Spontaneous Injuries

Naples, Florida remains one of the most active communities I have lived in, with patients ranging in age from 60-90 years old still playing tennis and golf. Many of these same patients are very healthy and walk multiple miles every day. In lieu of the very active lifestyle that our patients enjoy, we have noticed many of these patients experience various forms of tendonitis and in some cases spontaneous tendon ruptures. Even though this can seem intuitive that with wear and tear our tendons may break down over time, some points about this pathology are notable and should be reviewed to answer a key point in this discussion: "why would this happen?"

TIBIALIS ANTERIOR:



We have had several patients complain of sudden inability to lift up the foot at the ankle, and pain in the front of the ankle with increased swelling and soreness. Usually after 4 days this pain subsides but function of the ankle becomes less efficient and eventually one will notice toes are grasping at the floor and the inside of the foot remains lowered during the "swing phase" of walking. This is a partial foot drop.

On average, the area corresponding to 0.5 to 3.0 cm proximal to its bony insertion is the most frequently reported site of spontaneous rupture of tibialis anterior tendon. This region of avascularity also corresponded to the location of superior and inferior retinacula, which serve as pulleys for the ATT mechanism. The hypothesis is that the hypoxic state of the tissue in this critical zone and the chronic impingement by the retinacula render this region vulnerable to chronic degeneration and, eventually, to rupture. This hypothesis is also believed to pertain to the Achilles and posterior tibialis tendons with their corresponding anatomy and fascial impingements.

ACHILLES TENDON:






We see this spontaneous rupture very commonly in "weekend warrior" type individuals, who remain very active on Saturday but otherwise are not apt to consistent exercise. Usually this tendon will forcibly stretch while the individual is propulsing off the ground, leaving excessive force passing thru the tendon leading to the rupture. Although the Achilles tendon is the strongest and largest in the body, it also recieves the most force on a consistent basis, which may lead to degredation over time. Chronic pain in the tendon which seems to never fully resolve may actually be the bodys attempt to heal this area, when in actuality the chronic inflammation leads to weakening of the collagen bridges that give much of the tensile strength of this structure, and over time it becomes thickened and eventually may rupture.


POSTERIOR TIBIAL TENDON:





This tendon has a long history of slow, progressive weakening which leads to flatfoot deformity in adulthood. Usually the tendon is not likely to spontaneously rupture until a patient is in their forties. Being overweight is a major contributing factor to this tendon being problematic. Many patients are wrongly diagnosed initially with plantar fasciitis, and this heel pain leads to medial foot pain, and eventually ankle pain.


Many patients will also experience atypical tendon ruptures just from their other comorbidities. Rheumatoid arthritis, and other autoimmune disorders will have a much higher rate of spontaneous tendon ruptures. Also many patients who have been on various antibiotic therapy may experience widespread tendonitis and sometimes ruptures. Many times longstanding tendonitis (especially of the achilles tendon) will lead to eventual rupture without proper treatment and immobilization.

Don't ignore pain in the foot and ankle, as it may be your body's way to warn you of a possible tendon rupture waiting to happen!!

Dr Timm