LONGITUDINAL PERONEAL TENDON TEARS
Amol Saxena, D.P.M., F.A.C. F.A.S.*
Ben Pham, D.P.M. Resident, California College of Podiatric Medicine 11/05/96
* Address Correspondence to:
Department of Sports Medicine,
Palo Alto Medical Foundation
Longitudinal peroneal tendon tears are uncommon. Seven cases are presented: four involving peroneus brevis and three of the peroneus longus tendons. Evaluation and treatment methods are described along with a diagnostic algorithm. All patients noted relief of symptoms with surgical treatment. Magnetic Resonance Imaging proved useful in aiding diagnosis prior to surgery, revealing a hypertrophied peroneal tendon.
Key words: Peroneal tendon injury, longitudinal tear, peroneus longus, peroneus brevis.
Surgically documented longitudinal tears of the peroneal tendons are uncommon. The literature describes series of three to eight cases (1-5). This manuscript presents a series of seven surgically documented longitudinal peroneal tendon tears, four involving peroneus brevis and three with peroneus longus tendons.
The etiology of longitudinal peroneal tendon tears is unclear. The anatomical position of the peroneus brevis tendon and repetitive mechanical wear and tear of the tendon within the retrofibular groove may play a role in its injury (6). According to the early works of Sammarco and DiRaimondo, a cascade of events may result in the tearing of the peroneus brevis tendon. This is due to prolonged mechanical irritation within the fibular groove as a result from previous ankle trauma with the resultant lateral ankle instability and incompetency of the superior peroneal retinaculum. This may result in the recurrent subluxation of the peroneal tendons (1). This subluxation of the anterior half of the peroneus brevis tendon over the sharp posterior ridge of the fibula, coupled with compression from the peroneus longus tendon lying posteriorly, when it contracts, results in an eventual tear of the peroneus brevis tendon. These authors reported a lesion in the peroneus brevis tendon in the young athletic population with lateral ankle pain and symptoms of ankle instability. Their report suggests a more repetitive trauma to the peroneus brevis tendon with history of trauma and young age.
Sobel et. al.'s many studies have included cadaveric dissections showing evidence of longitudinal tear of peroneus brevis tendon in older populations without evidence of trauma or ligamentous injury (7-11). Not only ankle trauma but any injury that interferes with the competence of the superior peroneal retinaculum may contribute to longitudinal peroneus brevis tendon tears. These include a shallow fibular groove (or a general convex groove), anomalous low-lying peroneus muscle belly and anomalous peroneus quartus tendon.
Hypovascularity has been proposed by Frey et. al. to play a role in the peroneus brevis and posterior tibialis tendon degeneration (12). However, Sobel et. al. did not find a zone of hypovascularity within the peroneus brevis tendon correlating to the site of tears (8). It is unclear, therefore, whether hypovascularity is significant.
The etiology of peroneus longus tears is less concise. Some associate it with avulsion fracture to the os peroneum (1,3). Radiographs may reveal a proximally migrated os peroneum. Sammarco acknowledges chronic tears may occur in middle-age athletes and those with generalized disease (diabetes). Longitudinal peroneus longus tendon tears often occur at the lateral inferior margin of the cuboid (13).
Evaluation of lateral foot pain should include the history of previous events such as ankle trauma or instability. Physical examination should evaluate for swelling of the peroneal tendon sheath and the location of tenderness including above or below the lateral malleolus, the inferior margin of the cuboid, and the distribution of tenderness. Sobel popularized a test which he found helpful in diagnosing longitudinal peroneus brevis tendon tears known as the Peroneal Tunnel Compression Test (10). This is based on the premise that recreation of a force created by compression of the peroneus brevis tendon would result in reproducing the patient's symptoms. The test involves examining the patient's foot on the affected side with a knee flexed at 90 degrees and the foot and ankle hanging in the relaxed plantarflexed position. The examiner places his/her thumb firmly over the superior peroneal retinaculum from the posterior ridge of the fibula to the lateral aspect of the calcaneus and presses gently downward on the peroneal tendons while the foot is at rest. The patient is then asked to forcefully dorsiflex and evert the foot and ankle. Alternatively, the examiner may place the index, middle, and long fingertips directly posteriorly over the posterior edge of the fibula while resisting ankle eversion with the opposite hand. Positive results in either case are marked by recreation of the patient's pain in this region, and this may be accompanied by snapping, popping, or partial tendon subluxation being observed visually (6).
Radiographs of the foot and ankle, including axial views of the calcaneus, are routinely utilized. Axial views help rule out any arthritic spurs that may attenuate the peroneal tendons particularly laterally where the peroneal tubercle is visualized. Tenography may be used, but the variability in interpretation has caused this to fall out of favor (13). Magnetic Resonance Imaging (MRI) has been found to be most beneficial in order to identify peroneus brevis and longus degeneration, hypertrophy, and anomalous muscle bellies and accessory muscles such as the peroneus quartus. Furthermore, it may reveal the presence or absence of lateral ankle ligament structures, particularly if these will need to be reconstructed concomitantly to surgical repair of the peroneal tendon tears. MRI will indicate the presence of peroneal tendon abnormality by thin, irregular tendon margins as opposed to a normal, smooth contour. Even abnormal signal within the tendon, or fluid around the tendon, may also be found (14, 15).
A 42-year-old-male complained of persistent pain in the lateral aspect of the right foot despite any recent history of trauma. He had a history of ankle sprains from distance running on trails. Clinically, the patient described symptoms in the lateral aspect of the right cuboid and just inferior, along the course of the peroneus longus tendon. The patient's x-rays were completely unremarkable. The patient underwent physical therapy including cuboid manipulations, steroid injections and modification of his previous orthotic devices. He was also advised to use an ankle brace. None of these measure relieved his symptoms to any significant degree and the patient continued to have pain, not only with running but with daily activities. An MRI showed thickening of the right peroneus longus tendon on the lateral aspect of the calcaneus with increased fluid in the peroneal sheath (Fig. 1A & B). Because the patient was symptomatic despite conservative treatment for four months including refraining from running for six weeks, he consented to surgical exploration. Intraoperatively, findings included a hypertrophied peroneal sheath with early mucinoid degeneration (2) and longitudinal fraying of the right peroneus longus tendon (3). The pathologic report confirmed myxoid changes. The smaller degenerative tears were debrided and the tendon was tubularized using #3-0 polypropylene suture (4). The patient was placed in a medial-lateral fiberglass splint (to limit inversion) and was non-weight bearing for two weeks. At four weeks postoperatively, he discontinued the medial lateral splint, returned to an ankle brace, and began physical therapy. He was able to resume running at eight weeks postoperatively. By three months postoperatively he was able to run six miles every day, pain free. At two years postoperatively, he is at full activity level with no symptoms at the surgical site.
A 48-year-old male with a history of a previous severe ankle sprain years prior, complained of lateral right ankle pain increasing in severity over three years. Physical examination was remarkable for soreness along the peroneus brevis tendon, particularly from the fifth metatarsal base proximally to the lateral aspect of the ankle just inferior to the lateral malleolus. The x-rays were essentially negative. The patient underwent a physical therapy program (over two months which included ultrasound, electrical stimulation, and isokinetic strengthening), utilized a temporary orthotic and lace-up ankle brace but continued to have symptoms. Magnetic Resonance Imaging which showed thickening of the peroneal brevis tendon as it coursed underneath the lateral malleolus.
The patient underwent surgical exploration of the peroneal tendons. Intraoperatively, an intratendinous ganglion was found in a longitudinally split right peroneus brevis tendon spanning approximately 4 cm. The abnormal peroneus brevis tendon, which was debrided and the remaining tendon was tubularized with #3-0 polypropylene suture. The patient underwent a similar postoperative regimen (as the patient in Case 1). He used the ankle brace for a total of three months postoperatively and was able to return to bicycling and running with minimal symptoms; at a follow up of two years, he continues to be asymptomatic.
A 49-year-old male complained of insidious onset of pain along the lateral aspect of his right foot. He had to discontinue running because of persistent pain. Clinical examination revealed tenderness proximal to the right fifth metatarsal base. The ankle joint was stable. There was no clinical or radiographic sign of a fifth metatarsal fracture. Bone scan obtained was also negative. The x-rays showed only a small amount of calcific spurring at the peroneus brevis insertion (5). The Computed Tomography scan and MRI were essentially unremarkable, except for increased inflammatory changes and thickening at the right peroneus brevis tendon insertion (6). Conservative treatment did not relieve his symptoms. Surgical findings included a hypertrophic peroneus brevis tendon which was frayed over the fifth metatarsal base where the insertional calcification was noted. The calcification was debrided as it appeared to be fraying the overlying peroneus brevis tendon. The tendon was repaired utilizing nonabsorbable braided polyester suture and a Mitek anchor (to aid in tenodesis). The patient had a below the knee cast applied for three weeks since his tear involved insertion of the peroneus brevis. A below-the-knee removable cast boot was applied for an additional three weeks. After removal of the cast boot, the patient was placed into an ankle brace at six weeks postoperatively. He started physical therapy and continued to use the ankle brace for athletic activity until three months postoperatively, as the patient was able to return to bicycling and running by about two months postoperatively. The patient resumed running to his usual activity level and at two years postoperatively. He had no return of symptoms.
A 26-year-old female with a history of a left fifth metatarsal base fracture she sustained one year prior to presentation, complained of continued lateral left foot pain. The fifth metatarsal fracture healed uneventfully, however the patient continued to have symptoms of the lateral aspect of the foot, not only with athletic activity, but also daily activities which required her to stand eight to ten hours each day. X-rays were negative for any other sign of bony trauma including non-union of the fifth metatarsal, which appeared to be completely consolidated (7). A bone scan taken in order to rule out a stress fracture associated with the lateral aspect of the foot was negative. The patient therefore underwent conservative treatment and was advised to use a lace-up ankle brace for three months. She continued to have pain on the lateral aspect of the foot, particularly on the lateral aspect of the cuboid and calcaneus without any appreciable edema. A stress view of the midfoot was performed to rule out any occult midfoot sprain; this was negative.
The patient's symptomatology continued over the next two months despite rest, physical therapy, and temporary foot orthoses/bracing. Therefore, MRI was ordered. The results showed slight thickening of the peroneus longus tendon with increased fluid noted in the sheath (8). Therefore the patient was consented for exploration of the peroneal tendon complex.
Intraoperatively, fraying was noted of the left peroneus longus tendon, spanning approximately 2 cm. (The pathological evaluation of the debrided portion of abnormal tendon submitted yielded findings consistent with a tear.) The fraying was debrided and the tendon was tubularized with #3-0 polypropylene suture. She had a similar post-operative course as the patients in Cases 1 and 2. Eight weeks postoperatively she was able to start running and gradually resume other athletic activity including softball. At one year post operatively she is completely asymptomatic despite standing at work 10 to 12 hours per day.
It is important to note that in all four cases the area of the patient's pain was localized to the region of the pathological tendon tear. In addition, the patient's location of pain did not seem to change over the course of conservative treatment which ranged from 4 to 12 months. The authors point out that symptoms and self treatment often preceded professional evaluation and treatment for six months to several years. Most of the patients had a history of lateral ankle "trauma" and were athletic. LeMelle and Janis described similar findings with eight peroneus brevis tendon tears (5). The last two patients included in this series are currently three months post-operative and are being followed-up with similar regimens. The readers are asked to refer to Table 3 for details regarding the specifics with each patient.
Concomitant pathologies such as ankle instability, peroneal tendon subluxation, Os peroneum injury, and those listed in Table 1 should be addressed at the time of surgical repair of the longitudinal tendon tear (13). The senior author has treated other peroneal tendon pathologies that involved anomalous peroneal tendon or hypertrophied peroneus brevis muscle (which was excised) along with other ankle instability and peroneal retinacular injuries. The postoperative care is similar to that presented by other authors for isolated repair of longitudinal peroneal tendon injuries; two weeks of non-weight bearing in a cast or mediolateral splint, followed by an additional two weeks in a below-the-knee cast walker boot is commonly prescribed. After this an ankle brace to limit inversion/eversion is also used (13).
The most helpful diagnostic tool was the axial images from MRI which demonstrated enlargement of the involved peroneal tendon and often with fluid in the peroneal tendon sheath. Peroneal longus tendon injuries similar to what has been previously noted by Sammarco appear to be in the inferior lateral margin of the cuboid. These injuries may be misdiagnosed as cuboid syndrome. The authors refer the readership to Tables 1, 2, and 3 for additional information.
Patients that have had persistent lateral foot pain with prior history of lateral ankle injury should be considered for peroneal tendon injury. If typical conservative measures do not alleviate symptoms, MRI may be helpful in recognizing peroneal tendon pathology. Axial images typically reveal a thickening of the involved tendon and fluid in its sheath. Surgical debridement and repair of the involved peroneal tendon have yielded excellent results and full recovery in the five patients presented in this study. An additional two patients are three months post-operative and recovering well.
FIGURE LEGENDS: LONGITUDINAL PERONEAL TENDON TEARS
Figure 1A & B: Magnetic Resonance Imaging showing thicker right peroneus longus
tendon and increased fluid in peroneal sheath of patient in Case 1.
Figure 2: Mucoid degeneration of peroneal sheath of same patient.
Figure 3: Frayed peroneus longus tendon of same patient.
Figure 4: Peroneus longus tendon of same patient in Case 1 repaired and tubularized using continuously locked #3-0 polypropylene suture.
Figure 5: X-ray (from Case 3) showing calcific insertion of peroneus brevis tendon in fifth metatarsal base.
Figure 6A & B: Inflammatory response at peroneus brevis insertion, from patient in Case 3. (A) Computed Tomography, (B) Magnetic Resonance Imaging.
Figure 7: X-ray of patient's foot in case 4; note healed fifth metatarsal base fracture.
Figure 8: Magnetic Resonance Imaging of same patient above showing thickened peroneal tendon.
Figure 9: Magnetic Resonance Imaging of patient in Case 5 showing hypertrophied peroneal tubercle deep to peroneus brevis.
Figure 10: Magnetic Resonance Imaging of patient in Case 6 showing peroneus brevis tear with chronic villanous synovitis (arrows).
Figure 11: Magnetic Resonance Imaging of patient in Case 7 showing longitudinal tearing of peroneus longus tendon.
Figure 12: Photo of same patient's longitudinal tear.
DIFFERENTIAL DIAGNOSIS FOR LATERAL REAR FOOT PAIN:
Peroneal Tendinitis / Tenosynovitis
Ankle Sprain / Instability
Subtalar Sprain / Instability
Sinus Tarsi Syndrome
Peroneal Subluxation / Retinacular Tears
Calcaneal / Cuboid Fracture / Stress Fracture
Cuboid Syndrome/Subluxed Cuboid
Fifth Metatarsal Fracture/Stress Fracture (Jones)
Non-union Fifth Metatarsal Fracture
Midfoot (Chopart's) Sprain / Avulsion Fracture
Sural Nerve Neuritis
Accessory (Quartus)Peroneal Muscle/Tendon
Hypertrophied Peroneal Tubercle
Loose Bodies / Osteochondral Defect Ankle / Subtalar Joint
Peroneal Tendon Rupture
Longitudinal Peroneal Tendon Tear
|Running||L.T. P.L. tendon||3.5 yrs, No symptoms|
|L.T. P.B. tendon with intratendonous ganglia||2 yrs, No symptoms|
|Running||L.T. P.B. tendon calcific spur 5th metatarsal base||2 yrs, No symptoms|
|L.T. P.L. tendon||1 yr, No symptoms|
|Tennis||L.T. P.B. tendon
hypertrophied peroneal tubercle
|2.5 yrs, No symptoms|
Chronic villanous synovitis
|Soccer||L.T. P.L. tendon
torn calcaneal-fibular ligament
Legend: P.B. = Peroneus Brevis M =Male
P.L. = Peroneus Largus F = Female
L.T. = Longitudinal Tear yrs = years
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