J Knee Surg 2022; 35(11): 1181-1191
DOI: 10.1055/s-0042-1751246
Special Focus Section

How Common is Subsequent Posterior Tibial Tendon Dysfunction or Tarsal Tunnel Syndrome After Ankle Sprain Injury?

Kaitlyn S. Foster
1   Department of Rehabilitation Medicine, Brooke Army Medical Center, San Antonio, Texas
,
Tina A. Greenlee
1   Department of Rehabilitation Medicine, Brooke Army Medical Center, San Antonio, Texas
,
2   Doctor of Science Program in Physical Therapy, Bellin College, Green Bay, Wisconsin
,
Cory F. Janney
3   Naval Medical Center San Diego, San Diego, California
,
1   Department of Rehabilitation Medicine, Brooke Army Medical Center, San Antonio, Texas
4   Department of Rehabilitation Medicine, School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
› Author Affiliations
Funding This research was supported by the Department of Defense Clinical Rehabilitation Medical Research Program (CRMRP) Award #W81XWH-18-1-0788, under program number W81XWH-17-DMRDP-CRMRP-NMSIRRA

Abstract

Posterior tibial tendon dysfunction (PTTD) and tarsal tunnel syndrome (TTS) are debilitating conditions reported to occur after ankle sprain due to their proximity to the ankle complex. The objective of this study was to investigate the incidence of PTTD and TTS in the 2 years following an ankle sprain and which variables are associated with its onset. In total, 22,966 individuals in the Military Health System diagnosed with ankle sprain between 2010 and 2011 were followed for 2 years. The incidence of PTTD and TTS after ankle sprain was identified. Binary logistic regression was used to identify potential demographic or medical history factors associated with PTTD or TTS. In total, 617 (2.7%) received a PTTD diagnosis and 127 (0.6%) received a TTS diagnosis. Active-duty status (odds ratio [OR] 2.18, 95% confidence interval [CI] 1.70–2.79), increasing age (OR 1.03, 95% CI 1.02–1.04), female sex (OR 1.58, 95% CI 1.28–1.95), and if the sprain location was specified by the diagnosis (versus unspecified location) and did not include a fracture contributed to significantly higher (p < 0.001) risk of developing PTTD. Greater age (OR 1.06, 95% CI 1.03–1.09), female sex (OR 2.73, 95% CI 1.74–4.29), history of metabolic syndrome (OR 1.73, 95% CI 1.03–2.89), and active-duty status (OR 2.28, 95% CI 1.38–3.77) also significantly increased the odds of developing TTS, while sustaining a concurrent ankle fracture with the initial ankle sprain (OR 0.45, 95% CI 0.28–0.70) significantly decreased the odds. PTTD and TTS were not common after ankle sprain. However, they still merit consideration as postinjury sequelae, especially in patients with persistent symptoms. Increasing age, type of sprain, female sex, metabolic syndrome, and active-duty status were all significantly associated with the development of one or both subsequent injuries. This work provides normative data for incidence rates of these subsequent injuries and can help increase awareness of these conditions, leading to improved management of refractory ankle sprain injuries.

Disclaimer

The view(s) expressed herein are those of the author(s) and do not necessarily reflect the official policy or position of Brooke Army Medical Center, the U.S. Army Office of the Surgeon General, the Department of the Army, the Department of the Navy, the Uniformed Services University, the Defense Health Agency, the Department of Defense, nor the U.S. Government.




Publication History

Received: 30 January 2022

Accepted: 23 May 2022

Article published online:
09 August 2022

© 2022. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 
  • References

  • 1 Knapp PW, Constant D. Posterior tibial tendon dysfunction. In: StatPearls. Treasure Island, FL: StatPearls Publishing; 2021
  • 2 Geideman WM, Johnson JE. Posterior tibial tendon dysfunction. J Orthop Sports Phys Ther 2000; 30 (02) 68-77
  • 3 Gross KD, Felson DT, Niu J. et al. Association of flat feet with knee pain and cartilage damage in older adults. Arthritis Care Res (Hoboken) 2011; 63 (07) 937-944
  • 4 Conley T, Davenport II J. Pes Planus (Flat Feet) in Relation to Knee Pain. Published online 2018. Accessed October 20, 2021 at: https://digitalcommons.usm.maine.edu/thinking_matters/140/
  • 5 Myerson M. Adult acquired flat foot deformity. Foot Ankle Clin 2003; 8 (03) xiii-xiv
  • 6 Cancilleri F, Ippolito M, Amato C, Denaro V. Tarsal tunnel syndrome: four uncommon cases. Foot Ankle Surg 2007; 13 (04) 214-217
  • 7 Ahmad M, Tsang K, Mackenney PJ, Adedapo AO. Tarsal tunnel syndrome: a literature review. Foot Ankle Surg 2012; 18 (03) 149-152
  • 8 Cameron KL, Owens BD, DeBerardino TM. Incidence of ankle sprains among active-duty members of the United States Armed Services from 1998 through 2006. J Athl Train 2010; 45 (01) 29-38
  • 9 Hubbard-Turner T. Lack of medical treatment from a medical professional after an ankle sprain. J Athl Train 2019; 54 (06) 671-675
  • 10 McKay GD, Goldie PA, Payne WR, Oakes BW. Ankle injuries in basketball: injury rate and risk factors. Br J Sports Med 2001; 35 (02) 103-108
  • 11 Doherty C, Bleakley C, Hertel J, Caulfield B, Ryan J, Delahunt E. Recovery from a first-time lateral ankle sprain and the predictors of chronic ankle instability: a prospective cohort analysis. Am J Sports Med 2016; 44 (04) 995-1003
  • 12 van Rijn RM, van Os AG, Bernsen RMD, Luijsterburg PA, Koes BW, Bierma-Zeinstra SMA. What is the clinical course of acute ankle sprains? A systematic literature review. Am J Med 2008; 121 (04) 324-331.e6
  • 13 Feger MA, Donovan L, Hart JM, Hertel J. Lower extremity muscle activation during functional exercises in patients with and without chronic ankle instability. PM R 2014; 6 (07) 602-611 , quiz 611
  • 14 Fatima S, Bhati P, Singla D, Choudhary S, Hussain ME. Electromyographic activity of hip musculature during functional exercises in participants with and without chronic ankle instability. J Chiropr Med 2020; 19 (01) 82-90
  • 15 Doherty C, Bleakley C, Hertel J, Caulfield B, Ryan J, Delahunt E. Single-leg drop landing movement strategies 6 months following first-time acute lateral ankle sprain injury. Scand J Med Sci Sports 2015; 25 (06) 806-817
  • 16 Herb CC, Grossman K, Feger MA, Donovan L, Hertel J. Lower extremity biomechanics during a drop-vertical jump in participants with or without chronic ankle instability. J Athl Train 2018; 53 (04) 364-371
  • 17 Theisen A, Day J. Chronic ankle instability leads to lower extremity kinematic changes during landing tasks: a systematic review. Int J Exerc Sci 2019; 12 (01) 24-33
  • 18 Koldenhoven RM, Feger MA, Fraser JJ, Saliba S, Hertel J. Surface electromyography and plantar pressure during walking in young adults with chronic ankle instability. Knee Surg Sports Traumatol Arthrosc 2016; 24 (04) 1060-1070
  • 19 Lehr ME, Pettineo SJ, Fink ML, Meyr AJ. Closed chain dorsiflexion and the regional interdependence implications on fundamental movement patterns in collegiate athletes. Foot 2021; 49: 101835
  • 20 Bullock-Saxton JE. Local sensation changes and altered hip muscle function following severe ankle sprain. Phys Ther 1994; 74 (01) 17-28 , discussion 28–31
  • 21 Doherty C, Bleakley C, Hertel J, Caulfield B, Ryan J, Delahunt E. Dynamic balance deficits in individuals with chronic ankle instability compared to ankle sprain copers 1 year after a first-time lateral ankle sprain injury. Knee Surg Sports Traumatol Arthrosc 2016; 24 (04) 1086-1095
  • 22 Gerber JP, Williams GN, Scoville CR, Arciero RA, Taylor DC. Persistent disability associated with ankle sprains: a prospective examination of an athletic population. Foot Ankle Int 1998; 19 (10) 653-660
  • 23 Shah S, Thomas AC, Noone JM, Blanchette CM, Wikstrom EA. Incidence and cost of ankle sprains in United States emergency departments. Sports Health 2016; 8 (06) 547-552
  • 24 Benchimol EI, Smeeth L, Guttmann A. et al; RECORD Working Committee. The REporting of studies Conducted using Observational Routinely-collected health Data (RECORD) statement. PLoS Med 2015; 12 (10) e1001885
  • 25 Rhon DI, Clewley D, Young JL, Sissel CD, Cook CE. Leveraging healthcare utilization to explore outcomes from musculoskeletal disorders: methodology for defining relevant variables from a health services data repository. BMC Med Inform Decis Mak 2018; 18 (01) 10
  • 26 Bubra PS, Keighley G, Rateesh S, Carmody D. Posterior tibial tendon dysfunction: an overlooked cause of foot deformity. J Family Med Prim Care 2015; 4 (01) 26-29
  • 27 Edwards MR, Jack C, Singh SK. Tibialis posterior dysfunction. Curr Orthop 2008; 22 (03) 185-192
  • 28 Holmes Jr GB, Mann RA. Possible epidemiological factors associated with rupture of the posterior tibial tendon. Foot Ankle 1992; 13 (02) 70-79
  • 29 Hudes K. Conservative management of a case of tarsal tunnel syndrome. J Can Chiropr Assoc 2010; 54 (02) 100-106
  • 30 Lau JT, Daniels TR. Tarsal tunnel syndrome: a review of the literature. Foot Ankle Int 1999; 20 (03) 201-209
  • 31 Park S, Lee J, Cho HR, Kim K, Bang YS, Kim YU. The predictive role of the posterior tibial tendon cross-sectional area in early diagnosing posterior tibial tendon dysfunction. Medicine (Baltimore) 2020; 99 (36) e21823
  • 32 Frey BB. Hierarchical regression. In: The SAGE Encyclopedia of Educational Research, Measurement, and Evaluation. Thousand Oaks, CA: SAGE Publications, Inc; 2018
  • 33 Malehi AS, Pourmotahari F, Angali KA. Statistical models for the analysis of skewed healthcare cost data: a simulation study. Health Econ Rev 2015; 5: 11
  • 34 Blough DK, Ramsey SD. Using generalized linear models to assess medical care costs. Health Serv Outcomes Res Methodol 2000; 1 (02) 185-202
  • 35 Verkoeijen PP, Polak MG, Bouwmeester S, Vazire S, Savalei V. A practical illustration of methods to deal with potential outliers: a multiverse outlier analysis of study 3 from Brummelman, Thomaes, Orobio de Castro, Overbeek, and Bushman. Collabra Psychol 2018;4(01): Accessed July 9, 2022 at: https://online.ucpress.edu/collabra/article-abstract/4/1/30/112965
  • 36 Kannan KS, Manoj K, Arumugam S. Labeling methods for identifying outliers. Stat Inference Stoch Process 2015; 10 (02) 231-238
  • 37 Roy TC, Faller TN, Richardson MD, Taylor KM. Characterization of limited duty neuromusculoskeletal injuries and return to duty times in the U.S. Army during 2017-2018. Mil Med 2022; 187 (3-4): e368-e376
  • 38 Frank CB. Ligament structure, physiology and function. J Musculoskelet Neuronal Interact 2004; 4 (02) 199-201
  • 39 Hubbard TJ, Hicks-Little CA. Ankle ligament healing after an acute ankle sprain: an evidence-based approach. J Athl Train 2008; 43 (05) 523-529
  • 40 Herzog MM, Kerr ZY, Marshall SW, Wikstrom EA. Epidemiology of ankle sprains and chronic ankle instability. J Athl Train 2019; 54 (06) 603-610
  • 41 de Noronha M, Refshauge KM, Crosbie J, Kilbreath SL. Relationship between functional ankle instability and postural control. J Orthop Sports Phys Ther 2008; 38 (12) 782-789
  • 42 Inscore MC, Gonzales KR, Rennix CP, Jones BH. The effect of transitioning to ICD-10-CM on acute injury surveillance of active duty service members. Inj Epidemiol 2018; 5 (01) 32
  • 43 Kohls-Gatzoulis J, Angel JC, Singh D, Haddad F, Livingstone J, Berry G. Tibialis posterior dysfunction: a common and treatable cause of adult acquired flatfoot. BMJ 2004; 329 (7478): 1328-1333
  • 44 Hopkins JT, Coglianese M, Glasgow P, Reese S, Seeley MK. Alterations in evertor/invertor muscle activation and center of pressure trajectory in participants with functional ankle instability. J Electromyogr Kinesiol 2012; 22 (02) 280-285
  • 45 Kulig K, Popovich Jr JM, Noceti-Dewit LM, Reischl SF, Kim D. Women with posterior tibial tendon dysfunction have diminished ankle and hip muscle performance. J Orthop Sports Phys Ther 2011; 41 (09) 687-694
  • 46 Webster KA, Gribble PA. A comparison of electromyography of gluteus medius and maximus in subjects with and without chronic ankle instability during two functional exercises. Phys Ther Sport 2013; 14 (01) 17-22
  • 47 Feger MA, Donovan L, Hart JM, Hertel J. Lower extremity muscle activation in patients with or without chronic ankle instability during walking. J Athl Train 2015; 50 (04) 350-357
  • 48 Alvarez RG, Marini A, Schmitt C, Saltzman CL. Stage I and II posterior tibial tendon dysfunction treated by a structured nonoperative management protocol: an orthosis and exercise program. Foot Ankle Int 2006; 27 (01) 2-8
  • 49 Smith JT, Bluman EM. Update on stage IV acquired adult flatfoot disorder: when the deltoid ligament becomes dysfunctional. Foot Ankle Clin 2012; 17 (02) 351-360
  • 50 Vosoughi AR, Ravanbod H, Gilheany M, Erfani MA, Mozaffarian K. Posterior tibialis tendon rupture associated with closed medial malleolus fracture and avulsion of anterior talofibular ligament: a case report and review of the literature. Hong Kong J Emerg Med 2018; 25 (04) 232-235
  • 51 Cataldi C, Bacci N, Colasanti GB. et al. Posterior tibial tendon rupture associated with anterolateral distal tibial and medial malleolar fracture and a novel pattern of tibiofibular syndesmotic injury: a case report and review of the literature. J Foot Ankle Surg 2020; 59 (05) 1066-1071
  • 52 McPhail SM, Dunstan J, Canning J, Haines TP. Life impact of ankle fractures: qualitative analysis of patient and clinician experiences. BMC Musculoskelet Disord 2012; 13: 224
  • 53 Jackson LT, Dunaway LJ, Lundeen GA. Acute tears of the tibialis posterior tendon following ankle sprain. Foot Ankle Int 2017; 38 (07) 752-759
  • 54 Beckenkamp PR, Lin CWC, Chagpar S, Herbert RD, van der Ploeg HP, Moseley AM. Prognosis of physical function following ankle fracture: a systematic review with meta-analysis. J Orthop Sports Phys Ther 2014; 44 (11) 841-851 , B2
  • 55 Swart E, Bezhani H, Greisberg J, Vosseller JT. How long should patients be kept non-weight bearing after ankle fracture fixation? A survey of OTA and AOFAS members. Injury 2015; 46 (06) 1127-1130
  • 56 Kannus R, Jòzsa L, Renström R. et al. The effects of training, immobilization and remobilization on musculoskeletal tissue. Scand J Med Sci Sports 2007; 2 (03) 100-118
  • 57 Vandenborne K, Elliott MA, Walter GA. et al. Longitudinal study of skeletal muscle adaptations during immobilization and rehabilitation. Muscle Nerve 1998; 21 (08) 1006-1012
  • 58 Stevens JE, Pathare NC, Tillman SM. et al. Relative contributions of muscle activation and muscle size to plantarflexor torque during rehabilitation after immobilization. J Orthop Res 2006; 24 (08) 1729-1736
  • 59 Lamb SE, Marsh JL, Hutton JL, Nakash R, Cooke MW. Collaborative Ankle Support Trial (CAST Group). Mechanical supports for acute, severe ankle sprain: a pragmatic, multicentre, randomised controlled trial. Lancet 2009; 373 (9663): 575-581
  • 60 Hertel J. Immobilisation for acute severe ankle sprain. Lancet 2009; 373 (9663): 524-526
  • 61 Lin CWC, Donkers NAJ, Refshauge KM, Beckenkamp PR, Khera K, Moseley AM. Rehabilitation for ankle fractures in adults. Cochrane Database Syst Rev 2012; 11: CD005595
  • 62 Feger MA, Glaviano NR, Donovan L. et al. Current trends in the management of lateral ankle sprain in the United States. Clin J Sport Med 2017; 27 (02) 145-152
  • 63 Rhon DI, Fraser JJ, Sorensen J, Greenlee TA, Jain T, Cook CE. Delayed rehabilitation is associated with recurrence and higher medical care use after ankle sprain injuries in the United States Military Health System. J Orthop Sports Phys Ther 2021; 51 (12) 619-627
  • 64 Steven JL, Buer N, Samuelsson L, Harms-Ringdahl K. Pain-related fear, catastrophizing and pain in the recovery from a fracture. Scand J Pain 2010; 1 (01) 38-42
  • 65 Beckenkamp PR, Lin CWC, Engelen L, Moseley AM. Reduced Physical activity in people following ankle fractures: a longitudinal study. J Orthop Sports Phys Ther 2016; 46 (04) 235-242
  • 66 Galardi G, Amadio S, Maderna L. et al. Electrophysiologic studies in tarsal tunnel syndrome. Diagnostic reliability of motor distal latency, mixed nerve and sensory nerve conduction studies. Am J Phys Med Rehabil 1994; 73 (03) 193-198
  • 67 Samarawickrama D, Therimadasamy AK, Chan YC, Vijayan J, Wilder-Smith EP. Nerve ultrasound in electrophysiologically verified tarsal tunnel syndrome. Muscle Nerve 2016; 53 (06) 906-912
  • 68 Cimino WR. Tarsal tunnel syndrome: review of the literature. Foot Ankle 1990; 11 (01) 47-52
  • 69 McSweeney SC, Cichero M. Tarsal tunnel syndrome—a narrative literature review. Foot 2015; 25 (04) 244-250
  • 70 Sharma P. Inflammation and the metabolic syndrome. Indian J Clin Biochem 2011; 26 (04) 317-318
  • 71 Wearing SC, Hennig EM, Byrne NM, Steele JR, Hills AP. Musculoskeletal disorders associated with obesity: a biomechanical perspective. Obes Rev 2006; 7 (03) 239-250
  • 72 Monteiro R, Azevedo I. Chronic inflammation in obesity and the metabolic syndrome. Mediators Inflamm 2010; 2010: 289645
  • 73 Waterman BR, Owens BD, Davey S, Zacchilli MA, Belmont Jr PJ. The epidemiology of ankle sprains in the United States. J Bone Joint Surg Am 2010; 92 (13) 2279-2284
  • 74 Rabbito M, Pohl MB, Humble N, Ferber R. Biomechanical and clinical factors related to stage I posterior tibial tendon dysfunction. J Orthop Sports Phys Ther 2011; 41 (10) 776-784
  • 75 Lin CWC, Hiller CE, de Bie RA. Evidence-based treatment for ankle injuries: a clinical perspective. J Manual Manip Ther 2010; 18 (01) 22-28
  • 76 Chorley JN. Ankle sprain discharge instructions from the emergency department. Pediatr Emerg Care 2005; 21 (08) 498-501
  • 77 Hubbard TJ, Wikstrom EA. Ankle sprain: pathophysiology, predisposing factors, and management strategies. Open Access J Sports Med 2010; 1: 115-122
  • 78 van der Velde JHPM, Koster A, Strotmeyer ES. et al. Cardiometabolic risk factors as determinants of peripheral nerve function: the Maastricht Study. Diabetologia 2020; 63 (08) 1648-1658
  • 79 Esser N, Paquot N, Scheen AJ. Inflammatory markers and cardiometabolic diseases. Acta Clin Belg 2015; 70 (03) 193-199
  • 80 Applegate KA, Thiese MS, Merryweather AS. et al. Association between cardiovascular disease risk factors and rotator cuff tendinopathy: a cross-sectional study. J Occup Environ Med 2017; 59 (02) 154-160
  • 81 Li K, Deng G, Deng Y. et al. High cholesterol inhibits tendon-related gene expressions in tendon-derived stem cells through reactive oxygen species-activated nuclear factor-κB signaling. J Cell Physiol 2019; 234 (10) 18017-18028
  • 82 Guo S, Dipietro LA. Factors affecting wound healing. J Dent Res 2010; 89 (03) 219-229
  • 83 Kinoshita M, Okuda R, Yasuda T, Abe M. Tarsal tunnel syndrome in athletes. Am J Sports Med 2006; 34 (08) 1307-1312
  • 84 Jackson DL, Haglund B. Tarsal tunnel syndrome in athletes. Case reports and literature review. Am J Sports Med 1991; 19 (01) 61-65
  • 85 Churchill RS, Sferra JJ. Posterior tibial tendon insufficiency. Its Diagnosis, Management, and Treatment. Am J Orthop 1998; 27 (05) 339-347
  • 86 Jackson DL, Haglund BL. Tarsal tunnel syndrome in runners. Sports Med 1992; 13 (02) 146-149
  • 87 Mousavi SH, Hijmans JM, Rajabi R, Diercks R, Zwerver J, van der Worp H. Kinematic risk factors for lower limb tendinopathy in distance runners: A systematic review and meta-analysis. Gait Posture 2019; 69: 13-24
  • 88 Chodoroff B, Ball RD. Lumbosacral radiculopathy, reflex sympathetic dystrophy and tarsal tunnel syndrome: an unusual presentation. Arch Phys Med Rehabil 1985; 66 (03) 185-187
  • 89 Zheng C, Zhu Y, Jiang J. et al. The prevalence of tarsal tunnel syndrome in patients with lumbosacral radiculopathy. Eur Spine J 2016; 25 (03) 895-905
  • 90 Punt IM, Ziltener JL, Laidet M, Armand S, Allet L. Gait and physical impairments in patients with acute ankle sprains who did not receive physical therapy. PM R 2015; 7 (01) 34-41
  • 91 Kulig K, Reischl SF, Pomrantz AB. et al. Nonsurgical management of posterior tibial tendon dysfunction with orthoses and resistive exercise: a randomized controlled trial. Phys Ther 2009; 89 (01) 26-37