Tibialis anterior tendon variants: The forgotten risk in foot and ankle surgery

The tibialis anterior tendon (TAT) is a critical structure for foot dorsiflexion and medial arch stabilization. Despite its functional importance, the morphological variability of the TAT remains underrecognized in clinical and surgical settings. This review aims to present a comprehensive overview of TAT anatomical variants, their diagnostic imaging features, and implications for foot and ankle surgery.

We systematically analyze the current anatomical classifications of the TAT, with particular focus on the Olewnik et al. (2019) system, which integrates cadaveric dissection and high-resolution ultrasound findings. Comparative analysis with historical systems (Musiał, Brenner, Willegger) is included. Clinical risk stratification, imaging strategies (ultrasound, MRI), and type-specific surgical approaches are also discussed.

Six distinct TAT types (I-VI) were identified, with Type VI detectable only via ultrasound. Variants involving single-band insertions (Types V and VI) pose the highest intraoperative risk due to limited insertional dispersion and altered fiber rotation. Incorporation of morphological typing into preoperative imaging protocols significantly improves surgical planning and minimizes iatrogenic injury. A clinical algorithm and rehabilitation guidelines tailored to each TAT variant are proposed.

The morphological variability of the TAT has direct surgical, diagnostic, and rehabilitative implications. Integrating a type-based TAT classification into routine foot-and-ankle work flow sparticularly for procedures involving the medial cuneiform or first metatarsal may support preoperative planning; whether its use reduces complication or reoperation rates requires prospective validation. Multicenter prospective and biomechanical studies are needed to evaluate clinical impact and refine variant-based surgical planning.