Bilateral stenosing tenosynovitis of the peroneus longus tendon associated with hypertrophied peroneal tubercle in a junior soccer player: a case report

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.

Successful reconstruction of distal peroneus longus tendon dislocation associated with a split lesion - a case report

BACKGROUND

Peroneal tendon injuries are one of the differential diagnoses in lateral ankle and rearfoot pain. While partial tears are not uncommon, peroneal tendon dislocation at the peroneal tubercle is very rare. Until now, only three papers have been published, presenting five cases of peroneus longus tendon dislocation over the peroneal tubercle. This report adds a previously undescribed case of a peroneus longus tendon split tear that was partially dislocated and entrapped over the peroneal tubercle. The respective operative approach and the outcome are described.

CASE PRESENTATION

A 25-year-old international top-level speed skater developed a painful mass over the lateral calcaneal wall. There was no specific inducing injury in his medical history. In contrast to previous reports, according to the patient's history, a snapping phenomenon was not present. Conservative treatment was not effective. By inspection and palpation an enlarged peroneal tubercle was assumed. During operative exploration, we found an incomplete longitudinal split tear of the peroneus longus tendon, which was partially dislocated and entrapped over the peroneal tubercle. This mimicked an enlarged peroneal tubercle. A portion of the split tendon was resected. A deepening procedure of the flat groove of the peroneus longus tendon below the peroneal tubercle and a transosseous reconstruction of the avulsed inferior peroneal retinaculum were performed. After six months, the patient had completely reintegrated into his elite sport and has been free of symptoms since then.

CONCLUSIONS

From the presented case it can be speculated that the inferior peroneal retinaculum was overused, worn out, detached, or ruptured due to overpronation and friction the lateral edge of the low-cut speed skating shoe. Then the peroneus longus tendon experienced substantial friction with the peroneal tubercle with possible dislocation during ankle motion. This frictional contact may have finally led to further degeneration and a longitudinal tear of the tendon. Obviously, dislocations can develop insidiously resulting in lesions of the peroneus longus tendon at the peroneal tubercle, ultimately leading to a tendon entrapment. This mimics an enlarged tubercle. The pathology is very rare and can be successfully addressed surgically.

Diagnosis and Operative Treatment of Peroneal Tendon Tears

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

Diagnosis and Operative Treatment of Peroneal Tendon Tears

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

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

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

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

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

Surgical Treatment for Stenosing Peroneal Tenosynovitis

BACKGROUND:

Stenosing peroneal tenosynovitis (SPT) is an uncommon entity that is equally difficult to diagnose. We evaluated our outcomes with a local anesthetic diagnostic injection followed by surgical release of the sheath and calcaneal exostectomy.

METHODS:

Eleven patients diagnosed with SPT underwent surgery between 2006 and 2014. Upon initial presentation, all patients reported a persistent history of pain along the ankle. Ultrasound-guided injections of anesthetics were administered into the peroneal tendon sheath to confirm the diagnosis. In patients with a confirmed diagnosis of SPT, we proceeded with surgical intervention with release of the peroneal tendon sheath and debridement of the calcaneal exostosis. Retrospective chart review was performed, and functional outcomes were assessed using the Foot and Ankle Outcome Score (FAOS). FAOS results were collected pre- and postoperatively and were successfully obtained at 1 year or greater.

RESULTS:

Of these patients, all showed significant improvements ( P < .05) in 4 of 5 categories of the FAOS (pain, daily activities, sports activities, and quality of life).

CONCLUSION:

We present a case series in which the peroneal tendon sheath was diagnostically injected with anesthetic to confirm a diagnosis of SPT. In each of these cases, symptomatic improvement was obtained following the injection. With the fact that many of these patients had advanced imaging denoting no significant tears, we believe that this diagnostic injection is paramount for the success of surgical outcome.

LEVEL OF EVIDENCE:

Level IV, retrospective case series.

High-resolution US and MR imaging of peroneal tendon injuries

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

Endoscopic resection of the peroneal tubercle

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

The fascia of the limbs and back--a review

Although fasciae have long interested clinicians in a multitude of different clinical and paramedical disciplines, there have been few attempts to unite the ensuing diverse literature into a single review. The current article gives an anatomical perspective that extends from the gross to the molecular level. For expediency, it deals only with fascia in the limbs and back. Particular focus is directed towards deep fascia and thus consideration is given to structures such as the fascia lata, thoracolumbar fascia, plantar and palmar fascia, along with regional specializations of deep fascia such as retinacula and fibrous pulleys. However, equal emphasis is placed on general aspects of fascial structure and function, including its innervation and cellular composition. Among the many functions of fascia considered in detail are its ectoskeletal role (as a soft tissue skeleton for muscle attachments), its importance for creating osteofascial compartments for muscles, encouraging venous return in the lower limb, dissipating stress concentration at entheses and acting as a protective sheet for underlying structures. Emphasis is placed on recognizing the continuity of fascia between regions and appreciating its key role in coordinating muscular activity and acting as a body-wide proprioceptive organ. Such considerations far outweigh the significance of viewing fascia in a regional context alone.

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

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

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.