Peroneal Tendon Subluxation / Dislocation

Author: Chad Krueger

Topic updated on 05/12/13 8:45am

Introduction

Peroneal tedon dislocation and repetitive subluxation from behind lateral malleolus
Epidemiology
- most of these injuries occur in young, active patients
Mechanism
- rapid dorsiflexion of an inverted foot inversion leading to rapid reflexive contraction of the PL and PB tendons
- rapid contraction can also lead to injury to the superior peroneal retinaculum
Pathophysiology
- subluxation of the peroneal tendons leads to longitudinal tears over time which usually involves peroneus brevis at fibular groove
Associated conditions
- tears of the peroneus brevis and or longus
  - longitudinal in nature

Anatomy

Muscles & innervation
- peroneus brevis
  - innervated by the superficial peroneal nerve, S1
  - acts as primary evertor of the foot
  - tendoninous about 2-4cm proximal to the tip of the fibula
  - lies anterior and medial to the peroneus longus at the level of the lateral malleolus
- peroneus longus
  - innervated by superficial peroneal nerve, S1
  - primarily a plantar flexor and foot and first metatarsal
  - can have an ossicle (os peroneum) located within the tendon body
Space & compartment
- peroneal tendons contained within a common synovial sheath that splits at the level of the peroneal tubercle
- the sheath is runs in the retromalleolar sulcus on the fibula
  - peroneal longus is posterior in the sulcus (longus takes the long way around)
  - deepened by a fibrocartilaginous rim (still only about 5 millimeters deep)
  - covered by superior peroneal retinaculum (SPR)
    - originates from the posterolateral ridge of the fibula and inserts onto the lateral calcaneus (peroneal tubercle)
    - the inferior aspect of the SPR blends with the inferior peroneal retinaculum
    - is the primary restraint the peroneal tendons within the retromalleolar sulcus

Classification

Ogden Classification of Superficial Peroneal Retinaculum Tears
Grade 1	The SPR is partially elevated off of the fibula allowing for subluxation of both tendons
Grade 2	The SPR is separated from the cartilofibrous ridge of the lateral malleolus, allowing the tendons to sublux between the SPR and the cartilofibrous ridge
Grade 3	There is a cortical avulsion of the SPR off of the fibula, allowing the subluxed tendons to move underneath the cortical fragment
Grade 4	The SPR is torn from the calcaneous, not the fibula

Presentation

History
- patients often report they felt a pop with a dorsiflexion ankle injury
Symptoms
- clicking, popping and feelings of instability or pain on the lateral aspect of the ankle
Physical exam
- inspection
  - swelling posterior to the lateral malleolus
  - tenderness over the tendons
  - 'pseudotumor' over the peroneal tendons
  - voluntary subluxation of the tendons +/- a popping sound
- provocative tests
  - apprehension tests
    - the sensation of apprehension or subluxation with active dorsiflexion and eversion against resistance cause subluxation/dislocation and apprehension
  - compression test
    - pain with passive dorsiflexion and eversion of the ankle

Imaging

Radiographs
- recommended views
  - best recognized on an internal rotation view
- findings
  - may see a cortical avulsion off the distal tip of the lateral malleolus (rim fracture)
  - needed to evaluate for varus hindfoot
MRI
- best evaluated with axial views of a slightly flexed ankle
- can demonstrate anatomic anomalies leading to pathology
  - peroneus quartus muscle
  - low-lying peroneus brevis muscle belly

Treatment

Nonoperative
- short leg cast immobilization and protected weight bearing for 6 weeks
  - indications
    - all acute injuries in nonprofessional athletes
  - technique
    - tendons must be reduced at the time of casting
  - outcomes
    - success rates for nonsurgical management are only marginally better than 50%.
Operative
- acute repair of superior peroneal retinaculum and deepening of the fibular groove
  - indications
    - acute tendon dislocations in serious athletes who desire a quick return to a sport or active lifestyle
    - presence of a longitudinal tears
- groove-deepening with soft tissue transfer and/or osteotomy
  - indications
    - chronic/recurrent dislocation
  - technique
    - less able to reconstruct SPR so treatment focuses on other aspects of peroneal stability
    - typically involves groove-deepening in addition to soft tissue transfers or bone block techniques (osteotomies to further contain the tendons within the sulcus)
    - plantaris grafts can act to reinforce the SPR
    - hindfoot varus must be corrected prior to any SPR reconstructive procedure

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Qbank (6 Questions)

TAG

(OBQ11.95) A 35-year-old man injured his ankle while playing soccer two years ago. Ever since he has had persistent right ankle pain that has failed to improve with nonoperative modalities including physical therapy. A video of his right ankle is found below. Radiographs are shown in Figures A through C. What is the most appropriate next step in management? Topic

Review Topic

FIGURES: V

1. Physical therapy directed at proprioception and strengthening
2. Fibular shortening osteotomy
3. Surgical repair of the anterior talofibular ligament (ATFL)
4. Surgical repair of the calcaneofibular ligament (CFL)
5. Fibular groove deepening and superior peroneal retinaculum repair

PREFERRED RESPONSE ▶

DISCUSSION: The patient in this scenario has chronic peroneal subluxation. Radiographs are often normal in this condition. On physical exam, a consistent finding is subluxation of the tendons with resisted dorsiflexion and eversion of the ankle. This is most likely secondary to a disruption of the superior peroneal retinaculum (SPR). After a trial of non-operative management, surgical options include repair of the SPR, with or without fibular groove deepening.

Philbin et al reviewed peroneal tendon injuries. As 40% lead to chronic lateral ankle pain, they emphasized an accurate physical exam. They concluded that low-demand patients do well with a nonsurgical approach while high-demand patients may benefit from surgery.

Heckman et al reviewed operative techniques for peroneal disorders. They determined that operative repair consists of surgical repair of the (SPR) with or without fibular groove deepening for subluxation. Primary repair of the tendon is indicated for tears <50% while tenodesis is indicated for tears >50%.

The video depicts the clinical appearance of the peroneal tendons subluxing with ankle dorsiflexion.

Incorrect answers:
1. He has already completed a trial of non-operative management.
2. A fibular shortening osteotomy is not the treatment of this condition.
3. His exam is not consistent with an ATFL injury.
4. His exam is not consistent with a CFL injury.

REFERENCES:

1. Philbin TM, Landis GS, Smith B. Peroneal tendon injuries. J Am Acad Orthop Surg. 2009 May;17(5):306-17. Review. PMID:19411642 (Link to Abstract)

2. Heckman DS, Reddy S, Pedowitz D, Wapner KL, Parekh SG. Operative treatment for peroneal tendon disorders. J Bone Joint Surg Am. 2008 Feb;90(2):404-18. PMID:18245603 (Link to Abstract)

Question Authors:

Terrill Julien MD, John Badylak MD, Ben Taylor MD,

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TAG

(OBQ10.100) A 24-year-old female sprains her ankle playing tennis. After 3 months of bracing, physical therapy, and NSAID treatment she continues to complain of pain and a popping sensation over the lateral ankle. Physical exam is notable for tenderness over the lateral malleolus. Figure A shows the ankle at rest. Figure B shows the ankle during active eversion. Which of the following structures has been injured? Topic

Review Topic

FIGURES: A

1. Peroneus brevis
2. Inferior peroneal retinaculum
3. Superior peroneal retinaculum
4. Anterior talofibular ligament
5. Lateral process of the talus

PREFERRED RESPONSE ▶

DISCUSSION: The clinical photographs demonstrate subluxation of the peroneal tendons with eversion of the foot. This painful phenomenon occurs following rupture of the superior peroneal retinaculum, which keeps the peroneal tendons contained within the retromalleolar groove of the fibula. Treatment initially consists of conservative modalities including physical therapy. Failure of nonoperative treatment warrants surgical repair of the disrupted retinaculum and deepening of the groove if needed. An anatomic diagram of the peroneal tendons running through the superior and inferior retinaculum is provided in illustration A. Philbin et al reviews the anatomy, evaluation, and treatment of peroneal tendon injuries. Heckman et al reviews the different options for peroneal tendon injuries.

Illustrations: A

REFERENCES:

1. Philbin TM, Landis GS, Smith B. Peroneal tendon injuries. J Am Acad Orthop Surg. 2009 May;17(5):306-17. PMID:19411642 (Link to Abstract)

2. Heckman DS, Reddy S, Pedowitz D, Wapner KL, Parekh SG. Operative treatment for peroneal tendon disorders. J Bone Joint Surg Am. 2008 Feb;90(2):404-18. PMID:18245603 (Link to Abstract)

Question Authors:

John Badylak MD,

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(OBQ08.10) In the retromalleolar groove, as shown in Figure A, what is the relationship of the peroneus brevis tendon to the peroneus longus tendon? Topic

Review Topic

FIGURES: A

1. Anterior
2. Posterior
3. Medial
4. The peroneus longus tendon is not in the groove
5. The peroneus brevis tendon is not in the groove

PREFERRED RESPONSE ▶

DISCUSSION: At the level of the ankle the peroneal tendons are contained in the retromalleolar sulcus on the fibula. The sulcus is deepened by a fibrocartilaginous rim and covered by the superior peroneal retinaculum. In the retromalleolar sulcus at the level of the ankle joint the peroneus brevis tendon lies anterior to the peroneus longus tendon (see Illustration A and B).

Selmani et al provide a comprehensive review of peroneal tendon pathology and its treatment. The three broad categories of peroneal tendon pathology are peroneal tendinitis, peroneal subluxation, and peroneal tendon tears. Often these issues are interrelated and can even be progressive.

Philbin et al also provide a review of the topic discussing that the peroneal tendons are the primary evertors of the foot and function as lateral ankle stabilizers. In their treatment section they mention that lower demand patients may be candidates for nonoperative management, whereas high demand patients will probably benefit from surgical treatment.

Illustrations: A

REFERENCES:

1. Selmani E, Gjata V, Gjika E. Current concepts review: peroneal tendon disorders. Foot Ankle Int. 2006 Mar;27(3):221-8. PMID:16539908 (Link to Abstract)

2. Philbin TM, Landis GS, Smith B. Peroneal tendon injuries. J Am Acad OrthopSurg. 2009 May;17(5):306-17. PMID:19411642 (Link to Abstract)

3. Sarrafian SK. Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional. 2nd ed. Philadelphia, Pa: JB Lippincott Co; 1993. pp. 218-282

Question Authors:

Khalid Yousuf MD, Derek Moore, Ben Taylor MD,

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(OBQ07.41) A 17-year-old tennis player sustained an ankle sprain 4 weeks ago and now complains of painful popping behind the lateral malleolus. What physical exam will reproduce his symptoms? Topic

Review Topic

1. External rotation stress test
2. Resisted inversion
3. Resisted dorsiflexion
4. Resisted eversion
5. Resisted plantar flexion

PREFERRED RESPONSE ▶

DISCUSSION: The only structures behind lateral malleolus are peroneal tendons. The peroneal tendons are a common source of pathlogy in refractory ankle sprains. This patient is complaining of subluxing peroneal tendon(s) as a result of a torn superior retinaculum. This can be tested with resisted eversion as the peroneal tendons evert the ankle. Maffulli et al concluded that an anatomic repair of the retinaculum lead to good results in higher demand patients.

REFERENCES:

1. Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 233-248.

2. Maffulli N, Ferran NA, Oliva F, Testa V. Recurrent subluxation of the peroneal tendons. Am J Sports Med 2006;34:986-992. PMID:16452271 (Link to Abstract)

3. Philbin TM, Landis GS, Smith B. Peroneal tendon injuries. J Am Acad Orthop Surg. 2009 May;17(5):306-17. PMID:19411642 (Link to Abstract)

Question Authors:

Derek Moore,

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(OBQ05.258) Which of the following mechanisms of injury to the ankle is most likely to result in peroneal tendon instability? Topic

Review Topic

1. Plantarflexion and eversion
2. Dorsiflexion and eversion
3. Neutral ankle flexion and inversion
4. Dorsiflexion and inversion
5. Plantarflexion and inversion

PREFERRED RESPONSE ▶

DISCUSSION: Peroneal tendon instability occurs during an inversion injury to a dorsiflexed ankle with rapid reflexive contraction of the peroneus longus and peroneus brevis tendons. Patients often hear a pop” or feel a snapping sensation, followed by pain and swelling. The peroneals have a vascular watershed region just posterior to the fibula and are prone to longitudinal tears. Radiographs often show an avulsion fracture of the distal fibula (rim fracture) at the insertion of the superior peroneal retinaculum.Chronic instability of the peroneal tendons can be best demonstrated by positioning the ankle in dorsiflexion and resisting eversion. Treatment for acute injuries involves cast immobilization to allow the superior peroneal retinaculum to heal. Injuries recalcitrant to conservative management or high level athletes may benefit from superficial peroneal retinaculum repair and fibular groove-deepening procedures.

REFERENCES:

1. Clanton TO: Athletic injuries to the soft tissues of the foot and ankle in Coughlin MJ, Mann RA. Surgery of the Foot and Ankle ed 7. 1999 pages 1090-1209

2. Coughlin MJ: Disorders of tendons, in Coughlin MJ, Mann RA: Surgery of the Foot and ankle ed 7. 1999 pages 786-861

Question Authors:

Michael Hughes MD,

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Videos

Peroneal tendon subluxation

Foot & Ankle - Treatment Consult - Peroneal Tendon Subluxation / Dislocation

Demonstrates the snapping/subluxation of a peroneal tendon

3/2/2013

313 views

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Groups

ABOS II: Peroneal Tendon Subluxation / Dislocation

General - Oral Boards Review

7/29/2011

0 responses

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Evidence & References Show References

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Heckman DS, Reddy S, Pedowitz D, Wapner KL, Parekh SG. Operative treatment for peroneal tendon disorders. J Bone Joint Surg Am. 2008 Feb;90(2):404-18. PMID:18245603 (Link to Abstract)
Philbin TM, Landis GS, Smith B. Peroneal tendon injuries. J Am Acad Orthop Surg. 2009 May;17(5):306-17. PMID:19411642 (Link to Abstract)
Philbin TM, Landis GS, Smith B. Peroneal tendon injuries. J Am Acad Orthop Surg. 2009 May;17(5):306-17. Review. PMID:19411642 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Clanton TO: Athletic injuries to the soft tissues of the foot and ankle in Coughlin MJ, Mann RA. Surgery of the Foot and Ankle ed 7. 1999 pages 1090-1209
Coughlin MJ: Disorders of tendons, in Coughlin MJ, Mann RA: Surgery of the Foot and ankle ed 7. 1999 pages 786-861

Undefined

Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 233-248.
Maffulli N, Ferran NA, Oliva F, Testa V. Recurrent subluxation of the peroneal tendons. Am J Sports Med 2006;34:986-992. PMID:16452271 (Link to Abstract)
Philbin TM, Landis GS, Smith B. Peroneal tendon injuries. J Am Acad Orthop Surg. 2009 May;17(5):306-17. PMID:19411642 (Link to Abstract)
Philbin TM, Landis GS, Smith B. Peroneal tendon injuries. J Am Acad OrthopSurg. 2009 May;17(5):306-17. PMID:19411642 (Link to Abstract)
Sarrafian SK. Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional. 2nd ed. Philadelphia, Pa: JB Lippincott Co; 1993. pp. 218-282
Selmani E, Gjata V, Gjika E. Current concepts review: peroneal tendon disorders. Foot Ankle Int. 2006 Mar;27(3):221-8. PMID:16539908 (Link to Abstract)

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