What is a dislocation of the posterior tibialis tendon – and can Kristaps Porzingis play?

Posterior Tibialis Tendon Dislocation Following Medial Retinaculum Rupture in Athletes

Boston Celtics player Kristaps Porzingis has suffered an extremely rare ankle injury this week that doesn't have a black and white treatment plan. So what is the injury and why is it particularly problematic for the mobility of a basketball player?

A posterior tibialis tendon dislocation is an exceptionally rare condition, particularly when it occurs following a medial retinaculum rupture, which is the case with Porzingis. This injury can have significant implications for athletes, affecting both their athletic performance and daily life. Understanding the nature of this injury, its impact, and the long-term prognosis is crucial for athletes, trainers, and medical professionals.

Anatomy and Mechanism of Injury

The posterior tibialis tendon plays a pivotal role in stabilising the medial aspect of the ankle and foot. It aids in foot arch support and inverting the foot, which are crucial for activities requiring balance and agility. The medial retinaculum is a fibrous band that holds the tendon in place behind the medial malleolus, or that bump on in the inside of your ankle.

Dislocation of the posterior tibialis tendon typically occurs due to a high-impact trauma or a sudden twisting injury that forces the tendon out of its groove, particularly when the medial retinaculum is ruptured. In athletes, this might happen during high-intensity sports that involve rapid directional changes, jumping, or tackling, such as soccer, basketball, or gymnastics.

Impact on Athletic and Daily Function

Athletic Performance

Stability and Balance: The posterior tibialis tendon is crucial for maintaining stability and balance. Its dislocation disrupts these functions, making it difficult for athletes to perform movements that require precise foot control.

Pain and Inflammation: The initial injury and subsequent dislocation cause significant pain and inflammation, severely limiting athletic performance.

Mobility and Strength: The loss of tendon function leads to weakened foot and ankle strength, reducing an athlete’s ability to run, jump, and pivot.

Daily Activities

Walking and Standing: Individuals may experience pain and difficulty while walking or standing for prolonged periods.

Routine Movements: Simple movements like climbing stairs, squatting, or even maintaining posture can become challenging.

Foot Deformity: Chronic instability can lead to deformities, such as flatfoot, which further complicates daily activities.

Long-Term Prognosis

Whilst a lot is still unknown about the long-term prognosis of posterior tibialis tendon dislocation following medial retinaculum rupture due to it's rarity, it is largely dependent on the timeliness and effectiveness of the treatment.

Surgical vs. Conservative Treatment: While conservative treatments (e.g., immobilisation & physiotherapy) might be sufficient for partial injuries, complete ruptures and dislocations usually require surgical intervention to reattach and stabilise the tendon and retinaculum.

Recovery Time: Post-surgery recovery typically spans several months. Athletes might need 6 to 12 months before they can return to their previous level of performance.

Rehabilitation: Intensive physiotherapy focusing on strength, flexibility, and proprioception is crucial. Rehabilitation protocols are personalised based on the severity of the injury and the patient’s progress.

Ongoing Issues and Expectations

Even with appropriate treatment, athletes and individuals may experience ongoing issues:

Chronic Pain: Persistent pain is a common complaint, especially during high-impact activities or prolonged standing.

Recurrent Instability: Some patients may experience recurring instability or dislocation, necessitating further intervention.

Reduced Performance: Athletes might not regain their pre-injury level of performance due to residual weakness or psychological factors such as fear of re-injury.

Arthritis: There is a risk of developing arthritis in the affected joint over time due to the altered biomechanics and chronic instability that could result from this injury.

Conclusion

Posterior tibialis tendon dislocation following medial retinaculum rupture is a rare but significant injury that can substantially impact both athletic performance and daily functioning. Early diagnosis and appropriate treatment, whether surgical or conservative, are vital for optimal recovery. Long-term prognosis varies, with some individuals returning to near-normal function while others may face ongoing challenges such as pain, instability, and reduced athletic performance. Comprehensive rehabilitation and a gradual return to activity are essential components of recovery, with the goal of minimising long-term complications and maximising functional outcomes.

In the case of Porzingis, given he is a professional basketball player at the highest level and the requirement for explosive movements such as jumping, landing, pushing off and quick change of directions is relentless, his return journey is largely unknown at this time. It will be a matter of managing his return one day at a time and addressing the biomechanical and physical issues as they come into play.