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This is a 67-year-old male with a painful lump

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medially, so I'm looking for medial abnormalities.

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I've got my neurovascular bundle,

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the tibialis posterior, the flexor digitorum and hallucis,

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Tom, Dick, and Harry, three tendons.

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I've got two tendons over here, peroneus longus and brevis.

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I've got one tendon in the back, the achilles.

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And I've got four in the front

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that'll go unnamed for now.

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So, one, two, three, and four.

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I'm focusing medially, where there's a lot

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going on in the region of the deltoids.

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Although, I don't get that excited about the

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deltoid other than the spring ligament and

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tibiospring ligament, which are thickened over

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here, and the deltoid is usually not a structure

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that requires a lot of surgical attention.

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So, I'm going to focus on the tibialis

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posterior tendon, which is secured by the

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laciniate ligament or medial retinaculum.

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And normally, when it tears, and I'm

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going to do my search pattern from bottom

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to top, I prefer the toe be pointed.

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And that the axials be obliqued perpendicular to

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the orientation of the tendon, much like this.

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But they didn't give me that, so this was not

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performed properly for a tendon evaluation.

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But it's no matter.

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I've been doing this a long time.

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I can deal with it.

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And I'm going to follow my tendon down, knowing

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that this tendon, when it tears, gets big.

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Whereas the peroneus brevis,

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when it tears, it gets thinner or small.

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And we do have an abnormality of

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the peroneus brevis right here.

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But let's stay on the medial side because that

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currently is not symptomatic in this patient.

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You're seeing the brevis split into

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two parts here in front of the longus.

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So let's stay with the posterior tibial tendon,

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which when torn, results in collapse of the foot,

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pressure on the spring ligament, insufficiency

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of the spring ligament, and a painful flat foot.

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Tears of this tendon may be exacerbated

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by very stiff low cut shoes, and it

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almost never tears right at the insertion.

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It's usually retro and immediately inframalleolar.

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Now there are some conditions

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that predispose to this tear.

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One of which is a curious, very deep groove

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with large spurs on either side in the tibia.

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There's a small groove here with a

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small spur, and the tendon looks fine.

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But when that groove gets really deep, and the

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spurs get really big, they tear right there.

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The second place you have to pay very careful

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attention to the posterior tibial tendon is right

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behind the malleolus, immediately behind it.

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Because it likes to tear there, especially

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if there are spurs coming off in this locus.

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Here, not so much.

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It looks pretty smooth and concave forward.

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So as we go down, we are not seeing a tear.

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The tendon becomes more elliptical as we go down.

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It's a little flatter.

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And we're headed for the navicular.

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And when we head for the

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navicular, the tendon is gonna fan.

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It normally fans because of so many attachments.

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So I'm not that bothered by the fanning, except

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for the fact that I've been doing this such a

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long time, that I'm seeing it fan prematurely.

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I'm losing the signal a little early.

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I don't really like to lose the signal

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until the talus has disappeared.

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And I'm already losing the signal

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and the talus is still present.

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So I'm gonna have to resort to another projection.

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And that is the Sagittal PD Fat Suppression.

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Now remember we said this tendon

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hardly ever tears at the insertion.

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But this one did.

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Right there.

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All the way up to its insertion on the navicular.

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Now it is said that that tear

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will occur in patients that have

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very irregular shaped naviculars.

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Which this patient does.

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Let's blow it up.

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It is said that that tear will

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occur in Ost Naviculary Syndrome.

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where you have an accessory navicular, something

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like this, with a chondral interface between

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that navicular and the bone right here, and

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that's known as a type 2 accessory navicular.

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An ostibial externum, where you have a

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tendon and an ossicle inside it, not so much.

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And a cornuate navicular, where this

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ossicle fuses and makes for a big

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navicular, that's at higher risk.

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But not so much.

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So this patient has an irregular, ragged,

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spurred navicular, and has developed

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the very unusual distal, let's scroll

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it, distal posterior tibial tendon tear.

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It ends right about there,

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goes right up to the navicular.

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It's most atypical.

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And I've given you the other sites of

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potential tear and weakness, right behind

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the malleolus, and up in the tibia, where

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you have a very subtle indentation or groove,

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I'm not going to go through the entire search

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pattern, in this case, although I've given

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you several very important checklist dictation

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related things to put into your dictation

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as pertinent negatives or positives when

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you have a posterior tibial tendon injury.

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And one of them should include length.

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And here we get the length

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in the sagittal projection.