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Tendon Disorders of the Foot and Ankle, Part 1 : Peroneal Tendon Disorders Daniel S. Heckman, George S. Gluck and Selene G. Parekh Am J Sports Med 2009 37: 614 DOI: 10.1177/0363546508331206 The online version of this article can be found at: http://ajs.sagepub.com/content/37/3/614
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American Orthopaedic Society for Sports Medicine
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Clinical Sports Medicine Update
Tendon Disorders of the Foot and Ankle, Part 1 Peroneal Tendon Disorders Daniel S. Heckman,* MD, George S. Gluck,* MD, and Selene G. Parekh,*†‡ MD, MBA From the *Department of Orthopaedic Surgery, University of North Carolina ‡ School of Medicine, Chapel Hill, North Carolina, and Kenan-Flagler Business School, University of North Carolina, Chapel Hill, North Carolina
Pathologic abnormality of the peroneal tendons is an uncommon but underappreciated source of lateral hindfoot pain and dysfunction that can be difficult to distinguish from lateral ankle ligament injuries. When left untreated, peroneal tendon disorders can lead to persistent lateral ankle pain and substantial functional problems. Unfortunately, the treatment recommendations for these disorders are primarily based on case series and expert opinion. The goals of this review are to develop a current understanding of the anatomy and diagnostic evaluation of the peroneal tendons, and to present current treatment options and the authors’ preferred surgical techniques for operative management of peroneal tendon lesions. Keywords: peroneus longus; peroneus brevis; tendinitis; subluxation; ankle There are 3 primary categories of peroneal tendon lesions: (1) tendinitis and tenosynovitis, (2) tendon subluxation and dislocation, and (3) tendon tears and ruptures. These disorders are an uncommon but underappreciated source of lateral hindfoot pain and dysfunction that can be difficult to distinguish from lateral ankle ligament injuries.28 In a study by Dombek et al,12 only 60% (24) of 40 peroneal tendon disorders were accurately diagnosed at the first clinical evaluation. Peroneal tendon lesions are frequently encountered in patients with chronic lateral ankle instability11 or cavovarus hindfoot alignment,5 and usually result from prolonged, repetitive athletic activities or ankle inversion injuries.28,41 Typically, these conditions respond to nonoperative treatment such as physical therapy, use of nonsteroidal anti-inflammatory drugs (NSAIDs), and immobilization. When left untreated, peroneal tendon disorders can lead to persistent lateral ankle pain and substantial functional problems.9
proximal to the tip of the lateral malleolus. They course posterior to the lateral malleolus through a fibroosseous tunnel called the retromalleolar groove, with the peroneus longus tendon lying posterolateral to the peroneus brevis tendon. The retromalleolar groove is formed by the superior peroneal retinaculum (SPR) posterolaterally, the fibula anteriorly, and the posterior talofibular, calcaneofibular, and posterior-inferior tibiofibular ligaments medially.28 This sulcus is lined with fibrocartilage and varies in depth and shape. The SPR is a fibrous band of tissue 1 to 2 cm wide that serves as the primary restraint to peroneal tendon subluxation at the ankle (Figure 1).30 Distal to the ankle, the tendon sheath bifurcates around the peroneal tubercle as the peroneal tendons traverse the lateral aspect of the calcaneus. The tendons pass through the inferior peroneal retinaculum 2 to 3 cm distal to the tip of the fibula. The peroneus brevis tendon continues directly to its insertion onto the tuberosity of the fifth metatarsal. The peroneus longus tendon turns medially between the cuboid groove and the long plantar ligament and inserts onto the plantar surface of the base of the first metatarsal and the lateral aspect of the medial cuneiform. The os peroneum is located within the substance of the peroneus longus tendon at the level of the calcaneocuboid joint. It is estimated that the os peroneum is ossified in approximately 20% of the population47; however this figure has not been well-established in a large radiographic study. The peroneal tendons receive their blood supply through vincula from the posterior peroneal artery and the medial tarsal artery.44 It has been proposed that the peroneal tendons have critical avascular zones that may contribute to tendinopathy.38 Petersen et al31 described 3 distinct
ANATOMY The peroneus longus and peroneus brevis muscles reside in the lateral compartment of the leg and are innervated by the superficial peroneal nerve. Both peroneal tendons enter a common synovial sheath approximately 4 cm †
Address correspondence to Selene G. Parekh, MD, MBA, Bioinformatics Bldg, CB#7055, Chapel Hill, NC 27599 (e-mail: selene. parekh@gmail.com). No potential conflict of interest declared. The American Journal of Sports Medicine, Vol. 37, No. 3 DOI: 10.1177/0363546508331206 © 2009 American Orthopaedic Society for Sports Medicine
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retromalleolar groove and attenuation of the SPR, thereby increasing the risk of peroneal tendon injury. Hypertrophy of the peroneal tubercle (Figure 2) increases mechanical stress on the peroneal tendons, potentially leading to tendinopathy and restriction of normal gliding within the tendon sheath.14 A cavovarus hindfoot also increases mecha nical stress on the peroneal tendons at the lateral malleolus, peroneal tubercle, and cuboid notch, and thereby increases the likelihood of peroneal tendon injury.25
PERONEAL TENDINOPATHY AND PAINFUL OS PERONEUM SYNDROME
Figure 1. Lateral (A) and axial (B) diagrams of the lateral ankle and fibular groove.35 (Reproduced with permission from Rosenberg ZS, Bencardino J, Astion D, Schweitzer ME, Rokito A, Sheskier S. MRI features of chronic injuries of the superior peroneal retinaculum. AJR Am J Roentgenol. 2003; 181:1551-1557.)
avascular zones: 1 in the peroneus brevis tendon at the turn around the lateral malleolus, and 2 in the peroneus longus tendon. The first peroneus longus avascular zone extends from the turn around the lateral malleolus, and the second occurs where the tendon curves around the cuboid. These avascular zones correspond with the most frequent locations of peroneal tendinopathy.31 However, the presence of avascular zones has been refuted by several authors44; thus, the microvasculature of the peroneal tendons remains a subject of controversy. Several anatomic variations are thought to predispose to peroneal tendon disorders. A shallow or narrow retro malleolar groove may affect the stability of the peroneal tendons as they pass posterior to the fibula, potentially leading to tendon subluxation.45 A low-lying peroneus brevis muscle belly13 or the presence of an accessory peroneus quartus muscle51 can cause stenosis within the
Peroneal tendinitis and tenosynovitis involve inflammation of the tendon or tendon sheath, respectively. This is often precipitated by prolonged or repetitive activity, particularly after a period of relative inactivity.28 These disorders are common in runners, ballet dancers, and patients with chronic lateral ankle instability.2,11 Other causes include severe ankle sprains, fractures of the ankle or calcaneus, and peroneal tubercle hypertrophy.3,14,46 Painful os peroneum syndrome (POPS) is a term coined by Sobel et al47 to describe a spectrum of posttraumatic conditions of the peroneal tendons. The syndrome includes 1 of the following: (1) an acute fracture of the os peroneum or diastasis of a multipartite os peroneum, (2) a chronic fracture of the os peroneum associated with stenosing tenosynovitis of the peroneus longus, (3) partial or complete rupture of the peroneus longus tendon near the os peroneum, or (4) entrapment of the peroneus longus tendon and the os peroneum by a hypertrophied peroneal tubercle (Figure 3). Patients with peroneal tendinitis have pain posterior or distal to the lateral malleolus, along the course of the peroneal tendons, which is exacerbated by passive hindfoot inversion and ankle plantarflexion or by active-resisted hindfoot eversion and ankle dorsiflexion. Examination reveals tenderness and possible palpable tendon thickening along the course of the peroneal tendons. Swelling and warmth along the peroneal tendon sheath are a hallmark of acute peroneal tendinitis. Forefoot and hindfoot alignment should also be noted, as a cavovarus foot is associated with an increased rate of peroneal tendon disorders. A Coleman block test10 is useful to determine the primary malalignment in a cavovarus foot. If the hindfoot deformity corrects with the Coleman block test, then the deformity is caused by forefoot dysfunction, typically related to a plantar flexed first ray. If the hindfoot deformity does not correct with the Coleman block test, then hindfoot procedures need to be undertaken to address the malalignment. Weightbearing radiographs of the ankle and foot may reveal osseous lesions that can be associated with peroneal tendinitis or other diagnoses that need to be considered in the differential diagnosis of lateral ankle or foot pain, such as fractures of the calcaneus or lateral malleolus or the presence of an os peroneum. Peroneal tubercle hypertrophy or spurring of the retromalleolar groove is best identified with a Harris heel radiograph.7 A hindfoot alignment radiograph is helpful to identify a cavovarus foot position as a predisposing factor for peroneal tendinopathy, as well
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Figure 3. Lateral (A) and oblique (B) radiographs, and (C) sagittal short tau inversion recovery (STIR) MRI demonstrating a fragmented os peroneum (arrows). Note the proximity of the os peroneum to the calcaneocuboid joint.
Figure 2. Axial (A) and coronal (B) T1-weighted magnetic resonance images demonstrating a patient with a symptomatic hypertrophic peroneal tubercle (arrows). as to guide subsequent treatment of the varus malalignment.37 Magnetic resonance imaging is the standard method for evaluating tendon disorders.26 Magnetic resonance imaging findings with peroneal tendinitis include fluid within the tendon sheath and tendon thickening19 (Figure 4). Ultrasonography for the
evaluation of peroneal tendon disorders is gaining in popularity. It is relatively inexpensive and noninvasive, and does not expose the patient to ionizing radiation; however, it is highly user-dependent. Peritendinous fluid accumulation and tendon thickening are easily evaluated with ultrasonography. Peroneal tendinopathy and painful os peroneum syndrome should initially be treated nonoperatively. Operative treatment for refractory peroneal tendinopathy usually involves open tendon debridement and tenosynovectomy. It is imperative that any associated anatomic or biomechanical abnormalities also be corrected. Operative treatment of
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Authors’ Preferred Treatment for Peroneal Tendinitis
Figure 4. Axial T2-weighted MRI demonstrating circumferential fluid accumulation (arrow) within the peroneal tendon sheath in a patient with peroneal tenosynovitis. PLT, peroneus longus tendon; PBT, peroneus brevis tendon.
Patients with peroneal tendinitis are initially treated with conservative modalities. This includes NSAIDs, lateral heel wedges, physical therapy, and possibly a period of immobilization. Physical therapy must include stretching and strengthening activities, use of a biomechanical ankle platform system (BAPS) board, and other modalities employed by the therapist, including massage therapy, ultrasound, electrical stimulation, and iontophoresis. For patients’ painful tenderness, a period of immobilization in a short leg weightbearing cast or controlled ankle motion (CAM) boot is initiated to control inflammation. Once the pain subsides, patients are started in physical therapy. After 3 to 6 months of failed conservative care, patients are offered a tenosynovectomy. The patient is placed supine on the operating room table. A bump may be placed under the ipsilateral hip to aid in visualization of the posterolateral ankle. A thigh tourniquet is placed. A curvilinear incision is made from the base of the fifth metatarsal to the tip of the fibula, and more proximally along the posterior edge of the fibula if needed (Figure 5). Care is taken to protect the sural nerve, typically found at the distal extent of the incision. The peroneal tendon sheath is incised, allowing for inspection of the peroneus brevis and longus tendons. Stenotic areas of the sheath may be excised. Degenerated areas of the tendon or partial tears are resected or repaired (with a tubularization technique). The tendon sheath is left unrepaired to prevent a stenosis phenomenon. The SPR, if incised, must be meticulously repaired to prevent subluxation of the peroneal tendons. The subcutaneous tissues are closed with absorbable suture, and the skin is closed with staples. The extremity is placed in slight eversion in a bulky Jones splint to control edema. Postoperatively, patients are made nonweightbearing. Two weeks later, the staples are removed, and patients are placed in a short leg weightbearing cast or boot. Range of motion and strengthening activities are started 2 to 4 weeks after surgery.
Authors’ Preferred Treatment for Painful Os Peroneum Syndrome
Figure 5. Intraoperative photograph demonstrating the incision used for operative treatment of peroneal tendinitis. The line denotes the approximate location of the sural nerve.
painful os peroneum syndrome should include excision of the os peroneum and hypertrophied peroneal tubercle, if present, along with primary repair or tenodesis of the peroneus longus tendon.15 Unfortunately, the treatment recommendations for peroneal tendinopathy and POPS are based primarily on case series and expert opinion.
Patients with POPS are initially treated with conservative modalities. This includes NSAIDs, lateral heel wedges, physical therapy, and possibly a period of immobilization if painful tenderness is present. Physical therapy must include stretching and strengthening activities, use of a BAPS board, and other modalities employed by the therapist, including massage therapy, ultrasound, electrical stimulation, and iontophoresis. If a period of immobilization is required, a short leg weightbearing cast or CAM boot is initiated to control inflammation. Once the pain subsides, patients are started in physical therapy. After 3 to 6 months of failed conservative care, patients are offered an os peroneum excision. The patient is placed supine on the operating room table. A bump may be placed
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Figure 6. Intraoperative photograph demonstrating attenuation of the superior peroneal retinaculum in a patient with traumatic peroneal tendon subluxation.
under the ipsilateral hip to aid in visualization of the posterolateral ankle. A thigh tourniquet is placed. A curvilinear incision is made from the tip of the fibula, distally to the base of the fifth metatarsal. Care is taken to protect the sural nerve, typically found at the distal extent of the incision. The peroneus longus tendon sheath is identified and incised. The tendon is followed distally to the point where the tendon curves plantar to the cuboid. The os peroneum is identified and carefully shelled out of the peroneus longus tendon. If the tendon is intact, it can be reinforced with 2-0 nonabsorbable suture. If the tendon is attenuated or torn, it must be repaired. This can be performed with a modified Bunnell, Krackow, or tubularization technique. If more than 50% of the tendon is involved in the tear, tenodesis of the peroneus longus to the peroneus brevis can be performed. The proximal segment of the peroneus longus is tenodesed to the peroneus brevis using interrupted nonabsorbable sutures. The tendon sheath is left unrepaired to prevent a stenosis phenomenon. The subcutaneous tissues are closed with absorbable suture, and the skin is closed with staples. The extremity is placed in slight eversion in a bulky Jones splint to control edema. Postoperatively, patients are made nonweightbearing. Two weeks later, the staples are removed, and patients are placed in a short leg weightbearing cast or boot. Range of motion activities are started 2 to 4 weeks after surgery. Strengthening activities are initiated 6 to 8 weeks after surgery. Athletic activities are only started once rigorous physical therapy is completed.
PERONEAL TENDON SUBLUXATION AND DISLOCATION Peroneal tendon subluxation occurs when 1 or both tendons displace from the retromalleolar groove during tendon
Figure 7. Anteroposterior radiograph of the ankle demonstrating a fleck sign (arrow). loading. This is frequently associated with SPR injury or attenuation (Figure 6). The most common mechanisms involve the sudden, reflexive contraction of the peroneal muscles either during an acute inversion injury to the dorsiflexed ankle22 or during forced dorsiflexion of the everted foot.36 Peroneal tendon subluxation is often associated with sports requiring cutting maneuvers, especially during football, soccer, or skiing.23 Patients with peroneal tendon subluxation describe pain posterior to the fibula or above the joint line,36 and occasionally they experience a painful popping or snapping sensation in the lateral aspect of the ankle. Physical examination can be performed with the patient prone and the knees flexed 90°. Active dorsiflexion and eversion of the ankle or circumduction of the foot generally elicits painful dynamic tendon instability.36 Palpable snapping or crepitus of the tendons may be evident during these maneuvers. Substantial swelling, tenderness, and ecchymosis are often present posterior to the lateral malleolus in patients with acute peroneal tendon subluxation. Peroneal muscle strength is usually normal. A positive anterior drawer or talar tilt test indicates concomitant lateral ankle instability. Ankle radiographs may reveal a small avulsion fracture off of the lateral malleolus (Figure 7). This has been termed a fleck sign and indicates a grade III injury of the SPR.8 The fleck sign is commonly overlooked; however, it is pathognomonic for an acute dislocation of the peroneal
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from the fibula have been used to reinforce an attenuated or insufficient SPR.1,16,41,49 Peroneal tendon rerouting techniques have been reported in which the calcane ofibular ligament or peroneal tendons are divided and subsequently transposed underneath the calcaneofibular ligament to prevent subluxation.40,48 Peroneal groovedeepening procedures have also been used to treat sublu xation or dislocation, with the premise that a shallow posterior groove or a convex surface predisposes an individual to subluxation.20,32 Despite the number of tech niques that have been described, the available literature is limited to case series or reports with inadequate evidence to support any specific treatment.
Authors’ Preferred Treatment for Peroneal Tendon Subluxation/Dislocation
Figure 8. Axial T2-weighted MRI demonstrating a shallow retromalleolar groove (RG), a low-lying peroneus brevis muscle belly (PBMB), a flattened peroneus brevis tendon (PBT), and a longitudinal peroneus longus split tear (PLT) in a patient with peroneal tendon subluxation.
tendons. Magnetic resonance imaging offers superior visualization of injuries to the SPR and evaluation of the morphologic characteristics of the retromalleolar groove (Figure 8). Displacement of the peroneal tendons may be demonstrated on MRI with the ankle in dorsiflexion.42 Dynamic high-resolution ultrasonography provides realtime imaging, which allows identification of episodic peroneal subluxation that may be missed on MRI.29 Nonoperative treatment may be attempted for acute peroneal tendon dislocations; however, it is associated with a high rate of recurrence, particularly in athletes who subject the peroneal tendons to high stresses. Conservative management involves immobilization in a short leg cast with the foot in neutral to slight inversion to allow the SPR to heal to the posterolateral aspect of the fibula.41 Operative treatment is usually needed for a satisfactory outcome in high-demand individuals or in patients with chronic peroneal subluxation.32 Several operative procedures have been used to treat peroneal tendon subluxations and dislocations. Anatomic reattachment of the SPR can be performed using bone tunnels or suture anchors.1,23 This technique aims to restore the primary structure restraining the peroneal tendons. Bone block procedures involve performance of a sagittal osteotomy within the fibula, followed by posterior displacement of the lateral fragment to serve as a mechanical block to tendon displacement. Problems with nonunion, tendon irritation, and tendon adherence to the underlying bone have been noted with this technique.17,23 Local tissue transfers using Achilles, plan taris, or peroneus brevis tendon or a strip of periosteum
For athletes, surgical intervention is recommended, in an effort to optimize outcomes. If only the SPR is attenuated, it should be repaired directly. The patient is placed supine on the operating room table. A bump may be placed under the ipsilateral hip to aid in visualization of the posterolateral ankle. A thigh tourniquet is placed. A longitudinal incision is made, approximately 1 cm posterior to the fibula, and extended from 5 cm proximal to 2 cm distal to the tip of the fibula. Care is taken to protect the sural nerve, typically found at the distal extent of the incision. The SPR is identified and incised longitudinally 1 cm from the posterior edge of the fibula. The fibular ridge is roughened with a bur. Three to 4 drill holes are made lateral to medial, and directed slightly posteriorly. Sutures are then passed through the drill holes and the SPR, securing the avulsed retinaculum to the fibular ridge. These sutures are then tied. The retinaculum is imbricated along the incision line. The subcutaneous tissues are closed with absorbable suture, and the skin with staples. The extremity is placed in slight eversion in a bulky Jones splint to control edema. If the fibular groove is shallow, then a groove-deepening procedure is required, and the patient is placed supine on the operating room table. A bump may be placed under the ipsilateral hip to aid in visualization of the posterolateral ankle. A thigh tourniquet is placed. A longitudinal incision is made approximately 1 cm posterior to the fibula and extended from 3 cm proximal to 1 cm distal to the tip of the fibula. Care is taken to protect the sural nerve, typically found at the distal extent of the incision. The SPR is identified and incised. If attenuated, the SPR will be repaired as described above at the end of the case. The peroneus brevis and longus tendons are then identified and examined for tears, a low-lying muscle belly, or any other abnormalities. The peroneus brevis tendon is followed distally to the tip of the fibula and retracted. The tip of the fibula is identified. Under fluoroscopic guidance, a guide pin from a 6-0 cannulated screw system is placed over the midpoint of the fibula in the anteroposterior images, and slightly posterior on the lateral views. The guide pin is advanced proximally by 5 cm. The guide pin is then overdrilled and checked radiographically. The guide pin is
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Figure 9. Intraoperative photographs of a retromalleolar groove-deepening procedure demonstrating Kirschner wire (K-wire) placement (A), overdrilling of the K-wire (B), and tamping of the retromalleolar groove (RG) (C). Intraoperative fluoroscopic images of K-wire placement (D) and overdrilling of the K-wire (E).
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Figure 12. Intraoperative photographs demonstrating split tears of the peroneus brevis tendon at the level of the retromalleolar sulcus. Figure 10. Intraoperative fluoroscopic image of a superior peroneal retinaculum repair with 2 suture anchors.
3 mini-anchors (Figure 10). The subcutaneous tissues are closed with absorbable sutures, and the skin is closed with staples. The extremity is placed in a bulky Jones splint, in slight inversion to maintain the tendons in the newly deepened retromalleolar groove. Postoperatively, patients are made nonweightbearing. Two weeks later, the staples are removed, and patients are placed in a short leg weightbearing cast or boot. Range of motion activities are started 4 to 6 weeks after surgery. Strengthening activities are initiated 6 to 8 weeks after surgery. Athletic activities are only started once rigorous physical therapy is completed.
PERONEAL TENDON TEARS
Figure 11. Intraoperative photograph demonstrating a peroneus brevis tendon split tear in a patient with peroneal tendon subluxation.
then removed. The retromalleolar groove is then identified and deepened with a bone tamp and mallet (Figure 9). If injury is found in the peroneal tendons, this is repaired as detailed in the section below. If the SPR is attenuated, this is repaired as detailed in an earlier section of this article, or it can be imbricated in a pants-over-vest technique using nonabsorbable sutures. Alternatively, the SPR can be made taut and tacked into the fibula with 2 or
Most isolated peroneal tendon tears and ruptures result from acute ankle inversion injuries.2 Alternatively, attritional peroneal tendon tears can occur with chronic conditions such as lateral ankle instability, peroneal tendon subluxation (Figure 11), cavovarus foot position, and anatomic variations that lead to stenosis within the retromalleolar groove.3,5,39,45,46 Peroneus brevis tears are usually found within the retromalleolar sulcus, indicating that they are likely due to mechanical trauma in this region (Figure 12).43 Peroneus longus tears frequently occur in regions of high shear stresses, such as at the cuboid tunnel, at the os peroneum, at the peroneal tubercle, or at the tip of the lateral malleolus.14 Peroneus longus tears can be associated with a fracture through the os peroneum, as they are in patients with POPS.47 Peroneal tendon tears are typically accompanied by severe posterolateral ankle pain and swelling along the peroneal tendon sheath.21 Pain also may be present in the cuboid groove or on the plantar aspect of the foot with peroneus longus tears. On examination, tenderness and
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Figure 14. Intraoperative photograph demonstrating tubularization of a peroneus longus tendon tear. (Courtesy of Keith L. Wapner, MD.)
Figure 13. Axial T2-weighted MRI demonstrating a flattened, bisected peroneus brevis tendon (PBT) with associated fluid within the peroneal tendon sheath in a patient with a peroneus brevis tendon tear. swelling over the tendon sheath are consistent findings, and peroneal muscle strength is often decreased. Loss or limitation of plantar flexion of the first ray may indicate a peroneus longus tear. Peroneus brevis tears can be evaluated with the peroneal tunnel compression test.45 This maneuver involves applying manual pressure along the peroneal tendon sheath in the retromalleolar groove with the knee flexed 90º and the foot plantar flexed. Radiographs of the foot may demonstrate proximal migration or fracture of the os peroneum, which correlates with rupture of the peroneus longus tendon. Fractures of the base of the fifth metatarsal can indicate avulsion of the peroneus brevis tendon.6 Peroneal tendon anatomy and tears are readily visualized with MRI. A flattened tendon may be significant for a tear, particularly if associated with fluid on the T2-weighted magnetic resonance images. A peroneus brevis tear may appear as a C-shaped or bisected tendon or as increased intratendinous T2-weighted MRI signal (Figure 13).24 A peroneus longus tear may demonstrate a linear or round area of increased signal within the tendon,18 a fluid-filled tendon sheath, marrow edema along the lateral calcaneal wall, or a hypertrophied peroneal tubercle.27 Small tears may not be visualized on MRI; in these cases, the physical examination is critical in making the diagnosis. When performed by experienced operators, ultrasonography may be capable of detecting more subtle tendon tears than can be identified with MRI.34
Conservative treatment of peroneal tendon tears includes NSAIDs, physical therapy, activity modification, and immobilization in a brace or short leg walking cast. However, symptoms frequently persist despite nonoperative management, especially in the setting of chronic ankle laxity, chronic peroneal tendon subluxation, or hindfoot varus deformity.21,33 Operative treatment of peroneal tendon tears varies depending on the severity of injury. Krause and Brodsky21 proposed that tears involving less than 50% of the crosssectional area be treated with excision of the affected area followed by tubularization, and those involving greater than 50% of the cross-sectional area be treated with tenodesis. Redfern and Myerson33 developed an algorithm for operative management of peroneal tendon tears based on intraoperative pathologic findings. If both tendons are grossly intact (type I), the longitudinal tear is excised and the remaining tendon is tubularized (Figure 14). If 1 tendon is irreparable and the other tendon is functional (type II), a tenodesis between the 2 peroneal tendons is performed proximal to the tear. If both tendons are nonfunctional (type III), then reconstruction is indicated. If there is sufficient excursion and minimal scarring of the proximal musculotendinous unit, then the recon struction may be performed with a 1-stage tendon graft (hamstring allograft). For chronic tears with scarring of the tissue bed, a staged reconstruction using a Hunter rod may be needed (Figure 15).50 If there is minimal tendon excursion, then a graft reconstruction is unlikely to be successful and a tendon transfer should be performed.33 The flexor digitorum longus has been used because its excursion and work percentage are similar to those of the peroneus brevis.4 Techniques using the flexor hallucis longus and plantaris tendons have also been described.39,50 Again, it is imperative that any concomitant pathologic changes that may have led to the
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Figure 15. Intraoperative photograph demonstrating placement of a Hunter rod (A) and closure of the peroneal tendon sheath over the Hunter rod (B) in a patient with a chronic peroneal tendon tear. (Courtesy of Keith L. Wapner, MD.) peroneal tendon degeneration are also addressed in addition to the peroneal tendon reconstruction.
Authors’ Preferred Treatment for Peroneal Tendon Tears
After 3 to 6 months of failed conservative care, patients are offered surgical repair. The patient is placed supine on the operating room table. A bump may be placed under the ipsilateral hip to aid in visualization of the posterolateral ankle. A thigh tourniquet is placed. A curvilinear incision is made from the base of the fifth metatarsal to the tip of the fibula, and more proximally along the posterior edge of the fibula if needed, centered over the course of the peroneal tendons. Care is taken to protect the sural nerve, typically found at the distal extent of the incision. The SPR is incised 5 mm posterior to the fibula. The peroneal tendons are then examined, particularly the undersurface of these structures. If a low-lying peroneus muscle belly or a peroneus quartus muscle is present, the muscle is excised and any associated proliferating synovium is resected. A peripheral tear and fraying can be resected. A degenerative tear, accounting for less than 50% of the tendon, can be treated with debridement and tubularization of the tendon. This is performed with a 2-0 nonabsorbable suture. If the tear is greater than 50% of the tendon, a tenodesis can be performed between the proximal peroneus brevis and longus and the distal peroneus brevis and longus. The tendon is woven through in a Pulvertaft weave pattern and held in place with interrupted 2-0 nonabsorbable suture. It is important to note the location of the anastomosis and attempt to avoid impingement and stenosis. If the tendon is flattened, the circular structure of the tendon can be reestablished with tubularization of the tendon using a 2-0 nonabsorbable suture. The SPR must be meticulously repaired to prevent subluxation of the peroneal tendons. The subcutaneous tissues are closed with absorbable suture, and the skin is closed with staples. The extremity is placed in slight inversion in a bulky Jones splint to control edema. Postoperatively, patients are made nonweightbearing. Two weeks later, the staples are removed, and patients are placed in a short leg nonweightbearing cast or boot for an additional 2 weeks. Range of motion and strengthening activities are started 4 weeks after surgery. Athletic activities are only started once rigorous physical therapy is completed.
CONCLUSION
Patients with peroneal tendon tears can be initially treated with conservative modalities. This includes NSAIDs, lateral heel wedges, physical therapy, and possibly a period of immobilization if there is painful tenderness or edema. Physical therapy must include stretching and strengthening activities, use of a BAPS board, and other modalities employed by the therapist, including massage therapy, ultrasound, electrical stimulation, and iontophoresis. If a period of immobilization is required, a short leg weightbearing cast or CAM boot is initiated to control inflammation. Once the pain subsides, patients are started in physical therapy.
Peroneal tendon disorders are underappreciated sources of lateral ankle pain in athletes. Most athletes with peroneal tendon lesions can be treated nonoperatively with NSAIDs, physical therapy, heel wedges, or immobilization. Operative treatment is usually reserved for patients who have failed 3 to 6 months of conservative management. Peroneal tendinitis can be treated with a tenosynovectomy, and POPS is treated with excision of the os peroneum followed by primary repair or tenodesis of the peroneus longus, if necessary. Peroneal tendon subluxation in athletes should be managed operatively with primary repair and imbrication of the torn or attenuated SPR. If the retromalleolar groove is shallow, then a groove-deepening procedure is also
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required. Peroneal tendon tears that involve less than 50% of the tendon can be treated with simple debridement, while tears involving greater than 50% of the tendon are treated with a tenodesis between the 2 peroneal tendons. For irreparable or chronic tears involving both the peroneus longus and brevis, a peroneal tendon reconstruction should be performed. It is critical that all concomitant anatomic or biomechanical abnormalities that may have predisposed the patient to peroneal tendon injury also be corrected at the time of surgery. Current treatment guidelines for peroneal tendon disorders are based only on case series and expert opinion. Therefore, further investigations are needed to establish evidence-based treatment recommendations for these atypical but important causes of pain after ankle injuries in athletes. REFERENCES 1. Adachi N, Fukuhara K, Tanaka H, Nakasa T, Ochi M. Superior retinaculoplasty for recurrent dislocation of peroneal tendons. Foot Ankle Int. 2006;27:1074-1078. 2. Bassett FH 3rd, Speer KP. Longitudinal rupture of the peroneal tendons. Am J Sports Med. 1993;21:354-357. 3. Bonnin M, Tavernier T, Bouysset M. Split lesions of the peroneus brevis tendon in chronic ankle laxity. Am J Sports Med. 1997;25:699-703. 4. Borton DC, Lucas P, Jomha NM, Cross MJ, Slater K. Operative reconstruction after transverse rupture of the tendons of both peroneus longus and brevis: surgical reconstruction by transfer of the flexor digitorum longus tendon. J Bone Joint Surg Br. 1998;80:781-784. 5. Brandes CB, Smith RW. Characterization of patients with primary peroneus longus tendinopathy: a review of twenty-two cases. Foot Ankle Int. 2000;21:462-468. 6. Brigido MK, Fessell DP, Jacobson JA, et al. Radiography and US of os peroneum fractures and associated peroneal tendon injuries: initial experience. Radiology. 2005;237:235-241. 7. Bruce WD, Christofersen MR, Phillips DL. Stenosing tenosynovitis and impingement of the peroneal tendons associated with hypertrophy of the peroneal tubercle. Foot Ankle Int. 1999;20: 464-467. 8. Church CC. Radiographic diagnosis of acute peroneal tendon dislocation. AJR Am J Roentgenol. 1977;129:1065-1068. 9. Clarke HD, Kitaoka HB, Ehman RL. Peroneal tendon injuries. Foot Ankle Int. 1998;19:280-288. 10. Coleman SS, Chesnut WJ. A simple test for hindfoot flexibility in the cavovarus foot. Clin Orthop Relat Res. 1977;123:60-62. 11. DiGiovanni BF, Fraga CJ, Cohen BE, Shereff MJ. Associated injuries found in chronic lateral ankle instability. Foot Ankle Int. 2000;21:809-815. 12. Dombek MF, Lamm BM, Saltrick K, Mendicino RW, Catanzariti AR. Peroneal tendon tears: a retrospective review. J Foot Ankle Surg. 2003;42:250-258. 13. Geller J, Lin S, Cordas D, Viera P. Relationship of a low-lying muscle belly to tears of the peroneus brevis tendon. Am J Orthop. 2003;32:541-544. 14. Hyer CF, Dawson JM, Philbin TM, Berlet GC, Lee TH. The peroneal tubercle: description, classification, and relevance to peroneus longus tendon pathology. Foot Ankle Int. 2005;26:947-950. 15. Jones DC. Tendon disorders of the foot and ankle. J Am Acad Orthop Surg. 1993;1:87-94. 16. Jones E. Operative treatment of chronic dislocations of the peroneal tendons. J Bone Joint Surg. 1932;14:574-576. 17. Kelly RE: An operation for chronic dislocation of the peroneal tendons. Br J Surg. 1920;7:502-504. 18. Khoury NJ, el-Khoury GY, Saltzman CL, Kathol MH. Peroneus longus and brevis tendon tears: MR imaging evaluation. Radiology. 1996;200:833-841.
19. Kijowski R, De Smet A, Mukharjee R. Magnetic resonance imaging findings in patients with peroneal tendinopathy and peroneal tenosynovitis. Skeletal Radiol 2007;36:105-114. 20. Kollias SL, Ferkel RD. Fibular grooving for recurrent peroneal tendon subluxation. Am J Sports Med. 1997;25:329-335. 21. Krause JO, Brodsky JW: Peroneus brevis tendon tears: pathophysiology, surgical reconstruction, and clinical results. Foot Ankle Int. 1998;19:271-279. 22. Kumai T, Benjamin M. The histological structure of the malleolar groove of the fibula in man: its direct bearing on the displacement of peroneal tendons and their surgical repair. J Anat. 2003;203:257-262. 23. Maffulli N, Ferran NA, Oliva F, Testa V. Recurrent subluxation of the peroneal tendons. Am J Sports Med. 2006;34:986-992. 24. Major NM, Helms CA, Fritz RC, Speer KP. The MR imaging appearance of longitudinal split tears of the peroneus brevis tendon. Foot Ankle Int. 2000;21:514-519. 25. Manoli A 2nd, Graham B. The subtle cavus foot, “the underpronator”. Foot Ankle Int. 2005;26:256-263. 26. Mitchell M, Sartoris DJ: Magnetic resonance imaging of the foot and ankle: an updated pictorial review. J Foot Ankle Surg. 1993;32:311-342. 27. Mizel MS, Michelson JD, Newberg A. Peroneal tendon bupivacaine injection: utility of concomitant injection of contrast material. Foot Ankle Int. 1996;17:566-568. 28. Molloy R, Tisdel C. Failed treatment of peroneal tendon injuries. Foot Ankle Clin. 2003;8:115-129. 29. Neustadter J, Raikin SM, Nazarian LN. Dynamic sonographic evaluation of peroneal tendon subluxation. AJR Am J Roentgenol. 2004;183:985-988. 30. Niemi WJ, Savidakis J Jr, DeJesus JM. Peroneal subluxation: a comprehensive review of the literature with case presentations. J Foot Ankle Surg. 1997;36:141-145. 31. Petersen W, Bobka T, Stein V, Tillmann B. Blood supply of the peroneal tendons: injection and immunohistochemical studies of cadaver tendons. Acta Orthop Scand. 2000;71:168-174. 32. Porter D, McCarroll J, Knapp E, Torma J. Peroneal tendon subluxation in athletes: fibular groove deepening and retinacular reconstruction. Foot Ankle Int. 2005;26:436-441. 33. Redfern D, Myerson M. The management of concomitant tears of the peroneus longus and brevis tendons. Foot Ankle Int. 2004;25:695-707. 34. Rockett MS, Waitches G, Sudakoff G, Brage M. Use of ultrasonography versus magnetic resonance imaging for tendon abnormalities around the ankle. Foot Ankle Int. 1998;19:604-612. 35. Rosenberg ZS, Bencardino J, Astion D, Schweitzer ME, Rokito A, Sheskier S. MRI features of chronic injuries of the superior peroneal retinaculum. AJR Am J Roentgenol. 2003;181:1551-1557. 36. Safran MR, O’Malley D Jr, Fu FH. Peroneal tendon subluxation in athletes: new exam technique, case reports, and review. Med Sci Sports Exerc. 1999;31(7 Suppl):S487-S492. 37. Saltzman CL, el-Khoury GY. The hindfoot alignment view. Foot Ankle Int. 1995;16:572-576. 38. Sammarco GJ: Peroneal tendon injuries. Orthop Clin North Am. 1994;25:135-145. 39. Sammarco GJ. Peroneus longus tendon tears: acute and chronic. Foot Ankle Int. 1995;16:245-253. 40. Sarmiento A, Wolf M. Subluxation of peroneal tendons: case treated by rerouting tendons under calcaneofibular ligament. J Bone Joint Surg Am. 1975;57:115-116. 41. Selmani E, Gjata V, Gjika E. Current concepts review: peroneal tendon disorders. Foot Ankle Int. 2006;27:221-228. 42. Shellock FG, Feske W, Frey C, Terk M. Peroneal tendons: use of kinematic MR imaging of the ankle to determine subluxation. J Magn Reson Imaging. 1997;7:451-454. 43. Sobel M, DiCarlo EF, Bohne WH, Collins L. Longitudinal splitting of the peroneus brevis tendon: an anatomic and histologic study of cadaveric material. Foot Ankle. 1991;12:165-170. 44. Sobel M, Geppert MJ, Hannafin JA, Bohne WH, Arnoczky SP. Microvascular anatomy of the peroneal tendons. Foot Ankle. 1992;13:469-472.
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45. Sobel M, Geppert MJ, Olson EJ, Bohne WH, Arnoczky SP. The dynamics of peroneus brevis tendon splits: a proposed mechanism, technique of diagnosis, and classification of injury. Foot Ankle. 1992;13:413-422. 46. Sobel M, Geppert MJ, Warren RF. Chronic ankle instability as a cause of peroneal tendon injury. Clin Orthop Relat Res. 1993;296:187-191. 47. Sobel M, Pavlov H, Geppert MJ, Thompson FM, DeCarlo EF, Davis WH. Painful os peroneum syndrome: a spectrum of conditions responsible for plantar lateral foot pain. Foot Ankle Int. 1994;15:112-124. 48. Steinbock G, Pinsger M. Treatment of peroneal tendon dislocation by transposition under the calcaneofibular ligament. Foot Ankle Int. 1994;15:107-111.
49. Tan V, Lin SS, Okereke E. Superior peroneal retinaculoplasty: a surgical technique for peroneal subluxation. Clin Orthop Relat Res. 2003;410:320-325. 50. Wapner K, Parekh S, Pedowitz D, et al. Reconstruction of chronic peroneal tendon ruptures with staged Hunter rods and a flexor hallicus longus transfer. Tech Foot Ankle Surg. 2005;4:202-206. 51. Zammit J, Singh D. The peroneus quartus muscle: anatomy and clinical relevance. J Bone Joint Surg Br. 2003;85:1134-1137.
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