Current concepts review: peroneal tendon disorders

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.

[Peroneal tendon pathologies : From the diagnosis to treatment]

Peronealsehnenpathologien sind selten, jedoch häufig unterdiagnostiziert. Eine Assoziation mit einer chronisch lateralen Sprunggelenkinstabilität sowie mit einer varischen Rückfußachse kann bestehen. Pathologien der Sehnen lassen sich in 3 Kategorien einteilen: Tendinitis und Tenosynovitis, Sehnenrisse und Rupturen sowie Sehnensubluxation und Sehnenluxation. Die Magnetresonanztomographie ist die Standardmethode zur radiologischen Beurteilung. Die Diagnose und Behandlung basieren jedoch in erster Linie auf Anamnese und klinischer Untersuchung. Eine primär konservative Therapie kann versucht werden, ausgenommen bei Peronealsehnenluxationen des professionellen Sportlers. Die chirurgische Therapie sollte gezielt auf die zugrunde liegende Pathologie abgestimmt werden und kann dementsprechend divers von der tendoskopischen Synovektomie bis zur anatomischen Reparatur des superioren peronealen Retinakulums mit Vertiefung der retromalleolären Rinne ausfallen. Die postoperativen Ergebnisse zeigen eine hohe Patientenzufriedenheit und niedrige Reluxationsraten.

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.

Importance of Space-Occupying Anatomical Variations in Peroneal Tendoscopy

BACKGROUND

We hypothesized that peroneal tendons disorders are more commonly associated with anatomical variations, which could overcrowd the retrofibular groove.

METHODS

This single-center retrospective case study covered 84 consecutive cases that had undergone peroneal tendoscopy. Peroneal tendoscopy was performed on 82 patients, predominantly female (3:1) with a median age of 46 years. The preoperative evaluation and all the procedures were performed by a single surgeon using a standardized technique.

RESULTS

Two patients required revision surgery 8 and 52 months after the index procedure due to persistent posterolateral ankle pain. Peroneal tendoscopy was performed as a solitary procedure in 45.1% (37/82) of cases, while the remaining cases involved peroneal tendoscopy as a supplementary procedure. Low-lying peroneus brevis muscle belly (LLMB) was the most common finding in this series in 53.7% (44/82) of cases. In 41.5% (34/82) of cases, longitudinal tears of the peroneus brevis tendon were noted. Some patients presented with more than 1 concomitant peroneal tendon pathology. The LLMB was observed in 23.5% (8/34) of cases with a longitudinal tear of the peroneus brevis tendon.

CONCLUSION

Peroneal tendon anatomical variations, especially LLMB, were associated with the presence of peroneus brevis tendon ruptures and intrasheath peroneal tendon subluxations as well as posttraumatic posterolateral ankle pain. Due to high rates of undiagnosed and misdiagnosed cases of LLMB preoperatively, we believe special care should be taken to recognize it during tendoscopy. Peroneal tendoscopy is a high-efficiency, low-complication method to treat some peroneal tendon conditions.

LEVEL OF EVIDENCE

Level IV, case series.

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.

Impact of the T2-weighted axial oblique MRI sequence in the assessment of peroneal tendons

AIM

To define the role of the T2-weighted axial oblique sequence for the magnetic resonance imaging (MRI) assessment of peroneal tendon pathologies.

MATERIALS AND METHODS

Two radiologists interpreted 180 ankle MRI examinations using standard sequences alone and then in combination with an axial oblique sequence. The readers indicated how likely a peroneal pathology was present using a five-level confidence scale. Diagnostic confidence, interobserver agreement, and clinical correlation were compared. Changes in diagnosis were recorded.

RESULTS

For both readers, the diagnostic confidence was significantly higher using the axial oblique sequence for tendinosis and inframalleolar tenosynovitis for both tendons and for peroneus brevis partial and longitudinal split tears (p<0.001). For reader 1, the diagnostic confidence was also higher using the axial oblique sequence for peroneus longus partial tears (p=0.007). Changes in diagnosis were seen for tendinosis and tenosynovitis of both tendons and for peroneus brevis partial and longitudinal split tears in 0.6-10.8% of cases. Inter-rater reliability was significantly higher with the axial oblique sequence for the diagnosis of tendinosis, inframalleolar tenosynovitis, and partial tear for both tendons, and for peroneus brevis longitudinal split tear. Amongst 105 examinations with clinical information, peroneal pathologies were most frequently diagnosed as present in cases with lateral symptoms (17% versus 14%) and absent in cases without lateral symptoms (92% versus 86%) on the axial oblique sequence.

CONCLUSION

The axial oblique sequence for the assessment of peroneal tendons allows for higher diagnostic confidence, inter-rater reliability, and clinical correlation and can lead to changes in diagnosis.

Peroneal tendon dislocation in talus fracture and diagnostic value of fleck sign

Introduction

Talus fractures are not uncommon and one of the serious fractures in the foot and ankle. Peroneal tendon dislocation is one of the commonly missed soft tissue injuries which may have significant impact on the outcomes including persistent pain and swelling. They have been reported to be associated with calcaneum as well as talus fractures.

Aim

To report the incidence of peroneal tendon dislocation in talus fracture and the significance of fleck sign in the diagnosis of peroneal tendon dislocation.

Methods

We retrospectively reviewed 93 consecutive talus fractures in the period between 1/1/2011 to 1/11/2018. Inclusion criteria were: The patient underwent open reduction and internal fixation, had pre-operative CT scan that is available for review and three view ankle plain radiographs. Two independent authors review the radiographs for peroneal tendon dislocation, fleck sign and fracture classification, if any. Any dispute was resolved by the senior author.Patient records were reviewed for laterality, age, sex,mode of injury, associated injuries and operative interventions. 50 ankles met the inclusion criteria. 49 were males, mean age was 32.5 year and the predominant mode of injury was a fall from height.

Results

Peroneal tendon dislocation was found in ten patients out of 50 (20%). Risk of dislocation increased with severity of the fracture and neck fractures. Most of the dislocations were missed by surgeons and radiologist, and no additional procedures were done to address such an injury. The Fleck sign had a statistically significant correlation with peroneal tendons dislocations (p=.005)

Conclusion

Peroneal tendons dislocation is associated with as high as 20% of talus fractures. The authors recommend carefully reviewing CT scans by surgeons and radiologists alike to avoid missing such injury and allow for appropriate surgical approach utilization. The Fleck sign is a highly specific radiographic sign that has a statistically significant correlation with PT dislocation and hence we recommend intra-operative assessment of peroneal tendons in patients with the fleck sign.

Satisfactory functional and MRI outcomes at the foot and ankle following harvesting of full thickness peroneus longus tendon graft

AIMS

To evaluate the donor site morbidity and tendon morphology after harvesting whole length, full-thickness peroneus longus tendon (PLT) proximal to the lateral malleolus for ligament reconstructions or tendon transfer.

METHODS

A total of 21 eligible patients (mean age 34.0 years (standard deviation (SD) 11.2); mean follow-up period 31.8 months (SD 7.7), and 12 healthy controls (mean age, 26.8 years (SD 5.9) were included. For patients, clinical evaluation of the donor ankle was performed preoperatively and postoperatively. Square hop test, ankle strength assessment, and MRI of distal calf were assessed bilaterally in the final follow-up. The morphological symmetry of peroneal tendons bilaterally was evaluated by MRI in healthy controls.

RESULTS

Among the patients, the mean pre- and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score and Karlsson-Peterson score were 98.7 (SD 2.5; p = 0.480) and 98.5 (SD 2.4; p = 0.480), and 98.3 (SD 2.4; p = 0.162) and 97.9 (SD 2.5; p = 0.162), respectively. There was no significant difference between square hop test bilaterally (p = 0.109) and plantar flexion peak force bilaterally (p = 0.371). The harvested limb had significantly less eversion peak force compared to the contralateral limb (p < 0.001). Evidence of probable tendon regeneration was observed in all the patients by MRI and the total bilateral peroneal tendon index (mean ratio of harvested side cross-sectional area of peroneal tendon compared with the contralateral side) was 82.9% (SD 17.4). In 12 healthy controls, peroneal tendons (mean 99.4% (SD 4.3) were found to be morphologically symmetrical between the two sides.

CONCLUSION

The current study showed satisfactory clinical foot and ankle outcomes after full-thickness PLT harvesting and indicated the regenerative potential of PLT after its removal. Level of Evidence: Level IV, therapeutic retrospective case series. Cite this article: Bone Joint J 2020;102-B(2):205-211.

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.

Results of Peroneal Tendoscopy With a Technical Modification

BACKGROUND:

The aim of this study was to evaluate the role of tendoscopy in the diagnosis and treatment of peroneal tendon (PT) pathologies, and to evaluate the results of our technical modification.

METHODS:

Twenty ankles of 18 patients with retrofibular pain, operated on between 2006 and 2012, were included in this study. Peroneal tendoscopy was performed diagnostically for the patients who were diagnosed as having "peroneal tendinopathy" with physical examination, x-ray, or magnetic resonance imaging (MRI). After being diagnosed by peroneal tendoscopy, patients were definitively treated with either tendoscopy or open surgery.

RESULTS:

Thirteen of 20 ankles had accompanying ankle pathology with PT pathology, and the other 7 ankles had no concomitant pathology. We detected peroneal tenosynovitis (PTS) in 13 patients, PT tear in 7 patients, and vincula thickening in 1 patient. The American Orthopaedic Foot & Ankle Society (AOFAS) score was 76 preoperatively, and after 2 years' follow-up the AOFAS score was 96.

CONCLUSION:

Tendoscopy is a useful method for the diagnosis and treatment of PT pathologies. The patients with clinical suspicion of PT pathology were treated or diagnosed by peroneal tendoscopy with our technical modification.

LEVEL OF EVIDENCE:

Level IV, retrospective case series.

Peroneus longus tendon rupture: A case report

BACKGROUND

Peroneal tendinopathies are an under-diagnosed and potentially under-treated pathology. If left untreated it can be a cause of chronic lateral hindfoot pain. Its diagnosis is challenging owing to its low incidence and vague clinical presentation.

CASE SUMMARY

We share a case of a patient who experienced a chronic lateral ankle pain exacerbated after alighting from a bus. This patient came to our attention only after failing conservative management on two separate occasions. Plain radiographs and magnetic resonance imaging revealed rupture of the peroneus longus tendon (PLT). Findings were confirmed intra-operatively and tenodesis of the PLT to the peroneus brevis was performed. Patient was kept non-weight-bear with his foot everted and in plantarflexion before being converted to an off-loading boot at two weeks. Patient was started on a progressive rehabilitation programme at six weeks and was able to return to work shortly after with excellent outcomes.

CONCLUSION

We aim to share our experience in managing this patient and propose some pointers guided by available literature to avoid missing this commonly overlooked pathology.

Prevalence of Peroneal Tendon Instability in Calcaneus Fractures: A Systematic Review and Meta-Analysis

Peroneal tendon instability associated with an intraarticular calcaneal fracture is a common injury that still often passes undiscovered by both radiologists and orthopedic surgeons. Timely identification of this injury will guide the choice of surgical technique used and treatment of patients. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, several databases were searched through June 2017 for any observational or experimental studies that reported the prevalence/incidence of peroneal tendon subluxation/dislocation with a calcaneus fracture with regard to fracture classifications and the significance of the fleck sign. Nine studies were included, with 1027 patients and 1050 calcaneus fractures. The overall prevalence of peroneal instability (PI) in association with a calcaneus fracture was 29.3%. An increasing prevalence of PI increased the severity of the calcaneus fractures, 5.4% in Sanders I, 19% in Sanders II, 39.4% in Sanders III, and 49.5% in Sanders IV. The presence of a fleck sign is a strong indicator of PI, with a prevalence of 54.7%. The computed tomography findings can overestimate the presence of PI compared with the intraoperative findings. The global reported prevalence of peroneal tendon instability associated with intraarticular calcaneal fractures is high and increases with increasing severity of the calcaneus fracture.

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.

Incidence of reoperation and wound dehiscence in patients treated for peroneal tendon dislocations: comparison between osteotomy versus soft tissue procedures

PURPOSES

There is a lack of substantial clinical evidence endorsing the clinical outcomes of osteotomy for peroneal tendon dislocations. The aim of this study was to compare the post-operative reoperation rates following osteotomy techniques and soft tissues procedures using large database in order to investigate the efficacy of bony techniques.

METHODS

Patients who underwent osteotomy and soft tissue procedures for peroneal tendon dislocations were identified and subsequently analysed using the United Healthcare Orthopedic and the Medicare datasets (PearlDiver Patient Record Database, PearlDiver Technologies Inc., Fort Wayne, IN). The investigated period was from 2005 to 2012. The annual incidence, gender distribution, and incidences of reoperation and wound dehiscence following primary operative procedures were determined in these cohorts.

RESULTS

Of 6122 patients who received operative treatment for peroneal tendon dislocations, 1416 patients (23.1%) received the osteotomy technique, while 4706 (76.9%) were treated with the soft tissue techniques. The incidence of these operative procedures did not change significantly over the time periods of each database. In both databases, reoperation rates were 2.8% (40/1416) for osteotomy patients and 3.4% (158/4706) for soft tissue repair patients, with no statistical difference (2.8 vs. 3.4%. odds ratio 0.8, 95% confidence interval [CI] 0.6-1.2, [n.s.]) between them. Based on both databases, wound dehiscence occurred in 2.6% (37/1416) of the osteotomy patients and 2.3% (110/4706) of soft tissue repair patients with no statistical difference (2.6 vs. 2.3%, odds ratio 1.1, 95% CI 0.8-1.6, [n.s.]) between the groups.

CONCLUSION

The results of this study show that osteotomy techniques were frequently performed for patients with peroneal tendon dislocations. Nevertheless, osteotomy techniques for peroneal tendon dislocations are not associated with a lower risk of reoperation. In conclusion, soft tissue procedures offer a satisfactory method of treating peroneal tendon dislocations without any additional risk of reoperation when compared to osteotomy techniques that have potentially greater complication rates.

LEVEL OF EVIDENCE

III.

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.

Peroneal tendon disorders

Pathological abnormality of the peroneal tendons is an under-appreciated source of lateral hindfoot pain and dysfunction that can be difficult to distinguish from lateral ankle ligament injuries.

Enclosed within the lateral compartment of the leg, the peroneal tendons are the primary evertors of the foot and function as lateral ankle stabilisers.

Pathology of the tendons falls into three broad categories: tendinitis and tenosynovitis, tendon subluxation and dislocation, and tendon splits and tears. These can be associated with ankle instability, hindfoot deformity and anomalous anatomy such as a low lying peroneus brevis or peroneus quartus.

A thorough clinical examination should include an assessment of foot type (cavus or planovalgus), palpation of the peronei in the retromalleolar groove on resisted ankle dorsiflexion and eversion as well as testing of lateral ankle ligaments.

Imaging including radiographs, ultrasound and MRI will help determine the diagnosis. Treatment recommendations for these disorders are primarily based on case series and expert opinion.

The aim of this review is to summarise the current understanding of the anatomy and diagnostic evaluation of the peroneal tendons, and to present both conservative and operative management options of peroneal tendon lesions.

Cite this article: EFORT Open Rev 2017;2:281-292. DOI: 10.1302/2058-5241.2.160047

Endoscopic fibular groove deepening for stabilisation of recurrent peroneal tendons instability in a patient with open physes

This is a report of a rare case of recurrent traumatic peroneal tendon dislocation in a patient with open physes. Through fibular tendon endoscopy, an intramuscular needle was introduced under direct visualisation and implanted inferiorly to the growth plate while reclining the tendons posteriorly. A fibular groove deepening was performed in order to stabilize the tendons. The patient was able to return to full activity after 3 months. MRI taken 12 months after surgery showed neither signs of recurrence of the lesion nor growth plate disturbance. This is a first case report of peroneal tendons stabilisation by tendoscopic retro-malleolar groove deepening in a child. Level of evidence Case report, Level IV.

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.

A Proximal Fibularis Brevis Muscle Is Associated with Longitudinal Split Tendons: A Cadaveric Study

The anomalous distal musculotendinous junction of the fibularis brevis muscle has been hypothesized to contribute to the development of longitudinal fibularis brevis tendon tears. Specifically, the mass effect of the low-lying fibularis brevis muscle belly was thought to increase the pressure on the superior peroneal retinaculum and increase the probability of fibularis brevis tendon subluxation. A more recent examination of the fibularis brevis tendon junction found, contrary to this hypothesis, a statistically significant association between an anomalous proximal musculotendinous junction and the prevalence of longitudinal split tears. However, no rationale was offered. The present study examined the relationship between the musculotendinous junction and the prevalence of longitudinal fibularis brevis tendon tears. A total of 24 fibularis brevis tendon lengths were measured bilaterally in 12 human cadaveric specimens. The tendon lengths were assessed as the vertical distance from the most inferior aspect of the lateral malleolus to the most distal fibularis brevis musculotendinous extension. Only full-thickness tears were identified and included. The lengths of tendons with and without longitudinal tears were compared. Of the 24 tendons examined, 7 (29%) presented with full-thickness longitudinal tears from 4 cadavers (33%). The mean length for the tendons with tears was significantly longer (p < .001) than the mean length of those without tears (28.86 ± 3.02 mm versus 16.29 ± 7.30 mm). Our research concurs with the most recent findings, identifying a statistically significant association between an anomalous proximal muscle belly extension and longitudinal fibularis brevis tendon tears. Furthermore, we propose the hypothesis that a more proximal musculotendinous junction might predispose individuals to a lesser stabilizing effect of the muscle against the posterior lateral surface of the fibula, increasing the probability of anterolateral subluxation, attrition, and longitudinal tear development.

Peroneal tendon dislocation/subluxation - Case series and review of the literature

BACKGROUND

Dislocating or subluxing peroneal tendons is a relatively infrequent injury. Although infrequent it is very debilitating for the athlete. This retrospective study addresses primarily the surgical technique.

METHODS

Twenty-three patients between 2005 and 2014 were operated on for symptomatic dislocating or subluxing peroneal tendons. Five patients presented in the acute phase and 18 patients were late cases. Twenty patients were available for follow-up at a mean of 53.1 months. Three patients were classified as Stage III and 17 as Stage I/II. The procedures varied from pure repair of the superior peroneal retinaculum (SPR), reattachment of the SPR, groove-deepening or a combination of the above. No one procedure was favoured over the other. The choice of procedure was decided intraoperatively depending on the findings.

RESULTS

The mean postoperative VAS score was 1.5 with a mean AOFAS score of 85. Sixteen patients rated their results as excellent, one as good, one uncertain and two poor. The results showed no one procedure superior to another with respect to chronicity, stage or satisfaction score.

CONCLUSIONS

Several procedures have been described for this condition. Most published studies however, comprise of a small cohort of patients with good results following surgery. The surgical techniques vary and depend largely on the surgeon's clinical experience and preference. The authors conclude that the surgical technique described in this article is largely successful with a low complication rate and a high satisfaction rate.

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.

Identification of Peroneal Tenosynovitis by Point-of-Care Ultrasonography

BACKGROUND

Ankle pain is a frequent chief complaint, and although peroneal tendon disorders are relatively uncommon, if treated inappropriately they may cause persistent pain and dysfunction. Peroneal tendon disorders, including the tendon sheath inflammatory condition tenosynovitis, are a major cause of chronic lateral ankle pain. Although magnetic resonance imaging has emerged as the modality of choice to assess the majority of these injuries, dynamic ultrasonography detects tendon pathology such as tenosynovitis.

CASE REPORT

A 69-year-old woman presented to the Emergency Department (ED) after several months of atraumatic, progressive right foot and ankle pain. On physical examination, she had swelling and point tenderness posterior and inferior to the lateral malleolus, which was exacerbated by eversion. Plain radiography of the foot and ankle showed only soft tissue swelling. Bedside ultrasonography performed by the emergency physician quickly identified findings consistent with peroneal tenosynovitis without tears. Management with a walking boot and nonsteroidal antiinflammatory drugs was initiated prior to discharge. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In this case of peroneal tenosynovitis, point-of-care ultrasonography was used to promptly and accurately identify hyperemia, synovial thickening, and a marked effusion within the right peroneal tendon sheath. Nonoperative treatment of tenosynovitis was initiated in the ED while findings were subsequently confirmed with magnetic resonance imaging. Emergency physicians should be aware of the utility of identifying tenosynovitis by point-of-care ultrasonography, which can expedite nonoperative management and prevent long-term complications.

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.

Peroneal tendoscopy--more than just a solitary procedure: case-series

This study presents a series of 13 patients who underwent peroneal tendoscopy as a solitary or accessory procedure at our department in 2013. Patients were clinically diagnosed with peroneal tendons disorders and underwent an additional radiological assessment. Peroneal tendoscopy was carried out in a standard manner before any other arthroscopic or open procedure. Postoperative management depended on the type of pathology. We found 3 peroneus brevis tendon partial tears, 4 cases of a low-lying peroneus brevis muscle belly, 5 cases of tenosynovitis, and 1 case of an intrasheath peroneal tendon subluxation. In 5 patients peroneal tendoscopy was performed as a solitary procedure and in 8 patients as an accessory procedure – together with anterior or posterior ankle arthroscopy, combined posterior and anterior ankle arthroscopy, or open surgery. Both as a solitary and accessory procedure, peroneal tendoscopy was safe and successful, ie, all patients were without any symptoms at one-year follow-up. Our series of patients showed that peroneal tendoscopy can be used both as an independent procedure as well as a valuable accessory procedure.

Comparison of Outcome After Retinaculum Repair With and Without Fibular Groove Deepening for Recurrent Dislocation of the Peroneal Tendons

BACKGROUND

This study compared the operative outcome between retinaculum repair with and without fibular groove deepening for the treatment of recurrent traumatic peroneal tendon dislocation in young, active patients.

METHODS

A consecutive series of 29 patients who underwent operative treatment of recurrent peroneal tendon dislocation were evaluated. Thirteen patients were treated by the superior peroneal retinaculum repair with fibular groove deepening (group A) and 16 patients by superior peroneal retinaculum repair alone (group B). The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, visual analog scale (VAS) score for pain, and overall patient satisfaction were used to evaluate the clinical outcome after a minimum follow-up period of 12 months postoperatively. In addition, mean time to return to sports activity and tourniquet time were compared between groups.

RESULTS

Mean AOFAS score improved significantly from 59.3 points preoperatively to 92.2 points at the final follow-up in group A and from 58.5 points preoperatively to 91.3 points at the final follow-up in group B. Mean VAS score also improved significantly from 5.0 points preoperatively to 1.0 points at the final follow-up in group A and from 4.9 points preoperatively to 1.2 points at the final follow-up in group B. Improvements in AOFAS and VAS scores at the final follow-up were not significantly different between the 2 groups. Mean time to return to sports activity was approximately 3 months in both groups. Mean tourniquet time in group B was significantly shorter than that in group A (42.2 vs 29.5 min).

CONCLUSIONS

Isolated retinaculum repair compared to retinaculum repair with fibular groove deepening was a faster and simpler technique, but both techniques had good outcomes for the treatment of recurrent traumatic peroneal tendon dislocation.

LEVEL OF EVIDENCE

Level II, prospective, nonrandomized, comparative study.

Allograft reconstruction of peroneal tendons: operative technique and clinical outcomes

BACKGROUND

Irreparable peroneal tendon tears are uncommon and require complex surgical decision making. Intercalary segment allograft reconstruction has been previously described as a treatment option; however, there are no reports of the outcomes of this technique in the literature. We describe our technique and present our results using this method.

METHODS

A retrospective chart review was conducted to identify all patients who underwent intercalary allograft reconstruction of the peroneal tendons. Mechanism of injury, concomitant operative procedures, pertinent radiographic findings, pre- and postoperative physical examination, intercalary graft length, medical history, visual analog scale (VAS) score for pain, Short Form-12 (SF-12) physical health survey, Lower Extremity Functional Score (LEFS), and complications were reviewed.

RESULTS

Fourteen patients with peroneal tendon ruptures requiring reconstruction were identified. Mean follow-up was 17 months (range, 7-47 months; median, 12 months). The average length of the intercalary segment reconstructed was 10.8 ± 3.8 cm (range, 6-20 cm). The average postoperative VAS score decreased to 1.0 ± 1.4 (P = .0005). No patient had a higher postoperative pain score than preoperative pain score. Average postoperative eversion strength as categorized by the Medical Research Council grading scale improved to 4.8 ± 0.5 (P = .001). The average SF-12 score improved to 48.8 ± 7.8 (P = .02). The average LEFS improved to 86.4. ± 14.9 (P = .00001). Four patients experienced sensory numbness in the sural nerve distribution, and 2 of these were transient. There were no postoperative wound healing complications, infections, tendon reruptures, or reoperations. No allograft associated complications were encountered. All patients returned to their preinjury activity levels.

CONCLUSION

Allograft reconstruction of the peroneal tendons can improve strength, decrease pain, and yield satisfactory patient-reported outcomes. It can be performed without incurring the deleterious effects associated with tendon transfer procedures. We believe that allograft reconstruction is a safe and useful alternative in the treatment of irreparable peroneal tendon ruptures.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Tendoscopic groove deepening for chronic subluxation of the peroneal tendons

INTRODUCTION

Recurrent subluxation of the peroneal tendons over the lateral malleolus is an uncommon disabling condition in young people involved in sports. Injury to the superior peroneal retinaculum, sometimes in association with a shallow fibular groove, can lead to this condition. There are several surgical treatments for recurrent peroneal tendon subluxation, but no tendoscopy technique has been reported to date. The aim of this study was to describe a tendoscopic groove-deepening technique and its results for treating patients with recurrent subluxation of the peroneal tendons.

METHODS

Seven patients (3 women and 4 men; mean age 26.4 [21-32] years) with chronic subluxation of the peroneal tendons were treated with a tendoscopic procedure. All patients experienced pain at the lateral retromalleolar area and recurrent subluxation of the peroneal tendons. The right ankle was affected in 4 patients. Mean follow-up was 15.4 (8-25) months.

RESULTS

On tendoscopic examination, all patients had a flat fibular groove, and the superior peroneal retinaculum was found to be detached in 4 cases. Three patients had a superficial injury of the peroneus brevis tendon which was debrided. Tendoscopic deepening of the peroneal groove without superior peroneal retinaculum repair was performed in all cases. None of the patients experienced recurrent subluxation during follow-up. The AOFAS score increased from 75 preoperatively to 93 at final follow-up. No complications were reported in any case.

CONCLUSION

Tendoscopic deepening of the fibular groove was a reproducible, minimally invasive technique that provided a favorable outcome for recurrent subluxation of the peroneal tendons in our limited number of patients.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Snapping of the extensor digitorum longus due to attenuated inferior extensor retinaculum: case report

Level of Evidence: V, Expert Opinion

Novel use of a manual therapy technique and management of a patient with peroneal tendinopathy: a case report

Peroneal tendinopathy is an uncommon but underappreciated source of lateral hindfoot pain and dysfunction. There is a paucity of literature describing optimal intervention for those suffering with pain secondary to peroneal tendinopathy. The purpose of this case report is to describe the evaluation and treatment incorporating manual therapy and therapeutic exercise for a patient diagnosed with peroneal tendinopathy. The patient was a 50 year-old female with a history of chronic lateral ankle pain and whose presentation was consistent with peroneal tendinopathy. Despite attempts to improve pain and function with over-the-counter orthotics, manual therapy to a hypomobile talocrural joint, and strengthening of the peroneal tendons, successful response was not reported until a lateral calcaneal glide was added. Improvement in impairments (pain, talocrural dorsiflexion, unilateral heel raises, and Star Excursion Balance Test) and function (Lower Extremity Functional Scale and Global Rating of Change), were observed over a course of eight visits. The patient was able to return to work and her recreational work out routine without limitations. In conclusion a successful physical therapy intervention for a patient with peroneal tendinopathy included a unique manual therapy technique, the lateral calcaneal glide, in conjunction with other manual therapy techniques and a structured home exercise program.

Abnormal proximal musculotendinous junction of the peroneus brevis muscle as a cause of peroneus brevis tendon tears: a cadaveric study

Abnormal musculotendinous distal extension of the peroneus brevis has been implicated as a possible cause of peroneus brevis tendon tears. We investigated this relationship in 58 (46 male) fresh human cadavers. Torn lesions were classified according to Sobel et al. Musculotendinous distal extension of the peroneus brevis was measured in each ankle as the vertical distance from the musculotendinous junction of the peroneus brevis to the tip of the fibula. Tendons with and without tears were compared by sex, age at death, height, musculotendinous distal extension of the peroneus brevis, the common sheath bifurcation-fibular tip distance, the peroneus brevis and longus width at the musculotendinous junction, fibular groove depth, peroneal tubercle height, superior-inferior peroneal retinaculum wideness, and the presence of the peroneus quartus or an accessory peroneal muscle. Of 115 evaluable tendons, 15 (13%) had tears. All came from men. The average distance from the musculotendinous junction to the tip of the fibula was 27.0 mm in tendons with tears and 16.4 mm in tendons without (P = .04) Male sex (P = .03), age at death (P = .03), height (P = .04), and fibular groove depth (P = .003) were also related to the presence of tears. Our results do not support a relationship between abnormal musculotendinous distal extension of the peroneus brevis and peroneus brevis tendon tears; rather, proximal extension of the peroneus brevis musculotendinous junction may be related to peroneus brevis tendon tears.

Radiofrequency coblation for chronic foot and ankle tendinosis

PURPOSE

To evaluate outcomes of radiofrequency coblation for chronic tendinosis of the foot and ankle tendons.

METHODS

Records of 7 men and 8 women (16 feet) aged 27 to 65 years who underwent radiofrequency coblation for chronic tendinosis (combined with other procedures for other pathology) of the Achilles, posterior tibial, and peroneal tendons were retrospectively reviewed. The visual analogue scale (VAS) for pain status, the Short Form (SF-36) questionnaire for quality of life, and the American Orthopaedic Foot and Ankle Society (AOFAS) scores for functional status of the patients were determined pre- and post-operatively.

RESULTS

All patients reported significant reduction in pain at 3 months, with more than 63% attaining VAS scores of 0 at 6 months. AOFAS scores were significantly improved at both 3 and 6 months. Most components of SF-36 scores improved at 6 months except those for general health and role emotional; only those for bodily pain improved significantly. At postoperative month 3 and 6 respectively, 93 and 100% of the patients had their expectations met, whereas 93 and 88% had good-to-excellent satisfaction. There were no major complications.

CONCLUSIONS

Radiofrequency coblation for chronic tendinosis of the foot and ankle achieves good short-term outcomes and pain relief. It may be combined with other procedures for maximal benefit.

Peroneal tendon tears: associated arthroscopic findings and results after repair

PURPOSE

The purpose of this study was to identify the intra-articular pathology associated with peroneal tendon tears and report the outcomes after tendon repair or tenodesis with arthroscopic treatment.

METHODS

Thirty patients were evaluated who underwent ankle arthroscopy followed by peroneal tendon repair. Intra-articular pathology was treated arthroscopically before peroneal tendon surgery was performed. All patients were available for a minimum 2-year follow-up. Preoperative and postoperative American Orthopaedic Foot & Ankle Society and Karlsson scores were analyzed for all patients.

RESULTS

A total of 60 intra-articular lesions were treated arthroscopically in 30 ankles. We diagnosed 13 lesions preoperatively (22%), and 47 lesions (78%) were discovered during arthroscopy. Of the patients, 5 (17%) had associated anterolateral instability requiring an open reconstruction. Soft-tissue impingement was seen in 6 patients (20%), anterior osteophytes in 4 (13%), loose bodies in 4 (13%), osteochondral lesions in 4 (13%), extensive scar tissue in 24 (80%), extensive synovitis in 7 (23%), chondral injuries in 2 (7%), and a torn posterior transverse tibiofibular ligament in 2 (5%). Postoperative American Orthopaedic Foot & Ankle Society and Karlsson scores were significantly improved compared with preoperative scores. Patients with chronic complaints before surgery had better outcome scores than patients with an isolated, acute twisting injury. It is unclear whether the incidental pathology discovered at the time of arthroscopic examination influenced outcome measures.

CONCLUSIONS

All patients with peroneal tendon tears had associated intra-articular pathology, with the majority of patients having more than 1 intra-articular lesion. For patients meeting surgical criteria, correction of the tendon tears and arthroscopic treatment of the intra-articular lesions produced statistically significantly improved results and patient satisfaction, paralleling historical controls.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

The Singapore operation for chronic recurrent peroneal tendon subluxation--short-term follow-up in four patients

BACKGROUND

Recurrent peroneal tendon subluxation is an uncommon condition which is usually the result of sports related trauma. This injury may be misdiagnosed resulting in long-term disability. Most authors would recommend surgical treatment for patients who have a long history or in patients in whom conservative treatment has failed. Surgical treatment can also be considered in the acute phase when managing young athletic individuals.

METHODS

We report the outcome in four patients who underwent the Singapore operation for chronic peroneal tendon subluxation. All patients were operated on by the same surgeon and followed up at regular intervals with a minimum follow-up of two years.

RESULTS

In all four patients a Bankart type lesion was found in association with subluxation solely of the peroneus longus tendon. Following repair all patients returned to pre-injury activity levels within six months.

CONCLUSION

In our experience the Singapore operation is technically easy to perform and offers excellent results with high patient satisfaction levels.

A new peroneal tendon rerouting method to treat recurrent dislocation of peroneal tendons

BACKGROUND

The surgical treatment methods for recurrent dislocation of peroneal tendons are controversial. A simpler and more effective treatment method is valuable for these patients.

HYPOTHESIS

A new rerouting operation designed by the authors will have satisfactory results and avoid disadvantages of the old rerouting methods.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Seventeen consecutive male patients with unilateral recurrent peroneal tendon dislocations were treated by transposition of the calcaneofibular ligament from the tubercle of calcaneofibular ligament with a 1 x 1 x 1 cm3 bone block and elevation of this tubercle with another 1 x 1 x 1 cm3 calcaneal bone block, which were fixed by a 3.5-mm cancellous screw with a washer. All patients received clinical and radiographic follow-up for at least 2 years. The preoperative and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scales were used for functional results assessment.

RESULTS

All bone transposition sites healed radiographically at 6 weeks after surgery. Four patients had transient numbness over the lateral aspect of the injured foot, and 3 patients had swelling and pain involving the operative sites. All complications resolved by 3 to 5 months after the operation. No recurrent dislocation of the peroneal tendons was noted. The mean AOFAS ankle-hindfoot scale improved significantly, from 73.4 +/- 5.5 preoperatively to 100 at 2- to 5-year follow-up (P < .001). Normal ankle stability and no tightening of the lateral side of the injured ankles in the inversion position were noted.

CONCLUSION

This method is a simple, reliable, and reproducible operation to treat recurrent dislocation of the peroneal tendons. It allows early return to daily, working, and sports activities with satisfactory results.

Tendon disorders of the foot and ankle, part 1: peroneal tendon disorders

Pathologic abnormality of the peroneal tendons is an uncommon but underappreciated source of lateral hindfoot pain and dysfunction that can be difficult to distinguish from lateral ankle ligament injuries. When left untreated, peroneal tendon disorders can lead to persistent lateral ankle pain and substantial functional problems. Unfortunately, the treatment recommendations for these disorders are primarily based on case series and expert opinion. The goals of this review are to develop a current understanding of the anatomy and diagnostic evaluation of the peroneal tendons, and to present current treatment options and the authors' preferred surgical techniques for operative management of peroneal tendon lesions.

Operative treatment for peroneal tendon disorders

Peroneal tendon disorders are rare, are frequently missed, and can be a source of lateral ankle pain. Magnetic resonance imaging is the standard method of radiographic evaluation of peroneal tendon disorders; however, diagnosis and treatment are based primarily on the history and physical examination. Peroneal tenosynovitis typically responds to conservative therapy, and operative treatment is reserved for refractory cases. Operative treatment is frequently required for peroneal tendon subluxation and consists of anatomic repair or reconstruction of the superior peroneal retinaculum with or without deepening of the retromalleolar groove. Operative treatment of peroneal tendon tears is based on the amount of remaining viable tendon. Primary repair and tubularization is indicated for tears involving <50% of the tendon, and tenodesis is indicated for tears involving >50% of the tendon.

Acute peroneal tendon tears

Acute peroneal tendon tears lay at one end of a spectrum of peroneal tendon pathology. Because a tear represents a mechanical abnormality, surgical treatment is frequently required. Anatomical variants need to be considered as potential causes of lateral ankle pain. Most acute peroneus brevis tears are longitudinal, occur adjacent to the tip of the fibula, and require surgical treatment. Acute peroneus longus tears more commonly occur at the level of the cuboid tunnel and may initially be managed nonoperatively, but, if associated with stenosing tendonitis, may require debridement and tenodesis. Rarely, complete ruptures of both peronei occur and, if there is a significant defect, reconstructive procedures are required.

Tendon healing

An understanding of the processes of tendon healing and tendon-to-bone healing is important for the intraoperative and postoperative management of patients with tendon ruptures or of patients requiring tendon transfers in foot and ankle surgery. Knowledge of the normal process allows clinicians to develop strategies when normal healing fails. This article reviews the important work behind the identification of the normal phases and control of tendon healing. It outlines the failed response in tendinopathy and describes tendon-to-bone healing in view of its importance in foot and ankle surgery.