 2021. DOI: 10.1016/j.jhsa.2021.01.004

[4] Rupture of the Posterior Tibial Tendon. Evaluation of Injury of the Spring Ligament and Clinical Assessment of Tendon Transfer and Ligament Repair. The Journal of Bone and Joint Surgery (American Volume)*. 1997. DOI: 10.2106/00004623-199705000-00006

[5] Biomechanical analysis of human ligament grafts used in knee-ligament repairs and reconstructions.. The Journal of Bone & Joint Surgery. 1984. DOI: 10.2106/00004623-198466030-00005

[6] The posterior fibulotalocalcaneal ligament complex: a forgotten ligament. Knee Surgery, Sports Traumatology, Arthroscopy. 2021. DOI: 10.1007/s00167-020-06431-5

[7] Flexor hallucis tendinitis in a ballet dancer. A case report.. The Journal of Bone & Joint Surgery. 1981. DOI: 10.2106/00004623-198163090-00018

[8] Basic mechanisms of tendon fatigue damage. Journal of Shoulder and Elbow Surgery. 2012. DOI: 10.1016/j.jse.2011.11.014

[9] Chapter 116 Heel Pain. 2019.

[10] Surgical repair of the distal biceps brachii tendon: clinical and isokinetic long‐term follow‐up. Knee Surgery, Sports Traumatology, Arthroscopy. 2009. DOI: 10.1007/s00167-008-0705-9

[11] Ultrastructural Collagen Fibril Alterations in the Patellar Tendon 6 Years after Harvesting Its Central Third. The American Journal of Sports Medicine. 2007. DOI: 10.1177/0363546506293898

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