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Differential Plantaris-Achilles Tendon Motion: a Sonographic and Cadaveric Investigation

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Differential Plantaris-Achilles Tendon Motion: a Sonographic and Cadaveric Investigation PM R XXX (2016) 1-8 www.pmrjournal.org Original Research Differential Plantaris-Achilles Tendon Motion: A Sonographic and Cadaveric Investigation Jay Smith, MD, Ha˚kan Alfredson, MD, Lorenzo Masci, MD, Jacob L. Sellon, MD, Charonn D. Woods, MD Abstract Background: Differential motion between the plantaris and Achilles tendons has been hypothesized to contribute to pain in some patients presenting with Achilles tendinopathy. However, objective evidence of differential Achilles-plantaris motion is currently lacking from the literature. Objective: To determine whether differential, multidirectional motion exists between the plantaris tendon (PT) and Achilles tendon (AT) as documented by dynamic ultrasound (US) and postdissection examination in an unembalmed cadaveric model. Design: Prospective, cadaveric laboratory investigation. Setting: Procedural skills laboratory in a tertiary medical center. Subjects: Twenty unembalmed knee-ankle-foot specimens (9 right, 11 left) obtained from 6 male and 10 female donors ages 55-96 years (mean 80 years) with body mass indices of 14.1-33.2 kg/m2 (mean 22.5 kg/m2). Methods: A single, experienced operator used high-resolution dynamic US to qualitatively document differential PT-AT motion during passive ankle dorsiflexion-plantarflexion. Specimens were then dissected and passive dorsiflexion-plantarflexion was repeated while differential PT-AT motion was visualized directly. Main Outcome Measurements: Presence or absence of multidirectional differential PT-AT motion. Results: All 20 specimens exhibited smooth but variable amplitude multidirectional differential PT-AT motion. Whereas US readily demonstrated medial-lateral and anterior-posterior PT motion relative to the AT, differential longitudinal motion was only appreciated on dissection and direct inspection. Many specimens exhibited partial or complete encasement of the PT between the gastrocnemius portion of the AT and the soleus aponeurosis. Conclusion: Some degree of multidirectional differential PT-AT motion appears to be a normal phenomenon, and PT motion can be evaluated sonographically in both the medial-lateral and anterior-posterior directions. The existence of normal differential PT-AT motion suggests that alterations in PT motion or repetitive stress within the PT-AT interval may produce symptoms in some patients presenting with Achilles region pain syndromes. The PT should be evaluated in all patients presenting with Achilles, plantaris, or calf pain syndromes. Future research would benefit from the development of a sonographic classification system for PT anatomy and motion with the goal of differentiating normal versus pathologic states and identifying risk factors for symptom development. Level of Evidence: To be determined. Introduction symptomatic Achilles tendinopathy in some patients [6-14]. The PT typically lies directly adjacent to the Achilles tendinopathy is a common clinical disorder Achilles tendon (AT) and although smaller in size, the PT characterized by pain, swelling, and impaired perfor- is stronger, stiffer, and less extensible than the AT mance [1-4]. Achilles tendinopathy affects 1-2 people (Figure 1A-B) [6,15]. per 1000 among the general population and up to 10% of The anatomical and biomechanical differences elite long-distance runners [2-5]. Alfredson et al have between the PT and AT suggest the possibility that shear recently hypothesized that the plantaris tendon (PT) or compressive forces may promote pathologic changes may contribute to the development or perpetuation of in the peritendinous tissues within the PT-AT interface 1934-1482/$ - see front matter ª 2016 by the American Academy of Physical Medicine and Rehabilitation http://dx.doi.org/10.1016/j.pmrj.2016.10.013 2 Plantaris Motion Figure 1. (A) Anatomical dissection demonstrating the PM and PT in relation to the GM, SOL, and AT. The medial GM has been reflected laterally (to the left) to reveal the PT coursing between it and the underlying SOL in the proximal one-third of the leg. The GM serves as a landmark to initially identify the PT during sonographic evaluation. Note the close relationship between the PT and AT distally, better shown in (B). (B) Same specimen as (A), demonstrating the close proximity of the PT and AT in the distal leg. (C-D) Same anatomical specimen as (A), demonstrating transducer positioning to identify the PT between the medial GM and SOL proximally and adjacent to the AT distally. AT ¼ Achilles tendon; GM ¼ gastrocnemius muscle; PM ¼ plantaris muscle; PT ¼ plantaris tendon; SOL ¼ soleus muscle; TN ¼ tibial nerve. or the tendons themselves [6-10,12-14,16-19].In Doppler-guided ventral tendon scraping procedure for support of this hypothesis, Spang et al [7] documented refractory Achilles tendinopathy [8]. Consequently, the existence of neovascularization, hypercellularity, multiple therapeutic procedures have been developed and somatic and sympathetic nerve fibers capable of to target the PT-AT interval, including PT release, PT mediating pain within the fibrofatty tissue of the PT-AT transection, PT resection, and removal or ablation of interface in patients surgically treated for Achilles the presumably painful peritendinous tissues via surgical tendinopathy. Furthermore, removal of this tissue in resection or hydrodissection [9,10,14,18-23]. combination with PT resection improved pain and Despite the increased interest in the role of the PT resulted in functional recovery in patients who did in the pathoetiology of the Achilles region pain and not respond previously to an ultrasound (US) and the development of treatments targeting the PT or J. Smith et al. / PM R XXX (2016) 1-8 3 peritendinous tissue within the PT-AT interval, the specimens were obtained through the Department of mechanisms by which the PT may contribute to Achilles Anatomy’s Mayo Foundation Bequest Program. pain or Achilles tendinopathy have not been explored Fresh-frozen specimens were thawed at room tem- fully. More specifically, although it has been hypothe- perature immediately before use. Each specimen was sized that differential motion occurs between the PT examined sonographically to assess for differential, and AT during daily activities, formal documentation of multidirectional PT-AT motion by the primary author, this normal motion is lacking from the literature who had more than 13 years of experience performing [6-10,12-14,18,19]. diagnostic musculoskeletal US at the time of the inves- Recently, Han et al [11] reported the use of dynamic tigation. After sonographic evaluation, each specimen US to document symptomatic posttraumatic PT snapping also was dissected to directly visualize differential in a 30-year-old man treated successfully with surgical PT-AT motion. All scanning was performed with a Philips PT resection [11]. The authors hypothesized that iU22 US machine and either a 17-5 MHz or 15-7 MHz excessive dyskinetic PT motion resulted from disruption linear array transducer (Philips Healthcare, Bothell, of normal AT-PT soft-tissue connections after a twisting WA). This study was approved by the institutional review ankle injury [11]; however, the case report did not board at the primary author’s institution (institutional include a description of normal PT motion with respect review board no. 16-006838). to the AT. The primary author consistently has observed differential PT-AT motion during routine sonographic Scanning Technique evaluations of patients presenting with posterior heel pain syndromes, including Achilles tendinopathy. The leg was placed in a prone position with the ankle- During passive plantarflexion-dorsiflexion movements, foot hanging off the edge of the table. As previously the PT consistently but variably moves medial-lateral described, the PT tendon was identified as a small, and anterior-posterior with respect to the AT. Differ- ovoid structure lying between the distal muscu- ential superior-inferior motion, however, has not been lotendinous junction of the medial gastrocnemius mus- observed on US, perhaps as the result of technical cle and the underlying soleus muscle, measuring limitations. approximately 3-6 mm2 in cross-sectional area Consequently, the primary purpose of this investiga- (Figure 1C) [24-27]. If the PT was not identified readily, tion was to determine whether consistent, multidirec- the transducer was moved superiorly to improve tional differential motion occurs between the PT and contrast between the relatively hyperechoic PT and the AT, as documented by dynamic US and postdissection surrounding, primarily hypoechoic gastrocnemius and examination, via an unembalmed cadaveric model. We soleus muscles. hypothesized that, as predicted by anatomical and Once the PT was identified definitively, the trans- biomechanical data, differential multidirectional PT-AT ducer was moved distally to locate the region in which motion does consistently occur and therefore may be the tendon was most conspicuous relative to the adja- pathoetiologic in the development of Achilles pain cent soleus portion of the AT. In general, the PT was syndromes or tendinosis affecting the AT and/or PT. best visualized at or just distal to the musculotendinous Clinically, the results of this investigation would justify junction of the medial gastrocnemius. In most cases, further research to investigate the role of the PT (spe- tilting the transducer to produce anisotropy (ie, cifically differential PT-AT motion) in the pathogenesis rendering the tendons dark) increased the conspicuity of Achilles tendinopathy, as well as treatments target-
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