Background & Etiology

There are over 30 joints in the foot. The joints in the foot include the subtalar, talonavicular, calcaneocuboid, the metatarsocunieform joints, and the metatarsophalangeal joints. The precise movement of these joints as they work together is what enables us to run, walk, and jump. Tendons are connective tissues that attach muscle to bone. They are strong, fibrous structures that transfer the forces generated by the muscle to the bone, producing movement at the joint. The tendons in the foot are subject to significant stress, and can rupture under extreme pressure.

Tendon Rupture

When a tendon ruptures it can be extremely painful and cause a disability of the foot and ankle. A tendon rupture untreated can result in damage to the joints of the foot and ankle. The tendons in the foot include: the peroneals (peroneus brevis, peroneus longuis,) anterior tibialis, posterior tibialis, and Achilles tendon. Any of these structures may rupture, resulting in a serious condition that will typically require surgery to fix.

Achilles Tendon

The Achilles tendon is the largest tendon in the body. It is formed where the gastrocnemius muscle and soleus muscle of the calf join together. It runs from the calf muscles to the heel bone. The Achilles tendon plays a significant role in the ability to walk, run, stand on one’s toes and jump. Because the calf muscles are used for activities that produce great stress on the Achilles tendon, it is one of the most frequently ruptured tendons in the body. Pain from an Achilles tendon rupture commonly occurs at the back of the foot in the vicinity of the heel.

Posterior Tibialis Tendon

The posterior tibialis tendon is located along the inner side of the foot and ankle. It connects the posterior tibial muscle (located at the back of the shin bone) to the foot. Problems with this tendon typically occur underneath the prominence of the medial malleolus (inner ankle bone) because this tendon typically has a poor blood supply and is thus prone to injury and rupture.

Peroneal Tendon

There are two peroneal tendons, the peroneus longus and the peroneus brevis. These tendons run along the outside of the foot and ankle and are subject to the repetitive forces from walking and standing. Pain with this condition is typically located along the posterolateral area of the foot and ankle.

Anterior Tibialis Tendon

The tibialis anterior is a muscle located along the front of the tibia (shin bone). It is attached to the foot by the tibialis anterior tendon. This structure is responsible for the dorsiflextion of the foot and ankle. The anterior tibialis muscle plays a large role in dorsiflextion and deceleration of the foot when walking and running. Stress from a variety of movements including walking, running, or kicking, can cause the tibialis anterior tendon to rupture in the foot. Pain with this condition is typically concentrated along the front of the ankle or foot.

Common causes of a foot tendon rupture include:

  • The progression of or the final result of longstanding tendinitis of the involved tendon or an overuse injury.
  • An injury to the foot or a direct blow to the tendon.
  • As a result of a fall where an individual lands awkwardly on the foot
  • Laceration of the tendon
  • Weakness of the associated muscle in people with existing tendinitis places increased stress on the involved tendon.
  • Steroid use has been linked to tendon weakness
  • Certain systemic diseases have been associated with tendon weakness.
  • A sudden deceleration or stopping motions that cause an acute injury of the foot.
  • Injection of steroids to the involved tendon or the excessive use of steroids has been known to weaken tendons and make them susceptible to rupture.
  • Foot pain and swelling
  • Possible audible pop when the foot is injured, particularly the Achilles tendon.
  • Patient may have a history of prior foot pain or tendinitis, and may be active in sports.
  • Swelling, tenderness and possible discoloration or ecchymosis in the foot.
  • Indentation above the injured tendon where the torn tendon may be present.
  • Difficulty moving around or walking.
  • Individual has difficulty or is unable to move their foot with full range of motion.
  • MRI can confirm disruption or tear in the tendon.
  • Immediate pain at time of injury.

Early diagnosis and treatment is the key to a successful outcome for a rupture of any of the tendons in the foot. If diagnosis or treatment is delayed the integrity of the healing tissue can be compromised as a result of scarring and decreased blood flow. Surgical repair followed by structured and aggressive physical therapy is the treatment of choice for complete ruptures. In the case of a small partial tendon tear conservative treatment without surgery is an option.

Partial (small) Tendon Tear

  • Immobilization of the foot for 3-6 weeks to rest and promote healing. Individual will be placed in an immobilizer or brace and will move around with crutches to keep weight off of the foot.
  • Physical Therapy: following the period of immobilization your physician will decide when you are ready for physical therapy. Treatment will emphasize gradual weaning off the immobilizing device, increasing weight bearing, restoration of foot and ankle range of motion and strengthening of the associated muscles. It is important that the physician and therapist communicate during the early stages and progress your recovery program based on the principles of healing so as not to compromise the injured tendon.
  • Patient will be progressed to more functional activities as normal foot range of motion and strength is restored.

Complete Tendon Ruptures

  • Immediate surgical repair of the tendon is indicated in complete tears. Delaying surgery can lead to shortening of the tendon, formation of scar tissue and decreased blood flow, which can lead to a poor outcome.
  • Following surgery your foot will be put in an immobilizing device and you will be instructed to use crutches to limit weight bearing and protect the joint.
  • Over the next 2-6 weeks weight bearing will be increased and physical therapy will be initiated depending on the severity of the tear.
  • The surgeon will determine the physical therapy timeline and program.
  • Physical Therapy: treatment will emphasize gradual weaning off the immobilizing device, increasing weight bearing, restoration of foot range of motion and strengthening of the associated muscles. It is important that the physician and therapist communicate during the early stages and progress your program based on the principles of healing so as not to compromise the involved tendon.
  • Patient will be progressed to more functional activities as normal foot range of motion and strength is restored.

Physical therapy for a tendon rupture must remain conservative at the onset in order to protect the repair. Emphasis will be on rest, tendon protection, reducing the inflammation and increasing the blood circulation for healing. Following the surgeon’s timeline and protocol, a program of progressive weight bearing, stretching and strengthening will be initiated.

Common Physical Therapy interventions in the treatment of Foot Tendon Rupture include:

  • Manual Therapeutic Technique (MTT): hands on care including soft tissue massage, stretching and joint mobilization of the foot by a physical therapist to improve joint mobility and range of motion of the foot. Use of mobilization techniques also helps to modulate pain.
  • Therapeutic Exercises (TE) including stretching and strengthening exercises to regain range of motion and strengthen the muscles of the foot and lower extremity.
  • Neuromuscular Reeducation (NMR) to restore stability, retrain the lower extremity and improve movement techniques and mechanics (for example, running, kneeling, squatting and jumping) of the involved lower extremity to reduce stress on the tendons in daily activities. Taping, strapping or bracing may be indicated to rest the tendon and promote healing.
  • Modalities including the use of ultrasound, electrical stimulation, ice, cold, laser and others to decrease pain and inflammation of the involved tendon and burse.

Prognosis

If repair and treatment are initiated immediately, individuals with a rupture or tear of any of the tendons in the foot generally do well. Delay can result in the formation of scar tissue and retraction of the tendons. Other factors that can affect recovery are:

  • Age: Older individuals are generally weaker and take longer to heal affecting the functional outcome.
  • Strength: Individuals who are strong and in good condition prior to the injury generally do better following surgical repair.
  • Tissue: Tissue quality prior to the surgical repair will effect healing and recovery following surgery. Poor circulation and presence of scar tissue will interfere with the healing process.

The healing time for a tendon repair will take up to 8-12 weeks but restoration of function and ability to accept full activity, load and stress can take up to one year.

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