Tibial Tendon Injury?

author : AMSSM

comments : 0

Rest, though unwanted, may be only answer

Member Question from fitnesskelly:

I hurt mine almost three weeks ago doing a high knees exercise in a boot camp class at one of those heart rate training chain places (I do not recommend joining one - I joined as an alternative to swimming, stationary cycling and rowing indoors and was injured on my 3-4 class doing an exercise that they admitted was dangerous - high knees with a resistance band trying to pull me backwards. Now I regret joining). My foot landed wrong and ankle rolled out. It made the most disgusting series of pops. I stopped, went home, iced it 4x's a day, rested and took lots of Advil.

I saw the doc as soon as I could (three days later). The doctor X-rayed and I guess didn't see any kind of damage on the X-ray. He said I probably jammed the tendon and offered me a boot to wear for four weeks. They said I could keep exercising, but not to go crazy (rowing, swimming, upper body...found swimming hurt it unless I use a buoy, also found easy stationary cycling is OK). However, I've backed off to very little and I just try to sit a lot when I don't have to go somewhere so I can rest it. I'm finding that the pain is still as bad as when I hurt it. No bruising, but swelling on the inside and outside of my ankle. Pain into my arch. No way I will be out of the boot after four weeks. Follow-up appointment is scheduled for six weeks out, but I'm considering asking to move up to four weeks because I'm worried the tendon is torn and they will want to do a MRI and maybe surgery.

I've had a number of injuries and this is one of the worst in terms of pain. If needing surgery, I want to do that sooner rather than later so I'm healed up by June 1.

Answer from Steve N Green PA student and Aaron D Campbell, M.D.
Member AMSSM

First, let’s acknowledge that being injured when you are an athletic person is no fun. These are the scenarios that require the tenets of rest and patience, not often utilized by we athletes. From the description of your injury you have had a severe ankle sprain with possible tendon involvement. Clinically, the ability to bear weight is one of the primary indicators when evaluating any ankle injury, and it sounds like this has been problematic since the injury. Your doctor acted prudently by obtaining an x-ray to assess for any fracture. Unfortunately, x-rays are not 100% sensitive in detecting “occult”, or hidden fractures and sometimes a fracture won’t be discovered until a few weeks after the initial injury on a subsequent x-ray based on healing and new bone formation.

It seems likely, by your description, that you have suffered an inversion ankle sprain. This is when the outside of your ankle rolls towards the ground while the sole of your foot is exposed towards your midline. There are three main ligaments that can be affected, and often in a predictable and sequential manner where the severity of the sprain is relative to how many of the ligaments are involved. These ligaments are the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL). Ligaments can be stretched, partially torn, or completely torn, where the ATFL is the most commonly affected. Ankle/foot tendons such as fibularis (peroneous) longus and fibularis (peroneous) brevis, muscles that help with plantar-flexion (standing on your tip-toes) and eversion (rolling your ankle towards the middle of your body with the sole of your foot exposed to the side of your body) can also be involved. These tendons run superficial to the CFL and behind the lateral malleolus (the outer ankle bone).

If you have injured the “posterior tibial tendon” the mechanism is more typically an eversion injury. These are less common due to the strength of the deltoid ligaments (medial ankle) that connect the tibia to the calcaneus, talus, and navicular bones. The force required to produce an ankle sprain of this type is rare and is often associated with a fracture of the medial malleolus of the tibia.

Ankle sprains are graded on a scale of I-III. Grade I sprains involve mild stretching of the involved ligament, with associated swelling and tenderness, and one is generally able to bear weight without too much difficulty. Grade II sprains involve partial tearing of the involved ligament, with moderate swelling and tenderness, and bearing weight becomes difficult due to pain. There is usually concurrent bruising, and a decrease in function and range of motion (ROM). Grade III sprains involve a complete tear of the involved ligament(s), severe pain, swelling, and bruising, loss of function or ROM, and severe difficulty walking or bearing weight due to pain and instability. Grade III sprains sometimes need surgical intervention to re-establish joint stability.

Based on your description at the time of the injury of inability to bear weight or walk and swelling with no associated bruising, I would clinically classify your injury as a grade II ankle sprain. The fact that the pain is radiating to the arch of your foot supports the idea that there could be involvement of the fibularis longus tendon. Unfortunately, x-rays do not show soft tissues and a more thorough evaluation may require advanced imaging such as ultrasound or an MRI, to determine both your prognosis and any need for surgical referral.

Pain is your body’s way of forcing you to rest your injury, allowing it to heal. When you and your doctor decide that a return to your activity is indicated it is important to let pain guide what you do. If you are particularly sore after returning to a specific exercise or activity, at the site of the recent injury, it is probably best to avoid that activity for now. The common treatment of Rest, Ice, Compression, Elevation (RICE) is the basis of an acute treatment plan. In the case of ankle injuries, it typically takes about 4-6 weeks to fully recover based on the extent of the damage, and usually the sensation of stability is the last to return.

Management beyond the acute phase has the best results under the supervision of a physical therapist that can initiate a functional ankle rehabilitation program. This involves early ROM, and progressive strengthening of all the involved structures, including ligaments and tendons. There are also a variety of braces, wraps, and taping methods that can be utilized to provide additional support to the connective tissues during this period to decrease the risk of re-injury.

Steve N Green PA student, University of Utah
Aaron D Campbell MD, MHS, Sports Medicine & Urgent Care, University of Utah Healthcare

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date: April 29, 2016