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Peroneal Tendon Injuries
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(Redirected from Peroneal Tendonitis)
Contents
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
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
- Superior peroneal retinaculum
- Posterior fibula with a retromalleolar groove
- Calcaneofibular Ligament
Risk Factors
- Biomechanical/ Structural
- Hindfoot Varus
- Shallow or convex fibular groove
- Compression by the peroneus longus in dorsiflexion
- Hypertrophied peroneal tubercle and an enlarged retrotrochlear eminence
- Bony spur at the posterior lateral fibular groove
- Presence of peroneus quartus muscle in the peroneal sheath
- Orthopedic
- Systemic
- Pharmacology
- Fluoroquinolone Antibiotics
Differential Diagnosis
Differential Diagnosis Leg Pain
- Fractures & Dislocations
- Muscle and Tendon Injuries
- Neurological
- Vascular
- Other
- Pediatric Considerations
- Tibial Tubercle Avulsion Fracture
- Tibial Tuberosity Apophysitis
- Toddlers Fracture (Tibial Shaft Fracture)
Differential Diagnosis Ankle Pain
- Fractures & Dislocations
- Muscle and Tendon Injuries
- Ligament Injuries
- Bursopathies
- Nerve Injuries
- Arthropathies
- Pediatrics
- Fifth Metatarsal Apophysitis (Iselin's Disease)
- Calcaneal Apophysitis (Sever's Disease)
- Triplane Fracture
- Other
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
- 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
- Indications
- Vast majority of patients
- Eckert type I injuries
- Activity modification
- Medications
- Immobilization
- Tears: 4-8 weeks in a Tall Walking Boot or brace
- Tendinosis: Consider Tall Walking Boot for 4-6 weeks in refractory cases
- Physical Therapy
- Lateral Heel Wedge
- Corticosteroid Injection
- Should be performed under ultrasound guidance and can be considered for tendinosis/ tendonitis
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
- Internal
- External
- Sports Medicine Review Ankle Pain: https://www.sportsmedreview.com/by-joint/ankle/
- Sports Medicine Review Foot Pain: https://www.sportsmedreview.com/by-joint/foot/
References
- ↑ Monteggia, G: Instiuzini chirurgiche parte secondu. Milan, Italy: 336-341, 1803
- ↑ 35. Meyers, AW: Further evidences of attrition in the human body. Am. J. Anat. 34:241-267, 1924
- ↑ 24. Jones, E: Operative treatment of chronic dislocations of the peroneal tendons. JBJS 14 A: 574-576 , 1932
- ↑ 10. Burman, MS: Subcutaneous rupture of the tendon of the peroneal tendon. Ann Surg. 100: 368-372, 1934
- ↑ 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.
- ↑ Sammarco, GJ, Diraimondo, CV. Chronic peroneus brevis tendon lesions. Foot Ankle Int. 1989;9(4):163–170.
- ↑ Krause, JO, Brodsky, JW. Peroneus brevis tendon tears: pathophysiology, surgical reconstruction, and clinical results. Foot Ankle Int. 1998;19(5):271–279.
- ↑ . 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
- ↑ 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
- ↑ Vainio, K: The rheumatoid foot. A clinical study with pathological and roentgenological comments. Ann. Chir. Gynaecol. Fenniae. 45:Suppl.1, 1-167, 1956
- ↑ . 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
- ↑ 27. Molloy, R, Tisdel, C. Failed treatment of peroneal tendon injuries. Foot Ankle Clin. 2003;8(1):115–129.
- ↑ 51. Stockton, KG, Brodsky, JW. Peroneus longus tears associated with pathology of the os peroneum. Foot Ankle Int. 2014;35(4):346–352.
- ↑ 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
- ↑ Redfern, D; Myerson, M: The management of concomitant tears of the peroneus longus and brevis tendons. Foot Ankle Int. 25(10):695-707, 2004
- ↑ 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.
- ↑ 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.
- ↑ Waitches, GM; Rockett, M; Brage, M; Sudakoff, G: Ultrasonographic-surgical correlation of ankle tendon tears. J. Ultrasound Med. 17(4):249-256, 1998
- ↑ Krause, JO; Brodsky, JW: Peroneus brevis tendon tears: pathophysiology, surgical reconstruction and clinical results. Foot Ankle Int. 19(5):271-279, 1998.
- ↑ Eckert, WR; Davis, EA Jr: Acute rupture of the peroneal retinaculum. J Bone Joint Surg Am. 58(5): 670-672, 1976
- ↑ 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 2022 12:39:06
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