Peroneal brevis pain posterior to the lateral malleolus peroneal longus pain distal at the lateral cuboid Pes planovalgus deformity positive too many toes sign pain or inability to perform single-limb heel raise pain or weakness with resisted inversion of plantar-flexed footĪctivity modification arch support (taping, orthotics, a brace with air cell to lift arch) immobilization with walking boot physical therapy (eccentric exercises) Pain around the posteromedial ankle that radiates along the arch of the foot pain worsened with weight-bearing activity 2 This article reviews the diagnosis and treatment of posterior tibial, peroneal, and tibialis anterior tendinopathies ( Table 2). 4 – 7 The anatomy ( Figure 1 8 ) and pathophysiology of ankle tendinopathy have been described in detail. The cause of tendinopathy is often multifactorial, involving intrinsic and extrinsic risk factors ( Table 1). Tendinopathy refers to tendon degeneration without substantial inflammation and a generally chronic presentation. Abnormal mechanics can result in connective tissue changes and alterations in muscle function. They are responsible for energy absorption and transfer during propulsion, stability during stance, and proprioception. The biomechanics of the foot and ankle are intricate. Lower extremity musculoskeletal conditions, such as ankle sprains, 1 Achilles tendinopathy, 2, 3 and plantar fasciitis, 3 are commonly diagnosed by primary care physicians, whereas other tendon injuries involving the medial (i.e., posterior tibial), lateral (i.e., peroneal), and anterior (i.e., tibialis anterior) ankle can be missed. Surgical debridement can be considered if nonoperative treatment is ineffective. Initial treatment includes immobilization followed by physical therapy. Tibialis anterior tendinopathy presents as anterior ankle and medial midfoot pain and can be diagnosed with a positive tibialis anterior passive stretch test. Treatments include immobilization, laterally posted orthotics, and physical therapy for progressive tendon loading. Varus hindfoot is a known risk factor for peroneal tendinopathy. Peroneal tendon disorders are commonly mistaken for or occur concomitantly with lateral ankle sprains. Surgical treatment is considered for patients who do not respond to nonoperative treatments after three to six months and is based on the specific stage of tendinopathy. Nonoperative treatment options include support for the medial longitudinal arch and physical therapy focusing on eccentric exercises. Patients who have posterior tibial tendinopathy present with medial ankle pain, pes planovalgus deformity, and a positive too many toes sign. The posterior tibial tendon is the main dynamic stabilizing muscle of the medial longitudinal arch. Tendinopathies of the foot and ankle, including posterior tibial, peroneal, and tibialis anterior, are commonly overlooked by primary care physicians.
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