Letter Regarding: Risk Factors for Anterior Tibial Tendon Pathology

Abstract

with interest the article "Risk Factors for Anterior Tibial Tendon (ATT) Pathology" by Levitsky et al. 7 This article reported on the 2 clinical presentations of ATT pathology in a series of 94 patients. The first entity, ATT rupture, is a condition that was reported as early as 1947 by Moberg, 9 and more than 70 case reports and series have been documented in the literature ever since, with the largest series of 19 ruptures in 18 patients reported by Sammarco et al. 10 In this series, males represented a small majority (58%) of cases, whereas in the series of 15 ruptures reported by Levitsky et al, 7 62% were in women. Thus, it would appear that for ruptures of the ATT, sex probably is not a risk factor.The entity of distal tibialis anterior tendinopathy (DTAT) without rupture was first described in the radiological literature by Mengiardi et al 8 in 2005 and the clinical features by Beischer et al 1 in 2009, who reported on a series of 29 patients (33 feet) in this journal. They reported that this clinical entity was predominantly seen in women (93% of cases), with the majority being overweight or obese. They described the Tibialis Anterior Passive Stretch (TAPS) test, which can be useful in diagnosing the condition. The operative management of DTAT was reported by our group in 2010 again in this journal. 4 Our results would support the statement that most patients with DTAT can be successfully managed with nonoperative therapy, although we have found a custom accommodative insole effective in the majority. We have found that some with night pain as a major symptom can find relief by wearing a rigid ankle foot orthosis while sleeping.In the cohort of 79 patients with DTAT reported by Levitsky et al, 7 81% were women, and an average body mass index of 27.2 kg/m 2 was reported for the entire cohort. Thus, their findings support those reported initially by our group, although this was not acknowledged by Levitsky et al. 7 Although the majority (64/79) of their patient cohort displayed features of DTAT, there was no reference to this entity in their bibliography, with all references being to the rupture of the ATT. Indeed, a PubMed search identified 5 publications on DTAT since those I have mentioned. 2,3,5,6,11 Thus, it would appear that a limited literature review has been undertaken by Levitsky et al, 7 which in my view detracts from the merit of this otherwise interesting article.