Peroneal tendon subluxation: the other lateral ankle injury

Intrasheath Peroneal Tendon Subluxation: A Report of Three Cases with Technical Note

Peroneal intrasheath instability is a painful popping sensation and audible clicking of the lateral ankle. This condition is not commonly reported, and its exact incidence remains unknown. It consists of a transient retromalleolar subluxation of the peroneal tendons, with an abnormal motion of the peroneal tendons relative to each other, with the superior peroneal retinaculum intact. Diagnosis requires high clinical suspicion and dynamic ultrasound is the best imaging study to evaluate peroneal instability when the superior peroneal retinaculum is intact, for diagnosing peroneal intrasheath instability. The goal of the present study is to describe how to reach the diagnosis and to describe and evaluate the surgical technique for the treatment of this pathology. In the present report, we describe three cases of this pathology that received successful surgical treatment with peroneal groove-deepening procedure and retinaculoplasty of the superior retinaculum. This surgical technique provides good outcomes when conservative treatment fails.

Fibular morphology is not associated with incidence of peroneal tendon dislocation

PURPOSE

The association of peroneal tendon dislocation with peroneal bone morphology and postoperative redislocation rates remains unknown. This study compared the fibula morphology in patients with peroneal tendon dislocation with that in a control population.

METHODS

The study enrolled 48 patients who underwent surgery for peroneal tendon dislocation at our institution during between 2018 and 2023. Thirty-five patients with preoperative magnetic resonance imaging of the ankle were defined as Group D and 35 with magnetic resonance imaging of the ankle for other reasons and with similar background data were selected as the control group (Group C). The posterior tilting angle of the fibula, posterolateral angle and posterolateral edge angle were evaluated at the plafond level. The posterior tilting angle, posterolateral angle and retromalleolar bone shape according to the Rosenberg classification (flat, convex, concave) were evaluated at the midpoint between the plafond and the tip.

RESULTS

At the plafond level, the posterior tilting, posterolateral and posterolateral edge angles were 57.7 ± 11.1°, 123.8 ± 12.3° and 90.8 ± 13.7°, respectively, in Group D and 64.1 ± 15.4°, 121.1 ± 12.3° and 88.7 ± 12.2°, respectively, in Group C, with no significant differences. No significant between-group differences existed in the posterior tilting and posterolateral angles at the midpoint level. Moreover, no significant differences existed in distribution of the bone geometry according to the Rosenberg classification.

CONCLUSION

There were no differences in morphology between patients with peroneal tendon dislocation and controls. This study provides useful information on the indications for primary surgery and whether bony approach is useful for peroneal tendon dislocation.

LEVEL OF EVIDENCE

Level IV.

Comparison of Clinical Efficacy between Arthroscopic and Open Surgery for Ogden Type 1-2 Peroneal Tendon Dislocation

OBJECTIVE

While the incidence of peroneal tendon dislocation (PTD) is relatively low, it is frequently underdiagnosed in clinical practice, and the misdiagnosis or improper treatment of this condition may lead to a decline in patients' quality of life. Currently, the surgical treatment options for PTD mainly include open and arthroscopic surgery. However, in order to evaluate the advantages and disadvantages of these two surgical approaches, further comparative research is needed. Therefore, the aim of this study is to investigate the early clinical outcomes of arthroscopic and open surgery in the treatment of Ogden type 1-2 PTD.

METHODS

We conducted a comprehensive analysis of 46 patients diagnosed with PTD who underwent surgery at our institution between January 2017 and January 2023. The patients were divided into two groups: the open surgery group, consisting of 26 cases, and the arthroscopic surgery group, consisting of 20 cases. To compare the effectiveness of the surgical approach, we evaluated several parameters, including the integrity of the superior peroneal retinaculum on MRI images, functional scores, pain interference scores, and ankle eversion muscle strength. These assessments are conducted respectively before the surgery, 1 month after the surgery, 3 months after the surgery, and at the final follow-up for each group of patients (at least 6 months post-surgery). Demographics and intergroup comparisons of the two groups of data were analyzed by t-test or the Mann-Whitney U test. Intragroup comparisons of the two groups of data were analyzed by one-way analysis of variance (ANOVA) or the Kruskal-Wallis test, followed by post hoc multiple comparisons.

RESULTS

In the intragroup comparisons, both the arthroscopic surgery and the open surgery group demonstrated significant improvement in functional scores, pain interference scores, muscle strength, and MRI findings at the final follow-up postoperatively (p < 0.01). However, the open surgery group exhibited significant improvements in these outcomes at the final follow-up, while the arthroscopic surgery group showed significant improvement at 3 months postoperatively. In intergroup comparisons, the arthroscopic surgery group outperformed the open surgery group in functional scores, pain interference scores, and muscle strength 3 months after the surgery, with statistically significant differences (p < 0.01).

CONCLUSION

Arthroscopic surgery offers advantages in early clinical outcomes, such as pain relief, function, and muscle strength improvement. However, over time, both approaches provide similar results regarding effectiveness.

Comparison of Ultrasound and MRI with Intraoperative Findings in the Diagnosis of Peroneal Tendinopathy, Tears, and Subluxation

Suspected peroneal tendinopathy, tears, and subluxation are often confirmed preoperatively using magnetic resonance imaging (MRI) or diagnostic ultrasound (US). No study has directly compared the accuracy of these tests for the diagnosis of peroneal tendon pathology. The purpose of this study is to directly compare MRI and US to intraoperative findings in patients who underwent surgery for suspected peroneal pathology to determine the imaging diagnostic accuracy. Operative records and diagnostic images for 21 consecutive patients who had both MRI and US prior to surgery for suspected peroneal tendinopathy, tears, or subluxation were retrospectively reviewed. The results of this review are compared with the intraoperative findings to yield the sensitivity and specificity for each imaging modality. For the diagnosis of peroneal tendon tears, US was found to have a sensitivity of 88% and specificity of 100%, compared to 100% sensitivity and specificity for MRI. In the diagnosis of peroneal tendinopathy, both US and MRI had a sensitivity and specificity of 100%. In diagnosing peroneal subluxation, US was 100% sensitive compared to 66% for MRI, and both were 100% specific. In conclusion, US was found to be more effective in diagnosing peroneal subluxation and MRI was slightly more accurate in the diagnosis of peroneal tendon tears.

Is Subtle Cavovarus a Problem for Athletes?

Cavovarus or high-arched foot is a common foot deformity that occurs due to the disruption of the foot-driven equilibrium between the first metatarsal, fifth metatarsal, and the heel. This imbalance leads to an increase in the foot's normal plantar concavity. Cavovarus deformity ranges from a mild and flexible malalignment to a fixed, complex, and severe deformation. Subtle cavovarus foot, the mild form of the cavus foot, was first described by Manoli and colleagues.

Snapping ankles: peroneal tendon subluxation and dislocation

Peroneal tendon dislocation or subluxation is an orthopaedic condition that usually occurs as a result of injury to the superior peroneal retinaculum. The peroneal muscles are located in the lateral compartment of the leg, and their tendons run in the retromalleolar groove anchored by the superior peroneal retinaculum. Peroneal instability is usually classified using the Eckert and Davies classification, which was modified by Oden into a four-point grading system. The mechanism of injury is typically sudden forced dorsiflexion, resulting in aggressive tautness of the peroneal tendons, combined with a forced eversion of the hindfoot. Plain X-ray, ultrasound and magnetic resonance imaging are useful for imaging of the injury and in planning for surgery. Operative management has high success rates and there are multiple surgical techniques available, including superior peroneal retinaculum repair, tenoplasty, bone block procedures, groove deepening and endoscopic approaches, with little variation in outcome found between the approaches.

Return to Sport after Surgical Treatment for Dislocation of the Peroneal Tendon: A Systematic Review of the Current Literature

Purpose: This study aims to analyze the return to normal activities and sports after surgical management of peroneal tendon dislocation through different surgical techniques. Methods: This review included studies (retrospective case series, prospective cohort study) that analyzed different aspects: return to sport (RTS), American Orthopedic Foot and Ankle Society Score (AOFAS), Visual Analogue Scale (VAS), satisfaction, and redislocation episodes after surgical treatment. We performed a systematic review, analyzing 1699 articles. We researched our selected studies through PubMed, Scopus, and Cochrane. The last search was performed in December 2022. We used the MINORS score to perform a quality assessment of pooled data. In total, 20 studies were included. Results: The postoperative AOFAS score, VAS scale, and high satisfaction percentages all improve with surgical therapy. At long-term follow-up, the redislocation following surgical treatment is minimal. Compared to patients who only receive superior peroneal retinaculum (SPR) repair and other surgical procedures, patients with groove deepening and SPR repair have greater rates of returning to sports (bony and rerouting procedures). Conclusions: Peroneal tendon dislocation surgery offers good outcomes, a quick return to sport, and high patient satisfaction. Those who received both groove deepening and SPR repair as opposed to other surgical procedures have greater rates of returning to sports.

Anatomic Features of Patients With Recurrent Peroneal Tendon Dislocation

BACKGROUND

There are several anatomic variations of the peroneal muscles and lateral malleolus of the ankle that may play an important role in the onset of peroneal tendon dislocation.

PURPOSE

To investigate the anatomic variations of the retromalleolar groove and peroneal muscles in patients with and without recurrent peroneal tendon dislocation using magnetic resonance imaging (MRI) and computed tomography (CT).

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

A total of 30 patients (30 ankles) with recurrent peroneal tendon dislocation who underwent both MRI and CT before surgery (PD group) and 30 age- and sex-matched patients (control [CN] group) who underwent MRI and CT were included in this study. The imaging was reviewed at the level of the tibial plafond (TP level) and at the center slice between the TP and the fibular tip (CS level). The appearance of a malleolar groove (convex, concave, or flat) and the posterior tilting angle of the fibula were assessed on CT images. The appearance of accessory peroneal muscles, height of the peroneus brevis muscle belly, and volume of the peroneal muscle and tendons were assessed on MRI scans.

RESULTS

There were no differences in the appearance of the malleolar groove, posterior tilting angle of the fibula, or accessory peroneal muscles at the TP and CS levels between the PD and CN groups. The peroneal muscle ratio was significantly higher in the PD group than in the CN group at the TP and CS levels (both P < .001). The height of the peroneus brevis muscle belly was significantly lower in the PD group than in the CN group (P = .001).

CONCLUSION

A low-lying muscle belly of the peroneus brevis and a larger muscle volume in the retromalleolar space were significantly associated with peroneal tendon dislocation. Retromalleolar bony morphology was not associated with peroneal tendon dislocation.

Peroneal Tendon Dislocation: A Report of Two Cases

Ankle injuries are a very common cause of patient visits to the primary care units and emergency departments. Although the most frequent ones are lateral ligament sprains, peroneal tendon subluxations have the same inversion mechanism and are described as one of the main causes of lateral ankle pain and instability. They are often missed during the acute phases as they are misdiagnosed as ankle sprains since both injuries share similar mechanisms and often occur in athletes and patients with high sports activity. We present two different cases of peroneal tendon dislocation that illustrate how this pathological condition may be present under different circumstances. We aim, through these cases, to provide clinical awareness and help improve earlier diagnosis of this condition; we also demonstrate the effectiveness of surgical reattachment of the upper retinaculum that two of our patients underwent.

Peroneal Stabilization Via Tightening of the Peroneal Tendon Sheath

Peroneal subluxation is a rare but debilitating pathology that can be the result of a superior peroneal retinaculum tear or intrasheath laxity. On clinical examination of both cases, the pathology is observed when the ankle is circumducted in eversion and dorsiflexion. With a superior peroneal retinaculum tear, the tendons dislocate from the peroneal groove, whereas with intrasheath laxity the tendons remain in the groove. In the present case series, peroneal stabilization was performed for both superior peroneal retinaculum tear and intrasheath laxity. With our technique, the fibro-osseous connections of the peroneal tendon sheath are detached from the distal one third of the fibula. Drill holes are made through the fibula for suture to be passed through and the peroneal tendon sheath is reattached to the fibula through horizontal mattress sutures via pants over vest technique to restore tension to the sheath. A total of 5 patients underwent peroneal stabilization, 100% (5/5) of which had preoperative pain with palpation along the peroneal tendons and a palpable click with range of motion of the ankle joint. Postoperatively, 100% (5/5) of the patients were fully weight-bearing, compared to 60% (3/5) preoperatively. No patients had residual subluxation of the peroneal tendons postoperatively or a need for revisional surgery. Residual peroneal tendonitis was present in 20% (1/5) of patients and sural neuritis occurred in 20% (1/5) of patients. The peroneal tendons are physiologically tightened within the peroneal tendon sheath to mitigate the pathologic subluxation, without sacrificing tendons for transfer or using allograft material.Clinical Level of Evidence: Therapeutic, Case Series, Level 4.

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.

Peroneus Longus and Peroneus Brevis: A Review on Pathology and Updated Treatments

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Peroneus longus (PL) and peroneus brevis (PB) pathologies involve a variety of etiologies and degrees of dysfunction, which complicates their diagnoses.

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Patient presentation includes a spectrum of disease; however, despite advanced imaging, a misunderstanding of the pathology and diagnostic algorithms has contributed to continued misdiagnoses.

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This article summarizes the anatomy and the pathophysiology of the PL and the PB; it also provides updated treatment options and their associated outcomes in order to illuminate an often-misunderstood topic.

Nontraumatic Bilateral Recurrent Peroneal Tendon Dislocation with Pes Planovalgus: A Case Report

CASE

Peroneal tendon dislocation is a relatively infrequent problem. Most cases are traumatic, and nontraumatic cases are rare. In this case, a 21-year-old man had nontraumatic bilateral recurrent peroneal tendon dislocation on standing and pes planovalgus. We performed medial displacement osteotomy of the calcaneus for the pes planovalgus and reattachment of the retinaculum and groove deepening for the peroneal tendon dislocations.

CONCLUSION

The dislocations were attributed to the force of the tendon riding up the lateral malleolus on standing because of pes planovalgus. A good outcome was achieved by surgical intervention for both the pes planovalgus and peroneal tendon dislocations.

Tendoscopic peroneal retinaculum repair for recurrent peroneal tendon dislocation enables earlier return to sports than the open procedure

PURPOSE

The purpose of this study was to evaluate whether tendoscopic peroneal retinaculum repair for patients with recurrent peroneal tendon dislocation (RPTD) is more useful than an open procedure.

METHODS

Twenty-five patients with RPTD were retrospectively reviewed. Twelve patients (13 ankles) with RPTD underwent the open procedure (Group A) between 2008 and 2014, and 13 patients (14 ankles) underwent the tendoscopic procedure (Group B) between 2014 and 2017. Evaluation parameters included clinical results [the Japanese Society for Surgery of the Foot (JSSF) ankle-hind foot scale], operation time, complications, return to sports, and recurrence.

RESULTS

Postoperative JSSF ankle/hindfoot scale scores were significantly better than the pre-surgical scores in both groups. The mean operation time was significantly longer in Group B than in Group A (75.7 ± 20.5 vs 38.4 ± 10.5 min). There was one recurrence in Group A, but none in Group B. Group A had no complications, and Group B had one wound infection. Group B, excluding the case of infection, could return to sports earlier than Group A, excluding the recurrent case (13.4 ± 1.5 vs 12.2 ± 0.6 weeks).

CONCLUSIONS

This tendoscopic procedure needs longer operation time and is more technically demanding, but it is a useful procedure, because it is less invasive and can accelerate return to sports.

LEVEL OF EVIDENCE

III.

Non-operative treatment of peroneal tendon dislocations: A systematic review

Purpose

This study evaluated the clinical outcome of non-operative treatment of peroneal tendon dislocations.

Methods

A systematic review of literature was performed.

Results

Six studies were included. Redislocation rates differed between treatments: taping ≥ 3 weeks; 18/30 (60%) patients. Plaster cast ≥ 4 weeks; 5/13 (32%) plaster cast ≥ 6 weeks; 1/6 (17%). Strapping or taping treatment indicated a higher rate of pain and instability and a lower rate of ability to return to former activity.

Conclusions

A non-weight bearing cast ≥ 6 weeks was successful in 5/6 patients. A non-weight bearing cast might be a good alternative for surgical intervention.Level of Clinical Evidence: Level IV, systematic review of level IV studies.

Posterior ankle impingement disguised as peroneal tendon subluxation in young athletes - a case report

Posterior ankle impingement is a cause of posterior ankle pain common in those who perform frequent plantarflexion activities. Three young patients presented with posterior ankle pain which was initially attributed to peroneal tendon subluxation. However, detailed physical exam and imaging confirmed the diagnosis of posterior ankle impingement as the actual cause of pain. The peroneal tendon subluxation was not causal but an unrelated co-incidental finding. After failed prolonged conservative management (rest, immobilization and physical therapy), the patients underwent posterior ankle arthroscopic debridement for the impingement resulting in return to prior sporting activity without limitation and no recurrence of pain at 19 months follow-up. Posterior ankle impingement diagnosis could be masked by co-incidental asymptomatic peroneal tendon subluxation in pediatric patients.

Unusual accessory peroneal muscles, peroneus quartus, peroneus digiti quinti, and their association with peroneus brevis tendon tear

Background

Anatomic variation and supernumerary contents in the superior peroneal tunnel, and the prominence of the retrotrochlear eminence and peroneal tubercle are related to peroneal tendon disorders.

Objectives

To investigate the prevalence, origin, and insertion of accessory peroneal muscles, the prominence of the retrotrochlear eminence and peroneal tubercle, and their association with peroneal tendon tears.

Methods

We examined 109 formalin-embalmed legs of cadavers from Thai donors. Accessory peroneal muscles and peroneal tendon tears were noted. Associations with peroneal tendon tears were evaluated using a χ2 test.

Results

We found 48 accessory peroneal muscles comprising 13 peroneus quartus (PQ), 33 peroneus digiti quinti (PDQ), and 2 unusual muscles. All PDQ originated from the PB tendon and inserted on various parts of the 5th toe. The PQ originated mostly from the PB muscle belly and less from the tendinous part with various insertions on the retrotrochlear eminence, peroneal tubercle, cuboid, and dorsolateral surface of the 5th metatarsal base. Two unusual accessory muscles were identified, 1 coexisting with the PQ. A PB tendon tear was found in 13% of specimens. We found no association between the peroneal tendon tears and the accessory peroneal muscles, or prominence of the retrotrochlear eminence or peroneal tubercle.

Conclusions

The prevalence of PQ, PDQ, and unusual accessory peroneal muscles was concordant with previous findings. We noted a new type of unusual accessory peroneal muscle coexisting with the PQ. No association was found between peroneal tendon tears and the PQ, PDQ, or prominence of the retrotrochlear eminence or peroneal tubercle.

Reattachment of the superior peroneal retinaculum versus the bone block procedure for the treatment of recurrent peroneal tendon dislocation: two safe and effective techniques

PURPOSE

Clinical outcomes between reattachment of the superior peroneal retinaculum (SPR) and the bone block procedure were compared in this study to elucidate which procedure was safer and more effective.

METHODS

From 2012 to 2016, 25 patients with recurrent peroneal tendon dislocation underwent the bone block procedure (group A), and another 22 patients underwent reattachment of the SPR (group B). American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, Ankle Activity Score (AAS), time to return to sports activity, rate of return to sports level, range of motion (ROM) of the ankle, rate of recurrence, and overall patient satisfaction were collected to evaluate outcomes between the two groups.

RESULTS

In group A, 24 patients followed up at a mean period of 42.5 ± 16.7 months. The mean postoperative AOFAS score was 92.9 ± 3.9. The median time to return to sports activity was 6.0 months (IQR 4.3-6.0 months) with 19 patients (79.2%) returning to their previous sports level. Two patients experienced recurrent dislocation, and 22 patients (91.7%) were satisfied with the procedure. In group B, 20 patients followed up at a mean period of 35.8 ± 15.3 months. The mean postoperative AOFAS score was 95.0 ± 4.2. The median time to return to sports activity was 5.0 months (IQR 4.0-5.0 months) with 18 patients (90.0%) returning to their previous sports level. No recurrence was reported, and 18 patients (90.0%) were satisfied with the procedure. The time to return to sports activity in group B was significantly shorter than that in group A. There was no significant difference in complications or clinical outcomes between the two procedures.

CONCLUSION

Both procedures offered satisfactory results for recurrent peroneal tendon dislocation with low rates of recurrence and complications. However, the time to return to sports activity after the reattachment of the SPR was shorter than that after the bone block procedure.

LEVEL OF EVIDENCE

Retrospective Comparative Study, Level III.

Intrasheath Instability of the Peroneal Tendons: Dynamic Ultrasound Imaging

Peroneal intrasheath instability is a painful snapping condition of the lateral ankle. It consists of a transient retromalleolar subluxation of the peroneal tendons without disruption of the superior peroneal retinaculum or evidence of a previous definite trauma. In type A intrasheath instability, the peroneus longus and brevis tendons are intact, and there is an intertendinous intrasheath switch. In type B intrasheath instability, the peroneus brevis tendon has a longitudinal split tear through which the peroneus longus subluxates. Both types can be missed on a physical examination because there is no displacement of the peroneal tendons over the lateral malleolus. Dynamic ultrasound is the imaging modality of choice for evaluating retromalleolar subluxation of the peroneal tendons. This review article aims to provide an overview of the anatomic basis for peroneal intrasheath instability and provide physicians with guidelines for its ultrasound assessment.

Posterior Fibular Groove Deepening Procedure With Low-Profile Screw Fixation of Fibrocartilaginous Flap for Chronic Peroneal Tendon Dislocation

Chronic peroneal tendon dislocation is an uncommon disorder that frequently presents with concomitant pathology. Posterior fibular groove deepening and retinaculum repair have been increasing in popularity for treatment of peroneal tendon dislocations. The purpose of the present study was to introduce a posterior fibular groove deepening procedure using low-profile snap-off screws to securely and simply fix the fibrocartilaginous flap to facilitate faster rehabilitation and to assess the clinical outcomes of patients with chronic peroneal tendon dislocation and associated pathologic features. In the present retrospective case series, 34 ankles in 34 patients underwent the fibular groove deepening procedure using low-profile screws with superior peroneal retinaculum repair. The clinical outcomes were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale and patient subjective satisfaction rate. The time of return to recreational and sports activities was also assessed. Weightbearing ankle radiographs were evaluated to assess the stability of the flap by checking the screws. The mean follow-up period was 47.96 (range 12 to 142) months. The mean AOFAS scale score for all patients improved from 69.96 ± 13.14 to 87.72 ± 10.13 at the last follow-up examination (p < .001). Overall, 85.3% of patients subjectively rated their operative outcomes as excellent or good. The 18 (52.9%) patients with an isolated peroneal tendon dislocation had a faster return to recreational or sports activities than the 16 (47.1%) patients with concomitant pathologic features (2.95 ± 0.19 versus 4.14 ± 1.34 months; p = .002). No patient experienced residual dislocation, screw loosening, or irritation from the screws. The fibular groove deepening procedure using low-profile screws is be a simple procedure that offers rigid fixation. This leads to relatively fast rehabilitation and resumption of recreational or sports activities.

The ESSKA-AFAS international consensus statement on peroneal tendon pathologies

INTRODUCTION

Peroneal tendon injuries are a significant cause of lateral ankle symptoms in the active population. Accurate diagnosis and prompt treatment is important for minimizing the risk of long-term sequelae associated with chronic peroneal tendinopathy. Although several studies have been published on diagnostic strategies and treatment outcomes, there is no consensus on the optimal management of peroneal tendon pathologies.

PURPOSE

The purpose of this ESSKA-AFAS consensus statement was to conduct an international and multidisciplinary agreed guideline on management of patients with peroneal tendon pathologies.

METHODS

Using the Nominal Group Technique, a panel comprised of sixteen specialists spanning nine countries was convened by the ESSKA-AFAS board. In preparation for the meeting, relevant questions were identified and supported by a systematic literature search. During the meeting, the panel members gave presentations on each question, and the evidence supporting each subject was then vetted by open discussion. Statements were thereafter adjusted on the basis of the discussion and voted upon to determine consensus using a 0-10 range Likert scale. Agreement was confirmed when a mean score of at least 7.5 was reached.

CONCLUSION

This ESSKA-AFAS consensus statement on the optimal management of peroneal tendon pathologies is the result of international and multidisciplinary agreement combined with a systematic review of the literature.

LEVEL OF EVIDENCE

V.

The ESSKA-AFAS international consensus statement on peroneal tendon pathologies

INTRODUCTION

Peroneal tendon injuries are a significant cause of lateral ankle symptoms in the active population. Accurate diagnosis and prompt treatment is important for minimizing the risk of long-term sequelae associated with chronic peroneal tendinopathy. Although several studies have been published on diagnostic strategies and treatment outcomes, there is no consensus on the optimal management of peroneal tendon pathologies.

PURPOSE

The purpose of this ESSKA-AFAS consensus statement was to conduct an international and multidisciplinary agreed guideline on management of patients with peroneal tendon pathologies.

METHODS

Using the Nominal Group Technique, a panel comprised of sixteen specialists spanning nine countries was convened by the ESSKA-AFAS board. In preparation for the meeting, relevant questions were identified and supported by a systematic literature search. During the meeting, the panel members gave presentations on each question, and the evidence supporting each subject was then vetted by open discussion. Statements were thereafter adjusted on the basis of the discussion and voted upon to determine consensus using a 0-10 range Likert scale. Agreement was confirmed when a mean score of at least 7.5 was reached.

CONCLUSION

This ESSKA-AFAS consensus statement on the optimal management of peroneal tendon pathologies is the result of international and multidisciplinary agreement combined with a systematic review of the literature.

LEVEL OF EVIDENCE

V.

ACR Appropriateness Criteria® Chronic Ankle Pain

Chronic ankle pain is a common clinical problem whose cause is often elucidated by imaging. The ACR Appropriateness Criteria for chronic ankle pain define best practices of image ordering. Clinical scenarios are followed by the imaging choices and their appropriateness. The information is in ordered tables with an accompanying narrative explanation to guide physicians to order the right test. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Calcaneofibular Ligament Transfer for Recurrent Peroneal Tendon Subluxation in Pediatric and Young Adult Patients

BACKGROUND

Peroneal tendon subluxation is an uncommon cause of lateral ankle pain and instability but can be disabling for some young patients. Surgical management may be required to restore function for patients who fail nonoperative management. The purpose of this study was to determine the functional outcomes after surgical management of peroneal tendon subluxation in pediatric and adolescent patients.

METHODS

A retrospective review of patients presenting to our institution over a 10-year period yielded 18 cases of recurrent subluxation refractory to nonoperative management in 14 children or young adults (mean age 15.0 y). All patients failed nonoperative management and were treated operatively with isolated calcaneofibular ligament transfer to construct a new soft tissue restraint for the peroneal tendons. Patients were evaluated clinically and sent validated questionnaires, including the Foot and Ankle Ability Measure (FAAM) and the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale.

RESULTS

All 18 ankles of 14 patients had minimum 2-year follow-up. Ten of 18 ankles (55.6%) returned the outcome surveys at an average of 5.7 years after the index procedure (range, 2. 0 to 9.7 y). The average FAAM activities of daily living score was 93.5 (±2.9) and the sports subscale was 77.8 (±6.1). The mean AOFAS subjective scaled score was 84.3 (±4.5). All patients returned to sports and recreational activity. Complications included 1 case of recurrent subluxation (1/18, 5.5%) treated with revision to a Chrisman-Snook procedure and 4 ankles (4/18, 22.2%) with stiffness or arthrofibrosis treated with a secondary procedure of peroneal tendon release or lysis of adhesions.

CONCLUSIONS

Surgical management with rerouting of the peroneal tendons under the calcaneofibular ligament appears to be safe and effective for young patients with chronic peroneal tendon subluxation. It provides a low rate of recurrent subluxation, excellent stability, and good long-term functional outcomes. However, the potential for postoperative stiffness appears to be a limitation to the procedure and necessitates aggressive physical therapy to maintain ankle motion.

LEVEL OF EVIDENCE

Level IV- retrospective case series.

Tibialis Posterior Tendon Dislocation: A Review and Suggested Classification

Tibialis posterior tendon dislocation is a rarely described entity that is easily missed, resulting in delayed diagnosis and treatment. A review of the English published data on the topic showed inconsistency in the reporting of injuries and surgical management techniques, leading us to describe a novel classification system to guide treatment and future reporting. We also describe a case of tibialis posterior tendon dislocation in a professional volleyball player and our surgical technique for correction, including retromalleolar groove deepening.

The recognition and incidence of peroneal tendon dislocation associated with a fracture of the talus

AIMS

The purposes of this study were to clarify first, the incidence of peroneal tendon dislocation in patients with a fracture of the talus and second the factors associated with peroneal tendon dislocation.

PATIENTS AND METHODS

We retrospectively examined 30 patients (30 ankles) with a mean age of 37.5 years, who had undergone internal fixation for a fracture of the talus. Independent examiners assessed for peroneal tendon dislocation using the pre-operative CT images. The medical records were also reviewed for the presence of peroneal tendon dislocation. The associations between the presence of dislocation with the patient characteristics or radiological findings, including age, mechanism of injury, severity of fracture, and fleck sign, were assessed using Fisher's exact tests.

RESULTS

The pre-operative CT images showed peroneal tendon dislocation in eight out of 30 patients. Dislocation was found later in one patient whose pre-operative CT image had not shown dislocation. The overall incidence of peroneal tendon dislocation was 30% (9/30). The presence of dislocation was associated with the presence of a fleck sign (p = 0.03).

CONCLUSIONS

Surprisingly, approximately one-third of the patients who underwent internal fixation for a fracture of the talus had peroneal tendon dislocation. This was associated with a fleck sign. Cite this article: Bone Joint J 2017;99-B:489-93.

The Peroneus Quartus Muscle in a Locking Phenomenon of the Ankle: A Case Report

We present the case of a 64-year-old female who was referred to us with an unexplained clicking and locking phenomenon of the right ankle. The magnetic resonance imaging findings suggested a longitudinal tear of the peroneus brevis tendon. During tendoscopy, not only was a Raikin type B intrasheath tendon subluxation visible, but also a peroneus quartus muscle. The peroneus brevis tear was tubularized and the peroneus quartus muscle resected, which resolved the patient's complaints.

Dislocated Posterior Tibial Tendon Treated With Plate Buttress Fixation in a Collegiate Gymnast: A Case Report and Review of the Literature

Dislocation of the posterior tibial tendon (PTT) is a rare pathological process that occurs most often as a result of acute trauma. The injury involves forced dorsiflexion and eversion of the foot against a contracted posterior tibialis. Diagnosis of the injury is often difficult secondary to the rarity of the injury and its similarity with other benign injuries of the medial ankle. Routine diagnostic imaging often does not reveal the injury, and advanced imaging with magnetic resonance imaging or ultrasound to confirm the diagnosis is often required. The injury can be a result of an abnormal retromalleolar groove or a tear of the flexor retinaculum. Because nonoperative treatment frequently results in poor outcomes with continuing pain and progressive flat foot, operative treatment with repair of the flexor retinaculum with correction of the retromalleolar groove is the most described intervention. We report an acute case of PTT dislocation in a collegiate gymnast during competition and offer our technique for surgical correction in the setting of a partially torn, attenuated flexor retinaculum with plate buttressing of the PTT into its native uncorrected groove.

LEVELS OF EVIDENCE

Therapeutic, Level IV: Case study.

Return to sports and clinical outcomes in patients treated for peroneal tendon dislocation: a systematic review

PURPOSE

The aim of this study was to determine the outcome following different surgical treatment techniques in the treatment of peroneal tendon dislocation and to establish whether return to sports was achieved universally following the procedures.

METHODS

A systematic review and best-evidence synthesis was performed. PubMed and EMBASE were searched for eligible studies. The last search was done in March 2015. Quality assessment of pooled data was performed using a modified Macleod scale and a best-evidence synthesis was performed. In total, 14 studies were included.

RESULTS

Surgical treatment provides improvement in the post-operative AOFAS score (p < 0.0001) and high satisfaction rates. The redislocation rate is less than 1.5% at long-term follow-up. Patients treated with both groove deepening and SPR repair have higher rates of return to sports than patients treated with SPR repair alone (p = 0.022).

CONCLUSIONS

Surgical treatment of peroneal tendon dislocation provides good outcomes, high satisfaction and a quick return to sports. Rates in return to sports are significantly higher in patients treated with both groove deepening and SPR repair. To optimize treatment, the surgical management should involve increasing the superior peroneal tunnel volume by groove deepening and stabilizing the tendons by SPR repair.

LEVEL OF EVIDENCE

Level IV, systematic review of level IV studies.

Dynamic ultrasound of peroneal tendon instability

Ankle snapping may be caused by peroneal tendon instability. Anterior instability occurs after traumatic superior peroneal retinaculum injury, whereas peroneal tendon intrasheath subluxation is atraumatic. Whereas subluxation is mainly dynamic, ultrasound allows for the diagnosis and classification of peroneal instability because it allows for real-time exploration. The purpose of this review is to describe the anatomic and physiologic bases for peroneal instability and to heighten the role of dynamic ultrasound in the diagnosis of snapping.

Surgical Management of Irreducible Dislocation of the Peroneus Longus Tendon A Case Report

Peroneal tendon dislocation is often overlooked because the mechanism of injury is similar to that of lateral ligament sprains and the frequency of the disease is low. Therefore, it is difficult to treat peroneal tendon dislocation when diagnosed in the chronic state. Furthermore, because irreducible peroneal tendon dislocation has multiple causes, treatment is much harder. Herein, we present a rare case of irreducible dislocation caused by a complex pathogenesis. Surgical treatment yielded good results. Orthopedic surgeons should be aware of this issue and consider it in the preoperative simulation.

High-resolution US and MR imaging of peroneal tendon injuries

Injuries of the peroneal tendon complex are common and should be considered in every patient who presents with chronic lateral ankle pain. These injuries occur as a result of trauma (including ankle sprains), in tendons with preexisting tendonopathy, and with repetitive microtrauma due to instability. The peroneus brevis and peroneus longus tendons are rarely torn simultaneously. Several anatomic variants, including a flat or convex fibular retromalleolar groove, hypertrophy of the peroneal tubercle at the lateral aspect of the calcaneus, an accessory peroneus quartus muscle, a low-lying peroneus brevis muscle belly, and an os peroneum, may predispose to peroneal tendon injuries. High-resolution 1.5-T and 3-T magnetic resonance (MR) imaging with use of dedicated extremity coils and high-resolution ultrasonography (US) with high-frequency linear transducers and dynamic imaging are proved to adequately depict the peroneal tendons for evaluation and can aid the orthopedic surgeon in injury management. An understanding of current treatment approaches for partial- and full-thickness peroneal tendon tears, subluxation and dislocation of these tendons with superior peroneal retinaculum (SPR) injuries, intrasheath subluxations, and peroneal tendonopathy and tenosynovitis can help physicians achieve a favorable outcome. Patients with low functional demands do well with conservative treatment, while those with high functional demands may benefit from surgery if nonsurgical treatment is unsuccessful. Radiologists should recognize the normal anatomy and specific pathologic conditions of the peroneal tendons at US and MR imaging and understand the various treatment options for peroneal tendon and SPR superior peroneal retinaculum injuries. Online supplemental material is available for this article.

Peroneal tendon dislocation

INTRODUCTION

Peroneal tendon instability goes often mis- or undiagnosed in the acute setting of evaluation of ankle sprains. The current article provides a concise overview regarding peroneal tendon instability.

METHODS

A proper history, clinical assessment and imaging help to establish the correct diagnosis. Conventional radiography, ultrasound, magnetic resonance imaging and sometimes computed tomography may help to elucidate the pattern of injury.

RESULTS

Nonoperative treatment can be considered in the acute setting. However, high failure rates up to 50 % have been reported in the literature. This is even better reflected in the chronic stage of peroneal instability, in which most of the patients need surgical treatment. In contrast, surgical treatment attempts to restore structural stabilization of the peroneal tendon and retinacular complex. The simple reconstruction and repair of the damaged retinacular structures and tendons achieve excellent results. In patients with structural abnormalities of the retromalleolar groove, groove-deepening procedures may be considered. Most of chronic personal tendon instabilities need to be addressed by surgery due to the frustrating results obtained by nonoperative measures. However, reconstruction of the tendinous and retinacular structures can yield good-to-excellent outcomes.

Peroneal Tendon Disorders

Peroneal tendon pathology is often found in patients complaining of lateral ankle pain and instability. Conditions encountered include tendinosis; tendinopathy; tenosynovitis; tears of the peroneus brevis, peroneus longus, and both tendons; subluxation and dislocation; and painful os peroneum syndrome. Injuries can be acute as a result of trauma or present as chronic problems, often in patients with predisposing structural components such as hindfoot varus, lateral ligamentous instability, an enlarged peroneal tubercle, and a symptomatic os peroneum. Treatment begins with nonoperative care, but when surgery is required, reported results and return to sport are in general very good.

Trends in Ankle Arthroscopy and Its Use in the Management of Pathologic Conditions of the Lateral Ankle in the United States: A National Database Study

PURPOSE

This study aimed to investigate current trends in ankle arthroscopy across time, sex, age, and region of the United States as well as the use of ankle arthroscopy in the management of lateral ankle instability.

METHODS

Patients who underwent ankle arthroscopy and those who underwent ankle arthroscopy and lateral ankle ligament repair or peroneal retinacular repair from 2007 through 2011 were identified using the PearlDiver national database. These searches yielded volumes of unique patients, sex and age distribution, and regional volumes of patients. Χ-square linear-by-linear association analysis was used for comparisons, with P < .05 considered significant.

RESULTS

We identified 15,366 ankle arthroscopy procedures in the database from 2007 to 2011. Over the 5-year study period, there was a significant increase in the overall number of ankle arthroscopies being performed, from 2,814 in 2007 to 3,314 in 2011 (P < .0001). Female patients had ankle arthroscopy more frequently than did male patients (P = .027). The majority of patients who had ankle arthroscopy were between the ages of 30 and 49 years. The use of ankle arthroscopy during lateral ligament repair procedures increased from 37.2% in 2007 to 43.7% in 2011 (P < .0001). The incidence of combined ankle arthroscopy and peroneal tendon retinacular repair increased 50%, from 2.8/100 ankle arthroscopies in 2007 to 4.2/100 ankle arthroscopies in 2011 (P < .0001).

CONCLUSIONS

The incidence of ankle arthroscopy increased significantly from 2007 to 2011, outpacing shoulder, knee, and elbow arthroscopy. Ankle arthroscopy was performed more frequently in female patients and most commonly in patients younger than 50 years. The use of ankle arthroscopy in the surgical management of lateral ankle instability also increased significantly. The incidence of concomitant ankle arthroscopy and lateral ligament repair increased significantly, as did the incidence of concomitant ankle arthroscopy and repair of peroneal tendon subluxation.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Predictors of peroneal pathology in Broström-Gould ankle ligament reconstruction for lateral ankle instability

BACKGROUND

Chronic ankle instability has a well-known association with intra- and extraarticular ankle pathologies, including peroneal tendonitis and subluxation. Patients with peroneal pathology are at risk for failure of conservative treatment for their ankle instability, thus identifying these patients is important and helps to guide management. There has been no literature looking at, in patients with chronic ankle instability, which associated ankle pathologies and patient characteristics are predictive of peroneal pathology.

METHODS

A retrospective chart review was performed on all patients (N = 136) who underwent a Broström-Gould ankle ligament reconstruction at a single institution from 2010 to 2014. Preoperative clinical examinations and MRIs as well as operative procedures were documented. Patients with and without peroneal pathology were divided into 2 cohorts, and their preoperative characteristics underwent a univariate analysis with P < .05 defined as showing a significant difference.

RESULTS

Of patients undergoing lateral ankle ligament reconstruction, 53.3% required operative intervention for symptomatic peroneal tendon pathology. Female gender was the only significant predictor of peroneal pathology (P = .008). The presence of an osteochondral lesion of the talus (OLT) was a significant negative predictor of peroneal pathology (P < .001). The remainder of the variables (age, BMI, duration of symptoms, tobacco, traumatic etiology, worker's compensation, global hyperlaxity, contralateral ankle instability, sport participation, ankle tilt, and deltoid tear) did not show a significant difference between cohorts.

CONCLUSION

In patients who underwent Broström-Gould ankle ligament reconstruction for chronic lateral ankle instability, female gender was significantly associated with concomitant peroneal tendon pathology. Conversely, preoperative MRI findings of an OLT showed a significant negative association with peroneal pathology. All of the other variables did not show a positive or negative association.

Retrofibular osteochondroma with peroneal tendon subluxation

Osteochondroma of the bone can cause a range of complications involving tendons, joints and neurovascular structures. Distal fibular osteochondroma and non-traumatic peroneal tendon subluxation are both rare. In this case report, we describe an unusual case of distal retrofibular osteochondroma in a 36-year old male causing peroneal tendon subluxation. He presented with pain and instability around his ankle, but with no history of trauma. He successfully underwent osteochondroma excision, peroneal groove deepening and a Brostrom-Gould type reconstruction for the lateral ankle ligament insufficiency. Complete resolution of the symptoms of instability and subluxation was noted upon 6-month follow up.

Isolated dislocation of the posterior tibial tendon in an amateur snowboarder: a case report

Isolated dislocation of the posterior tibial tendon is an uncommon pathologic entity that typically occurs in the setting of acute trauma. The diagnosis remains challenging and is often delayed second to the rarity of the injury and symptoms similar to that of medial ankle sprains and other routinely diagnosed injuries about the ankle. The factors that predispose this tendon to dislocation include a hypoplastic retromalleolar groove, flexor retinaculum insufficiency, chronic repetitive trauma, and a structural abnormality from a previous medial malleolar fracture, or a combination thereof. Dislocation has also been cited as a complication of multiple local steroid injections and tarsal tunnel release. The mechanism of injury appears to involve forced dorsiflexion and eversion of the ankle when the posterior tibial tendon is contracted. Most cases do not respond well to conservative treatment and will require surgery to restore function and eliminate symptoms. We report a case of posterior tibial tendon dislocation related to a snowboarding injury and offer our technique for surgical correction.

A mistaken case of peroneal dislocation

This article is centred around the similarities and highlights some differences between a sports injury compared with any other injury profile. The authors use a musculoskeletal assessment, diagnosis and management of an injury based on a particular case study. The intention is to highlight how problems may be masqueraded in the history and perception of the injured athlete and how this perception may have complicated the injury and the rehabilitation process. This issue generates a renewed awareness for all primary care nurses and health practitioners who may be involved in treatment pathways for associated injuries related to sports medicine problems. The article gives an insight into peroneal dislocation/subluxation, but primarily focuses on peroneal tendonitis/tendonosis. The management of the injury briefly touches on the associated benefits (and risks) of barefoot running and its role in the prevention of sporting injuries. This article illustrates how the frustration of a chronic injury can lead to the athlete making ill-informed decisions and highlights the need for a thorough assessment and an evidence-based management plan that is negotiated with the athlete.

Imaging of snapping phenomena

Snapping phenomena result from the sudden impingement between anatomical and/or heterotopical structures with subsequent abrupt movement and noise. Snaps are variously perceived by patients, from mild discomfort to significant pain requiring surgical management. Identifying the precise cause of snaps may be challenging when no abnormality is encountered on routinely performed static examinations. In this regard, dynamic imaging techniques have been developed over time, with various degrees of success. This review encompasses the main features of each imaging technique and proposes an overview of the main snapping phenomena in the musculoskeletal system.