You are in: eMedicine Specialties > Orthopedic Surgery > FOOT AND ANKLE Peroneal Tendon PathologyArticle Last Updated: Mar 27, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 12
  Author: Kurtis Hort, MD, Foot and Ankle Surgery Fellow, Department of Orthopedic Surgery, Orthopaedic Associates of St. Augustine, Florida Kurtis Hort is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Foot and Ankle Society, AO Foundation, and Florida Medical Association Coauthor(s): James K DeOrio, MD, Director of Foot and Ankle Fellowship Program, Assistant Professor of Orthopedic Surgery, Orthopedic Surgery, St. Luke's Hospital, Jacksonville, Florida Editors: Heidi M Stephens, MD, Associate Professor, Department of Surgery, Division of Orthopedic Surgery, Director of Diabetic Foot Clinic, Assistant Dean for Clinical Outreach, University of South Florida College of Medicine; Courtesy Joint Associate Professor, Department of Environmental and Occupational Health, University of South Florida College of Public Health; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Shepard R Hurwitz, MD, Executive Director, American Board of Orthopaedic Surgery; Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital; Jason H Calhoun, MD, FAAOS, Chairman, J Vernon Luck Distinguished Professor, Department of Orthopedic Surgery, University of Missouri Author and Editor Disclosure Synonyms and related keywords: disorders of the peroneal tendons, peroneal tendon subluxation, peroneus brevis disorders, disruptions of the peroneus longus, disruptions of the peroneus brevis, fractured os peroneum, fragmented os peroneum, longitudinal tears of the peroneus longus, peroneus brevis tears, longitudinal tears of the peroneus brevis tendon, ankle sprain, primary peroneus longus tendinopathy, peroneus longus rupture, ankle pain, foot pain, tendon rupture, tenosynovitis INTRODUCTIONSection 2 of 12
  History of the ProcedureDisorders of the peroneal tendons have been reported infrequently. Monteggia described peroneal tendon subluxation in 1803,1 and this entity seems to be more commonly encountered than are disruptions of the peroneus longus or brevis alone. Nonetheless, peroneus brevis disorders have been described more often in the literature, with peroneus longus problems gaining more recent attention. However, much of the literature regarding both tendons is in the form of case reports. ProblemThe peroneal muscles make up the lateral compartment of the leg and receive innervation from the superficial peroneal nerve. The peroneus longus muscle originates from the lateral condyle of the tibia and the head of the fibula. The tendon of peroneus longus courses behind the peroneus brevis tendon at the level of the ankle joint, travels inferior to the peroneal tubercle, and turns sharply in a medial direction at the cuboid bone. The tendon inserts into the lateral aspect of the plantar first metatarsal and medial cuneiform. A sesamoid bone called the os peroneum may be present within the peroneus longus tendon at about the level of the calcaneocuboid joint. The frequency with which an os peroneum occurs is controversial, with many supporting the idea that one is always present. However, the os peroneum may be ossified in only 20% of the population. The peroneus longus serves to plantar flex the first ray, evert the foot, and plantar flex the ankle. The peroneus brevis originates from the fibula in the middle third of the leg. Its tendon courses anterior to the peroneus longus tendon at the ankle. It courses over the peroneal tubercle and inserts onto the base of the fifth metatarsal. The peroneus brevis everts and plantar flexes the foot. The peroneal tendons share a common tendon sheath proximal to the distal tip of the fibula. More distally, each tendon is housed within its own sheath. The common sheath is contained within a sulcus on the posterolateral aspect of the fibula, which prevents subluxation. The primary restraint to tendon subluxation is the superior peroneal retinaculum (SPR). This fibrous band originates on the posterolateral aspect of the fibula and inserts onto the calcaneus. It is reported to average 10-20 mm in width and to course in a posteroinferior direction, although variants are not uncommon. Problems may arise in either of the tendons alone, or both may be involved with subluxation. The hallmark of disorders of the peroneal tendons is laterally based ankle or foot pain. Whether the problem is tendinous degeneration or subluxation, the clinical manifestation is pain. With time, loss of eversion strength may occur. Problems arising with the peroneus longus include tenosynovitis and tendinous disruption (acute or chronic). The os peroneum may be involved with the degenerative process or as a singular disorder and can be fractured or fragmented. Longitudinal tears of the peroneus longus are uncommon but have been reported.2 Longitudinal tears of the tendon are the most common problem seen with the peroneus brevis tendon. These may be single or multiple. Tendinitis and tenosynovitis also may occur. Subluxation of both peroneal tendons may occur following an acute traumatic episode or may be of a more chronic nature. FrequencyDisorders of the peroneal tendons are less common than other tendon problems involving the Achilles or posterior tibial tendons. However, it is impossible to estimate their true frequency in the United States or abroad. EtiologyThe precise etiology of peroneal tendon disorders depends somewhat on the specific problem being addressed. All disorders may result following a traumatic episode, direct or indirect, with a lateral ankle sprain being the most common trauma. Brandes and Smith have reported that 82% of patients with primary peroneus longus tendinopathy had a cavo-varus hindfoot.3 The presence of an os peroneum also has been postulated to predispose to peroneus longus rupture. Ruptures likewise have been reported to occur secondary to rheumatoid arthritis and psoriasis, as well as diabetic neuropathy, hyperparathyroidism, and local steroid injection.4, 5, 6 Longitudinal splits in the peroneus brevis tendon appear to result from mechanical factors. Repetitive or acute trauma causes the attritional ruptures. These ruptures may result from an incompetent superior peroneal retinaculum that allows the peroneus brevis to rub abnormally against the fibula. Overcrowding from a peroneus quartus muscle also has been reported. The blood supply to the tendon has been shown to be adequate. Subluxation of the peroneal tendons results from disruption of the superior peroneal retinaculum and usually involves avulsion of the retinaculum from its fibular insertion. The mechanism of injury typically involves an inversion injury to the dorsiflexed ankle with concomitant forceful contraction of the peroneals. Some patients have a more chronic presentation and cannot recall a traumatic episode. Congenital dislocations also have been reported. An inadequate groove for the peroneals in the posterolateral fibula may be a cause of subluxation as well. Pathology of the longus and brevis tendons almost always occurs concurrently. Brandes and Smith noted a 33% incidence of concomitant problems.3 PathophysiologyBrandes and Smith have described and classified primary peroneus longus tendinopathy.3 They present 3 anatomic zones in which the tendon can be injured. Zone A is the level of the superior peroneal retinaculum. Zone B is the level of the inferior peroneal retinaculum. Zone C is the level of the cuboid notch. In their series, complete ruptures were most likely in zone C, while partial ruptures were more common in zone B. In the same study, surgical findings were classified into 3 groups. Group I pathology had no frank rupture but did have adhesions or thickening of the tendon. Group II pathology consisted of partial tears with some continuity of the tendon. Group III had complete ruptures with complete loss of continuity. All group III pathology occurred in zone C. Other attempts have been made to classify peroneal tendon pathology. Sobel et al have presented a classification for tears of the peroneus brevis tendon as follows:7, 8
Eckert and Davis have classified superior peroneal retinaculum (SPR) pathology as follows:9
ClinicalThe patient with peroneal tendon pathology typically complains of laterally based ankle or hindfoot pain. The pain usually worsens with activity. However, presentation and diagnosis often are delayed. Patients may or may not recall a specific episode of trauma. Brandes and Smith reported that only 9 of 22 patients with primary peroneus longus tendinopathy recalled an inciting event and that the event was an average of 4.3 months prior to presentation.3 Peroneal tendon subluxation or dislocation may present acutely following a traumatic injury to the ankle. However, it is not uncommon for these to present later with an uncertain history of trauma. Patients also may complain of snapping or popping in the ankle. On physical examination, there usually is tenderness to palpation along the course of the peroneal tendons. Edema also may be present. These disorders require a high level of suspicion. Even frank dislocations may be missed if not specifically evaluated. A provocative test for peroneal pathology has been described. The patient's foot is examined hanging in a relaxed position with the knee flexed 90º. Slight pressure is applied to the peroneal tendons posterior to the fibula. The patient is then asked to forcibly dorsiflex and evert the foot. Pain may be elicited, or the tendons may be felt to sublux. INDICATIONSSection 3 of 12
The primary indication for treating these disorders is pain. Nonsurgical treatment usually is attempted first. Failure of conservative measures is an indication for operative intervention. RELEVANT ANATOMYSection 4 of 12
See Problem. CONTRAINDICATIONSSection 5 of 12
The only true contraindication to surgery is inability to tolerate surgery for another medical reason. Because the surgery can be performed under regional anesthesia, this is rarely the case. Age is not a contraindication, as even elderly patients who place low demands on these tendons may experience significant pain relief following surgery. WORKUPSection 6 of 12
Lab Studies
Imaging Studies
Diagnostic Procedures
Histologic FindingsTorn or degenerated tendons or ganglia removed from peroneal tendons can show a myxoid pattern of degenerations (see Image 2, Image 8, and Image 9). TREATMENTSection 7 of 12
Medical therapyNonsteroidal anti-inflammatory medication to reduce pain and inflammation often is used. Any underlying medical problem (eg, diabetes, rheumatoid arthritis) should be medically controlled.15 After medical therapy is initiated, nonoperative treatment usually is attempted. In general, conservative therapy may include activity modification, footwear changes, temporary immobilization, and corticosteroid injection. Lateral heel wedges can take stress off of the peroneal tendons to allow healing. Nonoperative treatment of tenosynovitis alone often is successful, whereas a complete or partial tendon rupture often leads to surgery. Likewise, an acute injury is more likely to respond to conservative care than is a chronic process. Several authors have reported a high percentage of patients with tendon ruptures or subluxation that eventually require surgery. As with other disorders of the foot and ankle, the use of corticosteroid injection must be undertaken with extreme caution to avoid iatrogenic rupture. Surgical therapySurgical treatment is best considered under the specific pathology being addressed. With any procedure, it is important to remove abnormal-appearing synovium or tenosynovium, which can cause persistent pain if not removed. This can be accomplished easily with the use of a rongeur. For surgical repair, see Image 3, Image 4, Image 5, Image 6, and Image 7. Tenosynovitis Tenosynovitis may be treated surgically with simple division of the tendon sheath. Coughlin's description of the procedure is as follows16: A tourniquet is used. The tendons are exposed through an incision that curves from the posterior aspect of the fibula toward the base of the fifth metatarsal. Care must be taken to protect the sural nerve. The tendon sheath is opened longitudinally, and each tendon is examined. Any degenerated area of tendon generally is removed. A peroneus quartus can be excised. If the peroneal tubercle is proud, it may be smoothed or leveled. The tendon sheath is left unrepaired. Postoperatively, the patient is placed in a short leg cast. Weightbearing in the cast may begin after 2 weeks. Range of motion and strengthening are started after casting is discontinued at 4 weeks. Primary peroneus longus tendinopathy This disorder may be approached in a manner similar to that described above with subsequent debridement of the tendon, release of the inferior peroneal retinaculum, and smoothing of the peroneal tubercle. Brandes and Smith advocate adding a lateral closing wedge calcaneal osteotomy (Dwyer) if the patient has a cavus or varus deformity of the hindfoot.3 Postoperatively, a short leg cast may be used for up to 6 weeks to allow for the osteotomy to heal. Weightbearing in a protective boot is recommended for an additional 6 weeks. Os peroneum excision If symptoms are directly referable to the os peroneum due to fracture or fragmentation, it may simply be excised as follows. The inferior portion of the typical peroneal tendon approach is used. With pathology limited to the os peroneum, this may consist only of the portion from the tip of the fibula to the base of the fifth metatarsal. The tendon sheath is incised, and the os is sharply removed from the tendon in a shelling out fashion. The tendon may be repaired with interrupted absorbable or nylon suture if only a longitudinal defect is present. If the tendon has lost continuity, it may be repaired with a modified Kessler or similar stitch or tenodesed to the intact peroneus brevis tendon. Postoperatively, a short leg cast is applied for a total of 6 weeks, with weightbearing beginning after 3-4 weeks. A removable boot then is used for an additional 4 weeks with normal shoe wear to follow. Activity is advanced to tolerance following boot removal. Peroneus brevis repair The patient is placed supine with a sandbag under the ipsilateral hip. A thigh-high tourniquet is used. A curved longitudinal incision along the course of the peroneal tendons is extended from several centimeters above the lateral malleolus to the base of the fifth metatarsal. The superior peroneal retinaculum is incised sharply, leaving a small tag on the fibula for later repair. The tendons are inspected. The peroneus brevis will lie closer to the fibula. If a single longitudinal tear is noted, it simply may be repaired with a running Ethibond suture. If the tendon split represents less than 30% of the normal tendon width, it can be excised. If a peroneus quartus muscle is encountered, it simply may be resected. If multiple degenerative tears are present, they are debrided with an eventual attempt to tubularize the remaining tendon. Coughlin and Mann recommend tenodesis to the peroneus longus if less than one third of the tendon remains.16 After tendon pathology is addressed, the superior peroneal retinaculum is repaired over the tendons. The skin is closed in a routine fashion. Postoperatively, a short leg cast is applied for 6 weeks, with weightbearing started after 4 weeks. A boot is then used for an additional 4 weeks with daily range-of-motion exercises. Peroneal tendon subluxation Surgical treatment often is necessary to correct subluxing or dislocating peroneal tendons. If the problem is diagnosed early, acute repair of the peroneal retinaculum may be undertaken, though most often, intervention occurs later.17, 18, 19, 20 Acute repair of superior peroneal retinaculum A thigh tourniquet is used. The incision is in line with the peroneal tendons from 6 cm proximal to the tip of the fibula to 2 cm distal to it. The superior peroneal retinaculum is identified and sharply removed from the fibula 1 cm posterior to the fibula. A bony trough is then created on the posterolateral fibula parallel with the remaining edge of the retinaculum just posterior to it. This can be performed with an osteotome or with a burr. Three to four drill holes then are created in the fibula along the trough. An Ethibond suture is used to approximate the retinaculum to the fibula by passing it through both of the holes and the retinaculum. The retinaculum is then further imbricated to the portion that is still attached to the fibula with an absorbable suture. The skin is closed in a routine manner. If a large piece of the fibula has been avulsed, it may be internally fixed with a small fragment bone screw, making true repair of the retinaculum unnecessary. Postoperatively, a short leg cast is applied for 6 weeks, with weightbearing allowed after 4 weeks. Surgical options for chronic dislocation Surgical options for chronic dislocation have been grouped into 5 categories.21, 22
Follow-upFor excellent patient education resources, visit eMedicine's Foot, Ankle, Knee, and Hip Center and Sprains and Strains Center. Also, see eMedicine's patient education article Ankle Sprain. COMPLICATIONSSection 8 of 12
Recurrence of symptoms following surgical treatment is possible. Patients may complain of stiffness or tightness of the ankle following surgical repair. Surgical treatment also may be complicated by injury to the sural nerve or to the superficial peroneal nerve. The sural nerve may be more at risk due to its variable position. Infections may complicate any surgical procedure. The potential for blood clots or pulmonary embolus, while uncommon with foot and ankle surgery, must not be underestimated. OUTCOME AND PROGNOSISSection 9 of 12
Outcome following surgical treatment of peroneal tendon pathology is difficult to accurately assess. Much of the literature is in the form of case reports, with few large series in existence. Additionally, with the large variability in treatment, conclusions are hard to draw. Much of the decision making in this area is based on surgeon experience. Sammarco has reported 10 of 13 patients with good or excellent results using varied surgical treatments of peroneus longus problems.23 Eight of those patients also had associated peroneus brevis pathology. Thompson and Patterson reported on 3 of their patients with peroneus longus pathology who responded well to surgical debridement and tenodesis.24 Krause and Brodsky reviewed 20 cases of peroneus brevis tears and noted that good or excellent results can be expected with surgical treatment.25 Reports on subluxation treatment are even sparser. Nevertheless, if the procedure chosen is appropriate for the particular pathology present, a high percentage of satisfactory results can be expected. FUTURE AND CONTROVERSIESSection 10 of 12
The decision to use a specific procedure depends upon the specific pathology present and good surgical judgment. Also, the effectiveness of nonoperative versus operative treatment may be debated. The need for MRI evaluation and the timing of such, while becoming clearer, has yet to be convincingly defined. The need to proceed to surgery is always controversial. MULTIMEDIASection 11 of 12
REFERENCESSection 12 of 12
Peroneal Tendon Pathology excerpt Article Last Updated: Mar 27, 2008 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
