Updated: 4/24/2019

Peroneal Tendon Subluxation & Dislocation

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Subluxation/Dislocations
  • 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 
    • subfibular impingment secondary to calcaneal malunion 
  • Associated conditions
    • tears of the peroneus brevis and or longus  
      • longitudinal split tears more common than transverse
    • lateral ankle ligament injuries (ATFL, CFL) in up to 75% of patients with SPR injuries
Anatomy
  • Muscles & innervation  
    • peroneus brevis 
      • 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 
      • 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  
      • peroneus longus is posterior in the sulcus (longus takes the long way around)
      • peroneus brevis is anterior in the sulcus (brevis is behind the bone)
        • 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 
    • 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
Classification
 
Ogden Classification of Superior Peroneal Retinaculum (SPR) 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 (fleck sign, 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 tear  
    • 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 
Peroneal Brevis Tears
  • Introduction
    • presentation and physical exam is often very similar to peroneal tendon dislocation, however there is no instability of the tendon
  • Imaging
    • MRI is requried for diagnosis
  • Treatment  
    • nonoperative
      • NSAIDs, activity restriction and a walking boot are often the first line of treatment
      • failure rate may be as high as 83%
    • operative 
      • core repair and tubularization of the tendon  
        • indications
          • simple tears
      • debridement of the tendon with tenodesis of distal and proximal ends of the brevis tendon to the peroneus longus or reconstruction with allograft 
        • indications
          • complex tears with multiple longitudinal tears and significant tendinosis (> 50% of the tendon involved) 
      • debridement of both tendons with interposition allograft
        • indications
          • complex tears of both tendons with (involving over 50% of tendon substance) with preserved muscle excursion
      • debridement of both tendons with FHL transfer
        • indications
          • complex tears of both tendons with (involving over 50% of tendon substance) with no muscle excursion
      • hindoot osteotomy with peroneal tendon pathology 
        • varus hindfoot alignment contributes to peroneal pathology
        • consider calcaneal osteotomy or subtalar arthrodesis in patient with hindfoot varus and peroneal pathology
 
 

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Questions (21)
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(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? Review Topic

QID: 4646
1

Core repair and tubularization of the peroneus brevis tendon

9%

(291/3363)

2

Peroneal groove deepening

2%

(52/3363)

3

Excision of the diseased tendon without transfer

2%

(84/3363)

4

Excision of the diseased tendon with proximal and distal transfer to the peroneus longus

86%

(2879/3363)

5

Arthroscopic debridement of the peroneus brevis

1%

(20/3363)

L 2

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(OBQ13.252) Which of the following physical examination findings would suggest injury to the superior peroneal retinaculum? Review Topic

QID: 4887
1

Positive ankle anterior drawer test

1%

(34/4136)

2

Positive external rotation stress test

2%

(81/4136)

3

Crepitus over the anterolateral ankle joint

1%

(46/4136)

4

Palpable tendon snapping over the fibula during ankle dorsiflexion

95%

(3936/4136)

5

Tenderness at the base of 5th metatarsal with ankle eversion.

1%

(23/4136)

L 1

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(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? Review Topic

QID: 4581
FIGURES:
1

Debridement and attempted repair of peroneal brevis

3%

(112/4232)

2

Debridement and attempted repair of peroneal longus

9%

(364/4232)

3

Reconstruction of peroneal brevis with allograft

1%

(49/4232)

4

Debridement of peroneal brevis and tenodesis of peroneal brevis to longus

20%

(840/4232)

5

Debridement of peroneal longus and tenodesis of peroneal longus to brevis

66%

(2811/4232)

L 3

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(OBQ12.275) What is the most appropriate management of the injury shown in Figures A and B? Review Topic

QID: 4635
FIGURES:
1

Achilles tendon repair

3%

(67/2528)

2

Repair of superior peroneal retinaculum and deepening of the fibular groove

23%

(576/2528)

3

Posterior tibial tendon reconstruction with flexor hallucs longus transfer

5%

(133/2528)

4

Peroneus longus repair

57%

(1434/2528)

5

Peroneus brevis repair

12%

(305/2528)

L 4

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(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? Review Topic

QID: 3518
FIGURES:
1

Physical therapy directed at proprioception and strengthening

1%

(26/2316)

2

Fibular shortening osteotomy

1%

(15/2316)

3

Surgical repair of the anterior talofibular ligament (ATFL)

3%

(59/2316)

4

Surgical repair of the calcaneofibular ligament (CFL)

1%

(26/2316)

5

Fibular groove deepening and superior peroneal retinaculum repair

94%

(2176/2316)

L 1

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(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? Review Topic

QID: 3194
FIGURES:
1

Peroneus brevis

3%

(53/1940)

2

Inferior peroneal retinaculum

14%

(264/1940)

3

Superior peroneal retinaculum

82%

(1598/1940)

4

Anterior talofibular ligament

1%

(18/1940)

5

Lateral process of the talus

0%

(2/1940)

L 2

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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? Review Topic

QID: 396
FIGURES:
1

Anterior

77%

(1228/1587)

2

Posterior

10%

(159/1587)

3

Medial

10%

(155/1587)

4

The peroneus longus tendon is not in the groove

1%

(21/1587)

5

The peroneus brevis tendon is not in the groove

1%

(18/1587)

L 2

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(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? Review Topic

QID: 9104
1

Forced dorsiflexion and inversion

21%

(329/1600)

2

Forced dorsiflexion and eversion

29%

(463/1600)

3

Forced plantarflexion and eversion

5%

(75/1600)

4

Forced plantarflexion and inversion

45%

(721/1600)

5

Direct trauma to the fibula

0%

(3/1600)

L 5

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(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? Review Topic

QID: 1144
1

Plantarflexion and eversion

9%

(141/1625)

2

Neutral ankle position

1%

(18/1625)

3

Neutral ankle flexion and inversion

2%

(25/1625)

4

Dorsiflexion and inversion

44%

(723/1625)

5

Plantarflexion and inversion

44%

(714/1625)

L 5

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