Summary Peroneal Tendon Tears and Instability represent a spectrum of traumatic injuries to the lateral ankle that include tenosynovitis, tendinopathy, tendon tears and/or tendon instability. Diagnosis is made clinically with subfibular ankle pain with the sensation of apprehension or subluxation with active dorsiflexion and eversion against resistance. MRI studies can help identify the size of peroneal tendon tear and identify concomitant injuries to nearby structures. Treatment may be nonoperative or operative depending on patient activity demands, chronicity of injury, and peroneal instability. Epidemiology Incidence peroneal tendon tears seen in 23-77% of all cases of lateral ankle instability Prevalence peroneal tendon tears comprise 4% of all ankle injuries Demographics tendon instability seen in young, athletic populations Etiology Pathophysiology mechanism of injury rapid forced dorsiflexion of the inverted foot will cause strain through the contracted peroneal muscles, leading to superior peroneal retinaculum (SPR) tear most common pattern is longitudinal split tear in the PB if superior peroneal retinaculum tears, tendons will become unstable and subluxate or completely dislocate Associated conditions lateral ligamentous instability (ATFL, CFL) cavovarus hindfoot alignment Charcot-Marie Tooth low-lying muscle belly of peroneus brevis enlarged peroneal tubercle (29% of population) accessory peroneus quartus or quintus (10-34% of population) flat or concave retromalleolar sulcus (18% of population) os peroneum calcaneal malunion and subfibular impingement Anatomy Muscle innervation and biomechanics peroneus brevis (PB) innervated by the superficial peroneal nerve, S1 acts as primary evertor of the foot tendinous 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 (PL) 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 near the calcaneocuboid joint Space & compartment peroneal tendons contained within a common synovial sheath that splits at the level of the peroneal tubercle the sheath runs in the retromalleolar groove on the fibula peroneus brevis is directly posterior to the fibula at the level of the groove peroneus longus is directly posterior to peroneus brevis at the level of the groove 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 of the peroneal tendons within the retromalleolar sulcus at the level of the peroneal tubercle of the calcaneus peroneus longus is inferior peroneus brevis is superior both tendons covered by inferior peroneal retinaculum Blood supply supplied by branches of the anterior and posterior tibial arteries via vincula system entirety of both tendons are vascularized early descriptions of avascular zones disproven Classification Anatomic Classification of Superior Peroneal Retinaculum (SPR) Tears Grade 1 The SPR is partially elevated off of the fibula (fibrocartilaginous ridge remains intact) allowing for subluxation of both tendons Grade 2 The SPR is separated from the cartilofibrous ridge of the lateral malleolus, allowing the tendons to subluxate between the SPR and the fibrocartilaginous ridge Grade 3 There is a cortical avulsion of the SPR off of the fibula, allowing the subluxated tendons to move underneath the cortical fragment Grade 4 The SPR is torn from the calcaneus, not the fibula Raikin Classification of Intra-sheath subluxation Type 1 PL tendon lies deep in relation to the PB tendon Type 2 PL tendon subluxated through a PB tear Redfern and Meyerson Peroneal Tendon Tear Classification Type I Both tendons intact but with partial tearing Type II One tendon is intact but other is majority torn Type IIIa Both tendons are majority torn (unusable) and muscle belly has no excursion Type IIIb Both tendons are majority torn (unusable) but muscle belly has excursion Presentation History report feeling a pop with a distinct dorsiflexion ankle injury feelings of instability in lateral ankle sensation of stepping on a pebble if os peroneum is symptomatic Symptoms location lateral or posterolateral ankle pain may be more distal towards the fibular tip aggravating/alieving factors active eversion and/or plantarflexion passive dorsiflexion Physical exam inspection swelling posterior to the lateral malleolus tenderness over the tendons cavovarus hindfoot alignment '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 active circumduction may re-create tendon instability ankle drawer testing evaluate for concomitant ligamentous instability Imaging Radiographs recommended views standard weightbearing series optional views Harris view best to visualize peroneal tubercle morphology findings "Fleck sign" a cortical avulsion of the SPR off the distal tip of the lateral malleolus plantarflexed first metatarsal and high Meary's angle indicating cavovarus deformity proximal migration of the os peroneum is indicative of a peroneus longus rupture Ultrasound indications high degree of suspicion for tendon tears or instability findings dynamic view of tendon subluxation intra-sheath tendon subluxation sensitivity and specificity 90% accuracy for tendon tears user-dependent CT indications calcaneus malunion and lateral wall/subfibular impingement concern for retromalleolar groove abnormality or enlarged peroneal tubercle MRI indications high degree of suspicion for tendon tears or instability, or other concomitant pathology (ATFL/CFL insufficiency and talar OCD) views best evaluated with axial views of a slightly plantarflexed ankle decreases the "magic angle" effect of the curved path of the tendons findings edema and tendon thickening indicating tendinopathy significant circumferential fluid within sheath indicating tenosynovitis intra-substance tendon tears fatty infiltration of the muscle belly accessory tendons or low-lying PB muscle belly sensitivity and specificity 83-90% sensitivity 72-75% specificity Treatment Nonoperative short leg cast immobilization and protected weight bearing for 6 weeks indications all acute PB/PL instability in nonprofessional athletes outcomes over 50% failure rates for chronic instability cases failure rates as high as 83% for peroneal tendon tears period of activity modification and boot immobilization, followed by physical therapy indications first-line treatment for PB/PL tendinopathy, tenosynovitis and tears outcomes variable success rates reported Operative repair of superior peroneal retinaculum and deepening of the retromalleolar groove indications acute tendon dislocations in high-level athletes who desire a quick return to a sport/occupation presence of a longitudinal tear outcomes SPR repair yields high rate of return to sport and excellent patient-reported outcomes addition of groove deepening shows higher rate of return to sport than SPR repair alone (83-100%) groove-deepening with soft tissue transfer and/or osteotomy indications chronic/recurrent dislocations with bony abnormalities or incompetent SPR generally used as salvage procedures outcomes higher complications rate than SPR repair and groove deepening tenosynovectomy and tendon debridement with tubularization indications recalcitrant and symptomatic PB/PL tears less than 50-60% of the tendon width outcomes high rates of patient satisfaction tenosynovectomy and tendon debridement without tubularization indications recalcitrant cases of tenosynovitis and tendinopathy tendinopathic tissue to be resected should comprise less than 50-60% of the tendon width outcomes despite increasing popularity, long-term outcomes data does not exist tenodesis of distal and proximal ends of the brevis tendon to the peroneus longus indications complex tears of the brevis tendon with multiple longitudinal tears and significant tendinosis (> 50% of the tendon involved) outcomes success rates 70-80% with return to sports at 12 weeks debridement of both tendons with interposition auto- or allo-graft indications complex tears of both tendons with (involving over 50% of tendon substance) with preserved muscle excursion (Redfern and Meyerson Type IIIb) outcomes case series report good outcomes but no studies done compared to tenodesis debridement of both tendons with FHL/FDL transfer indications complex tears of both tendons (involving over 50% of tendon substance) with no muscle excursion outcomes small case series describing good patient-reported outcomes but residual eversion strength deficits hindfoot corrective osteotomy indications add to any case with rigid hindfoot-driven varus or valgus alignment outcomes high failure and recurrence rates seen when alignment not addressed Techniques Short leg cast immobilization and protected weight bearing for 6 weeks technique tendons must be reduced at the time of immobilization (and able to maintain reduced position) foot placed in slight plantarflexion and inversion Period of activity modification and boot immobilization, followed by physical therapy technique boot immobilization ended and physical therapy started once pain at rest has completely resolved may incorporate shoe orthosis to address hindfoot- or forefoot-driven varus Repair of superior peroneal retinaculum and deepening of the fibular groove approach longitudinal incision over the peroneal tendons technique careful dissection that avoids sural nerve branches SPR can then be split longitudinally leaving cuff of tissue for later repair, or sharply transected from fibula tendons can be evaluated for concomitant tears and groove assessed for morphology if groove deepening chosen, a small burr can be used to deepen groove alternatively, a small drillbit can be drilled retrograde from the fibular tip through the subcortical groove bone a tamp can then be used to depress the cortical bone and create a groove SPR can then be repaired via direct repair, bone tunnels, or suture anchors Groove-deepening with soft tissue transfer and/or osteotomy approach open approach as described above technique treatment focuses on other aspects of peroneal stability involves groove-deepening in addition to soft tissue transfers or bone block osteotomies to further contain the tendons within the sulcus plantaris grafts can be harvested or soft tissue allograft use to reinforce/reconstruct the SPR Tenosynovectomy and tendon debridement without tubularization approach endoscopic/tendonoscopic technique technique first viewing portal started 2cm distal to fibular tip, and second working portal made 3cm proximal to fibular tip tendon can be visualized and synovium/adhesions resected Tenosynovectomy and tendon debridement with tubularization approach open approach as described above technique SPR incised longitudinally and tendon exposed tendon tear location and type assessed and nonviable tissues debrided monofilament suture used to repair edges of remaining tendon to itself to create smooth-gliding tube SPR repaired Debridement of the tendon with tenodesis of distal and proximal ends of the brevis tendon to the peroneus longus approach open approach as described above technique SPR incised longitudinally and tendon exposed PB tendon tear location and type assessed and nonviable tissues debrided proximal end of PB tenodesed to PL in side-to-side fashion approximately 3cm proximal to the fibular tip distal end of PB tenodeses to PL in side-to-side fashion approximately 2cm distal to fibular tip SPR repaired Hindfoot corrective osteotomy approach incision based on osteotomy selected (distractive bone-block subtalar fusion, Dwyer osteotomy etc) technique neutral realignment goal of all surgical techniques Complications Sural neuroma incidence most common complication following surgery given proximity to peroneal tendons Recurrence of peroneal tendon instability risk factors unaddressed ankle malalignment treatment corrective osteotomy with/without soft tissue reconstruction Persistent pain risk factors overtightening of SPR repair causing tendon stenosis Tibial nerve compression incidence seen following FHL transfer prevention release adhesions between FHL and neurovascular bundle
QUESTIONS 1 of 28 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ18.28) A 22-year-old soccer player has persistent lateral-sided ankle pain after a low-grade ankle sprain 8 months ago. She has returned to competitive soccer but the pain still bothers her. On exam, she has full range of motion and no signs of ankle or tendon instability. Her most recent imaging is seen in Figures A and B. What is her diagnosis and corresponding treatment? QID: 212924 FIGURES: A B Type & Select Correct Answer 1 Symptomatic peroneus brevis tendon tear, tenodesis if tear less than 50% 10% (204/2053) 2 Os trigonum syndrome, excision 4% (79/2053) 3 Symptomatic peroneus brevis tendon tear, tubularization if tear less than 50% 82% (1676/2053) 4 Talar dome osteochondral defect, microfracture if lesion less than 2x2cm 2% (47/2053) 5 Talar dome osteochondral defect, osteochondral allograft is lesion greater than 2x2cm 2% (36/2053) L 2 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ17.175) A 22-year-old collegiate football player presents with persistent left lateral ankle pain 6 months after sustaining an ankle sprain during a game. He recalls catching his foot on astroturf with a dorsiflexion and inversion moment about his ankle. He was treated with physical therapy and a controlled ankle motion boot for several weeks following the injury with minimal relief. A current radiograph and an MRI of his ankle are shown in Figures A and B, respectively. What structure labeled in Figure C is most likely injured? QID: 210262 FIGURES: A B C Type & Select Correct Answer 1 1 3% (72/2105) 2 2 4% (76/2105) 3 3 1% (15/2105) 4 4 89% (1883/2105) 5 5 2% (43/2105) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ13.11) A 55-year-old recreational tennis player presents to clinic after initial rehabilitation complaining primarily about pain and swelling along the posterior fibula. He states he sprained his ankle six months ago, and was treated with bracing and proprioceptive training. He notes multiple sprains in the past, but the pain from prior sprains was different and always resolved. After an MRI demonstrated a peroneus brevis tear he is taken to the operating room. During surgery you identify multiple longitudinal tears in the peroneus brevis tendon, and a 3 cm portion of the tendon with significant tendinosis in over 70% of the cross-sectional area. What is the appropriate surgical procedure? QID: 4646 Type & Select Correct Answer 1 Core repair and tubularization of the peroneus brevis tendon 9% (366/4151) 2 Peroneal groove deepening 2% (63/4151) 3 Excision of the diseased tendon without transfer 3% (116/4151) 4 Excision of the diseased tendon with proximal and distal transfer to the peroneus longus 85% (3534/4151) 5 Arthroscopic debridement of the peroneus brevis 1% (27/4151) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ13.252) Which of the following physical examination findings would suggest injury to the superior peroneal retinaculum? QID: 4887 Type & Select Correct Answer 1 Positive ankle anterior drawer test 1% (47/4922) 2 Positive external rotation stress test 2% (90/4922) 3 Crepitus over the anterolateral ankle joint 1% (55/4922) 4 Palpable tendon snapping over the fibula during ankle dorsiflexion 95% (4683/4922) 5 Tenderness at the base of 5th metatarsal with ankle eversion. 1% (30/4922) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (SBQ12FA.50) A 26-year-old active woman is seen for persistent lateral ankle pain. She has tried a course of treatment with NSAIDs, physical therapy and bracing. Plain films are unremarkable, and her MRI image is shown in Figures A and B. What is the distal insertion point of the injured structure? QID: 3857 FIGURES: A B Type & Select Correct Answer 1 Navicular and medial cuneiform 9% (155/1790) 2 Base of distal phalanx of big toe 3% (50/1790) 3 First metatarsal base and medial cuneiform 19% (338/1790) 4 Fifth metatarsal base 67% (1193/1790) 5 Base of distal phalanx of digits 2-5 2% (40/1790) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ12.221) A 60-year-old with a history of diet controlled diabetes presents with ongoing 6-8 months history of lateral sided ankle pain. On physical exam, he is painful to resisted eversion, resisted plantar flexion of the 1st metatarsal and has a positive Coleman block test. A representative coronal MRI sequence at the level of the cuboid is shown in Figure A. Intra-operatively, the peroneal tendon located directly posterior to the fibula is found to be normal. The second peroneal tendon is found to have limited excursion, with multiple tears and fibrous tissue. Which of the following treatment options is ideal for this patient? QID: 4581 FIGURES: A Type & Select Correct Answer 1 Debridement and attempted repair of peroneal brevis 3% (136/5141) 2 Debridement and attempted repair of peroneal longus 8% (432/5141) 3 Reconstruction of peroneal brevis with allograft 1% (73/5141) 4 Debridement of peroneal brevis and tenodesis of peroneal brevis to longus 20% (1026/5141) 5 Debridement of peroneal longus and tenodesis of peroneal longus to brevis 66% (3412/5141) L 3 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ12.275) What is the most appropriate management of the injury shown in Figures A and B? QID: 4635 FIGURES: A B Type & Select Correct Answer 1 Achilles tendon repair 3% (87/3395) 2 Repair of superior peroneal retinaculum and deepening of the fibular groove 24% (812/3395) 3 Posterior tibial tendon reconstruction with flexor hallucs longus transfer 5% (181/3395) 4 Peroneus longus repair 56% (1896/3395) 5 Peroneus brevis repair 12% (399/3395) L 4 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? QID: 3518 FIGURES: V A B C Type & Select Correct Answer 1 Physical therapy directed at proprioception and strengthening 1% (34/2903) 2 Fibular shortening osteotomy 1% (23/2903) 3 Surgical repair of the anterior talofibular ligament (ATFL) 3% (85/2903) 4 Surgical repair of the calcaneofibular ligament (CFL) 1% (32/2903) 5 Fibular groove deepening and superior peroneal retinaculum repair 93% (2709/2903) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (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, while figure B shows the ankle during active eversion. Which of the following structures has been injured? QID: 3194 FIGURES: A B Type & Select Correct Answer 1 Peroneus brevis 3% (74/2681) 2 Inferior peroneal retinaculum 13% (348/2681) 3 Superior peroneal retinaculum 82% (2202/2681) 4 Anterior talofibular ligament 1% (40/2681) 5 Lateral process of the talus 0% (5/2681) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? QID: 396 FIGURES: A Type & Select Correct Answer 1 Anterior 77% (1657/2142) 2 Posterior 10% (213/2142) 3 Medial 10% (206/2142) 4 The peroneus longus tendon is not in the groove 1% (31/2142) 5 The peroneus brevis tendon is not in the groove 1% (27/2142) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (OBQ07.41.1) A 20-year-old male sustained an ankle sprain 4 weeks ago while skiing. He now complains of persistent painful snapping and popping posterior to the lateral malleolus. On exam, snapping is felt over the lateral fibula when the patient moves against resistance in dorsiflexion and eversion. What was the most likely mechanism of his injury? QID: 9104 Type & Select Correct Answer 1 Forced dorsiflexion and inversion 26% (625/2368) 2 Forced dorsiflexion and eversion 24% (579/2368) 3 Forced plantarflexion and eversion 5% (107/2368) 4 Forced plantarflexion and inversion 44% (1038/2368) 5 Direct trauma to the fibula 0% (6/2368) L 5 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (OBQ05.258) Which of the following mechanisms of injury to the ankle is most likely to result in disruption of the superior peroneal retinaculum with subsequent peroneal tendon instability? QID: 1144 Type & Select Correct Answer 1 Plantarflexion and eversion 9% (184/2160) 2 Neutral ankle position 1% (22/2160) 3 Neutral ankle flexion and inversion 2% (40/2160) 4 Dorsiflexion and inversion 45% (974/2160) 5 Plantarflexion and inversion 43% (933/2160) L 5 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic
All Videos (3) Podcasts (1) Login to View Community Videos Login to View Community Videos 2022 California Orthopaedic Association Annual Meeting Peroneal Tendon Tears: Repair, Transfer or Replace - Naudereh Noori, MD Naudereh Noori Foot & Ankle - Peroneal Tendon Tears and Instability 8/9/2022 221 views 4.6 (5) Login to View Community Videos Login to View Community Videos 2018 Orthopaedic Summit Evolving Techniques Chronic Peroneal Subluxation Treating with a Fibular Osteotomy - Troy S. Watson, MD (OSET 2018) Troy Watson Foot & Ankle - Peroneal Tendon Tears and Instability A 9/12/2019 457 views 4.7 (3) Login to View Community Videos Login to View Community Videos Peroneal tendon subluxation Chad Krueger Foot & Ankle - Peroneal Tendon Tears and Instability B 3/2/2013 5800 views 4.9 (24) Foot & Ankle⎪Peroneal Tendon Subluxation & Dislocation Foot & Ankle - Peroneal Tendon Tears and Instability Listen Now 24:3 min 10/16/2019 923 plays 4.5 (6)