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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]

Introduction

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

  • 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

Anatomy of the Lateral Compartment of the Leg and Peroneal Tendons

  • 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
  • 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
  • Peroneal Tendon Dislocation Test: ask patient to plantarflex and evert, observe for subluxation or dislocation

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

Tall Walking Boot

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

Peroneal tendon injuries rehab exercises

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

Prognosis and Complications

Prognosis

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

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

Internal

External

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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22 April 2026 15:45:27
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