Lesiones peroneros copia

Peroneal Tendon Injuries

Abstract

Peroneal tendon injuries are underdiagnosed and should beconsidered in every patient who presents with chronic lateral anklepain. Ankle sprains are common, and up to 40% of affectedindividuals experience subsequent chronic ankle pain. Identifyingthe source of chronic ankle pain can be difficult because of thelarge number of possible causes. The peroneal tendons are theprimary evertors of the foot and function as lateral ankle stabilizers.A careful physical examination, along with a thorough patienthistory and imaging studies, are critical in arriving at an accuratediagnosis. Understanding the anatomy of the peroneal tendons andknowledge of current treatment approaches for peroneal tendontears, subluxation and dislocation of the tendons, and peronealtenosynovitis are of great importance in achieving a favorableoutcome. Low-demand patients do well with a nonsurgicalapproach; high-demand patients may benefit from surgery.

Peroneal tendon disorders are asignificant but often overlooked

cause of lateral ankle pain. These in-juries are more common than typi-cally realized and must be consideredin every person who presents withlateral ankle pain, particularly inthose who report a history of anklesprain. Ankle sprains are commonathletic injuries. It is not uncommonfor persons with ankle sprains to ex-perience subsequent chronic lateralankle pain. The differential diagnosisof lateral ankle pain is extensive.

Anatomy

The perforating branches of the ante-rior tibial and peroneal arteries sup-ply blood to the lateral compartmentof the leg. The superficial peronealnerve, a branch of the common pero-neal nerve, innervates the peroneusbrevis and the peroneus longus mus-cles. The primary action of thesemuscles is, respectively, eversion andpronation of the foot, with a second-

ary action of weak plantar flexion.Together, the peroneal tendons pro-vide supplemental lateral ankle sta-bility, especially during the mid-stance and heel-raise portions of gait.

The peroneus brevis becomes ten-dinous 2 to 3 cm proximal to the tipof the fibula. The tendon lies ante-rior and medial to the peroneus lon-gus tendon at the level of the lateralmalleolus and inserts onto thedorsal-lateral surface of the tuberos-ity of the fifth metatarsal base. Herethe rare os vesalianum pedis is foundin <1% of the population.1 This isimportant to consider because theossicle must be differentiated froman acute fracture of the base of thefifth metatarsal. The peroneus brevismuscle functions as the primary ever-tor of the foot.

The peroneus longus musclecourses down the spiral twist of thefibula, becoming lateral at midtibiaand posterior to the peroneus brevisat the lateral malleolus. The tendonpasses beneath the peroneal troch-

Terrence M. Philbin, DO

Geoffrey S. Landis, DO

Bret Smith, DO

Dr. Philbin is Fellowship Director,Orthopedic Foot and Ankle Center,Columbus, OH. Dr. Landis isAttending Surgeon, TucsonOrthopaedic Institute, Tucson, AZ.Dr. Smith is Attending Surgeon,Moore Orthopaedic Clinic, Columbia,SC.

None of the following authors or amember of their immediate familieshas received anything of value fromor owns stock in a commercialcompany or institution relateddirectly or indirectly to the subject ofthis article: Dr. Philbin, Dr. Landis,and Dr. Smith.

Reprint requests: Dr. Philbin,Orthopedic Foot and Ankle Center,6200 Cleveland Avenue, Columbus,OH 43235.

J Am Acad Orthop Surg 2009;17:306-317

Copyright 2009 by the AmericanAcademy of Orthopaedic Surgeons.

Review Article

306 Journal of the American Academy of Orthopaedic Surgeons

lear process on the lateral side of thecalcaneus, over the peroneal tuber-cle, and then turns to the cuboid tun-nel, where it runs obliquely acrossthe plantar aspect of the foot. It in-serts on the plantar proximal surfaceof the first metatarsal and the lateralborder of the medial cuneiform.2 Theperoneus longus is a plantar flexor ofthe ankle joint and a primary plantarflexor of the first metatarsal. Locatedwithin the substance of the peroneuslongus, the os peroneum is found in!20% of the population and is usu-ally located plantar to the cuboid,lateral to the calcaneus, or at the cal-caneocuboid articulation.3

Peroneal Tendons andRetinaculaThe peroneus brevis and longus ten-dons share a common synovialsheath from a point 4 cm above thedistal fibula. This sheath bifurcatesat the level of the peroneal tubercledistally. The sheath passes through afibro-osseous tunnel that is rein-forced by the superior peroneal reti-naculum (SPR), the posterior talofib-ular ligament, the calcaneofibularligament, and the posterior inferiortibiofibular ligament4 (Figure 1). An-teriorly, the sheath is bordered by the

fibula in the area of the retromalle-olar sulcus. The peroneal retinacu-lum consists of superior and inferiorportions. The SPR is a fibrous bandof tissue that travels from the poste-rior ridge of the fibula to the lateralwall of the calcaneus. It acts as theprimary restraint to subluxation anddislocation of the tendons as theycourse around the tip of the fibula.Davis et al5 reported five anatomicvariations of the insertion of theSPR. The inferior peroneal retinacu-lum is distal to the tip of the lateralmalleolus. The fibers forming theinferior peroneal retinaculum areblended from the fascia overlying theanterior ankle joint and are knownas the cruciate crural ligament anteri-orly.

The sulcus in the posterior aspectof the distal fibula is typically con-cave, with a width of 5 to 10 mmand a depth of up to 3 mm.2 Thelack of concavity of the posterior dis-tal fibula, as seen in a cadavericstudy, may predispose to tendon dis-location.6 This same study reportedan absence of a fibular groove in11% of the specimens and a convex-ity in 7%. In addition to the fibulargroove, a fibrocartilaginous rim,which deepens the groove by 2 to 4

mm, provides additional stability tothe tendons.

Anomalous AnatomyAnomalous anatomy that may be in-volved in peroneal pathology in-cludes a low-lying muscle belly of theperoneus brevis, presence of a pero-neus quartus muscle, and a hypertro-phied peroneal tubercle. The pero-neus quartus has a varied origin butmost commonly arises on the pero-neus brevis and inserts in the ret-rotrochlear eminence of the calca-neus.7 It has a reported incidence of13% in the general population.8 So-bel et al9 found it to be present in 27of 124 cadaver dissections (21.8%).The peroneus quartus muscle wasidentified on magnetic resonance im-aging (MRI) in 10% of patients inone report10 and, more recently, in6.6% of evaluations.7 Other anoma-lous peroneal musculature has beendescribed, most notably the peroneusdigiti quinti muscle of Testut and theperonealcalcaneus muscle of Heck-er.11 The presence of a low-lyingmuscle belly or a peroneus quartusmight increase the risk of SPR lax-ity, with resultant peroneal pa-thology.12,13

Hyer et al14 performed a cadaveric

A, Lateral view of the ankle demonstrating the peroneal tendons beneath the superior and inferior peroneal retinacula.B, Superior view demonstrating the position of the peroneus brevis tendon anterior to the peroneus longus tendon.(Reproduced with permission from Coughlin MJ, Schon LC: Disorders of tendons, in Coughlin MJ, Mann RA, SaltzmanCL [eds]: Surgery of the Foot and Ankle, ed 8. Philadelphia, PA: Mosby Elsevier, 2007, vol 1, p 1210.)

Figure 1

Terrence M. Philbin, DO, et al

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study of 114 calcanei and identifiedthree main anatomic variants ofthe peroneal tubercle: flat, 42.7%;prominent, 29.1%; and concave,27.2%. Their study demonstratedthe possibility of a bony tunnel inone specimen (1%) that could easilyresult in peroneal disease.

Physical Examination

A complete, well-organized historyand physical examination of the af-fected foot and ankle, as well as ofthe contralateral foot and ankle, isessential. A thorough history canprovide direction in forming differ-ential diagnoses, especially in regardto long-term issues such as chroniclateral ankle pain. The examinationfor lateral ankle pain should befocused primarily on the ankle andits function. Overall function andstrength of the peroneal tendons, aswell as the integrity of the lateral lig-amentous complex, are evaluated.Signs and symptoms of subluxatedtendons and ligamentous instabilityof the ankle should be assessed. Spe-cific attention should be given to thehindfoot in both static and dynamicpositioning. Individuals with hind-foot varus may subject the peroneal

tendons to increased forces that pre-dispose the tendons to injury.15 Pa-tients with hindfoot varus should beevaluated for underlying neuromus-cular disorders, such as Charcot-Marie-Tooth disease and related mo-tor neuropathies. This subset ofpatients may have a unique pathol-ogy, and a missed diagnosis may re-sult in unpredictable outcomes.

Peroneal disorders include swellingposterior to the fibula or along thelateral wall of the calcaneus; tender-ness to palpation along the course ofthe peroneal tendons; the presence ofa “pseudotumor;” and pain with re-sisted eversion, passive inversionstretch, or resisted plantar flexion ofthe first metatarsal.16 Sobel et al13 de-scribed the peroneal compressiontest, which is used to assess pain,crepitus, and “popping” at the poste-rior edge of the distal fibula duringforceful eversion and dorsiflexion ofthe ankle.

Imaging Studies

Standard three-view, weight-bearingradiographs of the foot and ankle aremandatory for proper evaluation.Radiographs can reveal avulsionsaround the base of the fifth metatar-sal, which can indicate an eversiontype of ankle injury; this subjects theperoneus brevis tendon to increasedstress and possible injury. Similarly,injury to the peroneus longus tendonis suspected in the presence of a frac-ture of an os peroneum. It is fre-quently necessary to obtain radio-graphs of the contralateral extremityfor comparison. Tendon subluxationand dislocation should be suspectedwhen radiographs show a fleck avul-sion of the distal fibula (Figure 2);this is indicative of an injury to theSPR and is best recognized on an in-ternal rotation view. Hypertrophy ofthe peroneal tubercle can raise suspi-cion of tendinosis and tears of the

peroneal tendons.17

Ultrasonography may be useful asan imaging modality for peronealtendon evaluation. In homogeneousregions with hypoechoic areas, >1mm of fluid collection and/or tendonthickening indicates tendinosis. Ul-trasonography is helpful in diagnos-ing subluxation of peroneal tendons,and it has shown promise as a dy-namic imaging modality; it was usedto correctly diagnose 12 patientswith positional subluxation of theperoneal tendons.18 Grant et al19 re-ported 90% accuracy for ultrasonog-raphy in diagnosing peroneal tendontears.

Computed tomography is bestsuited for visualizing detailed os-seous anatomy. It is used to delineatebony abnormalities associated withperoneal tendon disorders, such asperoneal tubercle hypertrophy, calca-neal fractures, and convexity of thedistal fibular groove.

MRI offers an adjunctive imagingtechnique for diagnosing peronealtendon disorders.20 The transaxialplane with the foot in slight plantarflexion is the most useful view forevaluating the integrity of the pero-neal tendons.21,22 Normal tendonsshould exhibit homogeneous low-signal intensity on T1- and T2-weighted and short tau inversion re-covery (STIR) images.22 It is normalfor T2-weighted and STIR images toexhibit a thin area of high signal in-tensity surrounding the tendon in thetendon sheath.22 Areas of increasedsignal on T2-weighted and STIR im-ages, as well as loss of homogenoussignal, may indicate tenosynovitis,tendinosis, or a tear.21 Tendinosis andtenosynovitis are best visualized onT2-weighted or axial proton densi-ty–weighted images and are charac-terized by increased intermediate sig-nal intensity.23 Circumferential fluidwithin the common peroneal tendonsheath wider than 3 mm is highlyspecific for peroneal tenosynovitis.23

Anteroposterior radiographdemonstrating fleck avulsion of thedistal fibula.

Figure 2



Consideration must be given to the“magic angle” effect. This phenome-non is seen as variations in signals,especially T1-weighted images, fromtendons that have acute angulations(approximately 55° to the magneticfield)—that is, the peroneal tendonsas they proceed behind the lateralmallelous.21,22,24

In addition to imaging tendinosisand tears, MRI can be used to evalu-ate the possibility of tendon sublux-ation and dislocation. MRI scans canalso show variations in normal anat-omy, such as a low-lying musclebelly of the peroneus brevis, presenceof a peroneus quartus muscle, andhypertrophied peroneal tubercle.22

Peroneal TendonPathology

Tenosynovitis of the peroneal ten-dons is usually the result of a repeti-tive or prolonged activity, although itcan also occur after direct trauma.Additionally, anatomic variations,such as a hypertrophied peroneal tu-bercle or osseous calcaneal tunnel,may predispose an individual tostenosis and development of thistenosynovitis.11,12 Affected patientsreport pain, swelling, and point ten-derness over the peroneal tendons atthe posterolateral aspect of the an-kle. The patient history may reveal arecent inversion injury or a recent in-crease in athletic endeavors. Com-monly, pain is exacerbated by forcedplantar flexion and inversion or byresisted dorsiflexion and eversion.MRI can be useful in differentiatingtendinosis and tenosynovitis fromlongitudinal or complete tendontears.

Treatment begins with rest, ice, non-steroidal anti-inflammatory drugs,physical therapy, and, possibly, use ofan ankle brace and a lateral heel wedgeorthosis. Further nonsurgical treatmentcan include an orthotic rocker-bottom

boot or a short leg cast for 3 to 4 weeks.Corticosteroid injections into the ten-don sheath should be used judiciously,if at all. Nonsurgical treatment of per-oneal tenosynovitis is usually success-ful. When symptoms persist, surgical in-tervention may be indicated. It isimperative that a surgical plan addressboth the tendon pathology (ie, repair,débridement) and any underlying dis-order such as instability or varus posi-tioning. If present, a low-lying peroneusbrevis muscle belly (in the retromalle-olar region) or a peroneus quartusshould be débrided. A hypertrophiedperoneal tubercle should be excised. Acomplete tenolysis and tenosynovec-tomy should also be done.

Peroneus Brevis TearsPeroneus brevis tears were first de-scribed by Meyer25 in 1924. Studiesexploring the causes of peroneusbrevis tears have focused primarilyon hypovascularity, lateral ankle in-stability, and extrinsic compressionphenomenon. Sobel et al26 reportedthat hypovascularity did not play arole in peroneus brevis tears. Theircadaveric study showed “an amplesource of blood supply in the regionof the tear,” leading the authors toconclude that the primary mechan-ism was a mechanical disruption.Sammarco and DiRaimondo27 re-ported on several athletes who dis-played peroneus brevis tears whilebeing treated for lateral ankle insta-bility. Krause and Brodsky28 reportedon 20 patients who all had redun-dancy of the SPR. The level of thetears all corresponded to the distal 3cm of the fibula, where the tendonappeared to be compressed over theedge of the fibula. Sobel et al13 per-formed a cadaveric study in whichtension on the peroneus longus withthe foot in inversion resulted in com-pression of the peroneus brevis in thefibular groove. The flattening andsplaying of the peroneus brevis over

the anterior lip of the fibula led theauthors to conclude that longitudinaltears or splits in the peroneus brevistendon were caused by acute or re-petitive mechanical trauma. Gelleret al12 recently described the effect ofthe low-lying muscle belly with re-sulting pressure on the SPR, subse-quent instability, and peroneal tear.Extrinsic compression has beennoted to come from sources otherthan the peroneus longus tendon, in-cluding anomalous anatomy.

The patient who presents with pero-neus brevis tear may report a specifictraumatic event, failure to improve af-ter treatment for tenosynovitis, repeatedankle sprains, and chronic lateral an-kle pain and swelling. On examination,the patient has swelling and pain withpalpation over the peroneal tendons,pain with resisted eversion, and weak-ness. A bulbous pseudotumor in thearea of the peroneus brevis has been de-scribed by Webster.29 Mizel et al30 in-jected bupivacaine into the sheath toaid in diagnosis. MRI scans in addi-tion to plain radiography aid in thediagnosis of peroneus brevis tears.

Treatment of this condition mayinitially be nonsurgical, but surgicalprocedures should be consideredwhen symptoms are recalcitrant tononsurgical management. Krauseand Brodsky28 reported an 83% fail-ure rate with the use of nonsteroidalanti-inflammatory drugs, activitymodification, lateral heel wedges,and a walking boot or cast to treatperoneus brevis tears in the presenceof ankle instability. Because the out-come of nonsurgical treatment of aknown peroneus brevis tear may beless than satisfactory, surgical inter-vention should be considered. Giventhe likelihood that nonsurgical man-agement of peroneus brevis tear willbe unsatisfactory, serious consider-ation should be given to surgical in-tervention as the initial course of ac-tion.

Surgical treatment of peroneus


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brevis tears depends on the type oftear found at exploration. Single lon-gitudinal tears can undergo débride-ment, repair, and tubularization ofthe tendon31 (Figure 3). We use a 3-0absorbable suture for a core repair,then tubularize with 3-0 monofila-ment absorbable suture. Multiplelongitudinal tears with significanttendinosis (ie, >50% of the cross sec-tion of the tendon) and fibrillationmay undergo débridement and eitherdirect repair of or, more commonly,tenodesis to the peroneus longus ten-don. Tenodesis consists of excisingthe degenerated portion of the ten-don and suturing the proximal anddistal ends of the brevis tendon tothe peroneus longus.

Krause and Brodsky28 graded pero-neus brevis tears according to thecross-sectional area of involvement.Grade 1 tears were those with <50%involvement, and grade 2 tears had>50% involvement. Grade 1 tearsunderwent direct repair, and grade 2lesions underwent tenodesis. Whenthe tear is peripheral, up to 50% ofthe outer tendon can be excised.Steel and DeOrio32 reported that 9 of10 patients treated with surgical re-

pair were able to return to work(90%), but only 46% were able toreturn to sports at their preoperativelevel. Other studies have shown an85% to 95% return to athletic andfitness activities with surgical repairof peroneal tendon tears.33,34

Peroneus Longus TearsTears of the peroneus longus are un-common. Diabetes mellitus, hyper-parathyroidism, rheumatoid arthri-tis, and psoriasis can predisposeindividuals to peroneus longus tears.Other conditions associated withperoneus longus tears include ankleinstability, hindfoot varus, and a hy-pertrophied peroneal tubercle. Pero-neus longus tears are most com-monly related to direct trauma orsports injuries. Chronic tears are as-sociated with mechanical irritation,most commonly occurring at thecuboid tunnel, and longstandingtenosynovitis.

Patient history usually reveals ei-ther an acute traumatic event or aslow, progressive, insidious course.In addition to swelling and tender-ness over the lateral ankle, individu-

als with peroneus longus tears haveweakness and pain with resistedeversion, tenderness distal to the fib-ula, and pain with resisted plantarflexion of the first metatarsal. Frac-ture of the os peroneum can be anindicator of peroneal pathology. Hy-pertrophy of the peroneal tuberclecan also be seen on plain radio-graphs and is commonly believed tobe a contributing factor to peroneuslongus tenosynovitis, tears, and rup-ture. Boles et al17 recommend the useof Harris-Beath views to evaluate fortubercle enlargement. MRI is recom-mended when confirmation of thepathology is indicated because it al-lows easier evaluation of injury tothe tendon.

Treatment is based on the type ofthe tear and factors such as patientage, activity level, and duration ofsymptoms. Nonsurgical managementmay be considered for patients withminimal symptoms and no loss offunction. When symptoms persist,surgical options to consider for lon-gitudinal tears and acute ruptures in-clude débridement, tubularization,and end-to-end repair. For distal rup-tures near the insertion at the base ofthe first metatarsal, and chronic inju-ries with persistent symptoms and inwhich the tear is not amenable toend-to-end repair, tenodesis to theperoneus brevis tendon is recom-mended. Commonly, the diseasedportion of the tendon is excised, andthe proximal and distal ends of theperoneus longus tendon are suturedside-to-side with the peroneus brevis.

Painful Os PeroneumSyndromeSobel et al3 described painful os per-oneum syndrome in 1994. Clinicalentities involving the os peroneumand the peroneus longus tendon in-clude an acute fracture of the os per-oneum or an acute diastasis of amultipartite os peroneum; chronic os

Surgical techniques for managing single longitudinal tears of the peroneusbrevis tendon (A). Steps may include débridement (B), repair (C), andtubularization (D) of the tendon. (Reproduced from Chiodo CP: Acute andchronic tendon injury, in Richardson EG [ed]: Orthopaedic KnowledgeUpdate: Foot and Ankle 3. Rosemont, IL: American Academy of OrthopaedicSurgeons, 2003, pp 81-89.)

Figure 3



peroneum fracture resulting instenosing tenosynovitis; a partial oroveruse rupture of the peroneus lon-gus tendon; gross discontinuity ofthe peroneus longus tendon; and ahypertrophied peroneal tubercle thatentraps the peroneus longus tendonduring its excursion.3 Patients withacute painful os peroneum syndromehave a history of direct trauma or asupination-inversion injury. Symp-toms include tenderness along thetendon distal to the fibula and pares-thesias along the course of the suralnerve distal to the lateral wall of thecalcaneus. On examination, resistedplantar flexion or inversion stress ofthe first ray will exacerbate thesymptoms. There may also be weak-ness and pain on active eversion. Di-agnostically, radiographs show mi-gration of the os peroneum, thepresence of a multipartite os, and/or

an enlarged peroneal tubercle. Theimages should be compared with ra-diographs of the contralateral foot.Treatment may be nonsurgical; how-ever, Sobel et al3 found that only20% of patients treated nonsurgi-cally had acceptable results. Surgicaltreatment includes excision of the oswith débridement and repair of thetendon, depending on the severity ofthe peroneus longus disorder.

Concomitant Tears of thePeroneal TendonsThe diagnosis and treatment of con-comitant tears of the peroneal tendonsis a relatively new topic, and little hasbeen written about these injuries. Tearsof both tendons can be attributed to ste-roid injection, diabetes mellitus, rheu-matoid arthritis, and injuries associatedwith peroneal tendon subluxation, dis-

location, and instability. Diagnosis ofthese injuries can be made through his-tory, physical examination, and imag-ing studies.

Redfern and Myerson35 developeda treatment algorithm for concomi-tant tears of the peroneal tendons(Figure 4). The tears are classified astype I, in which both tendons are re-pairable; type II, in which only onetendon is repairable and usable; andtype III, in which both tendons areunusable. Type III tears are subdi-vided into types IIIa and IIIb. TypeIIIa tears have no proximal muscleexcursion and, therefore, are candi-dates for tendon transfer. Type IIIbtears have proximal peroneal muscleexcursion and can be treated with ei-ther single-stage or delayed allograftrepair. Treatment results depend onthe treatment of simultaneous injury,such as a cavovarus deformity, ankle

Algorithm for the intraoperative assessment of peroneal tendon tear. (Adapted with permission from Redfern D,Myerson M: The management of concomitant tears of the peroneus longus and brevis tendons. Foot Ankle Int2004;25:695-707.)

Figure 4


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instability, and peroneal dislocation.These same disorders can occur withall peroneal pathology and must beconsidered. Redfern and Myerson35

treated 29 feet for tears of both ten-dons, reporting a mean postopera-tive American Orthopaedic Foot andAnkle Society score of 82, comparedwith a preoperative mean of 61.

Wapner et al33 recently reportedthe results of treating concomitanttears with a Hunter rod and a flexorhallucis longus (FHL) transfer as asalvage procedure. They concludedthat patients with failed previous sur-gery present several surgical chal-lenges, including the need to create aviable tendon sheath for free move-ment and to reestablish a restraint totendon dislocation, to reestablishtendon stability, and to provide a vi-able motor to replace the atrophiedperoneal tendons. The surgeons per-formed a two-stage procedure inseven patients, with initial placementof a Silastic rod attached distally tothe free end of the tendon to estab-lish a synovial sheath. The secondsurgery occurred 3 months later,with an FHL harvest and Pulvertaftweave to reconstruct the peronealtendons. At an average 8.5-yearfollow-up, six of the seven patientswere pain-free.33

Hansen36 has advocated a single-stage FHL transfer to the peroneusbrevis. Flexor digitorum longustransfer and free gracilis tendon au-tograft have been described for con-comitant peroneal tears.

Subluxation and DislocationPeroneal tendon subluxation anddislocation are often differentiated asacute or chronic injury. Althoughsubluxation and dislocation are un-common causes of lateral ankle pain,both can be significantly disabling.Also, because they may be associatedwith lateral ankle instability, theseinjuries are easily misdiagnosed.

Quite often they occur in athletes;37

skiing has frequently been cited asone of the sports in which they oc-cur.38,39 The mechanism for sublux-ation and dislocation is commonly ahistory of a forceful dorsiflexion andeversion injury.39

Injured patients report a snappingand popping or giving way in the an-kle and often have a history of previ-ous ankle injury. Active circumduc-tion of the foot starting in plantarflexion and eversion may recreate thesymptoms. Recreation of sublux-ation can also be done via forceddorsiflexion or resisted plantar flex-ion with eversion.40 Fullness or swell-ing and tenderness just posterior tothe distal fibula are good indicatorsof peroneal tendon pathology. Hind-foot alignment should be evaluatedfor varus, and the examiner shouldassess lateral ankle stability. Manypatients have ligamentous injury inconjunction with peroneal tendon in-juries.41

In 1976, Eckert and Davis39 evalu-ated 73 patients with injury to theSPR and classified three types of in-jury. Grade I injuries (51%) werethose resulting in elevation of the ret-inaculum from the lateral malleolus,with the tendons lying between thebone and periosteum. Grade II inju-ries (33%) were characterized by thefibrocartilaginous ridge elevatedwith the retinaculum attached andthe tendons subluxated between thefibrocartilaginous ridge and the fib-ula. Grade III injuries (16%) repre-sented a thin cortical fragment ofbone avulsed from the fibula, withthe tendons displaced beneath thefibular fragment. In 1987, Oden42

added grade IV to this classificationsystem to describe an injury in whichthe SPR is torn from its posterior at-tachment to the calcaneus and deepinvesting fascia of the Achilles ten-don, with the retinaculum lying deepto the dislocating tendon (Figure 5).

TreatmentTreatment should be based on sev-eral factors: whether the injury isacute or chronic, the timing of theinjury, the associated clinical find-ings, and the age and activity level ofthe patient.31 Treatment in acutecases may consist of placing the footand ankle in a plantarflexed, in-verted, below-knee cast for 6 weeks.It is essential that the tendons be in areduced position before casting isdone.

Nonsurgical treatment has demon-strated a significant failure rate inpatients with chronic injury. Eckertand Davis,39 as well as Stover andBryan,43 consider nonsurgical treat-ment futile; they report a <50% suc-cess rate with nonsurgical manage-ment in patients with chronicdisorders. Surgical treatment is usu-ally preferred in these patients. Mostpatients are young, athletic, and ac-tive, and they desire a rapid return toan active lifestyle. Direct repair ofthe SPR is used most commonly foracute subluxation or dislocation in-juries. Excellent results and rapid re-covery have been reported with di-rect repair.37,44

Many surgical treatments havebeen discussed for chronic injuries,such as tissue transfer, bone blockprocedures, and groove deepening.These can be classified into severalcategories, which address primaryrepair of the SPR versus the need foradditional support to the SPR repair.

Tissue TransferTissue transfer techniques can beused to reinforce the SPR. Jones45

and Escalas et al38 used Achilles ten-don tissue to reinforce their repair(Figure 6). Other tissues used includethe plantaris,46 and the peroneusbrevis or quartus.47

The authors’ preferred method ofSPR repair begins with sharp exci-sion of retinacular tissue from the



fibula. The tendons are evaluated,and repair or débridement of the ten-dons is performed. When the retinac-ulum is amenable to primary repair,

the edge of the fibula is shaved downto a fresh bleeding bed, and a pants-over-vest repair is performed, allow-ing the excess retinacular tissue to

act as reinforcement. During primaryrepair of the SPR, a thorough evalua-tion of the retromalleolar groove isappropriate (Figure 7). Many tech-niques have rerouted the tendonsand used other structures to stabilizethe tendons. Platzgummer48 used thecalcaneofibular ligament to reinforcethe tendons (Figure 8).

Bone Block ProceduresBone block procedures that involveosteotomies of the fibula attempt toprovide a bony lip at the distal fibulato help prevent subluxation and dis-location of the peroneal tendons(Figure 9). Despite good results inmost patients, these procedures havehigh complication rates because ofthe internal fixation that is used.47

Groove DeepeningGroove deepening has also been pro-posed as a mechanism for providingincreased stability to the peronealtendons (Figure 10). In 1979, Zoell-

Classification of injuries to the superior peroneal retinaculum (SPR). Grade I,injury resulting in elevation of the retinaculum from the lateral malleolus, withthe tendons lying between the bone and periosteum. Grade II, thefibrocartilaginous ridge is elevated, with the retinaculum attached and thetendons subluxated between the fibrocartilaginous ridge and the fibula.Grade III, a thin cortical fragment of bone is avulsed from the fibula, with thetendons displaced beneath the fibular fragment. Grade IV, the SPR is tornfrom its posterior attachment to the calcaneus and deep investing fascia ofthe Achilles tendon, with the retinaculum lying deep to the dislocating tendon.(Adapted with permission from Coughlin MJ, Schon LC: Disorders oftendons, in Coughlin MJ, Mann RA, Saltzman CL [eds]: Surgery of the Footand Ankle, ed 8. Philadelphia, PA: Mosby Elsevier, 2007, vol 1, p 1211.)

Figure 5

The Ellis-Jones technique forreconstructing the peronealretinaculum, using a portion ofAchilles tendon. The inset showsthe bony tunnel that is created topass the harvested section ofAchilles tendon, recreating arestraint for the peroneal tendons.(Reproduced with permission fromCoughlin MJ, Schon LC: Disordersof tendons, in Coughlin MJ, MannRA, Saltzman CL [eds]: Surgery ofthe Foot and Ankle, ed 8.Philadelphia, PA: Mosby Elsevier,2007, vol 1, p 1215.)

Figure 6


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ner and Clancy49 described the firstgroove-deepening procedure with thegoal of increasing the depth of thegroove by 6 to 9 mm. They advo-cated plication of the SPR to aug-ment the repair. However, despite thesuccess of this procedure, McGarveyand Clanton50 reported a 30% com-plication rate with groove-deepeningprocedures.

A newer technique has been de-scribed by Shawen and Anderson.51

The fibula is sequentially reamed outfrom the tip in line with the peroneal

groove; then the thinned cortical rimis impacted. This allows the smoothposterior surface of the fibula to re-main undisturbed. Porter et al52 re-cently described a groove-deepeningprocedure that involves removing abone flap, excavating the subchon-dral bone from the distal posteriorfibula, and reattaching the flapwithin the deepened groove and re-constructing the SPR. The authorsreported good results with an accel-erated rehabilitation protocol. Theirpreferred method is to ream the tip

of the fibula, then impact the poste-rior surface as described by Shawenand Anderson.51 All patients arecarefully evaluated for any underly-ing disease of the foot before any op-eration is performed to repair theretinaculum or the tendons.

Any evidence of hindfoot varusmust be surgically corrected. We per-form a lateralizing Dwyer calcanealosteotomy. In the presence of lateralligament instability, a lateral liga-ment reconstruction, such as a Bros-tröm procedure, is completed.

Primary repair of acute peroneal tendon dislocation. A, A curvilinear incision is made over the peroneal tendons(arrows). The dislocated peroneal tendons are identified along with the tear in the superior peroneal retinaculum(SPR). B, Placement of the incision in the SPR. Inset, View of the position of the peroneal tendons in a dislocatedposition. C, The peroneal tendons are then relocated, and the SPR is primarily repaired. Inset, Primary repair of theSPR and repair of the avulsed retinacular sleeve. (Reproduced with permission from Coughlin MJ, Schon LC:Disorders of tendons, in Coughlin MJ, Mann RA, Saltzman CL [eds]: Surgery of the Foot and Ankle, ed 8. Philadelphia,PA: Mosby Elsevier, 2007, vol 1, p 1214.)

Figure 7



Postoperative Care

Most of the SPR and peroneal ten-don repair procedures have a similarpostoperative course. In the operat-ing room, a Jones dressing with pos-terior splint is applied. The foot isplaced in neutral to a slightly in-

verted position and the ankle at 90°.The patient is non–weight bearing,and sutures are removed 10 dayspostoperatively. The leg is thenplaced in a non–weight-bearing,below-knee fiberglass cast, with thefoot in neutral to slight inversion andthe ankle at 90°, for 4 to 6 weeks, af-ter which the patient is transitioned

out of the cast into a high-top walk-ing boot. The patient may beginweight bearing at 4 to 6 weeks in thewalking boot. This may be modifiedwhen an additional procedure (eg,osteotomy) has been performed.

Physical therapy focusing on rangeof motion is started under the guid-ance of the therapist when the pa-tient is placed in the walking boot at8 weeks postoperatively. We recom-mend three 2-week phases of physi-cal therapy. The initial phase focuseson progressive weight bearing in aregular shoe as well as joint mobili-zation. We often fit our patients for afunctional athletic ankle brace to useduring activities. The second phasefocuses on improving range of mo-tion and proprioception, with nor-mal gait pattern. The final phase ofphysical therapy focuses on increas-ing strength and returning to activity.

Platzgummer method of tendon rerouting. A, The dislocated peronealtendons are identified, and the calcaneofibular ligament is divided. B, Theperoneal tendons are relocated, and the calcaneofibular ligament isreattatched to the distal fibula (arrow), keeping the tendons in position.(Reproduced with permission from Coughlin MJ, Schon LC: Disorders oftendons, in Coughlin MJ, Mann RA, Saltzman CL [eds]: Surgery of the Footand Ankle, ed 8. Philadelphia, PA: Mosby Elsevier, 2007, vol 1, p 1215.)

Figure 8

Bone block procedures for repairing subluxating peroneal tendons. A, Asagittal cut is made in the distal portion of the fibula, and the bone is rotatedback, creating a block to prevent the peroneal tendons from disclocating.B, In an alternative technique, a small wedge of fibula is displacedposteriorly (arrow) so as to create a similiar block. (Reproduced withpermission from Coughlin MJ, Schon LC: Disorders of tendons, in CoughlinMJ, Mann RA, Saltzman CL [eds]: Surgery of the Foot and Ankle, ed 8.Philadelphia, PA: Mosby Elsevier, 2007, vol 1, p 1217.)

Figure 9

Groove-deepening procedure withosteoperiosteal flaps. Theosteoperiosteal flap is created onthe posterior aspect of the fibula atthe retromalleolar groove. The flapis elevated (inset a), and thecancelleous bone is removed (insetb). The osteoperiosteal flap is thentamped into the created void(arrow) and the peroneal tendonsrelocated (inset c). Note the repairof the superior peronealretinaculum in the final inset (*).(Reproduced with permission fromCoughlin MJ, Schon LC: Disordersof tendons, in Coughlin MJ, MannRA, Saltzman CL [eds]: Surgery ofthe Foot and Ankle, ed 8.Philadelphia, PA: Mosby Elsevier,2007, vol 1, p 1217.)

Figure 10


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At approximately 3 months after sur-gery, the patient is evaluated forreturn-to-activity status. Prior to re-turn to activity, the patient is evalu-ated for orthoses. For débridementof tenosynovitis only, without repair,an accelerated postoperative proto-col is used. The patient is transi-tioned out of the postoperative dress-ing directly into a removable walkingboot, and physical therapy is startedapproximately 3 to 4 weeks aftersurgery, with a similar prescriptionof three 2-week phases.

Summary

The diagnosis of peroneal tendondisorders is often missed in the eval-uation of the patient with lateral an-kle pain. Understanding the func-tional expectations of the patient isuseful in selecting the best course oftreatment. Persons with minimalsymptoms and loss of function oftendo well with a nonsurgical approach.In contrast, higher-demand patientswith more loss of function, especiallythose involved in athletic activities,may benefit from surgical treatment.A thorough history and physical ex-amination, combined with judicioususe of imaging techniques, shouldaid in making the correct diagnosis.Awareness of these disorders, theircharacteristics, and treatment op-tions provides a more rapid diagno-sis for the patient and a more effec-tive management algorithm for thephysician.

References

Evidence-based Medicine: There areno level I or level II studies cited.References 19, 23, 26, and 28 are levelIII case-control studies. References5-10, 12-14, 16-18, 20-22, 24, 25, 27,29, 30, 32-35, and 37-51 are level IVcase series. References 3 and 15 arelevel V expert opinion.

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