Distal Peroneal Brevis Tendon Injection

Other Names

• Distal Peroneal Brevis Tendon Sheath Injection
• Distal Peroneal Brevis Tendon Percutaneous Tenotomy
• Distal Peroneal Brevis Tendon Injection
• Ultrasound-guided peroneus brevis tendon sheath injection
• Ultrasound-guided peroneus brevis intratendinous injection
• Peroneus brevis–peroneus longus common sheath corticosteroid injection
• Peroneus brevis insertional injection
• Fibularis Brevis tendon sheath injection

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Background

Peroneus Brevis

Key Points

• Transducer: high frequency, linear array
• Needle: 25 gauge, 1.5 inch
• Sonographically evaluate dynamically prior to any procedure

Anatomy of the Distal Peroneal Brevis Tendon

• Muscle originates the distal 2/3 of the fibula and anterior intermuscular septa
• Inserts on the tuberosity of the 5th metatarsal
• Muscle has become tendon by the time it passes posterior to the lateral malleolus
• Peroneal longus tendon runs posterior and lateral to peroneal brevis tendon
• These are surrounded by a peroneal tunnel or osteofibrous tunnel

Palpation Guidance vs Ultrasound Guidance

• Injections of the tendon sheath are described using fluoroscopy, palpation guidance, and ultrasound guidance
• Muir found ultrasound guidance to be 100% accurate vs 60% accuracy with palpation guided injections

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Indications

• Peroneal Tenosynovitis (Tendonitis)
• Peroneal Tendon Subluxation (& Dislocation)
• Peroneal Tendon Tear

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Contraindications

• Absolute
  • Anaphylaxis to injectates
  • Overlying cellulitis, skin lesion or systemic infection
• Relative
  • Can be treated with less invasive means
  • Hyperglycemia or poorly controlled diabetes
  • Lack of symptom improvement with previous injection

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Procedure

Demonstration of needle and probe position for the short axis, in plane approach to tendon sheath injection

Ultrasound view with needle in plane for short axis approach to tendon sheath injection. (* is lateral malleolus)

Probe and needle position for long axis, in plane needle tenotomy

Ultrasound view of long axis, needle in plane approach for needle tenotomy. (* is lateral malleolus)

Equipment

• Sterile prep (i.e. chloraprep, chlorhexidine, iodine, etc)
• Gloves
• Needle: typically 21-25 gauge, 1.5 inch
• Syringe: 5-10 mL
• Gauze
• Ethyl Chloride
• Bandage
• Injectate
  • Local anesthetic
  • Corticosteroid
• Sterile probe cover

Ultrasound Findings

• Common ultrasound findings include:

Tendon Sheath Injection: Short Axis, In Plane

• Patient Position
  • Patient Supine
  • Ankle internally rotated with lateral ankle facing up
• Transducer Position
  • Short axis over the fibula and peroneal brevis tendon
• Needle Approach/ Orientation
  • In plane
  • Posterior to anterior
• Target
  • Common peroneal tendon synovial sheath
• Pearls and Pitfalls
  • Dont confuse pathology of the peroneal tendon sheath with tear of the calcanofibular ligament
  • Peroneus quartus is a frequent anatomic variant, can be confused with a peroneus brevis split

Needle Tenotomy: Long Axis, In Plane

• Patient Position
  • Patient Supine
  • Ankle internally rotated with lateral ankle facing up
• Transducer Position
  • Long axis over the peroneal brevis tendon
• Needle Approach/ Orientation
  • In plane
  • Proximal to distal
• Target
  • Insertion of peroneus brevis

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Aftercare

• Motor exam should be intact
• No major restrictions in most cases
• Can augment with ice, NSAIDS
• Can consider Ankle Compression Sleeve after

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Complications

• Infection
• Damage to surrounding tissue

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See Also

Internal

• Procedures Main
• Foot And Ankle Anatomy
• Physical Exam Foot
• Foot Pain Main

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