Peroneal Tendon Injuries

By Dr Owen Mattern MBBS | Unaccredited Orthopaedic Registrar

References

  • JAAOS 2009;17:306-317
  • Campbell’s Operative Orthopaedics 11th Ed
  • DeLee and Drez’s Orthopaedics Sports Medicine 3rd Edition

Anatomy

  • Peroneus brevis and longus
    • Primary action eversion and pronation
    • Weak plantar flexors
    • Lateral ankle stabilizers
    • Supplied by superficial peroneal nerve
    • Blood supply by perforating branches anterior tibial and peroneal arteries
    • Stability – midstance and heel-raise portions of gait
    • Cross ankle joint in common tunnel and sheath
      • Sheath bifurcates at peroneal tubercle
  • Peroneus Brevis Tendon
    • Anterior and medial to PLT
    • Inserts into dorsolateral tubercle 5th MT
  • Peroneus Longus Tendon
    • Lateral and posterior to PBT
    • Inserts into lateral base 1st MT and medial cunieform
  • Both have good blood supply
  • Superior Peroneal Retinaculum
    • Fibrous band that blends with periosteum
    • Posterior ridge of fibula to lateral wall calcaneum
    • Attached to a fibrocartilaginous rim that deepens groove in posterior fibula
  • Anomalous Anatomy
    • Some variants may predispose to lax SPR increasing risk of pathology
      • Anomalous muscle
        • Peroneus quadratus (13-21%)
        • Peroneus digiti quinti (of Testut)
        • Peronealcalcaneus muscle (of Heckman)
      • Low lying PB muscle belly
    • Possible boney tunnel causing impingment

Classification

  • Disorders of Peroneal Tendons
    • Tendinitis without subluxation
      • Middle-aged athletes
      • Attritional ruptures can occur
    • • Tendinitis with peroneal tendon instability at SPR
      • Young athletes, acute ankle injury of chronic ankle instability
      • Rupture of SPR
    • • Stenosing tenosynovitis of PLT
      • Often with painful os perineum
      • Secondary to boney tunnel at the level of cuboid

Examination

  • Often have concominant lateral ankle instability
  • Need to check for tendon subluxation
  • Tendon strength, subluxation, peroneal compression test (popping, pain and crepitus at posterior distal fibula on forced eversion), pain and swelling along tendon, pseudotumour
  • Hindfoot varus – need to assess for charcot marie tooth and other motor neuropathies
  • Assess for hindfoot varus, high arch, limitation of subtalar movement in eversion
  • All predispose to peroneal pathology due to increased forces through the tendons

Investigations

  • Plain xrays – MUST INCLUDE WB
  • Ultrasound
    • >1mm of fluid of tendon thickening indicates tendinosis
    • Can help diagnose subluxing tendons
  • CT
    • Especially for bony abnormalities
  • MRI
    • Normal tendon low signal intensity in T1, T2 and STIR
    • Increased intensity on T2/STIR may indicate tear, tendinosis or tenosynovitis

Treatment

Tenosynovitis/tendinitis

  • Result of repetitive or prolonged activity
  • Pain, swelling and point tenderness often wit recent trauma
  • Rx
    • RICE, NSAID’s, ankle brace, lateral heel wedge orthosis
    • Any surgery needs to address underlying problem as well as treating and debriding tendon/tendon sheath
      • Often surgery is for tears

Partial Tears

  • Cadaveric study showed tendon to splay and flatten after compression over fibular groove
    • Most commonly PBT
  • Up to 83% failure rate for conservative Rx
  • Good return to work (90%) but variable return to sport following repair (46-95%)
  • Krause and Brodsky grading system
    • Grade 1 <50%
      • Direct repair
    • Grade 2 >50%
      • tenodesis

Complete Tears

  • More common in
    • T2DM, RA, steroid injection, injuries associated with tendon subluxation
  • Concomitant tears graded by Redfern and Myerson
    • Grading
      • Type 1 – both tendons repairable
      • Type 2 – one tendon repairable
      • Type 3 – neither tendon repairable
    • Treated 29 patients according to protocol and had a mean improvement from 61 to 82 of AOFAS score
  • Wapner
    • Wapner reported method for treatment of concominant tears
      • 2-stage procedure
      • Silastic rod attached distally to tendon to create synovial sheath
      • 3/12 later FHL tendon transfer and reconstruction to distal tendon
      • 6/7 patients pain-free at 8.5 years

Subluxation and Dislocation

  • Commonly reported in skiers
    • 0.5% of all skiing injuries are complete peroneal dislocation
    • Result of forceful dorsiflexion and eversion
    • Recreated by circumduction and eversion
  • Often mis-diagnosed as ankle sprain in acute injury
  • Four grades (Eckert and Davis 1976, Oden 1987)
    • Grade 1 – elevation of SPR and periosteum with tendon lying between periosteum and bone
    • Grade 2 – elevation of SPR with fibrocartliage ridge
    • Grade 3 – Cortical avulsion fracture
    • Grade 4 – tear of SPR from calcaneal and achilles tendon
  • Rx of acute dislocations controversial
    • Small sample sizes with mixed outcomes
    • Some efficacy for plaster 5-6/52
    • Poor responses to taping
    • Overall poor response in up to 50% of cases
    • Still recommend trial non-operative
      • 4- 6/52 in BKPOP with tendons reduced
    • Surgical Rx often involves direct repair SPR

Chronic dislocation

  • >50% poor results
  • Rx options
    • SPR reconstruction with tendon sling
    • Bone blocks
    • Groove deepening procedures
    • Rerouting procedures
    • SPR reattachment and reinforcement with local tissue
  • Jones tissue transfer technique
    • described in 1932
      • slip of achilles passed 1 inch above lateral malleolus
      • Tendon slip needs to be anchored with foot in dorsiflexion and supination
      • 6/52 in short leg POP
    • Results: Escalas 1980
      • 28 procedures.
      • 15 patients were followed for 6.8years.
      • 14/15 excellent results.
      • 1/15 reported instability of lateral ankle but none found clinically.
      • 3/15 decrease in hindfoot inversion, 4/15 lost 7degrees of dorsiflexion
    • CAN ALSO USE OTHER TENDONS – redundant peroneus quartus to reconstruct SPR
  • Kelly bone block procedure and modification – 1920
    • Modification eliminated surgical fixation
      • DuVries modification
        • Marti 1977, Micheli et al 1989 and Mason et al 1996 – good results.
        • Some crepitation of tendons thought to result from inferior posterior displacement.
        • Immobilized for 5-8/52
  • Groove Deepening
    • Zoellner/Clancy –
      • raise an osteoperiosteal flap,
      • cancellous bone removed 6-9mm and flap reimpacted.
      • Excellent results in 10 patients.
      • Immobilized for 3-6/52 in POP then ankle hinge.
      • Other studies of 17 patients reported excellent results.
      • Can be used in conjunction with a periosteal flap

Summary

  • Uncommon injuries
  • Tears often need to be debrided +/- tenodesis
  • Acute subluxation of tendons can trial non-operative management
  • Chronic subluxation of tendons needs a surgical intervention
    • No strong evidence for any procedure over others
  • In all cases you need to correct any underlying foot deformity for best outcome