Peroneal Tendon Disorders

MRI findings of peroneal tendon tears do not necessarily correlate to clinical findings in paediatric and adolescent patients

PURPOSE

Pathologic abnormality of the peroneal tendons are thought to be an under-appreciated source of vague ankle and hindfoot pain in paediatric patients, partly because they can be difficult to diagnose and differentiate from lateral ankle ligament injuries. While magnetic resonance imaging (MRI) is the primary imaging modality used to detect peroneal tendon pathology, previous studies in adults have found that positive MRIs demonstrate a positive predictive value (PPV) of associated clinical findings around 48%. There are no similar known published studies in the paediatric population. Our objective was to determine the positive predictive value of peroneal tendon pathology as diagnosed by MRI as related to positive clinical exam findings in the paediatric and adolescent population.

METHODS

This IRB approved retrospective study was conducted at a tertiary children's hospital. Inclusion criteria included patients under 18 years from our tertiary care institution with (a) ankle MRI findings indicating pathology of the peroneus brevis/longus tendons confirmed by a board certified paediatric musculoskeletal radiologist and (b) formal review of the clinical examination by a fellowship trained paediatric orthopaedic surgeon. Patients with congenital deformities or previous surgical intervention of the lateral ankle were excluded.

RESULTS

Forty-seven patients (with 48 MRIs) met inclusion criteria over a ten year period. The majority of the positive MRI scans (70%) demonstrated a peroneus brevis split tear. Of the patients with positive findings on MRI, 17 patients had an associated positive clinical exam. The positive predictive value of MRI for peroneal tendon tears with positive clinical findings was 35.41% (95% confidence interval = 31.1% to 41.6%). There were 31 patients with MRI positive findings with a negative clinical exam.

CONCLUSION

Despite having a negative clinical exam, a high percentage of patients had positive MRI findings suggestive of peroneal tendon pathology which confirms findings of adult populations demonstrating a high rate of incidental finding of peroneal tendon pathology on MRI in paediatric patients.

Are enlarged peroneal tubercle and accessory anterolateral talar facet associated with calcaneal spur?

BACKGROUND

As the anatomical variations of the foot, enlarged peroneal tubercle (EPT) and accessory anterolateral talar facet (AALTF) have attracted the attention of foot surgeons in recent years. However, EPT and AALTF have not been examined for a relationship with calcaneus spur (CS) as a common osteophyte.

METHODS

The subjects were 369 individuals who died in northeastern Thailand and were preserved as skeletal specimens. The authors examined for the presence of left and right EPT, AALTF, and calcaneus spur (CS). We divided the EPT (+) group with EPT and the EPT (-) group without it and also divided the AALTF (+) group with AALTF and the AALTF (-) group without it. The age at death and the presence of CS were compared statistically between the EPT (+) and EPT (-) groups and between the AATLF (+) and AALTF (-) groups.

RESULTS

Out of the total 369 cases, EPT was found in 117 cases (31.7%), AALTF was positive in 91 cases (24.7%), and CS was found in 194 cases (52.3%). In comparison between EPT (+) and EPT (-) groups, CS was significantly higher (p < 0.0001) in the EPT (+) group, but there was no significant difference in age at death. In comparison between AALTF (+) and AALTF (-) groups, there was no significant difference in age at death or CS.

CONCLUSION

This study showed a strong relationship between EPT and CS, and the prevalence of EPT and AALTF by age in Thailand was first reported. We believe it helps to know the pathogenesis and biomechanism of EPT and AALTF.

TRIAL REGISTRATION

Not applicable.

Surgical treatment options for chronic instability of the peroneal tendons: a systematic review and proportional meta-analysis

INTRODUCTION

Several surgical techniques for chronic instability of the peroneal tendons have been reported. Yet, the most optimal technique has not been clarified. This study aims to perform a systematic review and meta-analysis of all existing evidence and compare all published surgical techniques in both the athletic as the nonathletic population.

MATERIALS AND METHODS

A systematic review and a proportional meta-analysis, with a random-effects model, were carried out according to the PRISMA guidelines, using the keywords "chronic luxation" OR "instability" AND "peroneal tendon" AND "treatment" OR "treatment protocol". Four surgical techniques were compared in patients with chronic peroneal instability, comprising superior peroneal retinaculum (SPR) repair or replacement, groove deepening procedures (primarily with additional SPR operations), rerouting procedures, and bony procedures (respectively group S, G, R and B). Outcomes of interest include the pre- and postoperative American orthopedic foot and ankle society hindfoot score, return to sports, postoperative redislocation and complications. Pooled estimates of the last two outcomes were obtained.

RESULTS

For the systematic review, 31 studies were eligible. Of these, 25 papers met the criteria for inclusion in the meta-analysis. All techniques demonstrated a clinical improvement postoperatively. Group B, however, demonstrated overall more unsatisfactory results, and higher complication rates were observed for both group R and group B. The latter was established by the proportional meta-analysis as well [95% confidence interval group S: (0.01-0.10); group G: (0.02-0.10); group R: (0.13-0.57); group B: (0.24-0.40)]. Concerning surgical efficacy (= no postoperative redislocation), no significant difference was statistically observed. Finally, considerable differences in study quality were identified.

CONCLUSION

Surgical treatment results in excellent clinical and functional outcomes in patients with chronic peroneal instability. More inferior results were demonstrated for rerouting and bony procedures. However, no high-quality studies are available and future randomized controlled trials are necessary to advocate for the most advantageous approach.

Symptomatic Accessory Ossicles of the Foot and Ankle

Accessory ossicles are small noncalcified, calcified or ossified structures found throughout the body, often noted as incidental findings. Specifically in the foot and ankle, there are at least 24 different ossicles described the majority of which are incidental. However, there are accessory ossicles that can be symptomatic, leading to significant pain and discomfort. While many of the symptomatic ossicles have been described in the literature, there are several that are under-recognized or under-reported for example, os interphalangeus and os calcaneus secundarius syndromes. This manuscript will review common and uncommon accessory ossicles including painful os peroneum, os naviculare, os calcaneus secundarius, os trigonum and os interphalangeus syndromes as well as medial sesamoiditis, with attention to the clinical and imaging findings and with an outline of the current management.

Imaging Tendon Disorders in Athletes

Imaging plays a critical role in evaluating pathology affecting athletes from various fields. Tendon pathology manifests in terms of mechanical, degenerative, enthesitis, neoplastic, and overuse diseases. Tendon pathologies in athletes usually involve injuries to commonly injured tendons such as the tendons involving the ankle, elbow, rotator cuff, hip abductors, patellar tendon, and Achilles tendon. For the purposes of this article, the focus will be on the tendons involving the ankle such as the tibialis posterior and peroneal tendons. The 2 most common imaging modalities used for the evaluation of tendons are ultrasound (US) and magnetic resonance imaging (MRI). There are several emerging imaging techniques such as T2 mapping, ultra-short echo time MRI, and sonoelastography. These novel imaging techniques are all in research phase and have not been adapted to routine clinical practice.

Prevalence of Abnormal Ultrasonographic Findings in Asymptomatic Peroneal Tendons

Background:

The peroneus longus (PL) and peroneus brevis (PB) tendons comprise the lateral compartment of the leg and stabilize the foot during weightbearing. Peroneal tendinopathy can precipitate lateral ankle pain and induce functional disability. The progression of peroneal pathology to lateral ankle dysfunction is thought to stem from asymptomatic, subclinical peroneal tendinopathy. There may be clinical benefit to identifying asymptomatic patients with this condition before progression to disability. Various ultrasonographic characteristics have been observed in peroneal tendinopathy. The purpose of this study is to identify the frequency of subclinical tendinopathic characteristics in asymptomatic peroneal tendons.

Methods:

One hundred seventy participants underwent bilateral foot and ankle ultrasonographic examination. Images were assessed for abnormalities of the PL and PB tendons by a group of physicians who recorded frequencies of abnormalities. This team consisted of an orthopaedic surgeon specializing in foot and ankle surgery, a fifth-year orthopaedic surgery resident, and a family medicine physician with musculoskeletal sonographer certification.

Results:

A total of 340 PL and 340 PB tendons were assessed. Sixty-eight (20%) PL and 41 (12.1%) PB tendons had abnormal traits. Twenty-four PLs and 22 PBs had circumferential fluid, 16 PLs and 9 PBs had noncircumferential fluid, 27 PLs and 6 PBs had thickening, 36 PLs and 12 PBs had heterogenicity, 10 PLs and 2 PBs had hyperemia, and 1 PL had calcification. In Caucasian participants, male gender was associated with increased frequency of abnormal findings, but there were no other significant differences based on age, body mass index, or ethnicity.

Conclusion:

In our studied population of 170 patients who had no complaints of associated symptoms, we found that 20% of PLs and 12% of PBs displayed ultrasonographic abnormalities. When we included all unusual findings within and around the tendons, prevalence rates of ultrasonographic abnormalities were 34% for PLs and 22% for PBs.

Level of Evidence:

Level II, prospective cohort study.

Presurgical Perspective and Postsurgical Evaluation of Non-Achilles Tendons of the Ankle and Retinaculum

The vast majority of non-Achilles ankle tendinopathies are related to overuse. This article discusses the clinical aspect, imaging appearance, and management of tendinopathies of the lateral, medial, and the anterior compartments with a focus on presurgical perspective and postsurgical evaluation.

Changes in the Kinematics of Midfoot and Rearfoot Joints with the Use of Lateral Wedge Insoles

The lateral wedge insole (LWI) is a typical orthopedic treatment for medial knee osteoarthritis pain, chronic ankle instability, and peroneal tendon disorders. It is still unknown what the effects are in the most important joints of the foot when using LWIs as a treatment for knee and ankle pathologies. Objectives: The aim of this study was to determine the influence of LWIs on the position of the midfoot and rearfoot joints by measuring the changes using a tracking device. Methods: The study was carried out with a total of 69 subjects. Movement measurements for the midfoot were made on the navicular bone, and for the rearfoot on the calcaneus bone. The Polhemus system was used, with two motion sensors fixed to each bone. Subjects were compared by having them use LWIs versus being barefoot. Results: There were statistically significant differences in the varus movement when wearing a 4 mm LWI (1.23 ± 2.08°, p < 0.001) versus the barefoot condition (0.35 ± 0.95°), and in the plantarflexion movement when wearing a 4 mm LWI (3.02 ± 4.58°, p < 0.001) versus the barefoot condition (0.68 ± 1.34°), in the midfoot. There were also statistically significant differences in the valgus movement when wearing a 7 mm LWI (1.74 ± 2.61°, p < 0.001) versus the barefoot condition (0.40 ± 0.90°), and in the plantar flexion movement when wearing a 4 mm LWI (2.88 ± 4.31°, p < 0.001) versus the barefoot condition (0.35 ± 0.90°), in the rearfoot. Conclusions: In the navicular bone, a varus, an abduction, and plantar flexion movements were generated. In the calcaneus, a valgus, an adduction, and plantar flexion movements were generated with the use of LWIs.

Postoperative Ankle Imaging, 2022

Postoperative ankle imaging requires knowledge of the underlying surgical techniques, the usefulness of various imaging modalities, as well as an appreciation for the desired clinical outcomes. Surgical procedures discussed in this article are tibiotalar fracture fixation, tibiotalar, subtalar, and tibiotalocalcaneal arthrodesis, total ankle arthroplasty, talar osteochondral lesion repair and grafting, lateral ligamentous repair and reconstruction, and peroneal and Achilles tendon repair and reconstruction. Imaging can play a vital role in determining if the expected outcome has been achieved and identifying complications, with particular emphasis placed on the use of radiographs, computed tomography (including weight-bearing), magnetic resonance imaging, and ultrasonography.

A Biomechanical Analysis of Peroneus Brevis Split Lesions, Repair, and Partial Resection

BACKGROUND

Peroneus brevis tendon tears are associated with chronic ankle pain and instability following sprain injuries. The aim of this study is to elucidate the biomechanical changes induced by a peroneus brevis split and surgical treatment by tubularizing suture or partial resection.

METHODS

Nine human lower leg specimens were biomechanically tested. Preexisting tendon pathology was ruled out by magnetic resonance imaging and histology. Specimens were subjected to sequential testing of 4 conditions of the peroneus brevis tendon: (1) native, (2) longitudinal lesion, (3) tubularizing suture, and (4) 50% resection. The outcome parameters were the tendon stiffness (N/mm) and the length variation of the split portion at 5 N load.

RESULTS

The median specimen age at death was 55.8 years (range 50-64 years). The longitudinal tendon split led to an elongation by 1.21 ± 1.15 mm, which was significantly reduced by tubularizing suture to 0.24 ± 0.97 mm (P = .021). Furthermore, 50% resection of the tendon elongated it by a mean 2.45 ± 1.9 mm (P = .01) and significantly reduced its stiffness compared to the intact condition (4.7 ± 1.17 N/mm, P = .024) and sutured condition (4.76 ± 1.04 N/mm, P = .011).

CONCLUSION

Longitudinal split and 50% resection of the peroneus brevis tendon led to elongation and loss of tendon stiffness. These properties were improved by tubularizing suture. The significance of these changes in the clinical setting needs further investigation.

CLINICAL RELEVANCE

Tubularizing suture of a peroneus brevis split can restore biomechanical properties to almost native condition, potentially aiding ankle stability in symptomatic cases. A split lesion and partial resection of the tendon showed reduced stiffness and increased elongation.

Peronealsehnenverletzungen

Hintergrund

Verletzungen der Peronealsehnen gelten als häufig unterdiagnostizierte Ursache lateraler Rückfußschmerzen. Prädisponierende Ursachen sind u. a. eine chronische laterale Instabilität sowie ein Rückfußvarus, da dies zu einer Überbelastung der Peronealsehnen führt. Klinisch äußern sich Peronealsehnenverletzungen meist unspezifisch mit lateralen Rückfußschmerzen.

Material und Methoden

In der Untersuchung zeigen sich Schmerzen bei Aktivierung der Sehnen gegen Widerstand. Die Sonographie zur Diagnostik bietet die Möglichkeit einer dynamischen Untersuchung, in der Magnetresonanztomographie (MRT) können gleichzeitig weitere Strukturen beurteilt werden. Zu unterscheiden sind eine Tendinopathie der Sehnen, eine Instabilität mit Luxation oder Subluxation verbunden mit Pathologien des superioren Peronealsehnenretinakulums sowie Längssplit und komplette Sehnenruptur. Bei Tendinopathien und Längsrissen erfolgt die Therapie primär konservativ. Ein kompletter Riss und eine Läsion über 50 % sollten operativ versorgt und, falls möglich, direkt genäht werden. Alternativ sind eine Tenodese oder ein Sehnenersatz mit einem Graft zu evaluieren.

Ergebnisse

Bei Patienten mit einer Peronealsehneninstabilität führen die Naht oder Rekonstruktion des superioren Peronealsehnenretinakulums zu guten Resultaten. Eine frühe Therapie zeigt eine bessere Heilungschance und kann somit zu einem besseren Outcome führen.

Schlussfolgerung

Zusammenfassend kann gesagt werden, dass bei chronischen lateralen Rückfußschmerzen an eine Peronealsehnenverletzung gedacht und bei Verdacht auf eine Läsion eine MRT oder eine Sonographie zur Bestätigung respektive Ausschluss der Diagnose durchgeführt werden sollte.

Innovative Medial Cushioning Orthoses Affect Peroneus Longus Electromyographic Activity during Running

Background: Over-supination processes of the foot and ankle involving peroneus longus (PL) damage during running sports have been treated conservatively with passive control tools, such as tapes, braces, or external ankle supports, but the effect of orthoses with typical lateral wedging orthoses (TLWO) on the muscular activity of PL during running remains unclear. Here we investigate the effects of innovative medial cushioning orthoses (IMCO) on PL activity during the full running gait cycle. In addition, we wished to ascertain the effects of innovative medial cushioning orthoses (IMCO) on PL activity during running. Methods: Thirty-one healthy recreational runners (mean age 34.5 ± 3.33) with neutral foot posture index scores, were selected to participate in the present study. They ran on a treadmill at 9 km/h wearing seven different orthoses (NRS, IMCO 3 mm, IMCO 6 mm, IMCO 9 mm, TLWO 3 mm, TLWO 6 mm and TLWO 9 mm), randomly performed on the same day while electromyographic activity of the PL muscle was recorded. Statistical intraclass correlation coefficient (ICC) to test reliability was carried out and the Wilcoxon test with Bonferroni’s correction was developed to analyze the differences between the conditions. Results: the reliability of all assessments showed data higher than 0.81, that is, “almost perfect reliability”; all EMG PL values wearing either TLWO or IMCO showed a statistically significant reduction versus NRS during the fully analyzed running gait cycle; the highest difference was set on NRS 23.08 ± 6.67 to TLWO 9 mm 17.77 ± 4.794 (p < 0.001). Conclusions: Muscular EMG activity of the PL during the full running gait cycle decreases when wearing either TLWO or IMCO relative to NRS; therefore, these orthoses could be prescribed to treat the strain and overload pathologies of PL. In addition, IMCO—as it less thick, compared with TLWO—can be used when aiming to achieve better running economy.

Intraosseous Anchorage of a Collagen Matrix Graft to Enhance Repair of Peroneus Brevis Tendon Degeneration

INTRODUCTION

Chronic degeneration of the peroneus brevis tendon (PBT) at its insertion to the base of the fifth metatarsal is uncommon; however, when present it can be a challenge to treat. Repair of the PBT often requires tubularization with or without a peroneus longus tendon transfer. These repairs, however, may not provide resultant full muscle strength, especially if ostectomy of the fifth metatarsal base is required. We report outcomes following a novel technique for anatomic repair of degenerative PBT with intraosseous fifth metatarsal base fixation of a collagen matrix graft.

METHODS

Thirteen consecutive patients (14 procedures) with degeneration of PBT that underwent tendon repair augmented with collagen matrix graft from 2011 to 2019 were reviewed retrospectively. We present outcome data of these 13 patients that were followed for at least 12 months.

RESULTS

Muscle strength, complications, and patient-reported subjective outcomes were reported. There were 10 females and 3 males. Average age was 49.1 years, and average follow-up was 34.9 months. Muscle strength was reported at 5/5 to the PBT by the final follow-up for 92% of patients. There were minimal complications, 84.6% (11/13) of patients had no limitation in activity level, and 92% (12/13) would recommend this procedure to a friend.

CONCLUSION

Outcomes for this novel repair technique for insertional degenerative PBT have never been reported before and show excellent results with long-term follow-up.

Peroneus brevis tendon injuries: Report of two cases and review of literature

The incidence of peroneal tendon disorders in the population is unknown and they are usually overlooked. We report two cases of peroneus brevis injuries and a comprehensive literature review was performed. The first case was a 53-year-old man presented with persistent pain on the lateral aspect on the left ankle during the last four years and difficulty to bear weight during the last year. MRI showed longitudinal tear of peroneus brevis tendon and the patient underwent surgical treatment. The second case was a 46-year-old woman with persistent pain on the lateral aspect of the ankle with a history of a road traffic accident two years ago. Although MRI showed a peroneus brevis tendon tear, this was a false positive finding. Surgical treatment revealed no tear and symphysiolysis managed to relieve patient's symptoms. Even though MRI is the most effective diagnostic tool in depicting peroneal tendon injuries, there are false positive findings. In cases when symptoms persist, surgical exploration is indicated.

Clinical and Functional Outcomes of Peroneus Longus to Brevis Tendon Transfer

BACKGROUND

Peroneal tendon lesions can cause debilitating pain, but operative treatment remains controversial. Some studies recommend peroneal tenodesis or transfer if more than half of the tendon is affected. However, clinical outcomes and inversion/eversion motion after peroneal transfer have not been investigated yet.

METHODS

Patients who underwent distal peroneus longus to brevis transfer for major peroneus brevis tendon tears with a minimum follow-up of 2 years were included. Clinical outcome parameters included the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, the German Foot Function Index (FFI-D), and Karlsson-Peterson score. Functional outcome was tested with a standardized active range-of-motion (ROM) and isokinetic strength measurement protocol, including concentric and eccentric eversion and inversion tests.

RESULTS

Of total 23 eligible patients, 14 (61%) were available for follow-up. Clinical outcome scores were good with AOFAS 86 ± 16 points, FFI-D pain 26% and FFI-D disability 26%, and Karlsson-Peterson score 78 ± 23 points. There was no difference in strength in comparison to the contralateral foot (all P > .05). Isokinetic strength was 16.3 ± 4.9 Nm (108% of contralateral side) and 18.8 ± 4.5 Nm (101%) at concentric 30 deg/s and eccentric 30 deg/s eversion tests, as well as 15.7 ± 5.2 Nm (102%) and 18.7 ± 3.3 Nm (103%) at concentric 30 deg/s and eccentric 30 deg/s inversion tests, respectively. There was no difference in ROM compared to the contralateral side (eversion/inversion 14.5-0-18.7 vs 14.1-0-16.1 degrees).

CONCLUSION

Peroneus longus to brevis transfer is a viable option for treating severe peroneus brevis tendon tears and does not compromise measurable strength or ROM in inversion or eversion in comparison to the contralateral ankle joint.

LEVEL OF EVIDENCE

Level IV, prospective case series.

Pediatric and Adolescent Figure Skating Injuries: A 15-Year Retrospective Review

OBJECTIVE

To analyze the characteristics of injuries sustained by young figure skaters who were evaluated at regional pediatric sports medicine clinics.

DESIGN

Retrospective chart review (2003-2017).

SETTING

Sports medicine clinics at a tertiary-level pediatric medical center.

PATIENTS

Two hundred ninety-four figure skaters (271 female and 23 male). Age rage: 9 to 19 years. Mean age: 14.2 ± 2.3 years.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Mechanism of injury (acute vs overuse), injured body areas, diagnoses for most commonly injured body areas, and distribution of bone stress injuries.

RESULTS

Eight hundred sixty-four figure skating-related injuries were identified. Approximately 68.9% were overuse and 31.1% were acute. In female figure skaters, the most frequently injured body areas were foot/ankle (29.6%), knee (19.3%), and back (15.8%). In male figure skaters, they were foot/ankle (25.4%), hip (16.4%), and knee (14.9%). Most common diagnoses at these body areas were tendinopathy (foot/ankle), extensor mechanism (knee), and posterior column bone stress injuries (back). All injuries to anterior knee structures, excluding bone contusions, were categorized as extensor mechanism injuries. About 11.8% of all injuries were bone stress reactions/fractures with the majority occurring at the back (42.2%), foot/ankle (32.4%), and lower leg (15.7%).

CONCLUSION

Most injuries sustained by figure skaters were overuse and occurred most commonly at the foot/ankle (29.6%), knee (19.3%), and back (15.8%). Approximately 1 in 10 injuries were bone stress reactions/fractures, and nearly 1 in every 3 skaters who presented with back pain was diagnosed with a posterior column bone stress injury. Health care providers who take care of young figure skaters need to maintain a high index of suspicion for overuse injuries, especially bone stress reactions/fractures.

Pathologies of the Peroneals: A Review

Peroneal tendon disorders remain an often overlooked source of lateral hindfoot pain and tenderness. Medical professionals who specialize in foot and ankle care are still far more likely to diagnose a peroneal tendon disorder as an ankle injury. In fact, acute peroneal dislocations are misdiagnosed in up to 40% of cases. The major subsets of peroneal disorders include peroneal tendonitis and tenosynovitis, painful os peroneum syndrome, subluxation, and tearing of the peroneal tendons. Proper history and physical exam maneuvers must be performed to help identify the source of the injury and differentiate these categories. Detailed imaging through X-ray and magnetic resonance imaging must also be used to diagnose the etiology of the patient's condition in order to direct management. Currently, there is very limited knowledge on peroneal pathologies, and treatment protocol is highly variable and limited to expert opinion. Despite the individual preferences and nuances held by each surgeon when it comes to operating, the overarching principles that guide appropriate management of tendonitis, subluxation, and tendon tear should maintain a higher level of consistency. Therefore, the authors of this review aim to elucidate the most current methods to diagnose these disorders as well as evidence-based practices for optimal management.Levels of Evidence: Level V.

Peroneal Tendinosis and Subluxation

Peroneal tendinosis and subluxation are lifestyle-limiting conditions that can worsen if not properly diagnosed and treated. Adequate knowledge of ankle anatomy and detailed history and comprehensive physical examination is essential for diagnosis. Peroneal tendinopathy is likely to result from overuse, whereas subluxation often precipitates from forceful contraction of peroneals during sudden dorsiflexion while landing or abruptly stopping. In athletes, conservative measures remain first-line treatment of tendinopathy, but surgery is often immediately indicated in cases of recurrent symptomatic subluxation or dislocation. Surgical technique varies on the type, mechanism, and severity of injury, but most procedures have a high success rate.

Prognostic factors in ankle sprains: a review

Ankle sprains are one of the most common musculoskeletal injuries, being the most frequent musculoskeletal trauma among athletes.

Most of these injuries are successfully treated conservatively; however, up to 70% of patients can develop long-lasting symptoms. Therefore, understanding prognostic factors for an ankle sprain could help clinicians identify patients with poor prognosis and choose the right treatment.

A suggested approach will be presented in order to positively identify the factors that should warrant a more aggressive attitude in the initial conservative treatment.

There are some prognostic factors linked to a better recovery and outcome; nevertheless, prognostic factors for full recovery after initial ankle sprain are not consistent.

Cite this article: EFORT Open Rev 2020;5:334-338. DOI: 10.1302/2058-5241.5.200019

Diagnosis and Operative Treatment of Peroneal Tendon Tears

Peroneal tendon tears are a common but under-recognized source of ankle pain and dysfunction. Recognition of the characteristic symptoms, physical findings, and imaging results of peroneal tendon tears is essential for accurate diagnosis and appropriate treatment. Acute, limited tears of a single peroneal tendon may be debrided and repaired. However, by the time operative treatment is undertaken, many tears of a single tendon are sufficiently advanced that the surgeon may need to consider excision of the nonviable segment and tenodesis of the damged tendon to the to the adjacent peroneal tendon. Irreparable tearing of both peroneal tendons may be treated with flexor tendon transfer and/or allograft reconstruction. This review article focuses on diagnosis and operative treatment of peroneal tendon tears, including the treatment algorithms, operative technique, and published outcomes.

Diagnosis and Operative Treatment of Peroneal Tendon Tears

Peroneal tendon tears are a common but under-recognized source of ankle pain and dysfunction. Recognition of the characteristic symptoms, physical findings, and imaging results of peroneal tendon tears is essential for accurate diagnosis and appropriate treatment. Acute, limited tears of a single peroneal tendon may be debrided and repaired. However, by the time operative treatment is undertaken, many tears of a single tendon are sufficiently advanced that the surgeon may need to consider excision of the nonviable segment and tenodesis of the damged tendon to the to the adjacent peroneal tendon. Irreparable tearing of both peroneal tendons may be treated with flexor tendon transfer and/or allograft reconstruction. This review article focuses on diagnosis and operative treatment of peroneal tendon tears, including the treatment algorithms, operative technique, and published outcomes.

Minimally invasive tenodesis for peroneus longus tendon rupture: A case report and review of literature

BACKGROUND

Peroneal tendon disorders are common causes of lateral hindfoot pain. However, total rupture of the peroneal longus tendon is rare. Surgical treatment for this condition is usually a side-to-side tenodesis of the peroneal longus tendon to the peroneal brevis tendon. While the traditional procedure involves a long lateral curved incision, this approach is associated with damage to the lateral soft tissues (up to 24% incidence).

CASE SUMMARY

A 50-year-old female had developed pain at the lateral aspect of the hindfoot 1 mo after an ankle sprain while walking in the street. Previous treatments were anti-inflammatory drugs, ice, rest and Cam-walker boot. At physical exam, there was pain and swelling over the course of the peroneal tendons. Ankle instability and cavovarus foot deformity were ruled out. Eversion strength was weak (4/5). Imaging showed complete rupture of the peroneal longus tendon associated with a sharp hypertrophic peroneal tubercle. Surgical repair was indicated after failure of conservative treatment (physiotherapy, rest, analgesics, and ankle stabilizer). A less invasive approach was performed for peroneal longus tendon debridement and side-to-side tenodesis to the adjacent peroneal brevis tendon, with successful clinical and functional outcomes.

CONCLUSION

Peroneus longus tendon tenodesis can be performed through a less invasive approach with preservation of the lateral soft tissue integrity.

Chronic Lower Leg Pain in Athletes: Overview of Presentation and Management

BACKGROUND

Athletes with chronic lower leg pain present a diagnostic challenge for clinicians due to the differential diagnoses that must be considered.

PURPOSE/QUESTIONS

We aimed to review the literature for studies on the diagnosis and management of chronic lower leg pain in athletes.

METHODS

A literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). The PubMed, Scopus, and Cochrane library databases were searched, and articles that examined chronic lower leg pain in athletes were considered for review. Two independent reviewers conducted the search utilizing pertinent Boolean operations.

RESULTS

Following two independent database searches, 275 articles were considered for initial review. After the inclusion and exclusion criteria were applied, 88 were included in the final review. These studies show that the most common causes of lower leg pain in athletes include medial tibial stress syndrome, chronic exertional compartment syndrome, tibial stress fractures, nerve entrapments, lower leg tendinopathies, and popliteal artery entrapment syndrome. Less frequently encountered causes include saphenous nerve entrapment and tendinopathy of the popliteus. Conservative management is the mainstay of care for the majority of cases of chronic lower leg pain; however, surgical intervention may be necessary.

CONCLUSIONS

Multiple conditions may result in lower leg pain in athletes. A focused clinical history and physical examination supplemented with appropriate imaging studies can guide clinicians in diagnosis and management. We provide a table to aid in the differential diagnosis of chronic leg pain in the athlete.

Peroneal Tendon Pathology: Treatment and Reconstruction of Peroneal Tears and Instability

Peroneal tendon pathology is becoming an increasingly recognized source of lateral-sided ankle pain. High clinical suspicion, along with judicious physical examination coupled with confirmatory advanced imaging modalities, are necessary to make an accurate diagnosis and aid in guiding treatment. Peroneal pathology encompasses several distinct conditions. Peroneal tendon tears and injuries to the peroneal retinaculum must be identified to guide treatment. Patients with peroneal pathology report high levels of satisfaction after surgical management with most returning to their preinjury level of function. An early and accurate diagnosis, along with treatment tailored to the individual, is necessary to obtain optimal outcomes.

The peroneus longus muscle and tendon: a review of its anatomy and pathology

This article will review the anatomy and common pathologies affecting the peroneus longus muscle and tendon. The anatomy of the peroneus longus is complex and its long course can result in symptomatology referable to the lower leg, ankle, hindfoot, and plantar foot. Proximally, the peroneus longus muscle lies within the lateral compartment of the lower leg with its distal myotendinous junction arising just above the level of the ankle. The distal peroneus longus tendon has a long course and makes two sharp turns at the lateral ankle and hindfoot before inserting at the medial plantar foot. A spectrum of pathology can occur in these regions. At the lower leg, peroneus longus muscle injuries (e.g., denervation) along with retromalleolar tendon instability/subluxation will be discussed. More distally, along the lateral calcaneus and cuboid tunnel, peroneus longus tendinosis and tears, tenosynovitis, and painful os peroneum syndrome (POPS) will be covered. Pathology of the peroneus longus will be illustrated using clinical case examples along its entire length; these will help the radiologist understand and interpret common peroneus longus disorders.

Clinical Outcomes and Complications of Peroneal Tendon Sheath Ultrasound-Guided Corticosteroid Injection

BACKGROUND

The treatment of symptomatic peroneal tendinopathy and tears traditionally begins with nonsteroidal anti-inflammatory drugs, activity modification, physical therapy, and immobilization, with surgery typically reserved for those failing nonoperative treatment. Ultrasound-(US)-guided peroneal tendon sheath (PTS) corticosteroid injection is an additional nonoperative modality, but limited data exist on its safety and efficacy. The purpose of this study was to assess clinical outcomes following US-guided PTS corticosteroid injection for chronic tendinopathy or tears.

METHODS

We retrospectively identified patients who had undergone US-guided PTS corticosteroid injection for pain due to peroneal tendinopathy, tears, or subluxation at our institution from 2012 to 2018. Underlying diagnosis was based on clinical examination, magnetic resonance imaging (MRI) results, and/or intraoperative findings, when available. Medical record data were supplemented by e-mail or telephone follow-up. Collected information included patient age, sex, body mass index (BMI), smoking status, workers' compensation status, prior surgeries about the foot and ankle, duration of symptoms prior to injection, perceived improvement in pain following injection and its duration, number of injections, progression to surgery, and any adverse outcomes of injection. We identified 96 patients (109 injections). Thirty-seven (38.5%) had previous foot and ankle surgery, with 17 (17.7%) having surgery specifically on the peroneal tendons.

RESULTS

Twenty-four of 96 (25%) progressed to have surgery on their peroneal tendons following injection. Following injection, 38/87 (43.7%) of patients reported 0-1 weeks of pain relief, 11/87 (12.6%) 2-6 weeks, 6/87 (6.9%) 7-12 weeks, and 32/87 (36.8%) greater than 12 weeks. Preinjection duration of symptoms was associated with postinjection duration of pain relief (P=.036). There were 2 reported complications (1.8%): 1 case of self-limited sural nerve irritation and 1 of peroneus longus tear progression.

CONCLUSION

Our study demonstrates US-guided PTS corticosteroid injection was safe and relatively effective in patients with symptomatic peroneal tendon tears or tendinopathy, including those who had undergone prior surgery, and may be considered in a comprehensive protocol of nonoperative management.

LEVEL OF EVIDENCE

Level IV, case series.

Anatomical variation in the ankle and foot: from incidental finding to inductor of pathology. Part II: midfooot and forefoot

Accessory anatomical structures in the ankle and foot usually represent incidental imaging findings; however, they may also eventually represent a source of pathology, such as painful syndromes, degenerative changes, be the subject of overuse and trauma, or appear as masses and cause compression syndromes or impingement. This review aims to describe and illustrate the imaging findings related to the presence of accessory ossicles and muscles in the midfoot and forefoot through different techniques, with special attention on those variants that associate factors of clinical relevance or that would trigger challenges in the differential diagnosis.

Reconstruction of the Peroneus Brevis Tendon Tears with Semitendinosus Tendon Autograft

Peroneal tendon disorders are common causes of lateral and retromalleolar ankle pain. For irreparable tears of the tendon, a salvage procedure is indicated with segmental resection followed by reconstruction with tenodesis, tendon transfer, or bridging the defect using allograft or autograft. Although there is insufficient evidence to guide which of these treatment options provides the best outcomes, reconstruction with tendon allograft has provided satisfactory clinical results and is effective for pain relief and restoration of tendon function. However, there are concerns about the use of tendon allografts which include its cost and availability, disease transmission, delayed incorporation, and stretching of the graft. The aim of this study is to present the surgical technique for the reconstruction of the peroneus brevis tendon tears using semitendinosus tendon autograft as an alternative to the allograft and report the short-term results of three cases.

[Injuries of the peroneal tendons : Often overlooked]

CLINICAL ISSUE

Injuries of the peroneal tendons are rare and often overlooked. Typical pathologies are tendinitis, tears and dislocation. Accompanying injuries are fractures. They are often associated with instability in the ankle and rearfoot deformities; therefore, these pathologies should be excluded or taken into consideration in the treatment. The clinical examination is crucial for the diagnosis.

DIAGNOSTIC WORK-UP

Ultrasound and magnetic resonance imaging (MRI) examinations are very helpful; however, the true extent of the tendon pathology is often first seen during surgery. Bony injuries and deformities are assessed radiographically and by computed tomography (CT).

PERFORMANCE

Although conservative treatment is generally used at the beginning of therapy, progression is more likely to occur in the case of tears; therefore, the correct timing for an operative therapy should not be missed. Dislocations are the domain of operative therapy. Acute tendinitis, on the other hand, is usually accessible to conservative therapy if it is not the result of a gross deformity.

ACHIEVEMENTS

Rehabilitation after operative treatment is demanding and prolonged especially after operative therapy of peroneal tendon tears. The results to be expected appear promising.

Unusual proximal fragment migration of an os peroneum fracture with associated peroneus longus tendon injury-a tree often hides a forest

We report the case of a 55-year-old male patient who presented to the emergency department after sustaining a right ankle trauma. Swelling and tenderness of the lateral aspect of the right ankle were present on physical examination without evidence of motor or sensory deficit. Ankle radiographs were performed and showed two bony fragments, the first located postero-inferiorly to the cuboid bone while the second was adjacent to the tip of the lateral malleolus. The diagnosis of an os peroneum fracture was made with high suspicion of an associated peroneus longus tendon rupture. Computed tomography (CT) and magnetic resonance imaging (MRI) of the right ankle confirmed the diagnosis of a subtotal retracted tendinous rupture. Successful surgical repair of the injured tendon was performed. This article illustrates the imaging findings of an os peroneum fracture with its associated tendinous injury and reviews the literature.

Ultrasound Intervention of the Lower Extremity/Pelvis

Musculoskeletal (MSK) conditions are growing in prevalence. Ultrasound (US) is increasingly used for managing MSK conditions due to its low cost and ability to provide real-time image guidance during therapeutic interventions. As MSK US becomes more widespread, familiarity and comfort with US-guided interventions will become increasingly important. This article focuses on general concepts regarding therapeutic US-guided injections of corticosteroids and platelet-rich plasma and highlights several of the US-guided procedures commonly performed, involving the pelvis and lower extremity.

Biomechanical Cadaveric Evaluation of Partial Acute Peroneal Tendon Tears

BACKGROUND

No clear guideline or solid evidence exists for peroneal tendon tears to determine when to repair, resect, or perform a tenodesis on the damaged tendon. The objective of this study was to analyze the mechanical behavior of cadaveric peroneal tendons artificially damaged and tested in a cyclic and failure mode. The hypothesis was that no failure would be observed in the cyclic phase.

METHODS

Eight cadaveric long leg specimens were tested on a specially designed frame. A longitudinal full thickness tendon defect was created, 3 cm in length, behind the tip of the fibula, compromising 66% of the visible width of the peroneal tendons. Cyclic testing was initially performed between 50 and 200 N, followed by a load-to-failure test. Tendon elongation and load to rupture were measured.

RESULTS

No tendon failed or lengthened during cyclic testing. The mean load to failure for peroneus brevis was 416 N (95% confidence interval, 351-481 N) and for the peroneus longus was 723 N (95% confidence interval, 578-868 N). All failures were at the level of the defect created.

CONCLUSION

In a cadaveric model of peroneal tendon tears, 33% of remaining peroneal tendon could resist high tensile forces, above the physiologic threshold.

CLINICAL RELEVANCE

Some peroneal tendon tears can be treated conservatively without risking spontaneous ruptures. When surgically treating a symptomatic peroneal tendon tear, increased efforts may be undertaken to repair tears previously considered irreparable.

Electromyography comparison of the effects of various footwear in the activity patterns of the peroneus longus and brevis muscles

BACKGROUND

Peroneus longus and brevis (PLB) disorders are commonly in people with lateral ligamentous instability, ankle pain, lateral hindfoot pain and structures of the proximal compartment of the lower legs and their muscle activity is believed to be influenced by different footwear types. The proposal of this research is to evaluate the effects of five types of footwear with respect to the barefoot condition and analyze the activity patterns of PLB muscles in healthy subjects during the gait cycle.

METHODS

Thirty healthy subjects were recruited in a laboratory in this cross-sectional research design. While walking, electromyography (EMG) activity was measured from PLB via surface electrodes in six experimental conditions: 1) barefoot, 2) minimalist, 3) pronated control, 4) air chamber, 5) ethyl-vinyl-acetate (EVA) and 6) boost. These data were obtained and compared.

RESULTS

The peroneus brevis showed significant reductions in the peak amplitude of the five footwear types (minimalist, pronation control, air chamber, EVA and boost) with respect to the barefoot condition in the propulsion phase of the gait cycle during walking (P = 0.034; P < 0.001; P < 0.001; P < 0.001; P = 0.006) and running (P = 0.004; P < 0.001; P = 0.001; P < 0.001; P = 0.001), respectively. Furthermore, peroneus longus showed significant reductions in the peak amplitude of these five footwear types with respect to the barefoot condition in the propulsion phase of the gait cycle during running (P = 0.005; P = 0.038; P = 0.019; P = 0.025; P = 0.021).

CONCLUSION

The EMG activity patterns of the PLB muscles may depend on the use of different types of sport shoes such as minimalist, pronation control, air chamber, EVA and boost footwear with respect the barefoot condition in different phases of the gait cycle during walking and running.

Acute Peroneal Injury

A high clinical suspicion and greater understanding of the anatomy and pathophysiology of lateral ankle injuries have enabled early diagnosis and treatment-improving outcomes of acute peroneal tendon tears. Multiple conditions can be the cause of lateral ankle pain attributed to the peroneal tendons: tenosynovitis, tendinosis, subluxation and dislocation, stenosing tenosynovitis, abnormality related to the os peroneum, as well as tears of the peroneal tendons. It is imperative for the clinician to maintain a high suspicion for peroneal tendon abnormality when evaluating patients with lateral ankle pain.

Tendonitis and Tendinopathy: What Are They and How Do They Evolve?

The development of tendinitis and tendinopathy is often multifactorial and the result of both intrinsic and extrinsic factors. Intrinsic factors include anatomic factors, age-related factors, and systemic factors, whereas extrinsic factors include mechanical overload and improper form and equipment. Although tendinitis and tendinopathy are often incorrectly used interchangeably, they are in 2 distinct pathologies. Due to their chronicity and high prevalence in tendons about the ankle, including the Achilles tendon, the posterior tibialis tendon, and the peroneal tendons, tendinitis and tendinopathies cause significant morbidity and are important pathologies for physicians to recognize.

Presentation, Diagnosis, and Nonsurgical Treatment Options of the Anterior Tibial Tendon, Posterior Tibial Tendon, Peroneals, and Achilles

Disorders of the anterior tibial tendon (ATT) are rare, and relatively few series have been described in the literature. Ruptures of the ATT are more common than tendinopathies of the ATT. For those patients with a tendinopathy, initial treatment may include activity and shoe-wear modifications.

CT and MR Imaging of the Postoperative Ankle and Foot

A variety of surgical procedures exist for repair of both traumatic and degenerative osseous and soft-tissue pathologic conditions involving the foot and ankle. It is necessary for the radiologist to be familiar with these surgical procedures, so as to assess structural integrity, evaluate for complicating features, and avoid diagnostic pitfalls. Adequate interpretation of postoperative changes often requires access to surgical documentation to evaluate not only the surgery itself but the expected timeline for resolution of normal postoperative changes versus progressive disease. Appropriate use of surgical language in radiology reports is another important skill set to hone and is instrumental in providing a high-quality report to the referring surgeons. The pathophysiology of a myriad of surgical complaints, beginning from the Achilles tendon and concluding at the plantar plate, are presented, as are their common appearances at computed tomography and magnetic resonance imaging. Commonly encountered entities include Achilles tendon tear, spastic equinus, nonspastic equinus, talar dome osteochondral defect, tarsal tunnel syndrome, plantar fasciitis, pes planovalgus, pes cavovarus, peroneal tendinosis, lateral ligament complex pathology, Morton neuroma, plantar plate tear, and metatarsophalangeal joint instability. Computer-generated three-dimensional models are included with many of the procedures to provide a more global view of the surgical anatomy. Correlation with intraoperative photographs is made when available. When appropriate, discussion of postoperative complications, including entities such as infection and failure of graft integration, is presented, although a comprehensive review of postoperative complications is beyond the scope of this article. Notably absent from the current review are some common foot and ankle procedures including hallux valgus and hammertoe corrections, as these are more often evaluated radiographically than with cross-sectional imaging. ^©RSNA, 2016.

Proximal peroneus longus tear: rare case in a teenage athlete and review of the literature

We present the case of a 15-year-old teenager who sustained an ankle inversion injury while playing American football, which yielded only minimal pain, but also foot numbness and a lateral leg bulge. Magnetic resonance imaging evaluation revealed a proximal peroneal tear. These rare injuries are often associated with compartment syndrome, a surgical emergency, which was ultimately excluded clinically in this patient. Relevant anatomy, mechanism of injury, and clinical manifestations are discussed.

T2* Mapping of Peroneal Tendons Using Clinically Relevant Subregions in an Asymptomatic Population

BACKGROUND

Peroneal tendon evaluation is particularly demanding using current magnetic resonance imaging (MRI) techniques because of their curving path around the lateral malleolus. Quantifiable, objective data on the health of the peroneal tendons could be useful for improving diagnosis of tendon pathology and tracking post-treatment responses. The purpose of this study was to establish a method and normative T2-star (T2*) values for the peroneal tendons in a screened asymptomatic cohort using clinically reproducible subregions, providing a baseline for comparison with peroneal tendon pathology.

METHODS

Unilateral ankle scans were acquired for 26 asymptomatic volunteers with a 3-Tesla MRI system using a T2* mapping sequence in the axial and sagittal planes. The peroneus brevis and peroneus longus tendons were manually segmented and subregions were isolated in the proximity of the lateral malleolus. Summary statistics for T2* values were calculated.

RESULTS

The peroneus brevis tendon exhibited a mean T2* value of 12 ms and the peroneus longus tendon was 11 ms. Subregions distal to the lateral malleolus had significantly higher T2* values ( P < .05) than the subregions proximal in both tendons, in both the axial and sagittal planes.

CONCLUSION

Peroneal tendon regions distal to the inferior tip of the lateral malleolus had significantly higher T2* values than those regions proximal, which could be related to anatomical differences along the tendon.

CLINICAL RELEVANCE

This study provides a quantitative method and normative baseline T2* mapping values for comparison with symptomatic clinically compromised peroneal tendon patients.

Peroneal tendon pathology: Pre- and post-operative high resolution US and MR imaging

Peroneal tendon pathology is an important cause of lateral ankle pain and instability. Typical peroneal tendon disorders include tendinitis, tenosynovitis, partial and full thickness tendon tears, peroneal retinacular injuries, and tendon subluxations and dislocations. Surgery is usually indicated when conservative treatment fails. Familiarity with the peroneal tendon surgeries and expected postoperative imaging findings is essential for accurate assessment and to avoid diagnostic pitfalls. Cross-sectional imaging, especially ultrasound and MRI provide accurate pre-operative and post-operative evaluation of the peroneal tendon pathology. In this review article, the normal anatomy, clinical presentation, imaging features, pitfalls and commonly performed surgical treatments for peroneal tendon abnormalities will be reviewed. The role of dynamic ultrasound and kinematic MRI for the evaluation of peroneal tendons will be discussed. Normal and abnormal postsurgical imaging appearances will be illustrated.

Os peroneum imaging: normal appearance and pathological findings

The os peroneum (OP) is a small sesamoid bone located inside the peroneus longus tendon (PLT), close to the cuboid. The OP can be the cause of pain and can be associated with lesions of the PLT. OP involvement in PLT disorders is frequently misdiagnosed by radiologists. Painful os peroneum syndrome (POPS) refers to a variety of conditions presenting with pain localized on the lateral aspect of the cuboid area. The syndrome can be observed as a consequence of local acute trauma such as ankle sprains or chronic overuse. Because of its intra-tendinous location, in tears of the peroneus longus tendon, the OP can show changes in its morphology or position, depending on the location of the tendon’s tear. Based on the level of the PLT tears, we propose a classification in three subtypes: tears localized proximal to the os peroneum (type I), at its level (type II) or distal to it (type III). These tears present with different changes on OP morphology or location. The aim of this article is to review the normal anatomy, imaging appearance and differential diagnosis of disorders of the OP as well as post-treatment imaging.

Teaching points

• PLT tears can be classified in three subtypes according to OP location.

• POPS is characterized by pain on the lateral aspect of the cuboid.

• OP involvement in PLT disorders is frequently misdiagnosed by radiologists.

Management of sports injuries of the foot and ankle

Sporting injuries around the ankle vary from simple sprains that will resolve spontaneously within a few days to severe injuries which may never fully recover and may threaten the career of a professional athlete. Some of these injuries can be easily overlooked altogether or misdiagnosed with potentially devastating effects on future performance. In this review article, we cover some of the common and important sporting injuries involving the ankle including updates on their management and outcomes.

Cite this article: Bone Joint J 2016;98-B:874–83.