Thank you all for coming today, it's nice to be back in person and for those of you at home, welcome as well. We're here to present an ankle tendon injury update for front to back. I'm the session moderator, Dr. Andrew Gordon. The session is also moderated by Dr. Kentaro Nishi. Ankle tendons are exciting. I'm excited, I hope you are too. I'll be starting off followed by Dr. Caldwell, Dr. Deluigi, then Dr. Nishi, and then we'll have a Q&A. And just to introduce our speakers briefly, Dr. Kentaro Nishi is our moderator, featured speaker. He's an assistant professor, Department of Human R at University of Pittsburgh. He's the director of the Sports Medicine Fellowship Program at UPMC, expert in advanced ultrasound guided procedures. He'll be talking to us about biomechanical approaches to reduce tendon injuries once we've gone over more of the anatomy pathology and treatments. And as we all know about Kentaro, he never ever sleeps. And there's no one more excited about ankle tendons than Dr. Mary Caldwell. She's assistant professor of Department of Human R at Virginia Commonwealth University, assistant program director for the Human R residency program at VCU and outpatient ambulatory director for Human R and fellowship trained in sports medicine at MedStar Georgetown National Rehabilitation Hospital. And her talk is on lateral medial ankle, peroneal and posterior tibialis tendon. Also features Dr. Jason Deluigi. He's chair of the Department of Human R at Mayo Clinic in Arizona. He's associate professor of Human R at Mayo Clinic School of Medicine, professor of Human R at Georgetown University, medical director of the Mayo Sports Medicine Independent Multidisciplinary Program. And he'll be talking to you about posterior ankle and Achilles tendon. I am in private practice at US Physiatry. I trained here in Baltimore and Human R at Johns Hopkins so it's great to be back. Fellowship trained like Dr. Caldwell in sports medicine at National Rehab Hospital. I serve as ultrasound faculty for the National Capital Sports Medicine Consortium where I trained in my fellowship. And I'll be talking to you about anterior ankle and tibialis anterior. So with that we will... How do we change the slides? So, yeah, cancel out of that and it should be my talk, the Gordon talk. Yeah, that one. Thanks. Perfect. All right. So, let's start by going into the anterior ankle. I have no disclosures. Um, we'll be talking about the four major anterior ankle tendons today. The, uh, tibialis anterior, the extensor hallicis longus, the extensor digitorum longus, and the peroneus tertius. Uh, these together, uh, comprise, uh, the musculature that's found in the anterior compartment of the leg. So, in terms of the anterior ankle tendons, uh, you find tibialis anterior most, uh, medially over here. And then as you go across, you'll find EHL, uh, EDL, and, uh, peroneus tertius. The tibialis anterior is the main dorsiflexor of the foot. Uh, its origin is a lateral condyle, upper two thirds of the lateral surface of the tibia, better known to us as Gertie's tubercle, uh, and also the anterior surface of the interosseous membrane. It inserts, uh, more distally, uh, where we're more concerned procedure-wise, uh, at the medial plantar surface of the medial cuneiform and the base of the first metatarsal bone on the inside of the foot. Its blood supply is mainly through the anterior tibial artery via the popliteal artery approximately, uh, and more medial, more distally rather, is the medial tarsal artery. Uh, it's innervated by the deep peroneal nerve, uh, through L4, L5, and S1. Mainly L4 and L5. The extensor hallucis longus, first toe extension, uh, of the MTP and the IP joints, uh, it exists in dorsiflexion and inversion of the foot as well. Uh, its origin is the anterior middle half surface of the fibula, uh, and the interosseous membrane. Its insertion is at the distal phalanx of the great toe. Its blood supply, again, is from the anterior tibial artery, and its innervation is at the deep peroneal nerve. Extensor digitorum longus, um, provides extension for toes twos through five. It exists in dorsiflexion. Its origin is at the anterior surface of the fibula, the interosseous membrane, and lateral tibial condyle, and its insertion is at the proximal distal phalanges of the lateral four digits of the foot, from toes two to five. And again, the innervation is with the, through the deep peroneal nerve. Finally, is peroneus tertius. Um, it doesn't really have a primary, um, mechanical responsibility, but it exists in dorsiflexion, inversion, and abduction of the foot. Uh, its origin is the medial fibula and the anterior intermuscular septum. Its insertion is at the dorsal surface of the base of the fifth metatarsal. Uh, its blood supply is, again, from the anterior tibial artery and innervation from the deep peroneal nerve, and note that the other peroneal nerves, um, not to steal Dr. Caldwell's thunder, but, um, she'll talk about that later through the superficial peroneal nerve. Um, risk factors for, uh, injury to the tibialis anterior particularly include overuse of ankle dorsiflexors, uh, running downhill, um, overstriding, uh, excessive pronation of the foot, restricted ankle range of motions, uh, when you have an abrupt change in direction, uh, excessive pressure when you put on, uh, uh, athletic shoes or boots or skis or ski boots and skates. And then also long distance runners and ultra marathoners that they're using their ankles more also prone to this. In tibialis anterior tendon injury, um, it's most commonly seen in overweight females ages 50 to 70. It's also seen in uphill, downhill running athletes. Um, telltale signs include antermedial ankle pain, swelling, stiffness, tight shoes, skates, and boots. Uh, differential can include lumbar radiculopathy, peripheral neuropathy, and peroneal nerve palsy, and physical exam findings will be, uh, tenderness to palpation over the antermedial side of the ankle, uh, swelling, crepitus, pain with resisted dorsiflexion. There can also be tightness of the Achilles at the same time. And, um, most notably there's steppage gait or a foot drop associated with, um, uh, the TA tendon not being able to do its job properly and imaging is with MRI and ultrasound. Um, tibialis anterior tendon irritation is often known as skate bite or lace bite. Um, so when you're putting on your hockey skate or your ski boot, for example, um, you get abnormal creasing of the boot tongue across the interior foot. It results from stiff, poorly broken and new or older skates and inflexible tongue, and you get this, uh, inflammation of the tendon. Uh, treatments include using more flexible booter skate, manual flexion of the boot skate tongue, um, positioning the boot tongue basically better or just more medial and putting foam on the inside of the tongue so that it doesn't rub up against the tendon as much, and NSAIDs and other approaches. Um, now there's EHL, the extensor hallucis longus. Uh, in this tendon injury, it's an acute overuse injury. Again, uh, you also see in uphill, downhill runners, you get tight calf muscles, uh, in patients and athletes that you see with this and also shoes that irritate the top of the foot can cause this, it's a similar differential diagnosis to TA tendon injury. And, uh, uh, the telltale, uh, exam finding would include, um, swelling of the great toe as well as, um, loss of extension of, uh, the great toe and drooping of it as well. Uh, extensor digitorum longus. Here you'll see more dorsal ankle pain. Uh, it results from overuse, uh, 14% of injuries sustained by ultra marathon runners, and they often have, uh, these ultra marathon runners, this shuffling gait that they use their ankles more because they're going such longer distance they have to economize and that's how they do it. Um, get it from excess pronation, tight fitting shoes, muscle imbalance, eccentric overload, and again, similar differential diagnosis. And, uh, on physical exam, um, there's a weak and painful extension of the second to fifth toes and, uh, simultaneous Achilles tightness as well. Peroneus tertius, tertius tension injury. Uh, this is also from overuse, uh, but it's a different kind of overuse. Uh, those who are running long distances or on even services, and they're probably running for longer periods of time than, you know, your average long distance or runner or ultra marathoner, and, um, uh, another group of people that this can happen to are people who are standing in place for long periods of time. Think of, uh, greeters at the grocery store or the department store, uh, security guards, people that are sitting there standing in one place for long periods of time tend to get, um, irritation of, uh, the PT tendon. And, uh, similar differential diagnosis. So in terms of anterior tendon, uh, ankle tendon injury, uh, the main types of pathology include calcification of the tendon, tendinosis or tendinopathy, a degenerative process, uh, tenosynovitis with more inflammation, and also, uh, tear or rupture of the tendon. Uh, generic treatment would include, uh, price protection, rice, uh, rest, ice, Generic treatment would include, uh, price protection, rice, uh, rest, ice, elevation, so forth, um, compression, uh, eccentric exercises to help with active lengthening of the muscle to take the pressure off the tendon, uh, correcting training errors, orthotics, shoe wear changes, uh, ultrasound guided injections, um, particularly for, um, extension digitorum longus, um, that extends to the second through fifth toes. You know, there's, uh, the, um, there's a tenosynovectomy procedure that can be done and then direct pair of reconstruction for a total rupture of the tendons. Looking at, uh, tibialis anterior tendon ultrasound, uh, this is, uh, an example of a normal ultrasound, uh, in both short and long axis when, uh, putting the probe transverse, um, you can see where the, um, tibialis anterior tendon rests over here. There's EHL there. Um, in the long axis, you can see it. This is with a high frequency probe, uh, some nice heterogeneity there and, uh, between the tibia and the talus there. Uh, a more degenerative tendinosis seen in ultrasound, uh, in tibialis anterior. You can see the cortical irregularities at its insertion on the medial cuneiform and long axis. Um, it's more, uh, hypoechoic, uh, within the tendon itself. And, uh, neovascularity can be noted with a color Doppler. Uh, a case example of tibialis anterior tendinosis, the 52 year old hiker jogger skier with a one year history of anterior ankle pain, uh, it's sharp burning, radiates from the center of the anterior ankle down toward the dorsal navicular area. The pain is worse going downhill and with plantar flexion. Um, and there's no other history of trauma. Um, on inspection, there's no visible abnormality that you can potentially see. You can have a nodule, uh, along the dorsal ax aspect of the navicular, more, um, intermedial on this side of the, uh, foot as well. Um, there's often no pain with dorsiflexion or plantar flexion on exam, but, um, one thing you want to rule out is, uh, high ankle sprain. So you do negative squeeze to get a squeeze test that's negative. External rotation test is negative. And, uh, under ultrasound, um, thank you, Dr. Onishi for these pictures. Um, we have, um, in the transverse, uh, there's transverse and long view. This is a short axis view of the tendon here. Um, as the trans, oh, wait a minute. Am I able to do this? Yeah, here we go. Good. So as the tendon is, uh, as the probe is moved more distally toward the dorsal aspect of the navicular bone, uh, where the, um, tendinosis is, you can see the, um, tendon, the hypochoic nature of the tendon, uh, degenerative. And then here, uh, this is just comparing the tendons on the left and the right. Um, this is a normal tendon. This is also obviously the hypochoic and degenerative tendon. And then, um, treatment for this is ultrasound can be with an ultrasound guided injection, this is a 10X procedure. Um, going in to clean up, um, some of the, um, loose debris in there. Loose debris in there. So you can see the needle penetrating the tendon. Uh, here, um, this is an example of, uh, tenosynovitis of the, uh, extension digitorum longus. Um, in long axis, you see, um, more of the hypoecogenicity and fluids surrounding, um, uh, the tendon region. And again, here in short axis, you can see two, three, four, and five as it fans out. Um, you can assess for partial and complete tendon tears and identify tendon edges using this method as well. Then there's tibialis anterior tendon rupture, uh, which we often talk about. Um, when you rupture TA, uh, it's usually accompanied by a pop, uh, followed by intermedial ankle swelling, dragging the foot while walking, more of a steppage gait. It's really funny. A friend of mine who I hadn't seen in years popped his TA the other day. He's an 82 year old swimmer. God bless him every day. And, uh, he's just letting it go. So, um, often the treatment can be non-operative. Um, on imaging, so there's, um, both ultrasound and MRI that you can use to identify the rupture. Um, here you can, um, see the rupture over here. And then, um, you know, there are slices as you go from, um, media from, uh, proximal to, um, distal and where the tendon ruptured and in the other, uh, MRI here, you can also see here where, uh, the tendon has ruptured on T1 imaging. Uh, treatment for tibialis anterior tendon rupture includes, um, non-operatives. You can use an AFO. You can splint or cast in the elderly, uh, disabled or more sedentary populations. Uh, surgical intervention is often reserved for higher demand, uh, patients who want to be more athletic and, um, you know, continue to have that function. Um, that's divided up between direct repair of the tendon versus reconstruction. Um, extensor hallucis longus, tenodesis or transfer is often the gold standard for this kind of thing when we're trying to reconstruct, um, you know, the function of the TA. Um, another way to do it is a sliding tendon graft, uh, where, uh, basically they take half of the existing, um, tibialis anterior and fold it over and try to, uh, create, um, a new thinner version of that. And then, um, there's a free tendon auto versus allograft that they take from another part of the body or from someone else or something else. Um, and finally, um, I feel like I can't talk about tibialis anterior without mentioning this. Um, this is not necessarily a tendon pathology, but rather, you know, when we talk about tibialis anterior spasticity in, um, you know, spinal cord or brain injury or stroke patients, um, it's treating, uh, and also in, uh, congenital, uh, deformities. Um, there's basically two parts to this. There's the equino-overactive calf part, the varus, the overactive, uh, tibialis anterior part that creates this inverting and supinating force on the foot. Um, operatively, um, they do Achilles lengthening. And then what they also do is split the tibialis anterior distally and take the lateral half and attach it to the cuboid and third cuneiform. And together that helps, um, restore the aversion force and maintain dorsiflexion. So with that, we reviewed the anterior ankle tendons and thank you, Baltimore. And thank you, AAP Menar. And thank you for your attention. And this I'd like to introduce Dr. Mary Caldwell. Okay, great. Thank you, Dr. Gordon. So thank you all for being here. Um, my residents often say that I yell when I'm presenting because I get so excited. So I'm super apologetic in advance if I get excited about this stuff. Um, so part one, we're going to talk about lateral ankle tendons. I will tell you, it's about a 20 minute talk for me. So try to stick with me. All right. But, um, if y'all get bored, just like wave and I'll skip that slide. All right. Um, so peroneal tendon pathology is we're going to, we're going to start with for lateral tendons. So. We just want to stick with just this slide. Perfect. All right. I'm going to give a quick shout out to Dr. Onishi's text. This textbook's amazing. If you guys haven't looked at it or checked it out, please do. Our chapter that I'm pulling from for this, for peroneal tendons, Dr. DeLuigi and myself were invited to write the chapter. It was a great experience. There's over like 100 resources that you can check out for this chapter alone. So if you're curious where it comes from, and it's all freshly done in 2021. All right. So lateral ankle tendons briefly, anatomy, examination, imaging, and cases. That's kind of how the breakdown's going to go for this. So when we talk about the cases, it's going to be tendinopathy, partial tears, or the rare complete tear, painful osteoporoneum syndrome, and then tendon subluxation and dislocation. So starting with an anatomy refresher, because if you're like me, I like to look at the anatomy every single time. It doesn't matter how many times I've done it. I want to make sure I'm not missing things. I like to recheck things. So the peroneus longus, or the PL as I'm going to call it, upper two thirds of the proximal lateral fibula, and you can trace it with this picture, travels deep in the retromalleolar groove to the cuboid notch, and then attaches to the medial cuneiform in the base of the first metatarsal. It makes perfect sense, right? If we look at where it's attaching and where it's going, eversion first ray flexion. It's what it's going to do. It's going to go to my first toe. It's going to evert my foot outwards, right? It also does plantar flexion of the foot and abduction of the foot. Innervation is the posterior peroneal, excuse me, superficial peroneal nerve, and then vascular supply or arterial supply is the posterior peroneal artery. Occasionally, don't forget about the os peroneum. So it's going to hang out in this tendon. Anybody want to take a guess at percentage? It's about 6 to 20% of people. It's a big range, right? If you see it, it can cause pathology. So it's just something to keep in mind, but it's going to be in your PL tendon typically. All right. Refresher on the peroneus brevis tendon. So distal two-thirds of the lateral fibula is where it starts, and then it travels again through the retromalleolar groove with its sibling, the peroneus longus, and then attaches to the base of the fifth metatarsal. So this one makes sense too, right? This one's not going under to the first toe, but this one's just going to do that eversion and abduction. Perfect sense. Check out the picture. It's all there, right? So innervation from the superficial peroneal nerve and arterial supply, the posterior peroneal artery. Just don't forget about nerves, arteries, all the other things that can hang out there. Stabilization of the peroneal muscles and the peroneal tendons. So this is the critical part to why pathology occurs in this tendon. It's the setup. It's what our anatomy is there. So things that you need to remember and the key things that are going to go with these tendons. The superficial peroneal retinaculum, it's at the level of the distal fibula. So if you check out my picture, it's that first area where their tendons are tracking through. It covers that retromalleolar groove, right? It's really critical to keeping these tendons in place when you have a forceful dorsiflexion movement or a dorsiflexion and eversion movement. It holds it there. You need that groove and you need that retinaculum. Another ligament that's there, the calcaneofibular ligament, something that we don't talk about as often, that prevents medial displacement of those tendons. Also really important. Then if we travel down about two to three centimeters distal to the lateral malleolus, you're going to see the inferior peroneal retinaculum. That's really there and they each have their own little retinaculum at each level. That's there to hold those tendons in place. It gives them a vector or a force to pull from, right? It's helping it do its job. So those are critical for what we're going to talk about. In general, when you're doing an examination of the lateral ankle, you want to look for things that set up patients or athletes or whoever, what population you're seeing for peroneal problems. So you're going to look for swelling. You're going to look at the anatomy, hindfoot varus or cavo varus. Do they have a high arch? Do they have a foot that has this varus deformity, hindfoot deformity, right? It's going to set them up for that lateral ankle pathology or overuse or problems that could occur. Palpation, you guys know this, inspection, palpation, range of motion, right? Palpation, really critical. Don't just do it at rest. Make sure you're doing it with activation of the tendons and you're tracing it. And don't forget about the muscle belly up top. Just because we're only talking about tendons, you don't have to stay focused at just the tendon area. Range of motion, is there excessive plantar flexion? Is there excessive dorsiflexion? Is there excessive eversion, inversion? How's the first toe moving? How are all the toes moving? Check out sensory vascular strength testing, special tests, you know, these Taylor tilt inversion tests. You're looking for excessive motion with those tests, which can also set you up for pathology. So imaging studies, when we talk about imaging for this, I do usually get a radiograph in somebody that's having lateral ankle pain. I'll tell you, most of the time I'm looking for, like, is there an os perineum like we spoke about? I don't want to forget that and I don't want to miss that. I'm also looking at things like other pathologies, subtalar degeneration. Is there a Taylor OCD present? I want to see if there's a reason that somebody is having this pain other than just a focal tendon problem. You just don't want to miss the things. If you only correct the one thing and you don't correct, like, the anatomy or the varus or the valgus deformity, you're not going to get them better. You're looking for any kind of avulsion injury that could have happened where the muscle's attaching. And then there's ultrasound, which I think we could talk about for a very long time, but I think it's the best tool we've got. So tendon structure from top to bottom. Is there synovitis? Is there tendinopathy? Does the tendon look hypoechoic? Is there a partial tear? Are there neovascular changes? Check both retinaculums, and you can do subluxation testing. So dynamic testing, really important. That's what you're there for. You can do it right in the office and give them a diagnosis. MRI, I don't use as much. It just also depends on your ultrasound skills. If you don't feel as confident in your ultrasound skills and you don't, you know, you can take courses on it, but an MRI can give you some pretty good information if ultrasound's not an option for you. So case one, peroneal tendinopathy. So 40-year-old guys, I do a ton of running medicine. I will warn you, you're going to see a lot of runners and dancers on my slides, but it's really common with these athletes. This is where you see these injuries. So 40-year-old marathon runner with rapid inversion movement in the ankle on a run two weeks ago. I just saw her in the office two days ago, and I changed the case because it was perfect. She was on a run two weeks ago, and she said she has persistent lateral ankle pain and some mild swelling. And she says, Dr. Caldwell, I'm running this marathon. I am not missing it. It's three weeks away. Get me there. And that's your typical runner, and if you don't help them, they're just going to go find someone else down the street. So examination shows swelling at the lateral ankle in the peroneal tendon and pain at the distal-fibular level of the tendon. She has pain with active eversion testing, and she has obvious swelling. So I put, you know, she's got it at the most common area, the hypovascular areas in the lateral ankle around the distal-fibular turn in the cuboid tunnel is where you're going to see most of these tendon, like these tendinopathies occur. And I ultrasounded it, and I could see it. Fortunately, she had no tear, but she had some pretty active tenosynovitis going on without an active tear. So nonoperative treatment, I think we all know the rule for rest, ice, elevation. It's never really worked for me, and when you look at the studies, it's not really a great option, but you're going to see people sometimes start with that. I think medicine's an art, and I think sports medicine's an art, and please, the evidence is not great for it. So remember that for each patient. They're all a little bit different. I like to use Tylenol over using a true anti-inflammatory. I think there's a reason that you should have some inflammation at the tendon to help with healing, and I don't always use an NSAID first line. I'll decrease the loading of the tendon, but you can never tell a runner not to run again, so we modify their activity. I have them do a walk-run program. I change it, run for 30 seconds, walk for 30 seconds, change your pace, lower your speed, decrease the amount of running you're doing. And then I tell them the best-case scenario and the worst-case scenario. Physical therapy is critical for this, and I sell it. They're going to need at least 20 to 30 sessions of exercise focusing on eccentric exercises, right? That stretching of the tendon, that lengthening of the tendon, giving the stem cells activation so they work the best they can. And I tell them that's two to three months of therapy. That's not a quick thing, but they want to run the marathon. So there's other things you can do, right? You can do prolotherapy. You can do PRP. You can do shockwave therapy. You could give a lecture on all of these, and many of you in the room have before, and you know this well. PRP can work well, improve function and pain scores. Prolo has a role. Nitrate patches might have a role. I'm not a big fan of steroid injections there, but you could. You just might rupture their tendon, and they're not going to like you after. So operative treatment. American Foot and Ankle Society says greater than three months of conservative treatment. If they fail it, then you can refer them for an open tenosynovectomy, which is really an open debridement and tendon repair. Pros and cons, open versus endoscopic. Know your foot and ankle surgeon. Know who you're working with. Know the different ones in the area. So open debridement and tendon repair, less risk of nerve injury, right? Less risk of actually infection with these, but longer return to sport. Whereas if they do a tenoscopy, it's a little bit longer. You can injure the soral nerve. It's higher rates, higher rates of infection. Hopefully that starts to shift, but shorter recovery. Pros and cons. So either way, they're post-op, two weeks non-weight-bearing, four weeks in a modified weight-bearing program before they do more rehabilitation. So this is a long process for them, and I will tell them from the beginning, here's the issue, here's what we can do, and here's the course. So case two, peroneal subluxation. So I was just in Croatia with Team USA Futsal, and this was a case that we had on the court, and I had my ultrasound with me. So a 17-year-old futsal player with rapid inversion and dorsiflexion movement associated with a pop in pain laterally. And I'm panicking. I'm like, oh my gosh, worst case scenario, he's sublux dislocated his peroneal tendons. I'm going to have to put him back in place. His career's over for the next year. He's going to hate me. Pull out the ultrasound, you guys, and his SPR is completely intact. He's got swelling in the lateral tendons, and he's got an intrasheath tendon subluxation. No bony injury, no ligament injury. This guy got lucky. This is one of those cases where he can continue to play. We did some modified range of motion activity. We got him back within 48 hours. He was thrilled, and I was a good person for this, right? You could brace them. You could do NSAIDs in this case, but they get back. This is different than your peroneal subluxation and dislocation. These are people that have a forceful passive dorsiflexion inversion moment, but now it comes out. It comes out of the groove, and you can have tearing of your SPR with it. You can have an avulsion injury with it. This is a bit different. This is not a good situation. You can tear the tendon with it. It can be chronic. In fact, 50% of them are actually unstable, so it's just not fun. Treatment. American Foot and Ankle Society says that if you have a high-level athlete with subluxation and dislocation, that person should get a surgery. It's highly likely it's going to happen again. If they're not a high-level athlete, you can cast or boot for six weeks and plantar flexion, and then you do PT, but again, 50% recur. The surgical side of this, there's many different things you can do. I'm not going to get into the details of it. However, most athletes will have a groove deepening with an SPR repair, and they have a better return to sport, but there's four different ways you can do this. Again, know your surgeons. Know who you're working with because you're the one referring your patient, and they just want to get back and play. All right. Case three. Peroneal tendon tears. 42-year-old female runner with lateral ankle pain for three years and a history of multiple ankle sprains. Pain is focal to the posterior lateral malleolus. You did a running analysis with excessive subtalar movement. This is where she got it. Running analysis with excessive subtalar movement. Again, ultrasound, if needed, shows a brevis tear. Physical therapy for two to three months. You prescribe. You check orthotics. You give her orthotics. You get them custom-made. They're not flimsy, so they should do decently. 40% improvement. Okay. She comes back. She still wants to run. You do PRP. Gets a little bit better. She's still having issues. At that point, I'll refer them to a surgeon. So in peroneal tendon tears cases, this is similar to those with tendinopathy. So you can have chronic tendinopathy associated with a tear without a tear. So keep that in mind. It can be a spectrum. Years of pain, usually, though it can be acute with injuries as well, like a sprain. Remember that longest tears occurs at the level of the inferior retinaculum and at the level of the cuboid notch. Brevis tears typically occur at the level of the distal tip of the fibula. Rupture is really uncommon. So you have operative treatment and non-operative treatment. If you do non-operative, it's usually a three-month trial. That's American Foot and Ankle Society guidelines from 2018. You can do a mobilization prior to PT if you want. You can do mobilization after PT if you want. It's just a matter of how you want to practice in your sports medicine clinic. You can consider orthotics. You can do PRP prolo injections. So then they say if symptoms last for more than three months, then they recommend a primary debridement and a tuberalization of the tendon. You basically excise the unhealthy tendon, re-approximate the healthy fibers, and then you can do a graft if it's irreparable, and kind of your last option is a tenodesis, but tenodesis can be rough, and it's a bit of a 12-week recovery after the surgery. Okay, last case here. So painful osteoporoneus syndrome, or POPS, or POPS. Seventeen-year-old high school football player with lateral ankle pain distal to the lateral malleolus comes into your office. He's had recurrent swelling and pain in this one location. He points to it on the side of his foot. He says he's tried PT, really limited help. He's tried bracing, really limited help. Every time he cuts, he feels it. So ultrasound and x-ray were performed in office. I could see it. You can see the crack through what's called that os perineum there. An MRI confirms and shows the fracture. You know, the only reason I got the MRI in this case is he was going to get the surgery with an outside surgeon, and they wanted an MRI to confirm it. I don't think you necessarily need that to confirm it, but trial to cast without help. I gave it a go just because he's a high school football player and not a professional football player, but it didn't work. So surgery to excise the ass and repair the tendon. So we just reviewed this painful os perineum syndrome. Typically, that pain plantar or lateral side of the foot. It's an inversion injury. Typically, you get ass compression against the cuboid bone at that level. You can have peroneal tendon tear with it. If it's not treated, it can be chronic. It can callus. It can cause problems with stenosis of the tendon. You can rupture the tendon. You can also have a different kind of thing like an impingement where you have a hypertrophy peroneal tubercle and an ass, and you're impinging the peroneal longest tendon at that level. So it's a spectrum. There's many ways this can happen. So treatment, we talked about it. If there's no PL rupture and a non-displaced fracture, you can try conservative casting first. However, if it's a displaced fracture, if it's just not getting better after the casting, they'll actually do an excision of it and an end-to-end repair of the tendon. And it works well. People do great. All right. Briefly in review, and then I promise you the medial ankle is much quicker. Acute or chronic peroneal tendon pathology, consider tendinopathy, partial tears, peroneal tendon subluxation, painful os peroneum syndrome. That's what I got for you. History and physical exam are key. Consider your best image. I'm so biased towards ultrasound. Non-operative management, immobilization, maybe. Depends on the case. NSAIDs, maybe. Orthotics, injections, bracing, maybe. And then there's several surgical options available. Basically, people do quite well. They do well with conservative therapy. They can do well with surgery. Just brace your patient for what they're going to go through. All right. Part two, medial ankle tendons. So again, I referenced Dr. Onishi's book. I think it's really good, really up to date. But if you want other detailed sources, happy to give them to you. All right. So medial ankle tendons. This is your Tom, Dick, and Harry mnemonic that everyone probably remembers from medical school, right? Posterior tibialis tendon, flexor digitorum longus, and flexor hallucis longus. And there they are running under the flexor retinaculum. Anatomy refresher, posterior tibialis tendon. Interosseous membrane between the tib-fib travels through the tarsal tunnel to the navicular and medial cuneiform. Posterior tibial artery is your blood supply. Tibial nerve is your innervation. It inverts the foot and plantar flex the foot at the ankle. It's a beautiful picture. I love it. Flexor hallucis longus, right? So this is your little bit more of a detailed slide. And I'm sorry, but I just, I love the flexor hallucis longus. And I think it's really cool because it's a really fun one to alter some. So it detaches to the posterior middle one third of the fibula, travels through the tarsal tunnel, and then along the talus of the cystic stenaculum tali, and then through the knot of Henry, deep to the intercesamoid ligaments, and finally finds a home at the base of the distal phalanx of the hallux. Why do we care? Because all of those places that I just named are places that it can get pinched or damaged. And we care because it changes how you're going to treat it. Innervated by the peroneal, or by the tibial nerve, and then the peroneal branch of the posterior tibial artery is your vascular supply. Flexes all the joints of the big toe, plantar flexion of the ankle joint. Lastly, DIC, flexor digitorum longus, from the posterior tib through the tarsal tunnel, under the FHL at the knot of Henry to the plantar surface of the foot to the base of the four distal phalanges. Posterior tibialis artery, blood supply, tibial nerve is your innervation. Flexion of the four smaller digits. All right, clinical exam, very similar to the other one, right? You're looking for hindfoot varus, hindfoot valgus. It's going to set you up for your pathology. You're checking your full range of motion, sensory strength testing, special tests. Make sure you're testing for excessive plantar flexion, especially in this compartment, and toe flexion extension. Imaging studies, same as before. Radiographs, not that much helpful, in my opinion. Ultrasound, way more beneficial, and then MRI can be useful as well. All right, quickly, case one, posterior tibialis tendon dysfunction. This is your 60-year-old overweight patient. Type 2 diabetic female comes in, feels like her ankle's turning in, and it's swelling. So there's a spectrum of posterior tibialis tendon dysfunction. Look for that too many toes sign. Does that mean the tendon's insufficient? Posterior tibialis edema, ultrasound performs. There's thickening of the tendon's hypochoic and fluke around it. CAM boots placed, PT referral. She does okay. She's not a surgical candidate. Her BMI is 45, so she chooses to brace intermittently as she needs it for long distances, and she does okay. So this is what you could go on for days about the spectrum of, I think, tibialis tendon staging. Basically, if it's not very elongated, and there's not significant weakness, or if they're not a surgical candidate, give it a trial of conservative therapy. You can boot. You can do an AFO. PT usually takes about three to six months. It's a long time. Consider Tylenol. 70% of them do great. But then you've got this other side. If they're really weak, they're a surgical candidate, they've got severe tendon degeneration, they do much better with surgery. And so I will send them to go talk to a foot and ankle surgeon to get an opinion. Flexor hallucis longus, case two. 30-year-old dancer comes in with first toe plantar pain and medial ankle pain. She's got pain over all those areas in red that you see in my picture. So pain over the tarsal tunnel. On exam, decreased range of motion at the first toe. This is pretty classic for FHL pain and also pain with testing. Ultrasound shows me that there's tendinopathy of the tendon. Treatment for it. Same thing with runners. Good luck telling a dancer to stop dancing. Relative rest. NSAIDs use if you want to try it. Physical therapy really works really great for this. There's a bunch of evidence going into therapy for this. You see the stretch in the corner using a towel. You can also use a book to do that, but it takes about 12 weeks of doing these exercises to turn things around. You can always consider a boot. If not helping, you might want to modify point work, but really we do activity modification and exercises. If four to six months of conservative care isn't helping, I offer them to go talk to a surgeon. It's about 90% success rate with this kind of care plan. Lastly, flexor digitorum longus. Jury's out, you guys. Not much evidence on it. It's kind of a clinical diagnosis. I guess no one sat down and just wanted to spend time researching it. Typically dancers, gymnasts, swimmers, runners, plantar pain. It's a pain with flexion of the toes. Second, third, and fourth digits and fifth digits to pain with flexion testing. It's really just unexplored. I'll sometimes throw an ultrasound on and see if there's swelling in it. I give them the same kind of stretches, foot yoga, orthotics, and I strengthen up the kinetic chain. Those are my kids that didn't want to be athletes but have no choice. Okay. Thank you, guys. And now I welcome Dr. DeLuigi, my mentor. While he's switching slides, I want to thank Dr. Gordon for inviting me to be part of this panel. I want to thank all of you for coming here in person. It's great to see everybody back. And also to all those that are participating virtually, it's great to be able to have that access so you're not missing the conference as well. Mine was uploaded earlier. Probably, yeah, it's probably under my name. You have it under Andrew Gordon's name, I guess. I uploaded it in the speaker room. No. So it was under the posterior ankle portion from the presentation upload. Probably if you click on the 1400 instead of the Andrew Gordon. That's why you always bring your flash drive with you. Even though you go through and you upload it, you check with the speaker room persons, and somehow it gets lost within an hour. There we go. Great, all right. Well thanks everybody. Sorry for that momentary technical delay again. So my talk here is on the posterior ankle. Predominantly on the Achilles tendon with pathology and treatment. I mixed in a combination of different images from the x-rays, MRIs, and ultrasound as well. But I also have an aspect where you have what a normal ultrasound would be looking like when we're looking at the Achilles here. So I have nothing to disclose. Again, I always talk about objectives. Become familiar with the different pathologies of the Achilles tendon. Become familiar of what normal and abnormal imaging may look like. As well as become familiar with the various different treatment options based on those pathologies. You know, when we're talking about the posterior aspect, there are different areas that can be injured. Achilles tendon and the peritoneal plantarus tendon. Again, if somebody has a plantarus retrocalcaneal bursitis, retro Achilles, or superficial Achilles bursopathy. As well as, you know, performing that dynamic scanning here of the Achilles tendon. So the majority of this talk, again, is gonna be more on the Achilles tendon aspect of it. So when we're looking at the Achilles tendon, it is the confluence of the gastrocnemius soleus and it inserts in the calcaneus. It also can incorporate into it the plantarus, or the plantarus could be separately attached adjacent to it. It is the strongest tendon in the body, but it is frequently injured because of that. Many of the activities that we do. It is surrounded by the peritoneum, which is that thin layer of vascular tissue. And without the tendon sheath, it's always abnormal if it's surrounded by fluid. So that peritonitis. So when we're looking at the gastrocnemius soleus and longitudinal axis, the normal aspects, again, you can place the probe and start in the proximal calf, you know, working longitudinally, you can scan distally and following the muscles into the muscular tendinous junction. So it becomes the tendon. And you can follow the tendon all the way down to its insertion. You know, when you are looking here, you can see a traumatic tear of the gastroc with the course of the calf pain, which is commonly also known as tennis leg from that standpoint, where you could see a tear right at the myotendinous junction or in either the soleus or the gastroc, more commonly the gastroc, but many times at that myotendinous junction. So you also would scan transverse, starting proximally working distally. So again, you place the probe anatomically transverse and you're looking at the medial gastrocnemius, the lateral gastrocnemius and the soleus deep, and you're watching that become the tendon. So when you're kind of sliding through that distally, again, you're getting used to that normal echo texture of the muscular portion, the myotendinous portion and the tendinous portion as you go distally. Once you get to the Achilles tendon itself, you're gonna be looking at it, scanning the length of the tendon as well as the width of the tendon. So on longitudinal, you'll be scanning medial and laterally to make sure you're getting all the different aspects of the Achilles tendon in your view. And here's, look, an appearance of a normal echo texture there. On the long axis here, you're looking at the normal fibular pattern here of the tendon end through insertion, looking for any cortical irregularities, swelling. And here also, you're looking at any distension of the fat pad that is in the area as well as some bursopathy. And this is where many times you could start picking up that retrocalcaneobursitis. You wanna scan horizontally. Many times with here, depending on how thin somebody's lower leg would be, sometimes you'll get loss of contact on either side of the Achilles tendon where you'll have air that's there. So you could put a little bit more standoff gel to be able to do that so it doesn't distort your echo texture there. And that will decrease that overall artifact. But again, as you're scanning, you're being able to look medial and laterally, looking for any changes here and then just with a deep to a discagers fat pad as you come all the way down to the overall insertion point. And this is all then with, sorry, this is all here without any of the aspects here of looking at, putting on ColorFlow Doppler, looking for any neovascularization or changes when you're having some of those areas where it may be some hypoechoic changes. So when we're gonna coming through here, then if you do have the MRI, right? So if somebody gets sent to you with ankle pain and they already have the MRI, many times what you do, you're gonna be looking at what you'd be kind of looking for what a normal MRI would be when you're also comparing then with a normal ultrasound. So you're looking here at the different areas. So you're looking for that normal texture loss of any changes in signal intensity here between your T1 and T2 weighted images as you're coming down. So kind of getting that what is normal look like and what does abnormal look like and then when you do have those two different imaging comparisons and you have that, many times our orthopedic colleagues require an x-ray already. So many times you're not seeing much specifically to Achilles tendon or even the retrocalcaneal bursitis. But what you would see is if there is an enthesopathy or if there's a bone spur there osteophyte, right? At that area, which then may show that there is either potentially a rheumatologic disorder that's going on, a calcific tendinopathy, or just some potentially micro tearing that's creating that burden spur over time. When we're looking at, again, the Achilles tendon injuries though, again, it's the strongest tendon in our body. We oftentimes can put our entire body weight on it, right? When we're testing strength testing, and we go back to old Hoppenfeld and some of the other different things you'd need to do, 20 calf raises for it to be five out of five strength if we're going all the way back to the aspect where most other muscles and tendons we're checking one time, right? So when you're going through all of this, you're able to lift that whole weight of your body. Again, it's surrounded by the peritoneum so that's gonna be a signal there where we could look for fluid, like a halo around the tendon. But because of that peritoneum, it's not ever normal to have a ring of fluid around it, right, so in that peritoneum. So if you do have a tear, one of the areas there, it's in that avascular area, which is about two to six centimeters from the calcaneal assertion. For most people, that's about four finger breaths if you're doing overall palpation, if you're not breaking out your tape measure from that standpoint. But it's kind of in that area. And many times, you do have a lot of pain and discomfort in that watershed area if it's not directly at its insertion. So here, we're looking here at some of the sonogram here of looking at the tendon here in long axis. You could see where it goes from right underneath A, right? It's thinned and then you get that thickened hypoechoic area and then it starts to taper down again as it gets distally. You know, when you put on the Color Flow Doppler, you see all of the neovascularization that comes up throughout the tendon here. And so again, this is looking at it in the long axis, but you could see that hypochoic changes, additional thickening, and you see that hyperemia when you get to the Color Flow aspect. And so this is one of those areas where you could tell you that it's more, there's definitely some active aspects that are going on. You know, and it's because of that neovascularization, many times if, you know, back when I was in fellowship now, you know, a decade and a half ago, it was right when people started talking about, you know, so, you know, perhaps you can, you know, there may be some ischemic or vascular related pain to Achilles tendon and they're using a quarter, you know, patch of nitridor, right, nitroglycerin, or you could put some nitro paste there and maybe it'll decrease some of that ischemic changes. Right, and that was before, that was right when like, people just started using ultrasound. So theoretically we were thinking about it, but you know, we were just starting to do ultrasound and not always plopping on that Color Flow Doppler, but we were thinking that perhaps there, those vascular changes there were causing some of the discomfort, so. Now when you talk about peritendinitis, and this was in that peritenone, it's when we talk about whether or not there's that ill-defined tendon margins, right, so now you're having fluid that's also occurring in the tendon, but also surrounding it in the peritenone. And there may or may not be different levels of, you know, sometimes you can see an entire halo all the way around it, but you see that hypochoic thickening there, and you see hyperemia, and then you also can see that there's fluid that is coming there. So when we're talking about that, so oftentimes our, that's our body's way of, right, sending more, you know, nutrients and growth factors there to try to help with that inflammatory healing process. But then it could be pathologic itself, right, so. So when you're then comparing it again with the MRI, right, so you're looking at that, you can see some of that white fluid here, white is white on a T2 here, around that tendon here, and in different images you can see a lot of fluid really there that's pocketing up in that peritone on this other patient on the right-hand side. So again, it's just regular tendonitis. Now again, you see that there's some fluid, that little bit of, you know, hyper-intense area in that Achilles tendon that's coming there. You can see the thickening, you know, again, you do have the ability with the MRI here, if you do have it, right, and many times our surgeons or our surgical colleagues are more used to looking at an MRI, so, you know, once you've worked with a surgeon, foot and ankle surgeon long enough, who've gotten used to seeing all of the ultrasounds you're doing, you know, they lean to it, but oftentimes they still wanna see the MRI with that, as Dr. Caldwell mentioned, you know, and so you'll be looking here again with those, you may have already identified it exactly with your ultrasound and all of that, but you know, at this point, and sometimes they'll say, well, can I at least go and talk to the surgeon, right, and I always say, well, there's, you know, it's not, if you do, it's not like you're going to, you know, buy surgery by just going there and talking to them, it's like, you know, like going and doing a test drive of a car, right, get all the best information possible, right, and so that way you're the most informed, but I'll talk to them all about it and say, more than likely they're gonna tell you exactly the same, but you can go talk to them yourself, so from that standpoint, but again, then going back and comparing it again to the ultrasound, we have some of the different, you know, imaging here with the different changes here on that dynamic assessment, so I know there's a lot going on it, so I'll let your eyes get caught up so you can see each of the four different aspects here of it, so right, you see that neovascularization, so, you know, both on transverse and longitudinal views, and then you're looking at that dynamic assessment as you're following the length of the Achilles tendon, you can see, you know, calcific changes that are occurring in the tendon, you're seeing calcific changes that are occurring, you know, at the insertion point, right, so they have some enthesophytes and osteophytes ongoing here in some cortical regularity. So, you know, when we talk about different studies, so you always kind of pull up a few different ones that have kind of been published over time, they've talked about, you know, potentially doing a single PRP in the mid-substance, so that, you know, is a retrospective review, where they went back and looked at it, where, you know, 25 of the 32 patients did well at six-month visits from that SEM1, you know, seven of them still had problems, so this is where people sort of potentially, you know, where we could say, you know, perhaps we can do just the, you know, a single PRP for the treatment of Achilles tendonitis. You know, again, you want to, there's the risk of steroid at that area, it's always, you know, interesting, as Dr. Caldwell mentioned from before, you know, steroids often, like, when she talks about shockwave therapy and prolotherapy and all of them, they're all considered experimental, you don't get paid for, right, they're all cash-based, PRP is too. What they do pay for is steroid, right, and that's the thing that's most likely going to cause a rupture if you don't put it in the peritoneum, right, so, you know, so from that standpoint, it behooves us to try to come up with more and more, you know, research and the literature, so insurance companies may finally change the way that they perceive this, so, and again, again, you know, PRP right there for that patella tendon, this is a prospective study with 14 patients, you need to use a number of different, you know, foot and ankle functional scores, and again, you know, it showed that it was effective, you know, comparatively, again, you know, the worst thing that you could do, right, as a person who does interventional procedures, right, would have something that makes it worse, right, and steroids have the highest likelihood of being able to do something worse, so, you know, if you are utilizing something, like, you know, when I needle, when I needle the Achilles tendon, I put them in a walking boot, right, so, or, you know, if they can't do that, they can put them on crutches, tell them no weight bearing, but I usually have a little bit more buy-in with my people that, you know, they would be in the walking boot, you could get them like the little scooter with the, you know, with the leg on it, but, you know, back until, you know, many times in all this original studies, right, a lot of what the Achilles tendonitis, right, eccentric exercises from the Scandinavian studies, right, it showed that it works, but we have many people who don't want to go through that whole process, so, as Dr. Caldwell mentioned, you know, from that standpoint, and a variation of, you know, what I, this part of my spiel that I always talk about is anything that I do, whether it's medicines, or needle, or, you know, tenotomy, or anything along that line, is to decrease the pain and help improve the function so you could do more exercises, right, you know, so I said the most important thing you're gonna do, again, to treat it now and prevent it to coming back is exercises, so whether you ever get a steroid injection, or we use a topical agent there, or we do PRP, it's so that you can do more exercises, right, so to get it healthy again, so I always reiterate that that's going to be the most important thing, and everything else I'm gonna do is to make you be able to do more, right, of that, so. Again, looking at, again, another study here, it was looking at it, again, they followed up through two years here after a single PRP, and again, it was shown that it was still gonna be effective here with the different foot and ankle scores, I mean, all the way out at two years from that standpoint, so, you know, from where we're going, I think, you know, PRP's been shown to be quite favorable for there. Again, it's not covered by the majority, if any, insurances. I've had periodic insurance companies cover it over time, but it's not always covered. Now, an interstitial tear, again, this is what it looks like, so, again, that's inside the integrity of the tendon itself. It usually doesn't touch any of the edges, right, so, because it's interstitial. And with that, there is a little bit more stability to this type of tear. I usually will tell patients that they could do fairly well with conservative management alone. You don't have to do any needle-based treatments, right, and, you know, but, you know, any of the topical agents, you know, a little bit of rest in the boot if they need to, but, again, it's gonna be mostly the exercises, you know, from that standpoint. So, oftentimes, I'll go and focus on the exercises. But if they're having, like, a lot of acute pain at that time, we'll talk about it, so. And now, compared to the rupture, right, this is where it snaps in half. So, many times, when we get to this point, you know, if they get sent to me and they said, hey, can you PRP this, you know, oftentimes, I said, if it's in two different parts, it's really gonna be hard for me to kind of have that meld all back together, right, without me trying and having anything to anchor it, to re-approximate it. So, you know, but I've had patients still ask me if they can still do that, right. So, oftentimes, this is here where, with that rupture, you're gonna see that disruption here of the fibers. And many times, they're going to need the surgical management to reattach that tendon. And so, again, you can look here on the ultrasound here when you're seeing that separation and the retraction of the two different edges here. And oftentimes, you have that large area of fluid that accumulates in that tendinous area in between, in that peritendinous area that's now separated and disrupted. So, that calcific changes here, again, it could be an osteophyte or it's in the tendon here. I would call this more the calcific tendinopathy or an enthesophyte, right, from that standpoint. You know, so many times that they are gonna be, and again, the plain x-ray, the MRI, and then we have some of the different aspects here, a case where you can kind of go in and using, you know, a 10X or any of the percutaneous needle tonotomies where you, you know, phacoemulsify and aspirate those areas again and help remove that calcium. Again, you could still compare doing an open surgical to enthesopathy versus percutaneous guidance. So, from that standpoint. So, I want to make sure there's enough time for Dr. Onishi, but thank you all for being here and watching the lecture here today. Thank you. While we are waiting for the slide to show up, by show of hands, who here thinks having a ligament injury or joint laxity could result in recurrent tendonitis, tendinopathy? So this is generally a well-accepted concept, so I might skip over that since I'm for the interest of time. Another question, since we still are trying to load the presentation, who here has performed percutaneous ligament repair? Thank you. All right, slide is up. Once again, thank you so much for your invitation, Dr. Golden. My name is Kenta Onishi from University of Pittsburgh Medical Center, and today I am not talking about tendinopathy since I ran out the tendon to talk about in the ankle, but instead we are talking about biomechanical approach to reduce tendon injury. Specifically, we are going to talk about ultrasound-guided anterior talofibular ligament repair. As everyone mentioned, I have a huge conflict of interest in talking about tendinopathy as I receive multiple federal, organizational, institutional grants, all investigating on different aspects of tendinopathy. And more importantly, I receive a loyalty for the textbook called Tendinopathy that everyone has nicely included in their slides. So I wanted to have a full disclosure before I get started. Today's objective is to describe the association between ankle ligament injury and tendinopathy first. And I'm going to do this in a single slide since I don't think I need to spend that much time. The second objective is to present biomechanical data on ultrasound-guided anterior talofibular ligament or ATFL repair. And we'll finish the presentation by discussing all the clinical data on ultrasound-guided ATFL repair as we've began to already perform this procedure on actual patient. So why am I talking about ligament when this session was all about ankle tendons? Well, as you can see from several publications, including most recent publication in 2022, the ligament injuries are associated with tendinopathy. And it seemed to be that when you have an ankle ligament sprains, there's increasing incidences of finding tendinopathy as an incidental findings. And as a clinician who treats these tendinopathies, that's something that we will pay attention to. For example, if you're treating a tennis elbow and if you've missed injury to radial collateral ligament, as you know, the clinical outcome for those cases is poorer compared to individuals with sound, intact radial collateral ligament in talking about lateral elbow tendon. And a similar phenomenon is happening with the ankle ligaments, where you have ankle ligament injury and you are tending to find more tendinopathy that is chronic. So just for your information, I just will list a couple recent studies. So today's main focus for my presentation is to discuss ultrasound-guided ligament repair especially the lateral ligament complex. And a special thanks go to Dr. Soichi Hattori who is a foot and ankle orthopedic surgeon who hailed from Japan to conduct this research study that I will be speaking to you about. Dr. Rich Debski is the lab director of University of Pittsburgh Orthopedic Robotic Laboratory, which houses this fancy device of six degree of robotic machine, which I will briefly talk about. Dr. Matt Hogan is now named as the next chair of the Department of Orthopedics at the University of Pittsburgh. And he's a foot and ankle surgeon who was very excited about this idea of using ultrasound to perform this surgical procedure. And of course, Calvin Chen is our roboticist who is out the roboticist that we can to operate this experiment. So just to briefly go over the basics of ankle sprain. Mechanism of injury is commonly due to forced inversion and AD reduction in plantar flexed foot. And it comprises as much as 30% of all sporting injury, formerly making this injury most common sporting injury that you will see in a clinic. And most injuries involve lateral ligament complex or LLC. What is LLC? LLC is made up of ATFL, CFL, and PTFL. And 90% of ankle sprain involves ATFL. About half of the cases, it involves calcaneofibular ligament and PTFL is rarely involved. So I just wanted to give you a basic review on this. 20% of acute ankle sprain, unfortunately progress on to this condition called the chronic ankle instability or CAI, which according to Dr. Takawa's publication from 2008 in American Journal of Sports Medicine, is defined as perception of instability associated with chronic pain, avoidance of sporting activity, and recurrent sprains. Unfortunately, those 20% of CAI fail conservative options such as continued physical therapy or injectable options in order to increase the stability of the joint and needing surgical procedures. There are two types of ankle instabilities. One is called functional or subjective instability where patient reports abnormal proprioception, muscle weakness, or range of motion deficits without occult clinical findings. And the other type is called mechanical or objective instability where you can see findings like this in the left side images. That is called ankles version of the Salka sign, which is commonly seen in a great three-ankle sprain while performing the anterior drawer test. When these mechanical instability is noted, most common practice used to be to perform an X-ray was weight. However, this tends to result in high false negative rate. So most recently, Dr. Shosgu published a paper that advocates for use of ultrasound where you can use 1.3 times increase of ATFL length as a surrogate findings to make a comment on the instability of the ankle. So ultrasound is kind of making name for itself as a diagnostic tool. But in the real clinical scenario, as we all know, ankle sprain can have a little bit of functional instability and a little bit of mechanical instability. So just an important thing to remember. And based on my clinical experience too, typically ATFL injury, even rupturing the ATFL does not result in noticeable detectable ankle instability unless you involve some parts of that calcaneofibular ligament. However, calcaneofibular ligament evaluation in clinostatic position or an atomic ankle neutral position is challenged as the fibular side of that calcaneofibular ligament is typically unechoic due to the fact that it's actually hiding underneath the distal fibular tip. So what our research team has done is to actually explore the possibility of using ankle motion to oviate the fibular side of a calcaneofibular ligament such as this. And we found out that adding dorsiflexion before putting the transducer actually bring the calcaneofibular ligament under tension which allows you to actually evaluate more precisely that fibular side of the calcaneofibular ligament. So I just wanted to talk about that. This was actually also discussed in Dr. Petron's paper in 2004. And this is called Sunrise Sign where the peroneal tendon sitting on top of the calcaneofibular ligament gets pushed up toward the skin. And this kind of allows you to make comments on competency of the calcaneofibular ligament. Little bit of review about the surgical history of ankle ligament repair. The first person to describe ankle stabilization surgery was Dr. Brostrom back in 1966 who performed direct repair of ATFL. Today's standard practice is what we call modified Brostrom repair where we'll use the suture anchor instead of direct repair driven into the distal fibula. But this most common practice still to date is an open surgical procedure which carries about 10% lifelong complication. Over the past 10 years due to the less invasive nature of the surgery arthroscopic Brostrom repair became very popular. The advantage of arthroscopic modified Brostrom procedure as you can imagine is because of the less invasive nature of the surgical less smaller size of incision these individual who undergo arthroscopic repair compared to open returns to activity slightly earlier. The major issue with arthroscopic modified Brostrom repair is the fact that it is non-anatomic and I will explain what that means. Dr. Terimoto in 2018 published the location of the anchor placement when performing arthroscopic Brostrom procedure. It really, the procedure itself hinges on the accuracy of the anchor placement. However, because tailored dome is usually in the way a surgeon tries to visualize the distal most of the fibula from the inside of the joint. You're actually not really seeing the most distal portion of the fibula and most commonly the anchor is driven into a location that's about eight millimeter on average proximal to the true footprint of ATFL. What does this mean biomechanically? According to Shoji's paper in AHA-7-2019 when you drive the anchor eight millimeter proximal to the anatomic footprints of ATFL then it results in increased internal rotation laxity and that is why I made a comment that arthroscopic Brostrom is non-anatomic and that is when we as in our research team decided perhaps since we can see the ATFL footprint or the ultrasound why don't we use ultrasound to guide this anchor placement. So the first study we've done was on actual 15 cadavers where we actually drive the anchor to the distal fibula at the footprint of ATFL under ultrasound guidance and our goal was to document the placement accuracy using CT reconstruction and also document if there were any neovascular injury. This was published in 2019 which is surprisingly only three years ago and based on our data compared to open placement ultrasound and guided placement was no different and as accurate and there was no neovascular injuries in the area so our conclusion was anchor positioning in ultrasound guided ATFL anchor placement was equivalent to open placement and anatomically as accurate and appears to be safe. Another advantage of using ultrasound in performing a Brostrom procedure is the size of that suture bite. This is the typical view that arthroscopic surgery can give you. Obviously you're looking the ATFL from inside the joint capsule so you're not able to see where the peroneal tendon is located and that's one of the genetic complications of arthroscopic suturing is you might suture this peroneal tendon that's sitting right next to the ATFL. However if you are using ultrasound then you can take a fairly aggressive suture bite without worrying about possibly umblicating the peroneal tendons. So our recent paper published investigated on the biomechanical side of this procedure and what we've done was to compare laxity in a kinematic ultrasound guided ATFL repaired ankle with those of intact as well as ATFL deficient ankle using our six degree of freedom robotic machine which is you know the video kind of does it all. It allows us to load the ankle joint in the known amount of force and torque so that we can make comments on whether that's as stable as healthy ankle or slightly less stable than healthy ankle. How is that compared to the ATFL deficient ankle? And our results show that ultrasound guided ATFL repair restored ankle biomechanics equivalent to that of an intact ankle improving from ATFL deficient ankles. So this is the schematic drawing and a little bit of video of how the ultrasound guided ATFL repair happens. The first step is performing the Brostrom repair using what we call Mason-Alley suture configurations which is basically crisscrossing umblicating the ATFL. And we initially tried to do the experiment just using this but this resulted in what we call cheese cutting of the ATFL. This alone wasn't strong enough repair so we've added good augmentation which is commonly done surgical procedure to augment the Brostrom repair. Schematic drawing of that procedure is shown here so it's a double ankle repair surgical procedure entirely done under ultrasound guidance. To finish my presentation, I wanted to briefly discuss the clinical experiences. A patient recruited in this clinical trials, this patient was chronic ankle instability after ultrasound guided ATFL repair for a minimum of six months. Several patients were ruled out due to OCDs and a peroneal tendinopathy that was concurrent so we only including individuals with ATFL repair. And that ended up with 12 patients, five females and seven males, six of them are athletes. And this is the post-procedural recovery process, it's essentially a 12-week rehabilitation program. And what we wanted to document was complication rate, functional scores, and how many of these athletic patients which was half of that 12 people returned to activities at six months. Here is the result. There was no prolonged pain which was commonly documented complication for open surgery or arthroscopic surgery. There was zero out of 12 at six months. There was no neovascular injuries. And a functional score, JSSF score is essentially the same as American Orthopedic Foot and Ankle Score. Went up from 50 on average to 89, essentially achieving 90. Same for the FAOS score, went from 68 to 94, nearly perfect. And those six athletes all returned by six months to sporting activities. And there's well-published complication data like I've been talking about for open surgery so we can actually compare this. And if you look at this, both arthroscopic and open surgery results in about 10 to 11% complication rate. So far, if you assume the same complication rate, we should have expected one or two people with persistent pain or a neovascular injury, but so far it's been zero. And in terms of function, these functional outcomes seems to be better in arthroscopic and open compared to what we achieved, which is essentially 90, slightly better, but these are the data of about 14 to 15 months. We were able to achieve the same similar functional outcome in six months. So in conclusion, ultrasound guided ATFR repair is as anatomic as open repair and biomechanically sound. Ultrasound guided ATFR repair appears to be safe and resulted in earlier functional improvement compared to some of the existing conventional procedures. Thank you so much for your attention. Right on time. With that, we'll open up the floor to questions. I know that we ran out of time here, so we're happy to take them individually or however you like. Thanks so much. Have a good afternoon. Thank you.

ankle tendon injuries

anterior ankle tendons

lateral ankle tendons

tendon injuries

diagnosis

treatment options

ultrasound assessment

conservative therapy

ankle ligament injury

biomechanical data

patient outcomes