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Os Peroneum Syndrome

From WikiSM

Other Names

  • Os Peroneum Syndrome
  • Painful Os Peroneum Syndrome (POPS)
  • Painful Os Peroneum

Background

  • This page refers to symptomatic os peroneum, often termed Painful Os Peroneum Syndrome (POPS)

History

  • The term "Painful Os Peroneum Syndrome" was first used by Sobel in 1994[1]

Epidemiology

  • Symptomatic Os Peroneum is a rare clinical condition which is poorly described in the literature
  • Os Peroneum
    • Identified in 4.7% to 30% of normal feet[2]
    • Bipartite approximately 30% of the time, bilateral 60% of the time[1]

Introduction

Illustration of fractures of the proximal fifth metatarsal and os peroneum[3]
(a) Normal os peroneum. (b) bipartite os peroneum[4]
Diagrams showing the progressive retraction of the os peroneum, implying injury to the inferior and superior peroneal retinacula (A-E). (A) The orange ossicle is depicted in its expected position along the lateral cuboid within the peroneus longus tendon (brown). The inferior peroneal retinaculum (dark gray lines) and the superior peroneal retinaculum (light gray lines) are also shown. (B) The ossicle is retracted proximally, suggesting injury to the peroneus longus tendon, but remains at the level of the lateral calcaneus because the inferior peroneal retinaculum is intact. The ossicle may be fractured, as in our case above. (C) The ossicle has retracted proximally between the inferior and superior peroneal retinacula, suggesting injury to the inferior peroneal retinaculum. (D) The ossicle is within or just adjacent to the superior peroneal retinaculum. (E) The ossicle is displaced proximally along the lateral fibula, implying injury to the superior peroneal retinaculum with further retraction of the peroneus longus tendon.[5]

General

  • Os Peroneum is an accessory ossicle located in the peroneus longus tendon
  • Can become symptomatic from a wide variety of conditions
  • Presents as lateral midfoot pain
  • Easily overlooked due to rarity of condition, practioner's lack of suspicion

Etiology

  • Fracture: acute or stress
  • Diastasis
  • Tenosynovitis
  • Multipartite os
  • Rupture of peroneal longus tendon
    • Strong contraction of muscle with sudden inversion or supination
    • Suggested that presence of os peroneum can predispose to rupture[6]
    • Thought to occur due to increased friction with adjacent structures

Acute POPS

  • Occurs as a result of trauma such as ankle sprain or supination
  • Results in fracture of the ossicle
  • May or may not be associated with peroneus longus rupture

Chronic POPS

  • Linked to healing fracture with subsequent calcification, remodeling or diastasis
  • Can result in tenosynovitis of the peroneal longus tendon

Anatomy of Os Peroneum

Anatomy of Peroneus Longus

  • Originates on the fibula and intermuscular septa
  • Inserts on the medial cuneiform, plantar aspect of the 5th metatarsal
  • Action: plantarflexion, eversion of foot

Risk Factors

  • Unknown

Differential Diagnosis

Differential Diagnosis Lateral Foot Pain

Differential Diagnosis Foot Pain

Clinical Features

History

  • Lateral midfoot pain
  • Worse with weight bearing

Physical Exam

  • Swelling over the cuboid
  • Tenderness to palpation of the ossicle
  • Pain can be provoked by plantarflexion, inversion

Special Tests

  • Needs to be updated

Evaluation

60-year-old female plain film of the feet in an oblique view. (a) Right foot: complaint side, showing an irregular and fragmented os peroneum with heterogeneous density (arrow). (b) Left foot: comparative contralateral side, showing a regular and complete os peroneum with regular contours and homogeneous density (arrow).[8]
60-year-old female ultrasonography of the long axis of the peroneus longus tendon. (a) Right foot: complaint side demonstrating a thickened and heterogeneous peroneus longus tendon (asterisk) and irregular and fragmented os peroneum, associated with swelling of the surrounding soft tissues. (b) Left foot: contralateral side for comparison, demonstrating a preserved echotexture of the peroneus longus tendon (asterisk) and regular contours of the os peroneum without changes in the surrounding soft tissues.[8]
60-year-old female right midfoot MRI. (a) Sagittal T2; (b) coronal T1; (c) fat suppressed T1 postgadolinium; and (d) axial fat suppressed T1 postgadolinium. Arrows show the os peroneum within the peroneal tendon, with irregular contours, bone marrow edema, and intense enhancement of the adjacent soft tissues, characterizing inflammatory changes. The peroneus longus tendon is thickened and heterogeneous, consistent with associated tendinopathy.[9]

Radiographs

  • Standard Radiographs Foot
  • Findings
    • Best seen on oblique view
    • May see displacement, fracture, diastasis, bipartite sesamoid
  • Displacement can be an indirect sign of tendon rupture
  • Bipartite ossicle
    • Can be difficult to distinguish fracture from bipartite os peroneum
    • Acutely, fracture margins are relatively nonsclerotic, bony pieces "fit together"

MRI

  • Ossicle is usually isointense to bone marrow
  • Presents clinically with increased intrasubstance signal within the tendon
  • Typically found close the the cuboid

Ultrasound

  • Easily identified because of the typical hypoechoic appearance of bone
  • Easily found within the peroneus longus tendon
  • Presents as a curved echogenic focus with posterior acoustic shadow[10]

CT

  • May see displacement, fracture, diastasis, bipartite sesamoid
  • Displacement can be an indirect sign of tendon rupture

Classification

  • Not applicable

Management

Nonoperative

Operative

  • Indications
    • Failure of conservative management
  • Technique
    • Excision of ossicle
    • Repair or peroneus longus tendon

Rehab and Return to Play

Rehabilitation

  • There is no specific protocol
  • Following program for peroneal tendinopathy

Return to Play/ Work

  • There are no return to play guidelines

Prognosis and Complications

Prognosis

  • Unknown

Complications

  • Chronic Pain

See Also

References

  1. ↑ 1.0 1.1 Sobel M, Pavlov H, Geppert MJ, Thompson FM, DiCarlo EF, Davis WH. Painful os peroneum syndrome: a spectrum of conditions responsible for plantar lateral foot pain. Foot Ankle Int 1994;15:112-124
  2. ↑ Oh S. J., Kim Y. H., Kim S. K., Kim M.-W. Painful os peroneum syndrome presenting as lateral plantar foot pain. Annals of Rehabilitation Medicine. 2012;36(1):163–166. doi: 10.5535/arm.2012.36.1.163
  3. ↑ Case courtesy of Frank Gaillard, Radiopaedia.org, rID: 7644
  4. ↑ Bianchi, Stefano, Chandra Bortolotto, and Ferdinando Draghi. "Os peroneum imaging: normal appearance and pathological findings." Insights into imaging 8 (2017): 59-68.
  5. ↑ Favinger, Jennifer L., Michael L. Richardson, and Felix S. Chew. "Progressive retraction of a fractured os peroneum suggesting repetitive injury to the peroneus longus tendon." Radiology Case Reports 13.1 (2018): 216-219.
  6. ↑ Brigido M. K., Fessell D. P., Jacobson J. A., et al. Radiography and US of os peroneum fractures and associated peroneal tendon injuries: initial experience. Radiology. 2005;237(1):235–241. doi: 10.1148/radiol.2371041067
  7. ↑ Miller, Theodore T. "Painful accessory bones of the foot." Seminars in musculoskeletal radiology. Vol. 6. No. 02. Copyright© 2002 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel.:+ 1 (212) 584-4662, 2002.
  8. ↑ 8.0 8.1 Chagas-Neto, Francisco Abaete, Barbara Nogueira Caracas de Souza, and Marcello Henrique Nogueira-Barbosa. "Painful os peroneum syndrome: underdiagnosed condition in the lateral midfoot pain." Case reports in radiology 2016.1 (2016): 8739362.
  9. ↑ Chagas-Neto, Francisco Abaete, Barbara Nogueira Caracas de Souza, and Marcello Henrique Nogueira-Barbosa. "Painful os peroneum syndrome: underdiagnosed condition in the lateral midfoot pain." Case reports in radiology 2016.1 (2016): 8739362.
  10. ↑ Donovan A., Rosenberg Z. S., Bencardino J. T., et al. Plantar tendons of the foot: MR imaging and US. Radiographics. 2013;33(7):2065–2085. doi: 10.1148/rg.337125167
  11. ↑ Andresen, Julian Ramin, Stephan Puchner, and Sebastian Radmer. "Successful treatment of a painful os peroneum using conservative measures, infiltration therapy, and shock waves." Journal of Surgical Case Reports 2023.12 (2023): rjad645.
Created by:
John Kiel on 19 November 2024 17:07:39
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Last edited:
20 November 2024 18:17:43
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