Peroneal Tendon Pathology PDF

Peroneal Tendon Pathology Allen J Kempf, DPM, MS, AACFAS, DABPM Assistant Professor College of Podiatric Medicine and Surgery Des Moines University CPMS Mission Statement To educate a diverse group of highly competent and compassionate Podiatric health professionals to improve lives in a global comm...

Peroneal Tendon Pathology Allen J Kempf, DPM, MS, AACFAS, DABPM Assistant Professor College of Podiatric Medicine and Surgery Des Moines University CPMS Mission Statement To educate a diverse group of highly competent and compassionate Podiatric health professionals to improve lives in a global community Objectives Demonstrate knowledge of the etiology of peroneal tendon pathology Recognize imaging techniques to identify peroneal tendon pathology Demonstrate knowledge of the management of peroneal tendon pathology Overview Anatomy Normal Mechanism and Function Clinical Exam Peroneal Tendon Imaging Pathology Treatment of Peroneal Tendon Pathology Conservative Management Surgical Management Peroneal Tendons: Anatomy Peroneal muscles compose the lateral compartment of the lower leg Tendons pass through retromalleolar groove posteriorly Reside in a shared synovial sheath that ends 1 cm distal to fibula P. brevis inserts on the base of the 5th metatarsal P. longus inserts to base of first metatarsal and medial cuneiform by passing through cuboid tunnel https://bjsm.bmj.com/content/44/14/1047 Peroneal Tendons: Anatomy Peroneal tendons innervated by superficial peroneal nerve Vascular supply via posterior peroneal artery https://www.lecturio.com/concepts/leg/ Biomechanics of Peroneal Tendons Peroneus brevis primary evertor of the foot and contributes to plantarflexion of the ankle Peroneus longus plantarflexes the first ray and everts the foot Peroneus longus also acts as plantarflexor of the ankle Peroneal muscles contract with sudden ankle inversion Help control the dynamic stability of the ankle joint https://www.orthogate.org/patient-education/ankle/peroneal-tendon-subluxation Peroneal Tendon Physical Exam Thorough history Previous history of ankle sprains/rearfoot or ankle fractures Evaluate overall limb alignment Evaluate for varus rearfoot (Coleman block test) Varus position applies increased abnormal force Rearfoot position may be result of forces p. longus applies to medial column Evaluate for concomitant wasting of intrinsic muscles, clawing of lessor digits or plantarflexion of first ray (neuromuscular disease) Anterior drawer and talar tilt tests https://musculoskeletalkey.com/cavovarus-deformity/ Peroneal Tendon Physical Exam Direct evaluation of peroneal tendons Palpation of fibular neck (common peroneal n.) Palpate entire tendon course Evaluate for edema of the muscle/tendon Palpation of peroneal tubercle and lateral wall of calcaneus Evaluate for pain against resisted inversion/eversion/dorsiflexion/plantarflexion Evaluate first ray range of motion/position Active circumduction of the ankle Subluxation Peroneal Tendon Imaging Peroneal Tendon Imaging Radiograph: AP and lateral Evaluate for pes cavus May need contralateral imaging for comparison Rule out stress fractures, tumors and osteophytes Oblique or Harris views may identify enlarged peroneal tubercle Fleck sign Pathognomonic for superior peroneal retinaculum avulsion https://www.researchgate.net/figure/A-fleck-sign-adapted-from-WWWEORIFCOM-cit-2015-0903-Available-from-WWW_fig8_321825474 Peroneal Tendon Imaging Ultrasound: Allows for dynamic evaluation of the structures May identify subluxation CT scan: Able to characterize retro malleolar groove Hypertrophied peroneal tubercle Lateral wall impingement (previous calcaneal fracture) h ttp s :/ / w w w.r e s e a r c h g a te.n e t/ f i g u r e / A x i a l - C T - s c a n - v i e w - s h o w i n g - th e - e n l a r g e d - p e r o n e a l - tu b e r c l e - a n d - th i c k e n e d - p e r o n e u s - l o n g u s _ f i g 4 _ 2 5 9 7 1 9 1 4 9 Peroneal Tendon Imaging MRI: Commonly used to evaluate pathology Tenosynovitis Tendon tear Superior peroneal retinaculum tears Low lying muscle belly Be aware of false positives Magic angle effect 55 degrees https://link.springer.com/article/10.1007/s00256-019-3168-9/figures/3 Peroneal Tendon Pathology Peroneal Tendon Pathology Outline Peroneal Tendinosis Peroneal Tendonitis/tenosynovitis Painful os peroneum syndrome (POPS) Peroneal Subluxation and Dislocation Peroneal tendon tear Peroneal tendon rupture Peroneal Tendinosis Characterized by thickening of the tendon with focal degeneration and swelling Commonly, tearing of the tendon occurs Pain to posterolateral ankle worsens with activity, improves with rest Pain directly over peroneal tendons Palpable mass that moves with tendon Peroneal Tendonitis/Tenosynovitis Peroneal Tendonitis Inflammation of the peroneal tendons Presents with ankle pain and swelling Pain posterior to lateral malleolus Peroneal Tenosynovitis Inflammation of the tendon sheath Often results from hypertrophied peroneal tubercle Can lead to rupture of the peroneus longus Painful Os Peroneum Syndrome (POPS) Painful condition resulting from multiple etiologies: Tearing of peroneus longus tendon Acute fracture of os peroneum Chronic fracture of os peroneum with stenosing tenosynovitis Entrapment of the longus and os peroneum from hypertrophied peroneal tubercle https://www.sciencedirect.com/science/article/pii/S1930043317305307 Peroneal Tendon Subluxation and Dislocation One or both tendons displaced from retromalleolar groove Have previous trauma that allows for disruption of tissues responsible for holding tendons in place, specifically the superior peroneal retinaculum (SPR) Most common mechanism: Forceful dorsiflexion of the ankle with hindfoot in an inverted position Low-lying muscle belly Peroneal Tendon Subluxation and Dislocation Subluxation presents as swelling and ecchymosis posterior to lateral malleolus Forced dorsiflexion of the foot with eversion causes pain Dorsiflexion = anterior force from tightening peroneal tendons Eversion = increased force on SPR Common in athletes performing cutting movements Can be reproduced with exam Resisted eversion Peroneal Tendon Subluxation and Dislocation Eckert and Davis Classification Grade I: SPR elevated from periosteum Grade II: Fibrocartilaginous ridge separated from fibula with SPR Grade III: Avulsion from Fibula h ttp s :/ / w w w.r e s e a r c h g a te.n e t/ f i g u r e / C l a s s i f i c a ti o n - o f - p a th o l o g y - i n - p e r o n e a l - te n d o n - d i s l o c a ti o n s - A - N o r m a l - B - G r a d e - I- C _ f i g 5 _ 3 3 7 3 4 9 3 0 8 Peroneal Subluxation and Low Lying Muscle Peroneal Tendon Tear: P. Brevis Peroneus brevis tear: More common in brevis than longus Commonly torn with chronic subluxation Factors causing tearing of the brevis: Increased pressure Hypo-vascularity Mechanical wear Increased inflammation Lack of space in retromalleolar groove Peroneal Tendon Tear: P. Longus Peroneus longus tear: At distal fibula, peroneal tubercle or os peroneum “Zone C”- area between inferior retinaculum and cuboid notch Risk factors include: Chronic stress and degeneration Hindfoot varus Cavovarus deformities More common in patients with POPS Peroneal Tendon Pathology Management Peroneal Tendonitis/Tendinosis Conservative: Non-steroidal anti-inflammatory medications Rest Reduction/modification of activity Orthotics with lateral forefoot posting Immobilization in refractory cases (short-legged cast/CAM boot) Physical Therapy Surgical: Open synovectomy Debridement of degenerate tendon Peroneal Tendon Pathology Management Peroneal Tendon Subluxation/Dislocation: Conservative: Non-steroidal anti-inflammatory medications Rest Reduction/modification of activity Orthotics with lateral forefoot posting Immobilization (short-legged cast/CAM boot) Physical Therapy Non-weight bearing in cast if type 3 Surgical: Direct SPR repair- anchor SPR to retromalleolar groove with anchor or suture Tighten SPR with pants over vest technique Retromalleolar groove deepening- allows for peroneal tendons to sit deeper in fibula Bone block- osteotomy of fibula to slide bone in front of tendon path Tendon re-routing- may translate tendons beneath CFL https://eorthopod.com/peroneal-tendon-subluxation/ Peroneal Tendon Pathology Management Peroneal Tendon Splits/Tears: Conservative: Non-steroidal anti-inflammatory medications Rest Reduction/modification of activity Orthotics with lateral forefoot posting Immobilization in refractory cases (short-legged cast/CAM boot) Physical Therapy Peroneal Tendon Pathology: Surgical Management Peroneal Tendon Splits/Tears: Redfern and Myerson Algorithm 2004 Decision based on amount of damage present Both tendons intact: Repair tendons, excise split, re-tubularize One tendon torn, one intact: If tear involves < 50% tendon re-tubularize If tear involves > 50%, perform tenodesis Both tendons torn, unusable: Tendon allograft Tendon transfer Peroneal Tendon Pathology: Management Painful Os Peroneum Syndrome (POPS): Conservative: Non-steroidal anti-inflammatory medications Rest Reduction/modification of activity Orthotics with lateral forefoot posting Immobilization in refractory cases (short-legged cast/CAM boot) Physical Therapy Surgical: Os peroneum is shelled out of longus tendon and tendon is repaired as necessary If unable to repair, tenodesis to brevis is performed Peroneal Tendon Pathology: Management Post-Calcaneal Fracture Impingement Surgical: Exostectomy of lateral calcaneal wall Repair of tendons as necessary Conclusions Peroneal tendon pathology is commonly overlooked/underdiagnosed Appropriate physical exam will lead to narrower differential or diagnosis Obtain appropriate imaging as needed Conservative and surgical management options are available for peroneal tendon pathology Questions https://www.flickr.com/photos/wingedwolf/5471047557 References Sharma A, Parekh SG. Pathologies of the Peroneals: A Review. Foot Ankle Spec. 2021 Apr;14(2):170-177. doi: 10.1177/1938640020916278. Epub 2020 Sep 25. PMID: 32975139. Davda K, Malhotra K, O'Donnell P, Singh D, Cullen N. Peroneal tendon disorders. EFORT Open Rev. 2017 Jun 22;2(6):281-292. doi: 10.1302/2058-5241.2.160047. PMID: 28736620; PMCID: PMC5508858. Landsman AS. Mcglamry's comprehensive textbook of foot and ankle surgery, 3rd ed (banks et al, eds). Journal- american podiatric medical association. 2004;94:216-216.