Updated: 11/8/2020

Peroneal Tendon Tears and Instability

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Summary
  • Peroneal longus (PL) and brevis (PB) tendon tears are common injuries which are often mistaken for ankle sprains
  • A spectrum of pathology including tenosynovitis, tendinopathy, tendon tears and/or tendon instability
  • Due to acute athletic injuries or chronic overuse activities
  • Tears mostly in a longitudinal pattern, as opposed to transverse tears of avulsions
Science
  • 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
  • Pathophysiology
    • mechanism of injury
      • rapid forced dorsiflexion of the inverted foot will cause strain through the contracted peroneal muscles, leading to tendon tearing  
        • 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 is runs in the retromalleolar groove 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 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 (51%) The SPR is partially elevated off of the fibula (fibrocartilaginous ridge remains intact) allowing for subluxation of both tendons
Grade 2 (33%) 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 (16%) There is a cortical avulsion of the SPR off of the fibula, allowing the subluxated tendons to move underneath the cortical fragment
Grade 4 (Oden modification) 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"- cortical avulsion of the SPR off the distal tip of the lateral malleolus  
      •  plantarflexed first metatarsal and high Meary's angle indicating cavovarus deformity
  • 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/PT 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
    • debridement of the tendon with tenodesis of distal and proximal ends of the brevis tendon to the peroneus longus 
      • indications 
        • complex tears 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 with (involving over 50% of tendon substance) with no muscle excursion (Redfern and Meyerson Type IIIa)
      • 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
 

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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? Tested Concept

QID: 4646
1

Core repair and tubularization of the peroneus brevis tendon

9%

(320/3743)

2

Peroneal groove deepening

2%

(57/3743)

3

Excision of the diseased tendon without transfer

3%

(100/3743)

4

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

86%

(3206/3743)

5

Arthroscopic debridement of the peroneus brevis

1%

(23/3743)

L 2 B

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

QID: 4887
1

Positive ankle anterior drawer test

1%

(40/4449)

2

Positive external rotation stress test

2%

(86/4449)

3

Crepitus over the anterolateral ankle joint

1%

(49/4449)

4

Palpable tendon snapping over the fibula during ankle dorsiflexion

95%

(4234/4449)

5

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

1%

(24/4449)

L 1 B

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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? Tested Concept

QID: 4581
FIGURES:
1

Debridement and attempted repair of peroneal brevis

3%

(124/4648)

2

Debridement and attempted repair of peroneal longus

8%

(388/4648)

3

Reconstruction of peroneal brevis with allograft

1%

(55/4648)

4

Debridement of peroneal brevis and tenodesis of peroneal brevis to longus

20%

(919/4648)

5

Debridement of peroneal longus and tenodesis of peroneal longus to brevis

67%

(3107/4648)

L 3 B

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

QID: 4635
FIGURES:
1

Achilles tendon repair

3%

(74/2838)

2

Repair of superior peroneal retinaculum and deepening of the fibular groove

23%

(649/2838)

3

Posterior tibial tendon reconstruction with flexor hallucs longus transfer

5%

(152/2838)

4

Peroneus longus repair

57%

(1611/2838)

5

Peroneus brevis repair

12%

(336/2838)

L 4 C

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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? Tested Concept

QID: 3518
FIGURES:
1

Physical therapy directed at proprioception and strengthening

1%

(28/2564)

2

Fibular shortening osteotomy

1%

(16/2564)

3

Surgical repair of the anterior talofibular ligament (ATFL)

3%

(65/2564)

4

Surgical repair of the calcaneofibular ligament (CFL)

1%

(27/2564)

5

Fibular groove deepening and superior peroneal retinaculum repair

94%

(2410/2564)

L 1 B

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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? Tested Concept

QID: 3194
FIGURES:
1

Peroneus brevis

3%

(60/2234)

2

Inferior peroneal retinaculum

13%

(297/2234)

3

Superior peroneal retinaculum

82%

(1837/2234)

4

Anterior talofibular ligament

1%

(26/2234)

5

Lateral process of the talus

0%

(4/2234)

L 2 B

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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? Tested Concept

QID: 396
FIGURES:
1

Anterior

77%

(1389/1793)

2

Posterior

10%

(176/1793)

3

Medial

10%

(175/1793)

4

The peroneus longus tendon is not in the groove

1%

(24/1793)

5

The peroneus brevis tendon is not in the groove

1%

(22/1793)

L 2 C

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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? Tested Concept

QID: 9104
1

Forced dorsiflexion and inversion

23%

(465/1984)

2

Forced dorsiflexion and eversion

27%

(529/1984)

3

Forced plantarflexion and eversion

5%

(92/1984)

4

Forced plantarflexion and inversion

44%

(882/1984)

5

Direct trauma to the fibula

0%

(5/1984)

L 5 C

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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? Tested Concept

QID: 1144
1

Plantarflexion and eversion

9%

(163/1863)

2

Neutral ankle position

1%

(19/1863)

3

Neutral ankle flexion and inversion

2%

(30/1863)

4

Dorsiflexion and inversion

45%

(840/1863)

5

Plantarflexion and inversion

43%

(805/1863)

L 5 C

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