Chronic peroneus brevis tendon lesions

Peroneus brevis split rupture is underreported on magnetic resonance imaging of the ankle in patients with chronic lateral ankle pain

Introduction

Peroneus brevis split rupture poses a diagnostic challenge, often requiring magnetic resonance imaging (MRI), yet splits are missed in initial radiological reports. However, the frequency of reported peroneus brevis split rupture in clinical MRI examinations is unknown.

Aim

This study aimed to investigate underreporting frequency of peroneus brevis split rupture in patients with lateral ankle pain.

Methods

We re-evaluated 143 consecutive MRI examinations of the ankle joint, conducted in 2021 in our region, for patients experiencing ankle pain persisting for more than 8 months. Two musculoskeletal radiologists, with 12 and 8 years of experience respectively, assessed the presence of peroneus brevis split rupture. Patients with recent ankle trauma, fractures, postoperative changes, or MRI artifacts were excluded. The radiologists evaluated each MRI for incomplete or complete peroneus brevis split rupture. The consensus between the raters was used as the reference standard. Additionally, raters reviewed the original clinical radiological reports to determine if the presence of peroneus brevis split rupture was noted. Agreement between raters' assessments, consensus, and initial reports was evaluated using Gwet's AC1 coefficients.

Results

Initial radiological reports indicated 23 cases (52.3 %) of peroneus brevis split rupture, meaning 21 cases (47.7 %) were underreported. The Gwet's AC1 coefficients showed that the agreement between raters and initial reports was 0.401 (standard error 0.070), 95 % CI (0.261, 0.541), p<.001, while the agreement between raters in the study was 0.716 (standard error 0.082), 95 % CI (0.551, 0.881), p<.001.

Conclusion

Peroneus brevis split rupture is underreported on MRI scans of patients with lateral ankle pain.

Normal Distal Excursion of the Peroneus Brevis Myotendinous Junction

A low-lying peroneus brevis muscle belly has been described as a risk factor for the development of peroneal tendon pathology, but this finding has primarily been described based on cohorts with pre-existing clinical findings. Therefore, the objective of this investigation was to evaluate the frequency of apparently abnormal low-lying muscle bellies from a series of subjects without clinical or imaging findings of peroneal tendon pathology. One hundred consecutive MRIs were reviewed with measurement of the distance from the distal peroneal myotendinous junction to the tip of the fibula. This distance was observed to be 23.9 ± 8.8 mm (10.8-55.4 mm; 95% confidence interval 22.2-26.7 mm). If one assumed that a myotendinous junction within 2 cm of the distal tip of fibula represented an abnormal low-lying muscle, then we observed 37% of extremities without clinical or radiographic evidence of peroneal tendon pathology that would be considered anatomically "abnormal." When a low-lying muscle belly was defined as occurring within 2 cm of the distal tip of the fibula, then a probability analysis of our data distribution found a 32.6% probability for individuals to have an "abnormally" low-lying muscle belly. These results indicate that what has traditionally been defined intraoperatively as an abnormally low-lying peroneus brevis muscle belly might simply represent intraoperative confirmation bias of relatively normal structural anatomy.

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

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

The Role of Peroneal Tendinopathy and the Cavovarus Foot and Ankle

Peroneal tendon pathology is often an overlooked and underdiagnosed condition. It is often confused with chronic ankle instability. It is important when surgically managed to assess the condition of the tendons, muscle viability and strength, and associated cavovarus deformity. Complex reconstruction may be needed, including 2-stage procedures with a silicone rod and tendon transfer.

Cavovarus Foot Surgery Including a Peroneus Longus Transfer: A 2- to 6-Year Follow-up

Background:

The primary aim of this longitudinal study was to describe patient satisfaction and clinical outcome at least 2 years following cavovarus foot surgery, utilizing a peroneus longus to brevis transfer, lateral ligament reconstruction, and corrective osteotomies of the first metatarsal, occasionally with the added calcaneal osteotomy.

Methods:

Sixteen patients (17 feet) were examined in 2010-2012, 3.5 (range, 2-6.5) years after cavovarus foot surgery performed in 2004-2010 utilizing a peroneus longus to brevis transfer, lateral ligament reconstruction, and osteotomy of the first metatarsal with or without additional calcaneal osteotomy. The mean age at surgery was 45 years. Evaluation at baseline before surgery and at follow-up assessed patient satisfaction, using the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score. At follow-up, visual analog scale (VAS) score for pain at walking was recorded, and a clinical and radiographic evaluation was included.

Results:

The mean AOFAS score improved from 57 (SD 11) to 83 (SD 12.5) points, with an average score improvement of 25 score points (95% confidence interval 16-35, P < .0001). Postoperative VAS score for pain at walking was mean 2 (range, 0-6). All feet had a residual cavovarus both clinically and on the radiographs.

Conclusion:

Patient satisfaction and clinical outcome was shown to improve pre- to postsurgery at intermediate follow-up after peroneus longus to brevis transfer and metatarsal osteotomies with or without additional calcaneal osteotomies as part of a cavovarus foot correction.

Level of Evidence:

Level IV, case series.

The vascularization of the peroneal tendons: An anatomic study

BACKGROUND

Arterial vascularization is intimately related to the peroneal tendon ruptures. Our purpose is to describe the vascular anatomy of peroneal tendons and assess differences in the vascularization patterns between peroneus brevis tendon (PBT) and peroneus longus tendon (PLT).

METHODS

Anatomical study of 22 cadaveric lower extremities. We exposed tendons' vascularization by injecting latex. To systematize the vascular description, we considered four anatomical regions in the PBT and six in the PLT.

RESULTS

Vascularization was supplied by the peroneal, anterior tibial and lateral plantar arteries and from the deep plantar arch through the vincula connecting the tendons. No avascular areas were found in the PLT. 22.7% of specimens had avascular areas in the PBT. Two visual vascularization patterns were found (arcuate and weblike). Increasing age and a web-like vascularization were associated with a lower number of blood vessels at the tendons' post malleolus area.

CONCLUSION

Peroneal tendons are well vascularized throughout their course, running through a common vincula, with vascularization provided by various arteries. Avascular areas were observed in the PBT, but none at the PLT.

Association of Cavovarus Foot Alignment With Peroneal Tendon Tears

BACKGROUND

Although it is a widely accepted clinical principle that cavovarus deformity predisposes to peroneal tendon problems, there are limited data to support that assumption. This study tested the hypothesis that cavovarus is associated with peroneal tendon tears and evaluated which radiographic measures correlated with that association.

METHODS

A retrospective comparison of radiographic measures of cavovarus in 234 consecutive patients operatively treated for chronically symptomatic peroneal tendon tears was compared to a matched control group. Measures included calcaneal pitch, anteroposterior (AP) talometatarsal and talocalcaneal angles, and talonavicular coverage angle. A novel coordinate system analyzed midfoot and hindfoot components of cavovarus. Analysis of variance was used to compare cohorts, and a Tukey-Kramer test used to analyze 3 subgroups of brevis and longus tears, and concomitant tears.

RESULTS

The distribution of tears was 73% peroneus brevis, 8% longus, and 19% both tendons. Compared with controls, the study group, and subgroups, had multiple measures of increased cavovarus, including greater calcaneal pitch (P = .0001), decreased AP talo-first metatarsal angle (P = .0001), and increased talonavicular coverage angle (P = .0001). Elevated medial longitudinal arch, and rotational changes in the radiographic profiles of the hindfoot were found with the coordinate system described by Yokokura.

CONCLUSION

This study found a statistically significant association of increased cavovarus deformity with peroneal tendon tears, compared to controls. It documented the relative incidence of tears of peroneus brevis, peroneus longus, and concomitant tears in a large surgical series. It demonstrated which simple radiographic angles and complex coordinate measurements of cavovarus deformity were significantly associated with peroneal tendon tears.

LEVEL OF EVIDENCE

Level III, retrospective comparative cohort study.

Diagnosis and Operative Treatment of Peroneal Tendon Tears

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

Diagnosis and Operative Treatment of Peroneal Tendon Tears

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

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.

Treatment of Insertional Peroneus Brevis Tendinopathy by Ultrasound-Guided Percutaneous Ultrasonic Needle Tenotomy: A Case Report

Insertional peroneus brevis tendinopathy is uncommon and treatment options for recalcitrant insertional lesions are rarely described in the literature. Ultrasound-guided percutaneous ultrasonic needle tenotomy has been described for the treatment of recalcitrant tendinopathy in the elbow, knee, and plantar fascia, but has not been described for the treatment of peroneal tendinopathy. We report a case of recalcitrant insertional peroneus brevis tendinopathy successfully treated with an ultrasound-guided percutaneous ultrasonic needle tenotomy. The treatment resulted in a rapid recovery, and the patient remained asymptomatic at the 6-month follow up. No complications were observed during follow up and the minimally invasive percutaneous procedures offers clear advantage over open techniques.

Magnetic resonance imaging analysis of the extensor carpi ulnaris tendon and distal radioulnar joint in triangular fibrocartilage complex tears

BACKGROUND

We compared the incidence of extensor carpi ulnaris (ECU) tendon and distal radioulnar joint (DRUJ) abnormalities using magnetic resonance imaging (MRI) between patients with triangular fibrocartilage complex (TFCC) tears and subjects without ulnar wrist pain. Additionally, we aimed to identify potential predictors of these MRI lesions.

METHODS

The TFCC group comprised 70 consecutive patients with TFCC tears. The control group comprised 70 age- and sex-matched subjects without ulnar wrist pain. We evaluated the presence or absence of fluid collection in the DRUJ and ECU peritendinous area and longitudinal ECU tendon splitting. Dimensions of the fluid collection area around the ECU tendon were measured to evaluate the severity. The incidences of these abnormal MRI findings were compared between the two groups. We analyzed the correlation between the presence of ECU tendon and DRUJ lesions and variables including age, magnitude of ulnar variance, and type of TFCC tear.

RESULTS

Significant differences were found between the two groups in the incidence of fluid collection of the DRUJ and ECU peritendinous area, and longitudinal ECU tendon splitting. Among the 70 patients with TFCC tears, age and the magnitude of ulnar variance were significantly correlated with the severity of fluid collection around the ECU tendon. The magnitude of ulnar variance in patients with DRUJ fluid collection was significantly larger than that in patients without fluid collection. There was a significant correlation between the presence of disc tears and DRUJ fluid collection.

CONCLUSION

We found a higher incidence of accompanying abnormal MRI findings of the ECU tendon and DRUJ in patients with TFCC tears than in the control group. The presence of disc tears, the magnitude of ulnar variance, and age may be risk factors for these MRI lesions associated with TFCC tears.

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.

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.

Limitation of magnetic resonance imaging in diagnosing longitudinal peroneal tendon tears

The purpose of this case study was to highlight a potential limitation of magnetic resonance imaging in diagnosing longitudinal tendon tears and to emphasize the importance of clinical examination for peroneal tendinopathy. We describe a 15-year-old female with lateral ankle pain, who was negative for peroneal tendon tear on magnetic resonance imaging. Owing to high clinical suspicion of peroneal tendon pathology, we opted to take the patient to the operating room and found a 6.5-cm longitudinal tear and a low-lying muscle belly of the peroneus brevis tendon. A low-lying muscle belly of the peroneal tendon has been shown to be associated with increased tendon tears.

Audit of foot and ankle surgeons' management of acute peroneal tendon tears and review of management protocols

INTRODUCTION

The aim of this audit was to identify whether there is consistent and successful management of acute peroneal tendon tears within orthopaedic foot and ankle consultants in the Wessex area of the UK. It was suspected that there was an absence of consistency between surgeons' practices and a more evidenced based management protocol could be developed.

MATERIALS AND METHODS

A questionnaire of the orthopaedic surgeons in Wessex investigated whether there was consistency in surgical management of peroneal tears.

RESULTS

Our results demonstrate that each of the nine surgeons' management of acute peroneal tendon tears varied greatly.

CONCLUSION

The evidence in the literature was examined in an attempt to produce a protocol to aid surgical decision-making. A randomised controlled trial is required for consistent evidenced based surgical management of peroneal tendon tears.

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.

Peroneal tendons well vascularized: results from a cadaveric study

PURPOSE

Peroneal tendon tears are relatively common injuries that seem to have a poor healing tendency. The discussion goes that peroneal tendons have avascular zones, contributing to the poor healing of those tears. The purpose of this study was to provide evidence on the vascularization pattern of the peroneal tendons.

METHODS

Ten adult fresh-frozen cadavers were obtained from a university-affiliated body donation programme. The femoral artery was injected with natural coloured latex at the level of the knee. Macroscopic and microscopic dissections were performed to visualize the vascularization towards the peroneal tendons. To expose intratendinous vascularity, the tendons were cleared using a modified Spälteholz technique.

RESULTS

In all specimens, blood was mainly supplied by the peroneal artery through a posterolateral vincula connecting both tendons. Branches were bifurcated every 3.9 ± 1.8 cm, starting 24 ± 5.3 cm proximal to the tip of the fibula. Eight out of 10 (80%) specimens had poor vascularized zones in the peroneus longus tendon. No avascular zones were found in the peroneus brevis tendon.

CONCLUSION

The peroneal tendons are well vascularized by the peroneal artery, via vessels running through a common vincula for both tendons. In the peroneus brevis, no avascular zones were found. To keep the tendons well vascularized and therefore improve tendon healing, surgeons should be careful leaving the vincula intact during surgical procedures.

Magnetic Resonance Imaging Analysis of Peroneal Tendon Pathology Associated With Low-Lying Peroneus Brevis Muscle Belly: A Case-Control Study

BACKGROUND

Low-lying peroneus brevis tendon muscle belly has been speculated to be an associated factor with symptomatic peroneal tendon pathology. Multiple studies have analyzed normal and anomalous anatomy associated with peroneal tendon pathology; however, no study has confirmed the clinical association between peroneal tendon pathology and low-lying peroneus brevis muscle belly.

PURPOSE

To identify the correlation of low-lying peroneus brevis muscle belly with peroneal tendon pathology.

STUDY DESIGN

Case-control study; Level of evidence 3.

METHODS

The level of peroneus brevis muscle belly was compared between patients with symptomatic peroneal tendon pathology (experimental group) and asymptomatic individuals with otherwise normal lateral ankle using magnetic resonance images.

RESULTS

Of the 32 consecutive patients with symptomatic peroneal tendon pathology, 28 (87.5%) demonstrated peroneus brevis muscle distal to the fibular groove while 53.8% of control patients demonstrated such findings (P = .022). The most common diagnosis associated with peroneal tendon pathology was ankle instability and osteochondral defect of the talus or tibial plafond. Peroneal tendon pathology in isolation was less common.

CONCLUSION

Peroneal tendon pathology is often associated with lateral ankle instability and osteochondral defects of the ankle joint. Low-lying peroneus brevis muscle belly may be a common anatomic variant, but in the setting of instability it can become a source of pain and pathology secondary to overcrowding.

LEVELS OF EVIDENCE

Diagnostic, level III: Case-control study.

The accessory peroneal (fibular) muscles: peroneus quartus and peroneus digiti quinti. A systematic review and meta-analysis

The denomination of "accessory peroneal muscle" (APM) refers usually to two muscles: the peroneus quartus (PQua) and the peroneus digit quinti (PQui) which were believed to be variants of a same muscle. Their morphology and prevalence show high variation in relevant literature mainly owing to the diverse terminology used to describe this muscle group. The aim of this meta-analysis is to generate more accurate description and frequency of those muscles. A total of 46 studies (3,928 legs/ankles) met the inclusion criteria. The aggregate results were: (a) a true APM prevalence of 16 % with 10.2 % for PQua vs. 34.3 % for PQui; (b) a crude prevalence of 16.6 % for PQua vs. 21.5 % for PQui; (c) a bilateral prevalence of 1.73 % for PQua vs. 12.5 % for PQui; (d) the PQua was significantly more prevalent in Indian populations compared to all other ancestries, and the PQui is significantly more prevalent in Europeans and Americans compared to Japanese and Korean populations; (e) though a tendency for higher frequency was found in males and on the right specimens, no significance was found for gender and side; for (f) the "surgical" occurrence of PQua in studies dealing with peroneal tendon surgery was 5.5 % where peroneal tendon pathology seems to be not associated with the presence of an APM; (g) the MRI prevalence of APM was 10.6 %; (h) APMs took origin from peroneus brevis in 60 %, from the distal fibula in 36 % and from other structures in 4 %; (i) APMs took insertion on retrotroclear eminence of the calcaneum in 53.4 %, on peroneal trochlea in 6.6 %, merged with a peroneal tendon in 9.3 %, and inserted on the extensor apparatus of the 5th toe in 18.4 %. Despite the acknowledged limitation owing to the varied terminology used to describe this accessory muscle group, the significant differences found between the aggregate frequency estimates of each muscle do not support the hypothesis that both muscles are variants of a same structure.

Peroneus Brevis Attrition & Longitudinal Split Tear without Subluxation and Associated Hypertrophy of Peronal Tubercle" - Treatment of an Uncommon Lesion

INTRODUCTION

Peroneus brevis tendinitis with its attritional longitudinal split rupture without any subluxation from peroneal groove and associated enlarged peroneal tubercle is un common presentation.

CASE REPORT

A 40 year old female presented with moderate swelling and tenderness over the lateral and dorso-lateral aspect of left ankle with history of old trauma to ankle with swelling, persistant pain and difficulty in walking. On physical examination during passive eversion and inversion the excursion of the peroneal tendons was painful. Most tender point was just posterior to the tip of the fibula. During surgery we found the intact superior peroneal ligament with both peroneal tendons placed at normal site without subluxation, tendon sheath was inflamed and swollen, on further dissection we could see the attrition of inner surface of the peroneus brevis and a 2 cm longitudinal split tear of the same.

CONCLUSION

Although rare but peroneus brevis tendon attrition and tear can occur without subluxation from peronal groove. Refractory ankle pain on lateral aspect presenting with on and off swelling should arise suspicion of peroneal tendon tear. Correct diagnosis and proper surgical repair can produce excellent results.

Salvage options for peroneal tendon ruptures

Reports have demonstrated that peroneal tendon tears can be successfully treated by direct repair or debridement and tubularization, based on the extent and nature of the pathology. Irreparable peroneal tendon tears or completely unsalvageable tendons after failure of previously attempted repairs are rare, and as a result there is a lack of high-level evidence to guide the management of these complex injuries. When irreparable tears are encountered the salvage options include tenodesis, bridging of the defect using allografts or autografts, and tendon transfers. The choice of treatment strategy depends on the presence of a functioning tendon or tendons and the viability and excursion of the peroneal musculature.

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.

Single-stage flexor tendon transfer for the treatment of severe concomitant peroneus longus and brevis tendon tears

BACKGROUND

Although peroneal tendon injuries are a common cause of lateral ankle pain, there is a paucity of literature specifically addressing the treatment of severe concomitant peroneus longus and brevis tears. The purpose of this study was to evaluate patient outcomes following a single-stage flexor tendon transfer for the treatment of severe concomitant tears of both peroneal tendons.

METHODS

Eight patients were treated with a single-stage flexor tendon transfer for severe concomitant peroneus longus and brevis tears over a 15-year period. Mean age at the time of surgery was 54 years (range, 41-67 years), including 4 male and 4 female patients. Tendon transfer of either the flexor hallucis longus (FHL) or flexor digitorum longus (FDL) was performed when both peroneal tendons were found intraoperatively to have severe nonreconstructable tears. Mean follow-up time from surgery was 58 months (range, 12-91 months). Preoperative and postoperative AOFAS hindfoot and visual analog pain scores were prospectively collected, and patient charts were reviewed for complications. A postoperative outcome questionnaire was administered during latest follow-up to assess return to activities, satisfaction, and self-rated patient outcome.

RESULTS

Mean pre- and postoperative AOFAS hindfoot scores increased from 64 (range, 54-77) to 86 (range, 69-100), whereas mean score for pain on a visual analog scale decreased from 4.2 (range, 0.5-6) to 0.7 (range, 0-3). One surgical complication occurred following FDL transfer in a patient who developed a transient peroneal nerve palsy, and 1 patient underwent a subsequent calcaneal osteotomy. Seven of 8 patients reported a return to preoperative activity levels, and no patient required bracing for activities of daily living. All patients reported satisfaction with surgical results, and 7 rated their outcomes as good or excellent.

CONCLUSION

Single-stage flexor tendon transfer is an effective surgical option for the treatment of severe concomitant peroneus longus and brevis tendon tears.

LEVEL OF EVIDENCE

Level IV, case series.

Accuracy of MR findings in characterizing peroneal tendons disorders in comparison with surgery

BACKGROUND

Previous studies have shown that magnetic resonance imaging (MRI) has a high sensitivity for peroneal tendon pathology but more studies with surgery as a reference standard are needed.

PURPOSE

To evaluate the accuracy of MRI compared to surgery for characterizing chronic peroneal tendon pathology.

MATERIAL AND METHODS

Ninety-seven patients (57 men, 40 women; mean age, 39 years; range, 15-64 years) with chronic lateral ankle instability underwent MRI followed by surgery, with a mean MR to surgery interval of 30 days. Sagittal, coronal, and axial T1-weighted spin-echo and fat-suppressed T2-weighted fast spin-echo images were obtained for all patients. Two blinded observers evaluated the MR images without clinical information, and the results were compared to surgical findings. The following peroneal injuries were observed: tendon split, interstitial tear, swelling of the tendon, fluid collection, superior peroneal retinaculum injury, and tendon dislocation.

RESULTS

Swelling of the peroneus longus tendon was the most common finding on MR imaging, followed by fluid collection and a split of the peroneus brevis tendon. Surgical findings showed that nine cases (9%) of interstitial tears were in the peroneus brevis and two cases (2%) were in the peroneus longus, with eight cases (8%) of splits in the peroneus brevis tendon. The sensitivity and specificity for detecting interstitial tears in the peroneus brevis were 44% and 99%, respectively. The sensitivity and specificity for detecting swelling in the peroneus brevis were 50% and 99%, respectively. The sensitivity and specificity for detecting interstitial tears for peroneus longus injuries were 50% and 96%, respectively. The sensitivity and specificity for detecting swelling in these injuries were and 100% and 96%, respectively.

CONCLUSION

MRI findings of chronic peroneal tendon pathology are diagnostically specific but not sensitive. MRI showed high sensitivity for diagnosing tendon swelling in the peroneus longus, but not in the peroneus brevis. MRI is sensitive but not specific for detecting negative findings.

Mid-substance peroneal tendon defects augmented with an acellular dermal matrix allograft

BACKGROUND

This study evaluated an acellular dermal matrix allograft augmentation for chronic mid-substance peroneous longus and brevis tendon tears. The hypothesis was that acellular dermal matrix allograft augmentation of chronic longitudinal mid-substance or complete tears of both peroneal tendons provides sufficient initial strength to allow a rapid rehabilitation program.

MATERIALS AND METHODS

A consecutive series of mid-substance peroneal tendon tears with tissue loss was prospectively evaluated with demographic data, American Orthopaedic Foot and Ankle Society hindfoot-ankle scores, subjective questionnaires, and functional tests as well as physical examination, pre-operative radiographs, and MRIs. Surgical reconstruction consisted of direct tendon repair, fibular sulcus deepening, and ;;gap jumping'' tubular grafting augmentation using an acellular dermal matrix. A rapid rehabilitation protocol was followed. Eleven cases were included (9 females and 2 males). Average age was 46 (range, 29 to 62) years. Followup was 16.9 (range, 12 to 22) months. Two patients had prior surgery for instability, peroneal tendon debridement, and repair. Four patients had previous tenodesis.

RESULTS

All showed extensive longitudinal tearing or complete peroneal tendon rupture on MRI. The mean postoperative AOFAS hindfoot score was 93.5 (range, 75 to 100). Four patients had 1 cm of calf atrophy. All patients were able to perform single-heel rise, had painless ankle and foot range of motion bilaterally, and eversion/inversion strength was within one half grade of strength of the contralateral side in all patients. No postoperative hindfoot varus was identified.

CONCLUSION

An acellular dermal matrix graft provided an effective ;;gap jumping'' augmentation for repairs of chronic degenerative peroneal tendon tears.

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.

Peroneal tendon injuries

Peroneal tendon injuries are underdiagnosed and should be considered in every patient who presents with chronic lateral ankle pain. Ankle sprains are common, and up to 40% of affected individuals experience subsequent chronic ankle pain. Identifying the source of chronic ankle pain can be difficult because of the large number of possible causes. The peroneal tendons are the primary evertors of the foot and function as lateral ankle stabilizers. A careful physical examination, along with a thorough patient history and imaging studies, are critical in arriving at an accurate diagnosis. Understanding the anatomy of the peroneal tendons and knowledge of current treatment approaches for peroneal tendon tears, subluxation and dislocation of the tendons, and peroneal tenosynovitis are of great importance in achieving a favorable outcome. Low-demand patients do well with a nonsurgical approach; high-demand patients may benefit from surgery.

Surgical treatment of peroneal tendon tears

The focus of this article is the diagnosis and treatment of peroneal tendon tears. The article first describes mechanisms of injuries resulting in peroneal brevis and longus tears. Associated pathologies, such as ankle instability, hindfoot varus, hypertrophied peroneal tubercle, are discussed. Following sections on diagnosis and conservative treatment, the article describes operative treatment for isolated peroneus brevis tear, isolated peroneus longus tear, and tears of both the peroneus longus and brevis. The authors also discuss hamstring allograft reconstruction, the silicone rod technique, flexor digitorum longus transfer to the peroneus brevis, and treatment of associated pathology.

Bilateral peroneus longus tendon rupture through a bipartite os peroneum

Peroneus longus rupture with associated involvement of the os peroneum is an uncommon injury, and a small number of cases have been reported. Several mechanisms of injury have been suggested, but the most accepted theory is due to an inversion force placed on a cavovarus foot type. The sesamoid often becomes the focal point of the mechanical stresses and may fracture. Although the purpose of the sesamoid is to protect the tendon from rupture, the os peroneum may actually encourage fatigue (tear/rupture) under certain circumstances. Because this injury occurs at the cuboid notch, primary repair is complicated because of the inability to access the tendon as it courses deep within the midfoot. We present a bilateral case of peroneus longus rupture with involvement of the os peroneum in a patient with a cavovarus foot type. The injuries were sustained from an identical mechanism and occurred almost 1 year apart. In both situations, a peroneus longus to peroneus brevis tendon transfer was performed above the ankle joint in conjunction with partial excision of the fractured os peroneum. To the authors' knowledge, this is the only reported case of peroneus longus rupture associated with fracture of the os peroneum to occur bilaterally.

Magnetic resonance imaging findings in patients with peroneal tendinopathy and peroneal tenosynovitis

OBJECTIVE

To compare the magnetic resonance (MR) imaging findings of a group of patients with clinically diagnosed peroneal tendonopathy and peroneal tenosynovitis with the MR imaging findings of a control group of patients with no clinical evidence of peroneal tendon disorder.

SUBJECTS AND METHODS

The MR examinations of 24 patients with symptomatic peroneal tendinopathy or peroneal tenosynovitis and 70 patients with no clinical evidence of peroneal tendon disorder were retrospectively reviewed to determine the presence or absence of four MR imaging findings: 1) predominantly or uniform intermediate signal intensity within the peroneal tendons on one or more axial proton density-weighted images, 2) predominantly or uniform intermediate signal intensity within the peroneal tendons on three consecutive axial proton density-weighted images, 3) intermediate T2 signal intensity within the peroneal tendons, and 4) circumferential fluid within the common peroneal tendon sheath greater than 3 mm in maximal width. The sensitivity and specificity of these MR imaging findings for determining the presence or absence or symptomatic peroneal tendinopathy or peroneal tenosynovitis were calculated.

RESULTS

The sensitivity of MR imaging findings 1, 2, 3, and 4 for determining the presence of peroneal tendinopathy or peroneal tenosynovitis were 92%, 92%, 50%, and 17% respectively. The specificity of MR imaging findings 1, 2, 3, and 4 for determining the absence of peroneal tendinopathy or peroneal tenosynovitis were 57%, 79%, 93%, and 100% respectively.

CONCLUSION

The presence of predominantly or uniform intermediate signal intensity within the peroneal tendons on three consecutive axial proton density-weighted images is a highly sensitive and moderately specific indicator of symptomatic peroneal tendinopathy. The presence of intermediate T2 signal within the peroneal tendons, and the presence of circumferential fluid within the peroneal tendon sheath greater than 3 mm in maximal width, are highly specific indicators of peroneal tendinopathy and peroneal tenosynovitis respectively.

Peroneal tendon tears: return to sports after operative treatment

BACKGROUND

Operative treatment has become the standard for peroneal tendon tears when nonoperative management fails. Successful return to sports has been reported in previous studies. We evaluated 30 patients who had operative treatment of peroneal tears.

METHODS

Patients who were evaluated by a questionnaire and by review of medical records, MRI, radiographs, and operative reports.

RESULTS

Nine of the 10 patients who were working outside the home were able to return to employment at the same level. A substantial number had residual symptoms, including scar tenderness (58%) and lateral ankle swelling (54%). Only 46% were able to successfully return to sports.

CONCLUSIONS

Although operative treatment was very effective in allowing patients to return to work, only half of our patients were able to return to sports at an average followup of 31 months.

Staged reconstruction for chronic rupture of both peroneal tendons using Hunter rod and flexor hallucis longus tendon transfer: a long-term followup study

BACKGROUND

Long-term followup (over 5 years) of staged reconstruction for chronic ruptures of both peroneal tendons using a Hunter rod and the flexor hallucis longus (FHL) tendon is presented.

METHODS

Seven patients with chronic ruptures of both peroneal tendons who had at least two previous surgeries that failed were treated with excision of the remaining portion of the peroneal tendons and implantation of a Hunter rod to the insertion of the peroneus brevis. Patients performed passive range of motion exercises for 3 months before removal of the Hunter rod and transfer of the FHL into the newly formed sheath, attaching it to the insertion of the peroneus brevis on the fifth metatarsal. The patients' ages ranged from 30 to 57 (average 38) years. All were women. All had at least two previous failed procedures (range two to six). The average time from initial injury to the index surgery was 4.6 (range 2 to 7) years. Patients were evaluated by physical examination and a questionnaire. The average range of followup was 8.5 years (range 143 to 167 months).

RESULTS

All wounds healed without complications. One patient (a workers' compensation patient) had continued complaints of pain and ambulated with a molded ankle-foot orthosis (MAFO). The remaining six patients reported complete relief of symptoms and returned to full preinjury levels of activity. One patient required a Broström ankle ligament repair 2 years after tendon transfer for a new injury but has remained pain free for the last 62 months. There were five excellent, one good, and one fair result. All patients stated they would repeat the surgery.

CONCLUSION

Staged reconstruction with excision of the remaining portion of the peroneal tendons and reconstruction with a Hunter rod and FHL transfer has been shown to be an effective long-term treatment for chronic peroneal tendon ruptures.

A quasi-linear, viscoelastic, structural model of the plantar soft tissue with frequency-sensitive damping properties

Little is known about the structural properties of plantar soft-tissue areas other than the heel; nor is it known whether the structural properties vary depending on location. Furthermore, although the quasi-linear viscoelastic (QLV) theory has been used to model many soft-tissue types, it has not been employed to model the plantar soft tissue. The structural properties of the plantar soft tissue were quantified via stress relaxation experiments at seven regions (subcalcaneal, five submetatarsal, and subhallucal) across eight cadaveric feet. The cadaveric feet were 36.9 +/- 17.4 (mean +/- S.D.) years of age, all free from vascular diseases and orthopedics disorders. All tests were performed at a constant environmental temperature of 35 degrees C. Stress relaxation experiments were performed; different loads were employed for different areas based on normative gait data. A modification of the relaxation spectrum employed within the QLV theory allowed for the inclusion of frequency-sensitive relaxation properties in addition to nonlinear elastic behavior. The tissue demonstrated frequency-dependent damping properties that made the QLV theory ill suited to model the relaxation. There was a significant difference between the elastic structural properties (A) of the subcalcaneal tissue and all other areas (p = 0.004), and a trend (p = 0.067) for the fifth submetatarsal to have less viscous damping (c1) than the subhallucal, or first, second, or third submetatarsal areas. Thus, the data demonstrate that the structural properties of the foot can vary across regions, but careful consideration must be given to the applied loads and the manner in which the loads were applied.

The peroneal groove deepening procedure: a biomechanical study of pressure reduction

BACKGROUND

The goal of this study was to identify pressure changes throughout the peroneal groove after a groove deepening procedure. We hypothesized that pressures would decrease.

METHODS

Twelve fresh-frozen foot and ankle specimens were used. A thin pressure strip containing four sensor pads was secured within the peroneal groove with pads 1 through 4 positioned at the calcaneofibular ligament (CFL) and at the distal, middle, and proximal groove, respectively. The midstance phase of gait was simulated with loads applied to the plantar foot and posterior tibial tendon and to the peroneus longus and brevis tendons. Pressures were recorded with the ankle in neutral, plantarflexion, dorsiflexion, inversion, and eversion. Groove deepening was done by osteotomizing the posterior fibular wall. Pressure readings were then recorded. Average pressures for each of the four sensor pads after the procedure were compared to those obtained before the procedure.

RESULTS

The mean pressure overlying the CFL increased at all five ankle positions; however, these changes were not significant. Significant decreases in pressure were noted within the distal and middle groove at all ankle positions after the peroneal groove deepening procedure. Pressure within the proximal groove increased at all but one position, with a significant difference noted in neutral and plantarflexion.

CONCLUSION

Pressures within the middle and distal peroneal groove significantly decreased after a groove deepening procedure. Combining this technique with peroneal tendon debridement may be advantageous for treatment of partial peroneal tendon tears or recalcitrant peroneal tendinitis.

Split lesions of the peroneus brevis tendon in the Japanese population: an anatomic and histologic study of 112 cadaveric ankles

Split lesions of the peroneus brevis tendon are believed to be rare and have received little attention in populations of Asian countries. The purpose of this study was to investigate the incidence of split lesions in the Japanese population. The peroneus tendons of 112 ankles from 30 male and 26 female adult human embalmed cadavers with an average age of 76.9 years (range, 55-93) were dissected. The presence of split lesions, determined by either thinning or longitudinal splitting of the peroneus brevis tendon, was examined. Forty-two ankles (37.5%) had split lesions, of which 21 (50%) showed a thinning appearance without splitting, and 12 (28.6%) had well-defined, full-thickness longitudinal tears. The incidence of split lesions of the peroneus brevis tendon in the Japanese population was similar to that in studies of the U.S. population, but the condition of the lesions was less severe. Although the clinical presence is expected to be extremely rare, we must consider a neglected split lesion of the peroneus brevis tendon when residual pain is observed in the retrofibular location.

Peroneal tendon tears: a retrospective review

Tears of the peroneal tendons are not uncommon but remain an underappreciated source of chronic lateral ankle pain. The purpose of this study was to identify the typical patient profile and nature of the injury, to analyze the course of treatment, and to determine the prevalence of complications seen with surgical repair. Forty patients with chronic pain over the peroneal tendons from the Foot and Ankle Institute at the Western Pennsylvania Hospital underwent peroneal tendon repair. During a 3-year period, a retrospective review was performed by evaluating medical records, surgical reports, and radiographs. The average patient age was 42 years (range, 13 to 64 years). The most common cause was an ankle sprain or other traumatic injury (58%). Peroneus brevis tears (35 patients; 88%), peroneus longus tears (5 patients; 13%), combined peroneus brevis and longus tears (15 patients; 37%), low-lying peroneus muscle belly (13 patients; 33%), lateral ankle ligamentous disruptions (13 patients; 33%), and peroneal subluxation (8 patients; 20%) were identified during surgery. The average follow-up was 13 months (range, 9 to 40 months). Ninety-eight percent of the patients were able to return to full activities without pain at final follow-up. The minor complication rate (transient symptoms) was 20%. Clinically significant (major) complications (continued symptoms or revisionary surgery) occurred in 10% of patients. This study indicates that lateral ankle ligamentous incompetence, combined peroneal brevis and longus tears, and low-lying peroneus muscle belly commonly coexist in patients with peroneal tendon injuries. Appropriate surgical intervention of peroneal tendon tears and their coexisting pathology yields successful and predictable results with few clinically significant complications.

Anatomical and possible clinical relationships between the calcaneofibular ligament and peroneus brevis--a pilot study

The authors have observed in their clinical practice patients presenting with chronic retromalleolar pain following lateral ankle injuries. It has been hypothesized that persistent retromalleolar pain following a supination sprain may be due to peroneus brevis (PB) tendon tears (Boruta et al. 1990). The aims of this study were to investigate whether an anatomical relationship exists between the calcaneofibular ligament (CFL) and PB, and if so, the significance of this relationship in the positions of supination sprain and talar tilt test. Seven out of eight cadaveric ankles demonstrated fibrous connecting tissue between the tendon of PB and CFL. Four of the eight ankles demonstrated PB tendon abnormalities. The presence of connecting tissue between CFL and PB suggests an anatomical basis for concomitant damage to the PB tendon with a supination sprain, thus supporting the hypothesis that there may be an anatomical basis for persistent retromalleolar pain subsequent to injury to the lateral ankle complex.

Peroneal tendon injuries: an evaluation of 49 tears in 41 patients

Forty-one patients sustaining 49 tears of the peroneal tendons were evaluated prospectively a minimum of 1 year after surgical treatment. Preoperative and postoperative function and activity were assessed by using the American Orthopedic Foot and Ankle (AOFAS) score. Mean age at the time of surgery was 44.0 +/- 11.7 years. Mean follow-up after the index surgery was 35.5 +/- 22.2 months. There were 17 women and 24 men. One woman had bilateral surgery 1 year apart. There were a total of 18 tears of the peroneus longus tendon; 11 of these were isolated, whereas 7 had a combined tear with peroneus brevis. There 31 peroneus brevis tears; 24 of these were isolated and 7 were combined. Using 3-way analysis of variance, there were no significant differences in return to activity or postoperative AOFAS scores among those with a longus, brevis, or combined tear. The mean return to activity for peroneus longus, peroneus brevis, and combined tears were 3.2, 3.6, and 3.7 months, respectively. The mean postoperative AOFAS scores were 90.6, 90.8, and 84.3 respectively. The mean preoperative AOFAS score was 52.0 +/- 16.8. The mean postoperative score was 89.7 +/- 10.3 (P <.00001). Using this scoring system, there were 24 excellent, 12 good, 4 fair, and 2 poor scores. Three patients underwent additional surgery. Fourteen of 16 athletes returned to full sporting level. The average return to activity for the entire group was 3.49 +/- 1.15 months.

Two cases of peroneus brevis tendon tear

A longitudinal tear of the peroneal tendon is thought to be the result of repetitive peroneal subluxation. However, this report documents two cases of longitudinal split of the peroneus brevis tendon that had no peroneal tendon subluxation. Primary suture was performed. Subluxation of the peroneal tendons was not identified surgically in either case.

Peroneus longus and brevis rupture in a collegiate athlete

Peroneal tendon injuries should be considered in the differential diagnosis of lateral ankle pain and instability. The spectrum of injury to the peroneal tendons includes tenosynovitis, tendinitis, subluxation, dislocation and tears. The mechanism, presentation and treatment of isolated peroneal brevis and longus injuries has been described in the literature. This is a case study of a rare combined peroneus brevis and longus injury in a young healthy collegiate athlete.