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This patient is presenting with a calcaneal malunion with sub-fibular impingement and tendinopathy of the peroneus brevis. The peroneus brevis is correctly identified by number 1 in the depicted MRIs. Peroneal tendon injuries can be a result of chronic subluxation out of the fibular groove or secondary to a calcaneus malunion causing sub-fibular impingement. The peroneus brevis and longus have a defined anatomic relationship in the retromalleolar sulcus and at the peroneal tubercle. The peroneus brevis lies anterior to the longus in the retromalleolar space and lies dorsal at the peroneal tubercle. These relationships help identify on MRI the pathological tendon. In our patient with a calcaneus malunion initial treatment would involve immobilization with NSAIDs, but would likely progress to hindfoot osteotomy or subtalar arthrodesis due to the sub-fibular impingement with possible repair or tenodesis of the brevis. Hyer et al. examined 114 calcanei and measured peroneal tubercle length, height, depth and structural description. They found a peroneal tubercle in 103 calcanei with an average length of 13.04 mm, height of 9.44 mm, and 3.13 mm deep. It was found to be flat in 44, prominent in 30, concave in 28, and a tunnel in 1. They concluded that understanding peroneal tubercle pathology may help understand peroneal tendon pathology. Philbin at el. reviewed peroneal tendon injuries. They discussed the pertinent anatomy, physical examination, and imaging. Additionally, the pathology, treatment, and post-operative care of peroneal tendon injuries including peroneus brevis and longus tears/subluxation and os peroneum were discussed. They concluded peroneal tendon injuries are often missed and having awareness will aid in improved diagnosis and treatment. Figure A is a clinical image depicting a calcaneus malunion of the right foot. Figure B is a coronal T1 MRI sequence at the peroneal tubercle level showing the dorsal relationship of the peroneus brevis (number 1) to the peroneus longus (number 2). Figure C is an axial T1 MRI sequence demonstrating the medial sided structures within the tarsal tunnel with the posterior tibialis tendon (number 3), flexor digitorum longus (number 4), and flexor hallucis longus (number 5). Incorrect answers: Answer 2: This is the peroneus longus tendon Answer 3: This is the posterior tibialis tendon Answer 4: This is the flexor digitorum longus tendon. Answer 5: This is the flexor hallucis longus tendon.
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