Recurrent hypertrophic peroneal tubercle associated with peroneus brevis tendon tear

Ultrasound measurements of the normal peroneal tubercle: validation of the normal anatomical measurements and evaluation of the intra- and interobserver reliability

Purpose

The aim of this study was to investigate if ultrasound could be a reliable and accurate tool to measure the size of the peroneal tubercle.

Material and methods

This study measured the width, length, and height of the peroneal tubercle in 100 asymptomatic patients, comparing the measurements to prior radiographs of the foot (if available) and previously reported anatomical data. This study also assessed the intra- and interrater reliability of ultrasound as a measurement tool.

Results

Our findings show that ultrasound measurements of the peroneal tubercle were consistent with values reported in the literature and prior radiographs concerning width. Both intra- and inter-observer measurements were reliable.

Conclusions

This study highlights the potential of ultrasound imaging as a promising tool to measure the peroneal tubercle, and it could contribute to a better understanding of peroneal tendon disorders.

Peroneus brevis tear caused by an impingement between hypertrophied peroneal tubercle and lateral malleolus

We report a 15-year-old female patient who sustained peroneus brevis injury caused by an impingement between the hypertrophied peroneal tubercle and lateral malleolus. The patient had pain for 3 years in the lateral side of her left ankle with unsuccessful conservative treatment. The oblique sagittal images of 3-dimensional magnetic resonance imaging and ultrasonography were useful in depicting the peroneus brevis injury and identifying the location of impingement between the hypertrophied peroneal tubercle and the tip of the lateral malleolus. The flatfoot deformity of the patient further aggravated the impingement. The patient was treated surgically, with excision of the enlarged tubercle and tendon repair. The ankle pain resolved 12 months postoperatively. Although rare, clinicians should recognize this condition as the cause of lateral ankle pain.

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.

CT scan assessment of the dimensions and morphological variations of the peroneal tubercle

PURPOSE

The hypertrophied peroneal tubercle may result in lateral ankle pain with peroneal tendon tenosynovitis and rupture. The aim of this study was to evaluate different configurations and dimensions of the normal peroneal tubercle using two-dimensional CT scan.

METHODS

Totally, 100 normal CT scans of cases older than 18 years of age were assessed to determine the shape of the peroneal tubercle. Moreover, height, length and width of different configurations of the normal peroneal tubercle were measured in axial and coronal sections of the ankle CT scans.

RESULTS

Four different configurations based on the axial cut of the calcaneus were found; single-convex (59%), double-convex (24%), plateau (9%), and convex-concave (8%) without statistically significant difference between genders (p-value: 0.526). Totally, mean of height, length and width were 4.42 ± 1.38 mm, 28.88 ± 6.58 mm and 17.17 ± 3.85 mm, respectively. Although mean of the height in the single-convex and the double-convex types were 4.5 ± 1.4 mm and 5.0 ± 1.4 mm, respectively, the highest peroneal tubercle in the single-convex and the double-convex group were 10.2 mm and 8.5 mm, respectively.

CONCLUSIONS

In cases with lateral ankle pain and suspicious to hypertrophied peroneal tubercle, two-dimensional CT scan can be an available practical modality to identify the pathological type of the peroneal tubercle based on the presented classification and normal values. As previously reported in the literature, considering cut-off point of 5 mm could result in overdiagnosis of the hypertrophied peroneal tubercle, especially in single-convex type; however, clinical correlation is always paramount.

LEVEL OF EVIDENCE

Level IV.

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.

Distal Peroneus Longus Dislocation and Pseudohypertrophy of the Peroneal Tubercle: A Systematic Review

Peroneal tendon injuries at the peroneal tubercle are rare. No systematic research regarding this pathology is currently available. In this systematic literature review, the author evaluated the present knowledge about peroneal tendon lesions at the lateral calcaneal wall. These lesions are predominantly associated with peroneal tubercle enlargement. Information on 25 respective patients (26 cases) has been published in 14 articles. Until now, only 3 reports presented 5 patients with dislocation of the peroneus longus tendon combined with inferior peroneal retinaculum lesions. In these cases, the peroneal tubercle was not enlarged. All reviewed patients were treated surgically. Enlarged peroneal tubercles were resected. Groove deepening and inferior peroneal retinaculum reconstruction addressed distal peroneus longus tendon dislocations. The reported results were either excellent or good. Recurrent dislocations can cause lesions of the peroneus longus tendon at the peroneal tubercle. This pathology is rare and can be addressed surgically. In cases without tendon dislocation, the enlarged peroneal tubercles are removed or shaped, whereas dislocations in normal shaped peroneal tubercles require groove deepening and inferior peroneal retinaculum reconstruction.

Heterotopic Ossification of the Peroneus Brevis Tendon in a Pediatric Patient

Heterotopic ossification (HO) is abnormal formation of mature lamellar bone in soft tissues. HO is most commonly diagnosed in the setting of localized trauma, which results in improper differentiation of progenitor cells, leading to aberrant tissue formation. In the pediatric population, nongenetic causes of HO have rarely been reported, especially HO involving the tendons of the ankle. We present a case of HO of the peroneus brevis tendon without systemic disease in a pediatric patient. The patient was a 7-year-old female with a normal birth and developmental history who first presented 6 weeks after a right ankle sprain with pain localized to the lateral calcaneus. Prominent swelling and tenderness to palpation were noted over the peroneal tubercle. Radiographic imaging showed dystrophic calcification within the peroneus brevis tendon. After failed conservative management, the heterotopic ossified mass (1.5 × 0.3 cm) was excised from the peroneus brevis tendon. The tendon was primarily repaired. The patient was followed up for 12 weeks postoperatively and achieved full resolution of her pain with a return to normal activity. HO has been theorized to be the result of an imbalance between bone mineralization and demineralization. In the setting of localized trauma, inductive agents have been implicated in pathologic bone formation. In the pediatric population, HO has rarely been diagnosed in the absence of genetic causes. In patients presenting with lateral foot and ankle pain, HO of the peroneal tendons should be considered in the differential diagnosis. In a patient with pain secondary to HO, surgical excision of the heterotopic mass can achieve symptom resolution.

Imaging Features of Symptomatic Hypertrophic Tuberculum Peroneum

Objective:

The aim of this article is to review the clinical and imaging features of symptomatic hypertrophic (TP) in a cohort of symptomatic patients.

Materials and Methods:

Twenty-three patients with chronic lateral ankle pain were retrospectively included in our study group. Patients underwent ultrasound (US), (cone beam) computed tomography (CB)CT or magnetic resonance (MR) examination or a combination of these examinations with a standardized protocol. Patients with an underlying fracture were excluded. The following parameters were recorded: clinical history, size of the TP on different imaging modalities, presence and grade of peroneus brevis/longus tenosynovitis and the presence of bone marrow edema at the os calcaneus on magnetic resonance imaging (MRI).

Results:

The mean width of the hypertrophic TP was 5.6 mm. Combined tenosynovitis of the peroneus longus (PL) and brevis tendon (PB) was most common, followed by isolated PL and finally PB tenosynovitis. Grade 1 tenosynovitis was most common. BME was present in 53% of the cases.

Conclusion:

The width of the TP is may be evaluated on the (oblique) coronal US, (CB)CT or non-fat suppressed MR images. Both US and MRI may detect and grade involvement of the peroneal tendons. By the use of fluid sensitive sequences, MRI may be of additional value to detect bone marrow edema as result of repetitive friction.

Endoscopic Resection of Peroneal Tubercle

Symptomatic hypertrophy of the peroneal tubercle can result in pain, clicking sensation, and limitation of ambulation. Surgical resection is indicated for symptomatic hypertrophied tubercle that is recalcitrant to conservative treatment. The purpose of this Technical Note is to report the details of tendoscopic resection of the hypertrophied peroneal tubercle. This is performed through zone 2 peroneus longus tendoscopy. Any associated hindfoot deformity and peroneal tendon pathology should also be addressed.

Rehabilitation after surgical treatment of peroneal tendon tears and ruptures

PURPOSE

The purpose of this study was to provide an overview of the available evidence on rehabilitation programmes after operatively treated patients with peroneal tendon tearsand ruptures.

METHODS

A systematic review was performed, and PubMed and EMBASE were searched for relevant studies. Information regarding the rehabilitation programme after surgical management of peroneal tendon tears and ruptures was extracted from all included studies.

RESULTS

In total, 49 studies were included. No studies were found with the primary purpose to report on rehabilitation of surgically treated peroneal tendon tears or ruptures. The median duration of the total immobilization period after primary repair was 6.0 weeks (range 0-12), 7.0 weeks (range 3.0-13) after tenodesis, 6.3 weeks (range 3.0-13) after grafting, and 8.0 weeks (range 6.0-11) after end-to-end suturing. Forty one percent of the studies that reported on the start of range of motion exercises initiated range of motion within 4 weeks after surgery. No difference was found in duration of immobilization or start of range of motion between different types of surgical treatment options.

CONCLUSION

Appropriate directed rehabilitation appears to be an important factor in the clinical success of surgically treated peroneal tendon tears and ruptures. There seems to be a trend towards shorter immobilization time and early range of motion, although there is no consensus in the literature on best practice recommendations for optimizing rehabilitation after surgical repair of peroneal tendon tears or ruptures. It is important to adjust the rehabilitation protocol to every specific patient for an optimal rehabilitation.

LEVEL OF EVIDENCE

Systematic Review, Level IV.

Complete encasement of the peroneal tendons by the peroneal tubercle

The peroneal tubercle is an osseous structure on the lateral side of the calcaneus present in 90% of individuals. Hypertrophy of the peroneal tubercle resulting in stenosing peroneal tenosynovitis has been well described in the literature. Repair of this condition involves operative treatment to remove the hypertrophied peroneal tubercle and repair any resulting tendon pathology. The authors report a unique case of a hypertrophied peroneal tubercle with an associated tarsal coalition, resulting in complete bony encasement of the peroneal tendons. In this case, a 50-year-old white man presented with worsening bilateral foot and ankle pain for several years. On examination, he had fixed hindfoot varus and bilateral equinocavovarus feet. Magnetic resonance imaging and weight-bearing radiographs showed a calcaneonavicular coalition. Intraoperatively, the authors discovered complete bony encasement of the peroneal longus and brevis tendons. On examination, the peroneal longus and brevis were severely stenotic, with the peroneal brevis to the point of near laceration. This painful condition was repaired by takedown of the calcaneonavicular coalition, the peroneal tubercle was resected, and the peroneal tendons were freed from their bony encasement. Tenodesis of the peroneus brevis to longus was performed and the hindfoot varus was corrected with wedge osteotomy of the calcaneus. The patient reported excellent postoperative results. At 3 months postoperatively, he was pain-free and his calcaneal osteotomy was well healed. This case appears to be the first of its type to be reported in the literature. The details of the case are presented along with a review of the relevant literature.

Peroneal tendon abnormalities in subjects with an enlarged peroneal tubercle

OBJECTIVE

To examine the association between inframalleolar peroneal tendon abnormalities and an enlarged peroneal tubercle.

MATERIALS AND METHODS

Two independent readers evaluated consecutive ankle MR imaging studies to classify inframalleolar peroneal tendon findings as normal, tenosynovitis, partial tear or complete tear. The size and morphology of the peroneal tubercle was also recorded. We performed statistical analyses for inter-observer agreement and to assess differences in peroneal tubercle size between groups with and without peroneal tendon abnormalities.

RESULTS

The study group comprised 121 subjects (mean age, 45.5 years) of whom 28% (34 out of 121) had lateral ankle symptoms. The peroneal tubercle was absent in 56% of subjects (68 out of 121). In subjects with a peroneal tubercle (>0 mm), the mean size was 3.5 mm (37% triangular and 7% plateau-shaped). Male subjects had significantly larger mean peroneal tubercle size than female subjects (2.1 ± 2.5 vs 1.2 ± 1.9 mm, P = 0.04). Overall, 26% (32 out of 121) of subjects had some peroneal tendon abnormality: 17% (20 out of 121) had tenosynovitis and 17 % (20 out of 121) had partial thickness tears. The peroneal tubercle size was significantly larger in subjects with peroneal tendon partial tears (P = 0.036), tenosynovitis (P < 0.001), and when both abnormalities were present (P = 0.007). ROC statistic showed 73% sensitivity and 74% specificity for detection of partial tears for peroneal tubercle size ≥4.3 mm.

CONCLUSION

Our study shows a significantly larger peroneal tubercle in subjects with inframalleolar peroneal tendon abnormalities. A cut-off of 4.3 mm showed good sensitivity and specificity for the presence of partial tears of the peroneal tendon.

Endoscopic resection of the peroneal tubercle

Hypertrophy of the peroneal tubercle can be a source of discomfort when wearing shoes. Occasionally, it can cause tenosynovitis or a tear of the peroneal tendons. The symptoms can be successfully treated by complete resection of the tubercle, tenosynovectomy, and early range of motion exercises of the hindfoot joints. Traditionally, this is an open procedure. We report the technique of endoscopic resection of the peroneal tubercle.

Prevalence of painful peroneal tubercles in the pediatric population

Pain isolated to the lateral aspect of the heel can be difficult to diagnose, particularly in the growing child. Peroneal tendinopathy or frank tears of the peroneal tendons secondary to an enlarged peroneal tubercle has been implicated as a potential source of pain in adults. Neither the prevalence of enlarged peroneal tubercles in the pediatric population nor the number of symptomatic tubercles in children has been elucidated. We conducted a review of children who presented to our institution with foot and/or ankle pain and who underwent 3-dimensional computed tomography. Initially, a radiographic review was undertaken of all computed tomography scans to determine the prevalence of peroneal tubercles in children. The peroneal tubercles were measured and then classified according to height. The children with tubercles 3 mm or greater in height (adult mean height) underwent a more detailed chart review to evaluate for the incidence of painful tubercles. During the study period, 2,689 children were seen for foot and ankle pain, and 367 underwent a computed tomography scan during their treatment course. Of these 367 patients, 57% had a measurable peroneal tubercle, and 162 (44%) met the criteria for chart review. Only 3 adolescents (1.9%) were found to have clinical symptoms and ultimately underwent surgical excision with successful relief of symptoms. Peroneal tubercle hypertrophy appears to exist in the pediatric population; however, in contrast to adults with associated peroneal tendinopathy and tears, the children in our series had isolated painful tubercles without significant tendinopathy. The clinical examination is important in the diagnosis, and treatment by excision appears to be successful. Although a relatively rare etiology of pain, it is important that treating physicians keep this pathologic process in the differential diagnosis, because conservative management might not reduce the pain in these children.

Painful prominences of the heel

Heel pain is a common malady, with reported prevalence ranging from 4% to 21%. Referral to foot and ankle specialists for heel pain is also common, but patient awareness of the cause of heel pain may be limited. Many misconceptions about how heel exostoses relate to heel pain exist in the medical community and the general patient population, with many patients referred for or presenting with the simple complaint ''I have a heel spur.'' This article reviews the common exostoses of the heel, including plantar, lateral, and posterior spurs, with specific attention to the cause and treatments.

Stenosing tenosynovitis of the peroneus brevis tendon associated with hypertrophy of the peroneal tubercle

Stenosing peroneal tenosynovitis is not an uncommon ailment. It has a number of different causes, one of which is hypertrophy of the peroneal tubercle. In this report, we present a case of stenosing tenosynovitis of the peroneus brevis tendon associated with hypertrophy of the peroneal tubercle without involvement of the peroneus longus tendon. The condition was fully resolved by means of operative treatment.