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Diagnosis and treatment of peroneal tendon injuries
Foot and Ankle Surgery 2000
6: 197]205
Review article
Diagnosis and treatment of peroneal tendon injuries G.J. SAMMARCO*{ AND P.G. MANGONE{ *Department of Orthopaedics, University of Cincinnati School of Medicine, {The Center for Orthopaedic Care, Inc. and {The Center for Orthopaedic Care, Inc., Cincinnati, OH, USA
Introduction The peroneal muscles act to evert and plantarflex the foot and ankle. They also help control the foot and ankle by preventing abnormal inversion and extension motion by resisting unexpected forces which may cause injury. With active contraction, they stabilise the joints through coordinated action in response to applied external loads. Disease of muscles and tendons often goes unnoticed. However, peroneal tendon abnormalities can complicate other disease conditions of the foot and ankle, contributing to pain, instability, and deformity. These may be acute or chronic and may affect one or both peroneal tendons. Gout, rheumatoid arthritis, and diabetes mellitus are systemic disorders which predispose to these conditions. The diagnosis of injury to the peroneal tendons requires diligence and is often is delayed. Early diagnosis relies on a detailed history, a thorough physical examination, and a high index of suspicion. This review includes tears of the tendons, dislocation, and tendinitis. The key elements of the history, physical examination, and special diagnostic imaging are also included. Guidelines for non-operative and operative treatment are presented as well as recommendations for postoperative rehabilitation.
Peroneus brevis Anatomy The peroneus brevis muscle brevis originates in the lateral compartment from the distal two-thirds of the Correspondence: G. James Sammarco, MD, The Center for Orthopedic Care, Inc., 2123 Auburn Ave, Suite 235, Cincinnati, OH 45219, USA. # 2000 Blackwell Science Ltd
fibular shaft and the intermuscular septum. It is innervated by the superficial peroneal nerve. The long musculotendinous junction extends to within 2]3 cm from the lateral malleolus. As the tendon passes into the fibro-osseous canal behind the lateral malleolus, it lies sandwiched between the posterior fibula and the peroneus longus tendon. The peroneus brevis tendon is pressed between the peroneus longus tendon and the fibula causing it to splay out into a `U' shape. The fibroosseus canal is bordered anteriorly by the fibula, posteriorly and laterally by the superior peroneal retinaculum, and medially by the posterior talofibular and calcaneofibular ligaments. The tendon enters its own synovial sheath proximal to the lateral calcaneal tuberosity and passes distally to insert on the styloid of the fifth metatarsal[ 1]. The blood supply of the tendon arises from vincula branches of the posterior peroneal artery. Unlike the posterior tibial tendon, there is no zone of hypovascularity in the tendon [2]. It is the strongest abductor of the foot and acts also as a secondary ankle flexor and foot evertor [1].
Peroneus brevis disruption Peroneus brevis tears are common [3]14]. Cadaver studies indicate that the incidence ranges from 11% to 37% [10, 11, 14]. The incidence of clinically significant tears, however, remains unknown. Such injuries are difficult to diagnose with the time from initial injury to diagnosis frequently greater than 12 months [4, 7, 9]. Lateral ankle pain is the most common presenting symptom with a peroneus brevis tear [9]. Other complaints include ankle instability and lateral ankle swelling [4, 7, 9, 15]18]. A history of an ankle sprain followed by chronic lateral ankle instability and posterolateral ankle pain is not unusual [4]. A 197
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tendon tear should be suspected in patients with chronic ankle instability for . 7 years associated with pain out of proportion to the amount of instability [17]. Since the differential diagnosis for chronic lateral ankle pain also includes a missed anterior calcaneal process fracture, lateral talar process fracture, and osteochondritis dissicans of the talar dome, these conditions must be ruled out [18]. Clinical and anatomical studies indicate that tears are produced by a combination of factors including compression of the brevis tendon against the posterior aspect of the fibula by the longus tendon and intratendinous shear stresses which allow longitudinal rents in the tendon to develop as it passes beneath the tip of the lateral malleolus [4, 7, 9, 10]12, 15] (Figure 1). This later theory is supported by fact that most tears are found on the undersurface of the tendon [9]. Histopathological specimens also show that mechanical irritation, not inflammation, is the predominant mode of failure [9, 11]. Laxity of the superior peroneal retinaculum has also been suggested as a contributing factor [3, 7, 13, 16]. Although subluxation of the tendon over the lateral fibular ridge has been suggested as a factor also, the incidence of this is unknown. A hypertrophied peroneus brevis muscle seen in athletes as well as an anomalous peroneus quartus muscle may also predispose the tendon to tear. In one study, 18% of cadaver specimens with a peroneus quartus also had a brevis tear present [14]. Another study reported the peroneus quartus muscle to be present in 36% of specimens in which a brevis tear also was identified [10]. It has been hypothesized that the anomalous muscle and tendon force the brevis tendon laterally against the fibular ridge which may result in a rent. This, however, is not substantiated by clinical data [12]. Even without a tendon tear, an anomalous peroneal muscle may be the cause chronic ankle pain and affect athletic performance [19, 20]. If an anomalous muscle is suspected, MRI may confirm the diagnosis [21, 22]. Physical examination relies on anatomical landmarks to determine the location of tenderness in order to focus on the diseased portion of the tendon. An important sign of a tendon tear is persistent swelling over the tendon sheath [7]. In addition, many patients also have tenderness over the tendon sheath as it courses beneath the lateral malleolus
Figure 1 Intraoperative photo of a peroneus brevis tear (arrow).
[7, 9]. Lateral ankle instability may be present though it is not directly related to the tendon tear, particularly in patients with chronic symptoms. Eversion weakness against resistance is uncommon [18]. Plain radiographs rule out bony abnormalities. Magnetic resonance imaging (MRI) is the best method by which to image tendon disease [23]27]. If a tear is present, MRI may show a tendon which appears abnormally shaped like a `boomerang' or a longitudinal rent. The appearance of a small bone spur at the lateral fibular ridge containing marrow signal also has been reported to be associated with tendon disease as well as a flat or convex shaped fibular groove, but an increase in the intratendon signal on T2-weighted images has not been found to be associated with a tendon tear [26]. An additional MRI finding is the `magic angle' effect. This is defined as increased intratendinous signal on the T1weighted image as the tendon curves obliquely into the plane of imaging. It should be recognized in order to avoid a false positive interpretation of the MRI [28]. Ultrasound has also been used to detect peroneal tendon tears [29]. Non-operative treatment is appropriate for those patients with minimal symptoms that do not significantly affect daily activities. This includes anti-inflammatory medication, rest, a flexibility programme and ankle bracing [1]. Corticosteroid injections are not recommended. Surgical repair is reserved for those patients who fail non-operative treatment or who have symptoms which affect # 2000 Blackwell Science Ltd, Foot and Ankle Surgery 2000, 6, 197]205
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function. At surgery, associated foot and ankle conditions also must be corrected. This includes lateral ankle instability, osteochondral talar dome fractures, or chronic ankle synovitis [9]. A tenosynovectomy of the peroneus brevis tendon is performed and the longitudinal tear, usually from 3]5 cm in length, is debrided and repaired using nonabsorbable 4]0 Dacron suture. If lateral ankle instability is also present, a direct repair of the ATFL is carried out or a repair using a split peroneus tendon graft harvested for a reconstruction using one of the two halves of the tear as graft [9]. If the tear is complete and there is retraction of the proximal stump, a free tendon graft using the plantaris tendon, peroneus tertius, or even a peroneus quartus transfer, if present, is recommended. Tenodesis of the brevis tendon to the lateral calcaneus is suggested if the proximal tendon stump of a completely ruptured tendon is retracted and fixed [1]. Postoperative care initially includes cast immobilization. After 2 weeks, a range of motion cast boot is prescribed and gentle range of motion exercises begun. Four weeks postoperatively, an ankle brace is prescribed along with a rehabilitation programme. If a lateral ligament reconstruction or a tendon graft has been performed, the patient is immobilized in a cast for 4 weeks, after which the cast is removed and the protocol outlined for direct repair is followed [1]. The patient is allowed to return to sports and high impact activites when the strength is 90% of the nonoperative leg.
Peroneus longus Anatomy The peroneus longus muscle originates from the fibula and intermuscular septum in the lateral compartment. It is innervated by the superficial peroneal nerve. The longus tendon enters a common synovial sheath with the brevis 2 cm proximal to the tip of the lateral malleolus. In this region, the longus tendon lies posterior and lateral to the brevis tendon. This causes the peroneus brevis tendon to splay out in response to the pressure exerted by the peroneus longus tendon. Both tendons pass beneath the lateral malleolus through a canal bordered anteriorly by the fibula, posteriorly and laterally by the superior # 2000 Blackwell Science Ltd, Foot and Ankle Surgery 2000, 6, 197]205
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peroneal retinaculum and medially by the posterior talofibular and calcaneofibular ligaments [30]. The longus tendon then enters its own fibroosseous canal usually inferior to the lateral calcaneal tuberosity and procedes distally until it turns beneath the cuboid. At this level, the tendon enters another tunnel and travels in the fourth layer of foot musculature to insert on the inferior base of the first metatarsal. The os peroneum is present in 20% of patients and is located within the tendon just proximal to and at the level of the cuboid [31]. The peroneus longus is the principle plantarflexor of the first metatarsal, and also serves as a secondary ankle flexor and foot pronator [17]32].
Peroneus longus disruption Although peroneus longus tears are not as common as tears of the peroneus brevis, they dramatically affect foot function. A tendon tear can occur independently but is occasionally associated with a tear of the peroneus brevis tendon. An acute tendon tear is caused by an injury related to a specific event. The event may even have occurred several months previously. A chronic tear develops without a known inciting event. In both types however, the time from onset of symptoms to diagnosis is often . 6 months [33]. Both acute and chronic peroneus longus tears present with lateral foot pain. The acute tear has an onset of sudden pain similar to that of an ankle sprain [33, 34]. A pop or snap may be felt at the time of injury [35, 36]. With a chronic tendon tear, lateral foot pain also is present, but symptoms develop insidiously. The patient with a peroneus longus tendon tear tends to be older than one with a peroneus brevis tear and often complains of associated lateral ankle instability [33]. Two mechanisms for the development of a peroneus longus tear have been suggested. One mechanism relates the tear to degeneration as a result to high intratendinous shear stresses as the tendon passes around the lateral calcaneus and into the cuboid groove. The other mechanism relies on evidence that proximal peroneus longus tears can be generated in cadavers using a mechanism similar to that which creates an inversion ankle sprain [15]. Fragmentation of the os peroneum through direct
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trauma or as an avulsion fracture is another injury mechanism. Clinical examination reveals tenderness and occasional swelling along the peroneus longus tendon. When an os peroneum is present, tenderness is localized at or just proximal to the bone. With complete rupture of the tendon distal to or through the os peroneum, the bony fragment is pulled proximally with the proximal tendon stump [17]. Resisted plantarflexion of the first ray and eversion of the foot produces pain along the lateral midfoot [36]. Plain radiographs obtained at the initial visit determine the presence or absence of an os peroneum and also reveals a fracture, fragmentation, or proximal position. If initial radiographs indicate normal position of the os peroneum, follow-up radiographs may demonstrate proximal migration of part or all of the os peroneum indicating a complete tear with retraction of the tendon [17]37] (Figure 2a]c). An enlarged lateral calcaneal tuberosity, which has been implicated in both peroneus longus tendon entrapment and in tendon tear, is best visualized on an axial heel view [38]39]. A peroneus longus tear with or without an os peroneum fracture is best imaged on MRI. Increased signal intensity on both T1- and T2-weighted images, thickening of the tendon, and increased fluid in the synovial sheath are highly suggestive for a tear [23]41]. As with a peroneus brevis tear, the `magic angle' effect must be considered [23]. The `painful os peroneum syndrome' (POPS) has been reported with various injury patterns in those patients in which the os peroneum is present [39]. However, a study of 15 patients with peroneus longus tendon tears reported the presence of an os peroneum in less than 50% of patients. Although the presence of the os peroneum is helpful in determining the diagnosis, its absence is more significant because it both delays the diagnosis and makes surgery technically more difficult because there are no bony fragments around which sutures can be placed to secure the repair [33]. For the acute rupture, non-operative treatment may be attempted in patients with minimal symptoms and no loss of function. In patients with significant pain and dysfunction, surgical repair is recommended. If an os peroneum is present and involved in the tear, it should be repaired or excised
Figure 2 (a,b) Oblique foot radiographs taken 3 months apart show progressive retraction of the os peroneum (arrow) indicating a peroneus longus tendon tear. (c) The lateral radiograph shows the os peroneum (arrow) has retracted to the level of the lateral calcaneal tubercle. (Reprinted from [33] with permission from AOFAS).
and the tendon repaired with non-absorbable suture. An algorithm for the treatment of peroneus longus tendon tears can aid the clinician in the proper diagnosis and treatment (Figure 3). A patient with a chronic partial longitudinal tear may improve with 2 weeks of cast immobilization # 2000 Blackwell Science Ltd, Foot and Ankle Surgery 2000, 6, 197]205
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Figure 3 An algorithm for the diagnosis and treatment of peroneus longus tendon tears. (Adapted from [33] with permission from AOFAS).
followed by a therapy programme of muscle stretching and strengthening. Moulded orthotics should be used when returning to athletic activities. If the patient does not improve, tenosynovectomy and repair of the tendon tear using non-absorbable 4]0 Dacron suture is recommended. If the tear is complete and the proximal stump cannot be advanced enough for an end to end repair repair, a bridging tendon graft is used. A retracted and fixed proximal tendon stump, seen frequently in a chronic tear, is best tenodesed to the lateral calcaneus [1] (Figure 4). This allows the tendon to act passively to control inversion. We do not recommend tenodesis of the retracted fixed stump to the adjacent peroneus brevis tendon because it will interfere with the # 2000 Blackwell Science Ltd, Foot and Ankle Surgery 2000, 6, 197]205
function of the only remaining abductor of the foot. Postoperative management is similar to the regimen detailed for a peroneus brevis tendon repair. Following the peroneus longus repair, a semirigid full orthotic is prescribed to encourage control foot pronation [17].
Peroneal tendon dislocation Anatomy The most important soft tissue restraint of the peroneal tendons at the ankle is the superior peroneal retinaculum which originates from the distal fibula and inserts at the Achilles tendon
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Figure 4 A complete rupture of the peroneus longus (arrow). (Reprinted from [33] with permission from AOFAS).
sheath and the lateral calcaneus [42, 43]. The groove behind the fibula is variable in shape from concave to almost convex [3]. At the lateral edge of the fibula, a rim of fibrocartilage several millimeters in width exists serving to deepen the groove which contains the peroneal tendons similar to the function of the glenoid labrum and the glenohumeral joint [44]. The superior peroneal retinaculum also serves the secondary function of resisting ankle inversion [45].
Tendon dislocation The mechanism of peroneal dislocation is acute ankle dorsiflexion and eversion with simultaneous forceful contraction of the peroneal muscles [44]. The injury may occur with different activities, but it has been described classically as an alpine skiing injury [44, 46, 47]. The most common finding following an
acute injury is swelling and tenderness at the posterior aspect of the distal fibula. One or both tendons may dislocate. After 24 h, the lateral ankle becomes diffusely swollen, but the tenderness remains localized. This helps to differentiate this injury from an ankle sprain. A bone fragment may be palpable if an avulsion occurs [44]. In contrast, chronic dislocation usually produces symptoms of ankle instability, often associated with a painful lateral ankle snap as the tendons dislocate and relocate over the lateral malleolus [46]. Active eversion and dorsiflexion may provoke dislocation and produce symptoms. Associated abnormalities that predispose the patient to dislocation include hindfoot valgus and laxity of the superior peroneal retinaculum [1]. There are four types of peroneal dislocation: grade I: injury tears the superficial peroneal retinaculum from its origin on the lateral fibula; grade II: injury tears the retinaculum from the lateral fibula and avulses the dense fibrocartilage ridge from the posterolateral fibula; grade III: injury tears the retinaculum from the lateral fibula, avulses the fibrocartilage ridge, and a flake fractures from the lateral malleolus; and grade IV: injury tears the retinaculum from the calcaneal insertion [47]. In grades I through III, the degree of peroneal tendon instability correlates with a higher grade of injury [44]. Initial radiographs usually reveal soft tissue swelling. If a flake fracture is present, this appears just lateral to the lateral malleolus. A computerised tomography (CT) scan is helpful if a bony avulsion is suspected but no fracture is seen on radiograph. Other diagnostic studies include MRI, kinematic MRI and high-resolution ultrasound [48]49]. Surgical repair is recommended for acute peroneal dislocation [3, 16, 44]. In patients with chronic peroneal dislocation and no pain or dysfunction, no treatment is necessary. Patients who are symptomatic however, are treated with reconstructive surgery. Several surgical techniques have been described to correct this problem including softtissue reconstruction [50], re-routing the tendons under the calcaneofibular ligament [51, 52], posterior sliding fibular osteotomy [16], and deepening of the fibular groove [1, 3, 53, 54]. All authors report good success using their own technique. In our experience deepening the fibular groove and reat# 2000 Blackwell Science Ltd, Foot and Ankle Surgery 2000, 6, 197]205
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taching the superior peroneal retinaculum to the lateral fibular border is preferred (Figure 5a]c). This type of repair is simple, requires no fibular osteotomy, preserves the anatomicalal position of the peroneal tendons, and has low morbidity. Intraoperatively, the peroneal groove is deepened sufficiently so that when the ankle is moved through a full range of dorsiflexion and plantarflexion, in both inversion and eversion, no tendon dislocation occurs. Bone wax is applied to the groove before replacing the tendons. The retinaculum is secured to the lateral fibular ridge using bone anchors or sutures through holes in the fibula. Postoperatively, the patient is immobilized in a cast for two weeks. Gentle range of motion is begun after the cast is removed and a range of motion boot applied. Four weeks postoperatively, an ankle brace is applied and a rehabilitation programme is increased to include strength and flexibility. If the patient is an athlete and wishes to return to sports, a lace up ankle brace is recommended.
Tendonitis Pathogenesis Peroneal tendonitis affects both the peroneus longus and the peroneus brevis tendons. Tendonitis occurs when an individual returns to activity without proper training or after a period of extended rest. For the athlete, changes in shoewear, training regimen, or training surface also contribute to the problem. In the worker, increased hours, a change in work station, or a change in type of labour can contribute to symptoms. Endurance sports lead to the development of tendonitis due to a high number of cyclic muscle contractions. This occurs even in a well conditioned athlete if the endurance limit of the tendon is passed.
Diagnosis and treatment Acute tendonitis presents with recent (, 6 weeks) onset of pain along the lateral ankle and foot. If the peroneus brevis tendon alone is affected, the pain is located posterior and distal to the lateral malleolus. Peroneus longus tendonitis presents with pain along the lateral calcaneal wall extending to the cuboid. Both types are aggravated by activity and relieved # 2000 Blackwell Science Ltd, Foot and Ankle Surgery 2000, 6, 197]205
Figure 5 (a) Clinical photo of peroneal tendon dislocation. The tendon (arrow) is dislocated from its normal location behind the lateral malleolus. (b) Intraoperative photo demonstrating the deepened fibular groove (arrow) after the rasp has been used to smooth the surface. (c) The redundant portion of the superior peroneal retinaculum has been excised and the remaining tissue reattached to the lateral fibular border (arrow).
with rest. In chronic tendonitis symptoms are present for . 6 weeks, but the clinical presentation
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is the same. A history of systemic disorders such as gout, rheumatoid arthritis, or tuberculosis is important since these conditions predispose the patient to tenosynovitis [55]. If the peroneus brevis is affected, tenderness is located just inferior to the tip of the lateral malleolus. If the peroneus longus is inflamed, tenderness is present along the lateral calcaneus to the cuboid. Active resistive muscle, flexion/abduction for the peroneus brevis and flexion/pronation for the perneus longus, provokes pain over the respective tendons. Swelling is visible since the tendons lie subcutaneously. A pseudotumour due to tendon degeneration may be present [56]. Radiographs are negative. An MRI reveals increased fluid within the tendon sheath, and the tendons may demonstrate intratendinous abnormalities [16, 27]. Thickening of the tendon sheath may also present in chronic tendonitis [41]. Treatment consists of rest, ice, and anti-inflammatory medication. If symptoms are severe, a cast or ROM boot immobilization is prescribed for 10 days. After symptoms resolve, the patient begins a progressive rehabilitation programme of stretching and strengthening of the peroneal musculature. Endurance exercises are added as required for athletic or occupational conditioning. In recalcitrant cases, tenosynovectomy provides a satisfactory outcome. After surgery, the patient is immobilized for 3 weeks before being allowed to begin active range of motion exercises. Progressive strengthening is then Instituted at 4 weeks postoperatively. Athletes can return to competitive sports when strength returns to 90% of the unaffected side. For the labourer, the patient's work schedule is progressively lengthened to full duty to build endurance, and ergonomic changes to the workplace may also be necessary to decrease the risk of recurrence.
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Review article
Diagnosis and treatment of peroneal tendon injuries G.J. SAMMARCO*{ AND P.G. MANGONE{ *Department of Orthopaedics, University of Cincinnati School of Medicine, {The Center for Orthopaedic Care, Inc. and {The Center for Orthopaedic Care, Inc., Cincinnati, OH, USA
Introduction The peroneal muscles act to evert and plantarflex the foot and ankle. They also help control the foot and ankle by preventing abnormal inversion and extension motion by resisting unexpected forces which may cause injury. With active contraction, they stabilise the joints through coordinated action in response to applied external loads. Disease of muscles and tendons often goes unnoticed. However, peroneal tendon abnormalities can complicate other disease conditions of the foot and ankle, contributing to pain, instability, and deformity. These may be acute or chronic and may affect one or both peroneal tendons. Gout, rheumatoid arthritis, and diabetes mellitus are systemic disorders which predispose to these conditions. The diagnosis of injury to the peroneal tendons requires diligence and is often is delayed. Early diagnosis relies on a detailed history, a thorough physical examination, and a high index of suspicion. This review includes tears of the tendons, dislocation, and tendinitis. The key elements of the history, physical examination, and special diagnostic imaging are also included. Guidelines for non-operative and operative treatment are presented as well as recommendations for postoperative rehabilitation.
Peroneus brevis Anatomy The peroneus brevis muscle brevis originates in the lateral compartment from the distal two-thirds of the Correspondence: G. James Sammarco, MD, The Center for Orthopedic Care, Inc., 2123 Auburn Ave, Suite 235, Cincinnati, OH 45219, USA. # 2000 Blackwell Science Ltd
fibular shaft and the intermuscular septum. It is innervated by the superficial peroneal nerve. The long musculotendinous junction extends to within 2]3 cm from the lateral malleolus. As the tendon passes into the fibro-osseous canal behind the lateral malleolus, it lies sandwiched between the posterior fibula and the peroneus longus tendon. The peroneus brevis tendon is pressed between the peroneus longus tendon and the fibula causing it to splay out into a `U' shape. The fibroosseus canal is bordered anteriorly by the fibula, posteriorly and laterally by the superior peroneal retinaculum, and medially by the posterior talofibular and calcaneofibular ligaments. The tendon enters its own synovial sheath proximal to the lateral calcaneal tuberosity and passes distally to insert on the styloid of the fifth metatarsal[ 1]. The blood supply of the tendon arises from vincula branches of the posterior peroneal artery. Unlike the posterior tibial tendon, there is no zone of hypovascularity in the tendon [2]. It is the strongest abductor of the foot and acts also as a secondary ankle flexor and foot evertor [1].
Peroneus brevis disruption Peroneus brevis tears are common [3]14]. Cadaver studies indicate that the incidence ranges from 11% to 37% [10, 11, 14]. The incidence of clinically significant tears, however, remains unknown. Such injuries are difficult to diagnose with the time from initial injury to diagnosis frequently greater than 12 months [4, 7, 9]. Lateral ankle pain is the most common presenting symptom with a peroneus brevis tear [9]. Other complaints include ankle instability and lateral ankle swelling [4, 7, 9, 15]18]. A history of an ankle sprain followed by chronic lateral ankle instability and posterolateral ankle pain is not unusual [4]. A 197
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tendon tear should be suspected in patients with chronic ankle instability for . 7 years associated with pain out of proportion to the amount of instability [17]. Since the differential diagnosis for chronic lateral ankle pain also includes a missed anterior calcaneal process fracture, lateral talar process fracture, and osteochondritis dissicans of the talar dome, these conditions must be ruled out [18]. Clinical and anatomical studies indicate that tears are produced by a combination of factors including compression of the brevis tendon against the posterior aspect of the fibula by the longus tendon and intratendinous shear stresses which allow longitudinal rents in the tendon to develop as it passes beneath the tip of the lateral malleolus [4, 7, 9, 10]12, 15] (Figure 1). This later theory is supported by fact that most tears are found on the undersurface of the tendon [9]. Histopathological specimens also show that mechanical irritation, not inflammation, is the predominant mode of failure [9, 11]. Laxity of the superior peroneal retinaculum has also been suggested as a contributing factor [3, 7, 13, 16]. Although subluxation of the tendon over the lateral fibular ridge has been suggested as a factor also, the incidence of this is unknown. A hypertrophied peroneus brevis muscle seen in athletes as well as an anomalous peroneus quartus muscle may also predispose the tendon to tear. In one study, 18% of cadaver specimens with a peroneus quartus also had a brevis tear present [14]. Another study reported the peroneus quartus muscle to be present in 36% of specimens in which a brevis tear also was identified [10]. It has been hypothesized that the anomalous muscle and tendon force the brevis tendon laterally against the fibular ridge which may result in a rent. This, however, is not substantiated by clinical data [12]. Even without a tendon tear, an anomalous peroneal muscle may be the cause chronic ankle pain and affect athletic performance [19, 20]. If an anomalous muscle is suspected, MRI may confirm the diagnosis [21, 22]. Physical examination relies on anatomical landmarks to determine the location of tenderness in order to focus on the diseased portion of the tendon. An important sign of a tendon tear is persistent swelling over the tendon sheath [7]. In addition, many patients also have tenderness over the tendon sheath as it courses beneath the lateral malleolus
Figure 1 Intraoperative photo of a peroneus brevis tear (arrow).
[7, 9]. Lateral ankle instability may be present though it is not directly related to the tendon tear, particularly in patients with chronic symptoms. Eversion weakness against resistance is uncommon [18]. Plain radiographs rule out bony abnormalities. Magnetic resonance imaging (MRI) is the best method by which to image tendon disease [23]27]. If a tear is present, MRI may show a tendon which appears abnormally shaped like a `boomerang' or a longitudinal rent. The appearance of a small bone spur at the lateral fibular ridge containing marrow signal also has been reported to be associated with tendon disease as well as a flat or convex shaped fibular groove, but an increase in the intratendon signal on T2-weighted images has not been found to be associated with a tendon tear [26]. An additional MRI finding is the `magic angle' effect. This is defined as increased intratendinous signal on the T1weighted image as the tendon curves obliquely into the plane of imaging. It should be recognized in order to avoid a false positive interpretation of the MRI [28]. Ultrasound has also been used to detect peroneal tendon tears [29]. Non-operative treatment is appropriate for those patients with minimal symptoms that do not significantly affect daily activities. This includes anti-inflammatory medication, rest, a flexibility programme and ankle bracing [1]. Corticosteroid injections are not recommended. Surgical repair is reserved for those patients who fail non-operative treatment or who have symptoms which affect # 2000 Blackwell Science Ltd, Foot and Ankle Surgery 2000, 6, 197]205
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function. At surgery, associated foot and ankle conditions also must be corrected. This includes lateral ankle instability, osteochondral talar dome fractures, or chronic ankle synovitis [9]. A tenosynovectomy of the peroneus brevis tendon is performed and the longitudinal tear, usually from 3]5 cm in length, is debrided and repaired using nonabsorbable 4]0 Dacron suture. If lateral ankle instability is also present, a direct repair of the ATFL is carried out or a repair using a split peroneus tendon graft harvested for a reconstruction using one of the two halves of the tear as graft [9]. If the tear is complete and there is retraction of the proximal stump, a free tendon graft using the plantaris tendon, peroneus tertius, or even a peroneus quartus transfer, if present, is recommended. Tenodesis of the brevis tendon to the lateral calcaneus is suggested if the proximal tendon stump of a completely ruptured tendon is retracted and fixed [1]. Postoperative care initially includes cast immobilization. After 2 weeks, a range of motion cast boot is prescribed and gentle range of motion exercises begun. Four weeks postoperatively, an ankle brace is prescribed along with a rehabilitation programme. If a lateral ligament reconstruction or a tendon graft has been performed, the patient is immobilized in a cast for 4 weeks, after which the cast is removed and the protocol outlined for direct repair is followed [1]. The patient is allowed to return to sports and high impact activites when the strength is 90% of the nonoperative leg.
Peroneus longus Anatomy The peroneus longus muscle originates from the fibula and intermuscular septum in the lateral compartment. It is innervated by the superficial peroneal nerve. The longus tendon enters a common synovial sheath with the brevis 2 cm proximal to the tip of the lateral malleolus. In this region, the longus tendon lies posterior and lateral to the brevis tendon. This causes the peroneus brevis tendon to splay out in response to the pressure exerted by the peroneus longus tendon. Both tendons pass beneath the lateral malleolus through a canal bordered anteriorly by the fibula, posteriorly and laterally by the superior # 2000 Blackwell Science Ltd, Foot and Ankle Surgery 2000, 6, 197]205
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peroneal retinaculum and medially by the posterior talofibular and calcaneofibular ligaments [30]. The longus tendon then enters its own fibroosseous canal usually inferior to the lateral calcaneal tuberosity and procedes distally until it turns beneath the cuboid. At this level, the tendon enters another tunnel and travels in the fourth layer of foot musculature to insert on the inferior base of the first metatarsal. The os peroneum is present in 20% of patients and is located within the tendon just proximal to and at the level of the cuboid [31]. The peroneus longus is the principle plantarflexor of the first metatarsal, and also serves as a secondary ankle flexor and foot pronator [17]32].
Peroneus longus disruption Although peroneus longus tears are not as common as tears of the peroneus brevis, they dramatically affect foot function. A tendon tear can occur independently but is occasionally associated with a tear of the peroneus brevis tendon. An acute tendon tear is caused by an injury related to a specific event. The event may even have occurred several months previously. A chronic tear develops without a known inciting event. In both types however, the time from onset of symptoms to diagnosis is often . 6 months [33]. Both acute and chronic peroneus longus tears present with lateral foot pain. The acute tear has an onset of sudden pain similar to that of an ankle sprain [33, 34]. A pop or snap may be felt at the time of injury [35, 36]. With a chronic tendon tear, lateral foot pain also is present, but symptoms develop insidiously. The patient with a peroneus longus tendon tear tends to be older than one with a peroneus brevis tear and often complains of associated lateral ankle instability [33]. Two mechanisms for the development of a peroneus longus tear have been suggested. One mechanism relates the tear to degeneration as a result to high intratendinous shear stresses as the tendon passes around the lateral calcaneus and into the cuboid groove. The other mechanism relies on evidence that proximal peroneus longus tears can be generated in cadavers using a mechanism similar to that which creates an inversion ankle sprain [15]. Fragmentation of the os peroneum through direct
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trauma or as an avulsion fracture is another injury mechanism. Clinical examination reveals tenderness and occasional swelling along the peroneus longus tendon. When an os peroneum is present, tenderness is localized at or just proximal to the bone. With complete rupture of the tendon distal to or through the os peroneum, the bony fragment is pulled proximally with the proximal tendon stump [17]. Resisted plantarflexion of the first ray and eversion of the foot produces pain along the lateral midfoot [36]. Plain radiographs obtained at the initial visit determine the presence or absence of an os peroneum and also reveals a fracture, fragmentation, or proximal position. If initial radiographs indicate normal position of the os peroneum, follow-up radiographs may demonstrate proximal migration of part or all of the os peroneum indicating a complete tear with retraction of the tendon [17]37] (Figure 2a]c). An enlarged lateral calcaneal tuberosity, which has been implicated in both peroneus longus tendon entrapment and in tendon tear, is best visualized on an axial heel view [38]39]. A peroneus longus tear with or without an os peroneum fracture is best imaged on MRI. Increased signal intensity on both T1- and T2-weighted images, thickening of the tendon, and increased fluid in the synovial sheath are highly suggestive for a tear [23]41]. As with a peroneus brevis tear, the `magic angle' effect must be considered [23]. The `painful os peroneum syndrome' (POPS) has been reported with various injury patterns in those patients in which the os peroneum is present [39]. However, a study of 15 patients with peroneus longus tendon tears reported the presence of an os peroneum in less than 50% of patients. Although the presence of the os peroneum is helpful in determining the diagnosis, its absence is more significant because it both delays the diagnosis and makes surgery technically more difficult because there are no bony fragments around which sutures can be placed to secure the repair [33]. For the acute rupture, non-operative treatment may be attempted in patients with minimal symptoms and no loss of function. In patients with significant pain and dysfunction, surgical repair is recommended. If an os peroneum is present and involved in the tear, it should be repaired or excised
Figure 2 (a,b) Oblique foot radiographs taken 3 months apart show progressive retraction of the os peroneum (arrow) indicating a peroneus longus tendon tear. (c) The lateral radiograph shows the os peroneum (arrow) has retracted to the level of the lateral calcaneal tubercle. (Reprinted from [33] with permission from AOFAS).
and the tendon repaired with non-absorbable suture. An algorithm for the treatment of peroneus longus tendon tears can aid the clinician in the proper diagnosis and treatment (Figure 3). A patient with a chronic partial longitudinal tear may improve with 2 weeks of cast immobilization # 2000 Blackwell Science Ltd, Foot and Ankle Surgery 2000, 6, 197]205
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Figure 3 An algorithm for the diagnosis and treatment of peroneus longus tendon tears. (Adapted from [33] with permission from AOFAS).
followed by a therapy programme of muscle stretching and strengthening. Moulded orthotics should be used when returning to athletic activities. If the patient does not improve, tenosynovectomy and repair of the tendon tear using non-absorbable 4]0 Dacron suture is recommended. If the tear is complete and the proximal stump cannot be advanced enough for an end to end repair repair, a bridging tendon graft is used. A retracted and fixed proximal tendon stump, seen frequently in a chronic tear, is best tenodesed to the lateral calcaneus [1] (Figure 4). This allows the tendon to act passively to control inversion. We do not recommend tenodesis of the retracted fixed stump to the adjacent peroneus brevis tendon because it will interfere with the # 2000 Blackwell Science Ltd, Foot and Ankle Surgery 2000, 6, 197]205
function of the only remaining abductor of the foot. Postoperative management is similar to the regimen detailed for a peroneus brevis tendon repair. Following the peroneus longus repair, a semirigid full orthotic is prescribed to encourage control foot pronation [17].
Peroneal tendon dislocation Anatomy The most important soft tissue restraint of the peroneal tendons at the ankle is the superior peroneal retinaculum which originates from the distal fibula and inserts at the Achilles tendon
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Figure 4 A complete rupture of the peroneus longus (arrow). (Reprinted from [33] with permission from AOFAS).
sheath and the lateral calcaneus [42, 43]. The groove behind the fibula is variable in shape from concave to almost convex [3]. At the lateral edge of the fibula, a rim of fibrocartilage several millimeters in width exists serving to deepen the groove which contains the peroneal tendons similar to the function of the glenoid labrum and the glenohumeral joint [44]. The superior peroneal retinaculum also serves the secondary function of resisting ankle inversion [45].
Tendon dislocation The mechanism of peroneal dislocation is acute ankle dorsiflexion and eversion with simultaneous forceful contraction of the peroneal muscles [44]. The injury may occur with different activities, but it has been described classically as an alpine skiing injury [44, 46, 47]. The most common finding following an
acute injury is swelling and tenderness at the posterior aspect of the distal fibula. One or both tendons may dislocate. After 24 h, the lateral ankle becomes diffusely swollen, but the tenderness remains localized. This helps to differentiate this injury from an ankle sprain. A bone fragment may be palpable if an avulsion occurs [44]. In contrast, chronic dislocation usually produces symptoms of ankle instability, often associated with a painful lateral ankle snap as the tendons dislocate and relocate over the lateral malleolus [46]. Active eversion and dorsiflexion may provoke dislocation and produce symptoms. Associated abnormalities that predispose the patient to dislocation include hindfoot valgus and laxity of the superior peroneal retinaculum [1]. There are four types of peroneal dislocation: grade I: injury tears the superficial peroneal retinaculum from its origin on the lateral fibula; grade II: injury tears the retinaculum from the lateral fibula and avulses the dense fibrocartilage ridge from the posterolateral fibula; grade III: injury tears the retinaculum from the lateral fibula, avulses the fibrocartilage ridge, and a flake fractures from the lateral malleolus; and grade IV: injury tears the retinaculum from the calcaneal insertion [47]. In grades I through III, the degree of peroneal tendon instability correlates with a higher grade of injury [44]. Initial radiographs usually reveal soft tissue swelling. If a flake fracture is present, this appears just lateral to the lateral malleolus. A computerised tomography (CT) scan is helpful if a bony avulsion is suspected but no fracture is seen on radiograph. Other diagnostic studies include MRI, kinematic MRI and high-resolution ultrasound [48]49]. Surgical repair is recommended for acute peroneal dislocation [3, 16, 44]. In patients with chronic peroneal dislocation and no pain or dysfunction, no treatment is necessary. Patients who are symptomatic however, are treated with reconstructive surgery. Several surgical techniques have been described to correct this problem including softtissue reconstruction [50], re-routing the tendons under the calcaneofibular ligament [51, 52], posterior sliding fibular osteotomy [16], and deepening of the fibular groove [1, 3, 53, 54]. All authors report good success using their own technique. In our experience deepening the fibular groove and reat# 2000 Blackwell Science Ltd, Foot and Ankle Surgery 2000, 6, 197]205
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taching the superior peroneal retinaculum to the lateral fibular border is preferred (Figure 5a]c). This type of repair is simple, requires no fibular osteotomy, preserves the anatomicalal position of the peroneal tendons, and has low morbidity. Intraoperatively, the peroneal groove is deepened sufficiently so that when the ankle is moved through a full range of dorsiflexion and plantarflexion, in both inversion and eversion, no tendon dislocation occurs. Bone wax is applied to the groove before replacing the tendons. The retinaculum is secured to the lateral fibular ridge using bone anchors or sutures through holes in the fibula. Postoperatively, the patient is immobilized in a cast for two weeks. Gentle range of motion is begun after the cast is removed and a range of motion boot applied. Four weeks postoperatively, an ankle brace is applied and a rehabilitation programme is increased to include strength and flexibility. If the patient is an athlete and wishes to return to sports, a lace up ankle brace is recommended.
Tendonitis Pathogenesis Peroneal tendonitis affects both the peroneus longus and the peroneus brevis tendons. Tendonitis occurs when an individual returns to activity without proper training or after a period of extended rest. For the athlete, changes in shoewear, training regimen, or training surface also contribute to the problem. In the worker, increased hours, a change in work station, or a change in type of labour can contribute to symptoms. Endurance sports lead to the development of tendonitis due to a high number of cyclic muscle contractions. This occurs even in a well conditioned athlete if the endurance limit of the tendon is passed.
Diagnosis and treatment Acute tendonitis presents with recent (, 6 weeks) onset of pain along the lateral ankle and foot. If the peroneus brevis tendon alone is affected, the pain is located posterior and distal to the lateral malleolus. Peroneus longus tendonitis presents with pain along the lateral calcaneal wall extending to the cuboid. Both types are aggravated by activity and relieved # 2000 Blackwell Science Ltd, Foot and Ankle Surgery 2000, 6, 197]205
Figure 5 (a) Clinical photo of peroneal tendon dislocation. The tendon (arrow) is dislocated from its normal location behind the lateral malleolus. (b) Intraoperative photo demonstrating the deepened fibular groove (arrow) after the rasp has been used to smooth the surface. (c) The redundant portion of the superior peroneal retinaculum has been excised and the remaining tissue reattached to the lateral fibular border (arrow).
with rest. In chronic tendonitis symptoms are present for . 6 weeks, but the clinical presentation
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is the same. A history of systemic disorders such as gout, rheumatoid arthritis, or tuberculosis is important since these conditions predispose the patient to tenosynovitis [55]. If the peroneus brevis is affected, tenderness is located just inferior to the tip of the lateral malleolus. If the peroneus longus is inflamed, tenderness is present along the lateral calcaneus to the cuboid. Active resistive muscle, flexion/abduction for the peroneus brevis and flexion/pronation for the perneus longus, provokes pain over the respective tendons. Swelling is visible since the tendons lie subcutaneously. A pseudotumour due to tendon degeneration may be present [56]. Radiographs are negative. An MRI reveals increased fluid within the tendon sheath, and the tendons may demonstrate intratendinous abnormalities [16, 27]. Thickening of the tendon sheath may also present in chronic tendonitis [41]. Treatment consists of rest, ice, and anti-inflammatory medication. If symptoms are severe, a cast or ROM boot immobilization is prescribed for 10 days. After symptoms resolve, the patient begins a progressive rehabilitation programme of stretching and strengthening of the peroneal musculature. Endurance exercises are added as required for athletic or occupational conditioning. In recalcitrant cases, tenosynovectomy provides a satisfactory outcome. After surgery, the patient is immobilized for 3 weeks before being allowed to begin active range of motion exercises. Progressive strengthening is then Instituted at 4 weeks postoperatively. Athletes can return to competitive sports when strength returns to 90% of the unaffected side. For the labourer, the patient's work schedule is progressively lengthened to full duty to build endurance, and ergonomic changes to the workplace may also be necessary to decrease the risk of recurrence.
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