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This is a 56-year-old male that has

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osteoarthritis, instability, innumerable

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complaints, and also a question of deficiency

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or tear of the posterior tibial tendon.

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So let's talk about this tendon for a minute,

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which arises from the tibia and fibula and

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inserts on the navicular, on the medial

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cuneiform, and then has small areas of

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insertion on virtually every bone of the

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midfoot and even on the base of the metatarsals.

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This is a foot structure that is

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involved in the eversion process.

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Inversion is usually formed by the fibularis

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brevis and longus and is its antagonist.

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So now let's move on to the case itself.

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Let's scroll the case and

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the findings are massive.

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It's one of these overwhelming cases.

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Where do you start?

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What's your search pattern?

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And I would suggest that with an arthritic

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case like this, with effusions everywhere,

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that you start out simple with just a skeleton.

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25 00:01:05,200 --> 00:01:07,060 So you go up and down on the skeleton.

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You can either go axial or sagittal.

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I'm using axial simply because I know that

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the posterior tibial tendon is at risk and

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it's easier to see axial than sagittal.

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Most of the time, I begin sagittal.

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And I always begin with a

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fat weighted and a water weighted.

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Unfortunately, I don't have

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any fat weighted axials.

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So I'm going with my T2 and my

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heavily fat-suppressed PD SPIR.

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So let's scroll and look

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at the bones for arthritis.

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Yes, there's osteoarthritis.

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Yes, there is spurring.

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But not horrible.

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And there are some changes in the

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bone that consist of erosions.

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What am I going to do next?

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I'm going to look at the ligamentous

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anatomy because I have a history

1:50

of instability and osteoarthritis.

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And I cannot really find an

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anterior talofibular ligament.

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It's gone and that's why there's instability.

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If there's no anterior talofibular ligament

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and it looks that bad, the odds of having

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an intact calcaneofibular ligament, low.

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In fact, it stops right there.

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It's too thick.

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It's torn.

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How about the posterior talofibular ligament?

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That's part of my search pattern.

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You already know from prior discussion that

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that never tears unless you have an ankle

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dislocation, which there's no history of.

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And here are some fibers of the

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posterior talofibular ligament.

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Let's go higher into the high ankle,

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where we see a deficient anterior tib-fib

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ligament, maybe a little widening of the

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syndesmosis, and some irregularity and ill

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definition of the posterior tib-fib ligament.

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But it certainly doesn't look acute.

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So I'm covering my ligaments.

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I don't really care that much

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at this point about the deltoid.

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Although the deltoid is swollen,

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we hardly ever repair it.

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We'll come back to it.

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The retinacula.

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I would do a quick check.

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Extensor.

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Lateral.

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Medial.

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And also see what's going on with the posterior

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medial and posterior lateral retinacula.

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All of which are slightly wavy.

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thickened, and somewhat redundant. Now, coming back to my skeleton, even

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though I have lots of spurs, I am paying

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very careful attention to certain ones,

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like the spurs in the retrofibular groove,

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because I want to know if I'm at risk for

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having a peroneus longus and brevis tear, and I do have one.

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I have a peroneus brevis split tear evolving

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right here in this spurred irregular groove.

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What's another groovy thing

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that I'm interested in?

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I'm interested in the posteromedial and lateral

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processes and their groove, which is narrowed.

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It's dysplastic and the spurs that come off them.

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In other words, the hallucis isn't

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sitting very nicely in the groove.

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Is the hallucis torn?

3:54

Well, no.

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There's the hallucis tendon and muscle.

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It's not torn.

3:58

Is it normal?

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No, it's a little gray on the PD SPIR.

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It's getting a little grayer.

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It's getting a little grayer and a little

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fibrillated and a little irregular.

4:08

It's sitting behind these two small

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excrescences, but no, it's not torn.

4:16

Okay?

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Let's move on to the rest of

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the structures on that side.

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We've already talked briefly

4:23

about the brevis and longus.

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We didn't track them all the way because

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that's not what this case is about.

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But we would have in the proper situation.

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And it would have gone achilles, one,

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120 00:04:32,972 --> 00:04:37,690 peroneus brevis and longus, two, three, Tom, Dick, and Harry.

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Tom is nowhere to be found.

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And then, Tom, Harry, Dick,

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and the peroneus tertius.

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So, one, three, four.

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Where there should be three, there's only two.

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We've got a problem.

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And no, that is not the posterior tibial tendon.

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That is a vessel.

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So let's go up high so we

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can find the three tendons.

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And there they are.

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There is Tom.

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Tom is huge.

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There's Dick.

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And here is Harry.

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Now let's follow Tom.

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Tom is a big fat thing right here.

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There's Tom.

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It's getting thinner.

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There's Tom.

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There's Tom sitting behind this irregular

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tibial groove, which should not have a spur.

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So now we got three groovy areas to check out.

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The retrofibular groove, the groove between the

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posteromedial, and lateral talar processes,

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and then a groove that does not belong along

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the medial free edge of the tibia, which is

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associated with posterior tibial tendon tears.

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150 00:05:45,905 --> 00:05:47,055 Let's keep going, shall we?

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Wait a minute.

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Where did Tom go?

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There's Tom.

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Tom's getting smaller.

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Tom's getting smaller.

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Tom is gone.

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There's a big hole.

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So Tom's retracted way, way up.

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Now let's see if we can find Tom down.

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So, no Tom.

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There's Dick.

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There's Harry.

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There's the neurovascular bundle.

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Let's keep going, shall we?

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Our superficial ligament looks terrible.

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It's thickened.

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It's irregular.

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It's got a tear in it.

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But we need to find Tom.

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Run the hunt

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for red October for Tom.

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No Tom, just fluid.

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We're gonna find Tom, right at the very end.

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Here comes Tom, right as it

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inserts on the navicular.

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And you can see one of the slips

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going off towards the cuneiforms.

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There are innumerable slips.

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Because there's so much fluid in the ankle

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joint, dissecting down into the patent,

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we can see Henry's master knot, and the knot

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consists of the crossing of the flexor digitorum and hallucis.

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They come together, and sometimes this

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big sheath that's distended full of

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fluid is confused with a ganglion.

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It's simply fluid coming

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down from the ankle joint,

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offloading into this space.

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We also have fluid around the peroneus

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longus, which is going plantar,

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and the peroneus brevis, which is intact.

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We also have a large, irregular,

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degenerated tear with intrasubstance

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delamination of the tibialis anterior.

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So, lots of things are going on in this

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ankle as we do our complete axial survey.

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Let's put up the sagittal, shall we?

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Because we need to see where the torn end is.

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Now, that is the stump right there of

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what's left of Tom, the tibialis anterior.

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There's Harry in the front.

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You could easily come up with a

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pitfall where you confuse the flexor

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digitorum with the tibialis posterior.

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That would be a mistake.

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Where is the tibialis posterior?

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Up here.

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So there is a tremendous amount of

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separation between that location and

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this location, which you have to measure.

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You should also measure above,

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either the anterior or posterior funiculus or interfunicular

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groove of the tibia

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so the clinician knows exactly where to go fishing

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for the proximal end of the tibialis posterior.

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Now let's keep scrolling a sagittal and we

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see our large pseudomass and Henry's master

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knot tracking down from the joint space.

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We're also doing our inspection again of bones.

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There are innumerable erosions.

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We're not going to spend a tremendous amount

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of time talking about the arthritis other than

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the massive anterior spur that is contributing

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to anterior tibiotalar impingement syndrome.

8:55

But the coronal fat suppression water-weighted

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image has limited value in this particular case.

9:02

It will show you the very swollen irregular

9:05

deltoid and all the osteoedema of the medial

9:10

malleolus and the lateral malleolus from

9:12

arthrosis, reactive edema, and micro instability.

9:16

But I'm more interested in where is, where is Tom?

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And that's a tough one to solve.

9:22

There's Tom right there.

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That's the stump of Tom.

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There's nothing going down beyond that.

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So, if we want to find the proximal end,

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we'd measure from some key landmark to

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this location to assist the surgeon.

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Now while we're at it, we also found some bodies,

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some synovial metaplastic bodies, that were

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hanging around in the flexor hallucis sheath.

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So we're doing a capsular check.

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We're looking for other bodies.

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There's another body.

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And we could keep going.

9:54

So we're going to search the entire

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articular surface for erosions,

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and bodies, and hyperplasia, and metaplasia.

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That's all part of the search pattern.

10:05

We're going to look for soft tissue masses,

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innumerable ones, all consisting of capsular

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distension, bursal distension, and stuff

10:16

that is located within these structures.

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We're also going to do an overall bone survey

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again in the other projection, just to make sure

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there isn't a specific pattern of bone injury.

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And then finally, in a case like this,

10:29

although not relevant, we would be

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checking for the neurovascular bundle,

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especially in the posterior tibial region,

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to make sure that the patient doesn't have

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a mass there that's encroaching on the

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neurovascular bundle structures, and there isn't.

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Searching for classic tarsal tunnel syndrome.

10:47

And we also alluded to our search for anterior

10:50

and posterior impingement, which this patient has.

10:53

And finally on our way out, we'll check the

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plantar fascia, which is probably the best

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thing that this patient has going for them.

11:00

An example of massive

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posterior tibial tendon tear.

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Small peroneus brevis tear, small tibialis

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anterior tendon tear, anterior impingement

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syndrome, tibiotalar posterior impingement

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syndrome, tibiotalar capsulitis,

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synovial metaplasia, osteoarthritis, and

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the list, and hits, just keep on coming.