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Proceedings of the 16th

Italian Association of Equine Veterinarians
Congress

Carrara, Italy
January 29-31, 2010

Next SIVE Meeting:

Feb. 4-6, 2011 – Montesilvano, Pescara, Italy

Reprinted in the IVIS website with the permission of the

Italian Association of Equine Veterinarians – SIVE

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Understanding the tarsal sheath

Gaynor Minshall
BVSc CertES(Orth) MRCVS
Newmarket Equine Hospital, Newmarket, Suffolk, England

INTRODUCTION third of the metatarsus the deep head and su-

The tarsal sheath and contents are poorly de-
scribed in the literature, however the anatomy
is critical to understanding the pathology, mak-
ing accurate diagnoses and thus directing ap-
propriate case management.
ANATOMY
The deep digital flexor consists of three heads;
the deep head (the largest), the medial head and
the superficial head. The tendon of insertion of
the medial head, [medial digital flexor tendon
(MDFT)], has a separate sheath and combines
with the lateral digital flexor tendon immedi-
ately distal to the termination of the tarsal
sheath. From close to the musculotendinous
junction to between the proximal quarter and
perficial head [known together as the lateral
digital flexor tendon (LDFT)] are invested by
the tarsal sheath. Within this the LDFT has a
continuous, broad but thin, mesotenon attach-
ment on the caudo/plantaromedial margin
(Fig. 1). The tarsal sheath is enclosed by the
tarsal tunnel which is formed by the sustentac-
ulum tali and tarsal flexor retinaculum. This
produces a visible indentation between proxi-
mal and distal out pouches of the tarsal sheath.
Distally the tarsal sheath terminates as a cul-de-
sac which has a synovial fold attached to the
LDFT and dorsomedial sheath wall producing
a blind dorsomedial pouch1. The lateral exten-
sion of the tarsal sheath extends further distal
than its medial counterpart. The plantar neu-
rovascular bundles for the distal limb are locat-
ed in the fibrous layer of the wall and the tarsal
retinaculum and not within the sheath lumen.

Figure 1 - Dissection of
right tarsal sheath (proxi-
mal to right) demonstrating
the extensive mesotenon of
the LDFT.

SDFT: Superficial digital

flexor tendon
MT: Mesotenon
LDFT: Lateral digital flex-
or tendon
C: Calcaneus

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CLINICAL
EXAMINATION

The appearance and distri-

bution of distension associ-
ated with the tarsal sheath
requires careful appraisal as
these are associated with
differing disease entities.
Tenosynovitis of the tarsal
sheath can be distinguished
from tarsal sheath synovio-
coeles (Fig. 2), disruption of
the sheath wall (Fig. 3), dis-
tension of the MDFT sheath
and acquired tarsal bursae.

RADIOGRAPHY

Radiographs should include Figure 2 - Tarsal synoviocoele.

routine dorsoplantar, latero-
medial, dorsolateral-plantaro-
medial and dorsomedial-plan-
tarolateral oblique projections
of the tarsus together with a
dorso 45°medial-plantarolat-
eral oblique to profile the sus-
tentaculum tali and flexed Figure 3 - Torn tarsal sheath wall.
plantaroproximal-plantarodis-
tal oblique (skyline) of the
sustentaculum tali.

ULTRASONOGRAPHY

The author uses both linear

and curvilinear probes and
weight bearing and non
weight bearing assessments
in both transverse (Fig. 4)
and longitudinal section for
complete evaluation. A sys-
tematic approach is essen-
tial; this starts proximome-
dially assessing the muscu-
lotendinous junctions, the
Figure 4 - Transverse ultrasonograph of the tarsal sheaths at the level of the prox-
LDFT and MDFT, synovial imal metatarsus.
fluid, mesotenon, sheath MT: Mesotenon - LDFT: Lateral digital flexor tendon
wall and the osseous reflec- M: Medial digital flexor tendon

136
Proceedings of the Annual Meeting of the Italian Association of Equine Veterinarians, Carrara, Italy 2010
Published in IVIS with the permission of SIVE
tion of the sustentaculum tali. Knowledge of
the normal ultrasonographic appearance and
the normal boundaries of the sheath wall are
important.
CONTRAST STUDIES
When clinical and ultrasonographic differenti-
ation has not been possible, then contrast stud-
ies can assist in differentiation of synovio-
coeles, acquired bursae etc.
LESIONS
Tearing of the LDFT
Tearing of the LDFT can be of varying sever-
ity and invariably is associated with distension
of the sheath. Ultrasound has proved a reliable
predictor. In long standing cases these may be
accompanied by dystrophic mineralisation
and/or remodelling of the sustentaculum tali.
Musculotendinous avulsions
Musculotendinous avulsions are relatively un-
common and usually are associated with tear-
ing of the sheath wall. The prognosis in foals
is frequently favourable however in adults a
more cautious prognosis must be given.
Disruption of the mesotenon
The presentation is similar to and may be con-
comitant with tearing of the LDFT, although in
the absence of the latter the lameness is usual-
ly less severe. Diagnosis can be made by ultra-
sonographic assessment. In chronic cases recoil
of the mesotenon and adhesions to the tarsal
sheath wall are common. Ongoing tenosynovi-
tis frequently necessitates tenoscopy to remove
disrupted tissue.
Disruption of the tarsal sheath wall
This is most common proximolaterally but al-
so can be seen in the metatarsus. In the acute
phase there is usually soft tissue swelling
which obscures the normal boundaries of the
sheath. Frequently there is an increased sur-
137
Proceedings of the Annual Meeting of the Italian Association of Equine Veterinarians, Carrara, Italy 2010
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face temperature reflecting the acute inflam-
matory response to escape of synovial fluid.
Following second intention healing the tarsal
sheath boundaries are usually more extensive
than normal. Repeat tearing also can occur re-
sulting in continued expansion of the sheath
lumen.
Tarsal sheath synoviocoeles
This is a commonly encountered condition
which occurs from focal tearing of the sheath
wall. These are usually plantarolateral creat-
ing a variably sized fluctuant swelling of the
distolateral crus. Careful ultrasonographic as-
sessment usually will detect confluence with
the tarsal sheath. Most tears are small and act
as a valve. In acute cases when there is mini-
mal lameness, drainage and intra-thecal med-
ication with short acting corticosteroids in
combination with restricted exercise can pro-
duce complete resolution. Refractory cases re-
quire tenoscopic intervention; however the
post-operative cosmetic appearance is vari-
able ranging from complete resolution to per-
sistent distension.
Penetrating injuries of the tarsal sheath
Complete radiographic and thorough ultra-
sonographic examinations are vital to manage-
ment. Injuries that penetrate the mesotenon re-
sult in markedly compromised visualisation at
surgery and may require subtotal resection of
this for access.
CONCLUSION
Complete evaluation of the tarsal sheath, asso-
ciated and adjacent structures requires radi-
ographic, ultrasonographic and frequently
tenoscopic examination.
BIBLIOGRAPHY
1. McIlwraith, C. W., Nixon, A. J., Wright, I. M., Boen-
ing, K. J. (2005) Tenoscopy of the Tarsal Sheath. In:
Diagnostic and Surgical Arthroscopy in the Horse
3rd Ed 393-403.