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Insertion of the anterior tibial tendon a
cadaver study
K. Anagnostakos, A. Kristen, J. Kelm
Klinik für Orthopädie und Orthopädische
Chirurgie, Universität des Saarlandes,
Homburg/Saar, Germany (Direktor Prof. Dr. med.
D. Kohn)
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The anterior tibial tendon rupture is an
infrequent injury of the lower extremities (120
reported cases in 103 years!)
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Many patients complain about local tenderness on
the area between cuneiform and first metatarsal
bone prior to the tendon rupture MRI/sonography
tears beneath superior extensor retinaculum
or between superior and
inferior extensor
retinaculum
Anatomy??
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27 formaldehyde-fixed cadavers examined 53 feet
(27 right 26 left 1 left leg was amputated)

• Tendon prepared along its entire course
• beneath the superior extensor retinaculum till
  insertion
• Special attention paid on osseous or tendinous
• abnormalities along its insertion
• Photographs taken to document the pattern

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3 insertion types
Type I
36/53 feet (68 )
Tendons insertion into the medial side of the
cuneiform and the base of the first metatarsal
bone
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3 insertion types
Type Ia 19/36 wide split cuneiform
narrow split first metatarsal
bone Type Ib 13/36 two slips of equal
width Type Ic 4/36 narrow split cuneiform
wide split first metatarsal
bone
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3 insertion types
Type II
13/53 feet (25 )
Tendons insertion into the medial side of the
Os cuneiforme
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3 insertion types
Type III
4/53 feet (7 )
Type I additional tendon taking its origin from
the anterior tibial tendon near its insertion
into the cuneiform and attaching to the proximal
part of the first metatarsal
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• No tendons type inserting only
• into the first metatarsal bone
• No significant differences
• between left and right feet
• No significant differences
• between male and female

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Literature - 5 anatomic studies
Type I Insertion into both cuneiform and first
metatarsal bone a) wide slip cuneiform narrow
slip first metatarsal b) two slips of equal
width c) narrow slip cuneiform wide slip
first metatarsal Type II insertion only into the
medial cuneiform Type III Type I additional
tendon Type IV insertion only into the first
metatarsal bone
Arthornthurasook, A Gaew-Im, K. J Med Assoc
Thai, 73 692-6, 1990. Brenner, E. Clin Anat, 15
217-23, 2002. Luchansky, E Paz, Z. Anat Anz,
162 129-36, 1986. Musial, WW. Folia
Morphologica, 22 237-47, 1963. Anagnostakos et
al. Foot Ankle Int 27330-9 2006.
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The most common insertion type Type I (Type Ia
vs Type Ib) Strong variations for Type II
(Brenner 1.3 - Musial 4.1 vs present study
25 )
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Only Luchansky and the present study Type III
insertion Only Brenner Type IV insertion
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Conclusion
Lee et al. AJR 2006 187161-8
MRI precise data along the entire tendons
course except for the area beneath the inferior
extensor retinaculum near its insertion site
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Conclusion
false surgical reconstruction altering of the
foot biomechanics e.g. flatfoot
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Thank you for your attention