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Peroneal Tendon Injuries

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Other Names

  • Peroneal Tendon Disorders
  • Peroneal Tendinopathy
  • Peroneal Tenosynovitis
  • Peroneal tendon subluxation
  • Peroneal tendon dislocation
  • Peroneal tendon split
  • Peroneal tendon tear
  • Peroneal tendinosis
  • Superior Peroneal Retinaculum (SPR) Injury

Background

  • This page refers to disorders of the Peroneal Tendons
    • This includes tendinopathies, subluxation, dislocation and tearing

History

  • 1803: The first peroneal tendinopathy was a subluxation described my Monteggia[1]
  • 1924: First description of an isolated split of the peroneal tendon[2]
  • 1932: Operative treatment of chronic dislocation of peroneal tendons[3]
  • 1934: Burman described 3 regions of peroneal tendons associated with increased incidence of tenosynovitis[4]

Epidemiology

  • Only 60% of peroneal tendon disorders are accurately diagnosed at the first clinical evaluation[5]
  • Most commonly seen young active patients (need citation)
  • Tears
    • Peroneus brevis tear is more common than longus
    • Of 47 patients with lateral ankle complaints, 36% were found to have attrition of the peroneus brevis tendon[6]
    • Retrospective review: 88% had brevis tears, 13% longus and 37% had both[5]

Pathophysiology

  • General
    • Often missed cause of lateral ankle pain

Etiology

  • Acute
    • Sudden contraction of the peroneal muscle group
    • Inversion Ankle injury
  • Chronic
    • History of acute injury
    • Tendon rubbing over posterolateral fibula
    • Chronic lateral ankle instability
    • Anatomic variants: abnormal fibular retromalleolar groove, hindfoot alignment or cavus foot

Peroneal Tendonitis

  • General
    • Characterized by gradual onset of pain, swelling, warmth of the posterolateral ankle
    • Lateral ankle instability can lead to laxity
    • Increased motion of the tendons around the fibula with stretched superior peroneal retinaculum
    • Low lying peroneus brevis muscle belly having to go through the narrow tendon sheath

Peroneal Tendon Subluxation

  • Acute instability can be
    • Rupture of the superior peroneal retinaculum (SPR)
    • Fibular groove avulsion
  • Chronic subluxation
    • Associated with fibular groove flattening and laxity of the superior retinacular retinaculum or ligament

Peroneal Tendon Tear

  • General
    • Occurs at the musculotendinous junction
    • May be acute, vast majority are chronic[7]
    • Most tears are longitudinal and result from chronic subluxation over the distal fibula
    • Often related to a sentinel event which is remote relative to patient presentation
  • Location
    • Majority of tears at tip of fibula, bony prominence where pressure is applied against tendon
    • This suggests most tears are mechanical in etiology
  • Etiology: Peroneus brevis
    • Chronic: subluxing tendon can splay or split over the sharp posterolateral edge of the fibula
    • Acute: compression of the peroneus brevis tendon between the posterior fibula and peroneus longus tendon causes a split lesion during an inversion injury
    • Both can lead to the so-called 'split lesion'
  • Etiology: Peroneus Longus
    • Acute: laceration of the tendon, avulsion of the tendon at or through the os peroneum, or dislocation at the lateral malleolus

Pathoanatomy

  • Lateral Compartment of the Leg
    • Contains Peroneus Longus, Peroneus Brevis (sometimes referred to as Fibularis)
    • Functions: Eversion, weak ankle plantarflexion, dynamic ankle stabilizer
    • Both tendons cross the joint posteriorly to the lateral malleolus
    • Tendon orientation at the level of the ankle is brevis anterioromedial to longus
    • They share a common synovial sheath until they pass the fibula where they divide into separate sheaths
  • Peroneus Longus
  • Peroneus Brevis
    • Strongest abductor of the foot because it attaches on the 5th Metatarsal
  • Os peroneum
    • Seen in about 20% of population[8]
    • Ossified sesamoid bone at the level of the calcaneocuboid joint
  • Peroneus Quartus
    • Most commonly runs form the peroneus brevis to the retrotrochlear eminence of the calcaneus
    • Associated with peroneus brevis tears, and subluxation
  • Peroneal Tunnel

Risk Factors


Differential Diagnosis

Differential Diagnosis Leg Pain

Differential Diagnosis Ankle Pain


Clinical Features

  • History
    • Patients typically report posterolateral hindfoot or ankle pain
    • The tendon may look swollen or enlarged (more commonly in brevis than longus tears)[12]
    • Patients may describe a snapping sensation
  • Physical Exam: Physical Exam Ankle
    • Swelling proximal to or at lateral malleolus: brevis pathology
    • Swelling at or distal to peroneal tubercle: longus pathology
    • Pain with resisted eversion, ankle dorsiflexion
    • Pain with passive inversion, ankle plantar flexion
    • Subluxation/ crepitus of the peroneal tendon over posterior fibula can sometimes be palpated
    • Strength may be diminished
    • Presence of eversion does not exclude rupture or tear
    • Rotate the ankle to see and feel if the tendons subluxate anteriorly over the lateral malleolus
  • Special Tests
    • Peroneal Tunnel Compression Test: foot is dorsiflexed, everted with pressure applied to the retrofibular region of the peroneal tendons
    • Plantarflex 1st Ray: loss or limitation of plantarflexion suggests dysfunction of peroneus longus

Evaluation

Radiographs

  • Standard Radiographs Ankle, Standard Radiographs Foot
    • Standard views
    • Axillary Heel View: can demonstrate the peroneal tubercle and the retromalleolar groove
  • Os Peroneum
    • Seen in 20% of the population
    • visible on internal rotation oblique foot radiographs at the level of the calcaneocuboid joint
    • Migration of the os peroneum proximal can suggest peroneal longus tendon disruption[13]

MRI

  • Imaging modality of choice
  • Findings of peroneal tendonitis/ tendonosis
    • Peritendinous fluid
  • Findings of peroneal subluxation/ dislocation
    • Information on the status of the SPR
    • Documenting the shape of the fibular groove
  • Findings of peroneus longus tear
    • Heterogeneity and/or discontinuity of the tendon
    • Empty, fluid-filled tendon sheath
    • Marrow edema along the lateral calcaneal wall
    • Hypertrophied peroneal tubercle
  • Diagnostic accuracy
    • Peroneus brevis tears diagnostic accuracy correlated to surgical findings[14]
      • Sensitivity: 93%
      • Specificity: 75%
    • Another study has reported that MRI does not reliably predict the degree of peroneal tendon pathology when compared with intraoperative findings[15]
  • Magic Angle Effect
    • Factitious appearance of heterogeneity, increased signal in a tendon when it intersects the main magnetic vector at an angle of 55°[16]
    • Peroneal tendons are susceptible to this, especially at the tip of the lateral malleolus

Ultrasound

  • When comparing diagnostic ultrasound to the gold standard of operative exploration[17][18]
    • Sensitivity: 100%
    • Specificity: 85-90%
    • Diagnostic Accuracy: 90-94%
  • Findings
    • Peritendinous fluid is characteristic of tendonitis

Peroneal Tenography

  • Involves the injection of radiopaque contrast medium into peroneal tendon sheaths to allow visualization of the tendon
    • Infrequently used, suboptimal diagnostic technique which makes it a limited method
    • Can co-administer local anesthetic and other medications

CT

  • Useful to evaluate bony pathology
  • Not generally indicated for peroneal tendon disease

Classification

  • Based on pathology
    • Tendinitis/ Tendinosis
    • Tendon Tears/ Ruptures
    • Tendon Dislocations/ Subluxation

Krause and Brodsky Classification for Tears

  • Designed to help guide surgical decision making[19]
  • Grade I are lesions that are less than 50% of cross-sectional area
    • Intervention: tendon repair is recommended
  • Grade II are lesion that are more than 50% of cross-sectional area
    • Intervention: tenodesis is recommended

Eckert and Davis Classification for Superior Peroneal Retinaculum

  • Classification for degree of SPR injury[20]
  • Grade I: SPR elevated from fibula
  • Grade II: Fibrocartilaginous ridge elevated from fibula with SPR
  • Grade III: Cortical fragment avulsed with SPR

Management

Prognosis

  • Tendinosis/ Tendonitis
    • Majority of cases will resolve with conservative measures

Nonoperative

Operative

  • Indications
    • Failure of conservative measures
    • Acute subluxation/ dislocation
  • Tear: Techniques
    • Repair
    • Tenodesis
    • Reconstruction
    • Allograft Reconstruction
  • Tendonitis/ Tendinosis Techniques
    • Synovectomy
    • Excision of peroneus quartus muscle
    • Peroneal tubercle osteotomy
  • Subluxation/dislocation Techniques
    • Primary repair of SPR
    • Groove deepening procedures
    • Bone block
    • Tendon rerouting
    • Reconstruction of SPR

Rehab and Return to Play

Rehabilitation

  • Surgical
    • Non-weightbearing 2-6 weeks
    • Begin weight bearing in a cast or walking brace
    • Median immobilization period is 6-8 weeks[21]

Return to Play/ Work

  • Surgical
    • Needs to be updated
  • Non-surgical
    • Typically within 1-2 weeks
    • Recommend Lace Up Ankle Brace or Kinesiology Tape initially
    • Can ween or discontinue as strength and function return to 90-100% of the unaffected ankle

Complications

  • Surgical
    • Most common: parasthesia of incision site from damage to branches of the Sural Nerve
    • Healing issues
    • Scarring, recurrent tears, degeneration
  • Ankle Instability

See Also


References

  1. Monteggia, G: Instiuzini chirurgiche parte secondu. Milan, Italy: 336-341, 1803
  2. 35. Meyers, AW: Further evidences of attrition in the human body. Am. J. Anat. 34:241-267, 1924
  3. 24. Jones, E: Operative treatment of chronic dislocations of the peroneal tendons. JBJS 14 A: 574-576 , 1932
  4. 10. Burman, MS: Subcutaneous rupture of the tendon of the peroneal tendon. Ann Surg. 100: 368-372, 1934
  5. 5.0 5.1 Dombek MF, Lamm BM, Saltrick K, Mendicino RW, Catanzariti AR. Peroneal tendon tears: a retrospective review. J Foot Ankle Surg 2003;42:250-258.
  6. Sammarco, GJ, Diraimondo, CV. Chronic peroneus brevis tendon lesions. Foot Ankle Int. 1989;9(4):163–170.
  7. Krause, JO, Brodsky, JW. Peroneus brevis tendon tears: pathophysiology, surgical reconstruction, and clinical results. Foot Ankle Int. 1998;19(5):271–279.
  8. . 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. 15:107-111, 199466
  9. Rosenberg, ZS; Feldman, F; Singson, RD; Price, GJ: Peroneal tendon injury associated with calcaneal fractures: CT findings. AJR Am. J. Roentgenol. 149:125-129, 1987
  10. Vainio, K: The rheumatoid foot. A clinical study with pathological and roentgenological comments. Ann. Chir. Gynaecol. Fenniae. 45:Suppl.1, 1-167, 1956
  11. . Truong, DT; Dussault, RG; Kaplan, PA: Fracture of the os peroneum and rupture of the peroneus longus tendon as a complication of diabetic neuropathy. Skeletal Radiol. 24(8):626-628, 1995
  12. 27. Molloy, R, Tisdel, C. Failed treatment of peroneal tendon injuries. Foot Ankle Clin. 2003;8(1):115–129.
  13. 51. Stockton, KG, Brodsky, JW. Peroneus longus tears associated with pathology of the os peroneum. Foot Ankle Int. 2014;35(4):346–352.
  14. Lamm, BM; Myers, DT; Dombek, M; Mendicino, RW; Catanzariti, AR; Saltrick K. Magnetic Resonance Imagings and surgical correlation of Peroneus Brevis Tears.J. Foot Ankle Surg. 43(1): 30-36, 2004
  15. Redfern, D; Myerson, M: The management of concomitant tears of the peroneus longus and brevis tendons. Foot Ankle Int. 25(10):695-707, 2004
  16. Gyftopoulos, S, Bencardino, JT. Normal variants and pitfalls in MR imaging of the ankle and foot. Magn Reson Imaging Clin N Am. 2010;18(4):691–705.
  17. Grant, TH, Kelikian, AS, Jereb, SE, McCarthy, RJ. Ultrasound diagnosis of peroneal tendon tears: a surgical correlation. J Bone Joint Surg Am. 2005;87(8):1788–1794.
  18. Waitches, GM; Rockett, M; Brage, M; Sudakoff, G: Ultrasonographic-surgical correlation of ankle tendon tears. J. Ultrasound Med. 17(4):249-256, 1998
  19. Krause, JO; Brodsky, JW: Peroneus brevis tendon tears: pathophysiology, surgical reconstruction and clinical results. Foot Ankle Int. 19(5):271-279, 1998.
  20. Eckert, WR; Davis, EA Jr: Acute rupture of the peroneal retinaculum. J Bone Joint Surg Am. 58(5): 670-672, 1976
  21. van Dijk, PA, Lubberts, B, Verheul, C, DiGiovanni, CW, Kerkhoffs, GMMJ. Rehabilitation after surgical treatment of peroneal tendon tears and ruptures. Knee Surg Sport Traumatol Arthrosc. 2016;24(4):1165–1174.
Created by:
John Kiel on 11 June 2019 01:47:14
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Last edited:
4 October 2021 15:04:22
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