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Classification of peroneal tendon dislocation (reproduced with permission from Bentley G, ed. European Surgical Orthopaedics and Traumatology The EFORT Textbook. Berlin: Springer Publications, 2014). 52
Source publication
Pathological abnormality of the peroneal tendons is an under-appreciated source of lateral hindfoot pain and dysfunction that can be difficult to distinguish from lateral ankle ligament injuries.
Enclosed within the lateral compartment of the leg, the peroneal tendons are the primary evertors of the foot and function as lateral ankle stabilisers.
P...
Context in source publication
Context 1
... and the fibula. In Grade III injuries (16%), a thin cortical fragment of bone is avulsed from the fibula. In 1987, Oden 36 added grade IV to this classifica- tion in which the SPR is torn from its posterior attachment to the calcaneus and deep investing fascia of the Achilles tendon, the tendon lies superficial to the peroneal retinac- ulum ( Fig. 9). 36 ...
Citations
... El tratamiento inicial será conservador, mediante reposo, frío local, antiinflamatorios no esteroideos (AINE), la reeducación funcional en casos de sobrecarga por ejercicio y plantillas en casos con desaxaciones. Si este tipo de tratamiento no funciona, se puede considerar inmovilizar con una bota de marcha unas 6 semanas (26) . Las infiltraciones con corticosteroides pueden producir una rotura tendinosa y deben ser evitadas. ...
... En cuanto al tratamiento, las lesiones agudas pueden ser tratadas mediante inmovilización, aunque con una baja probabilidad de éxito (alrededor del 50%). Las lesiones de grado III serían las que tienen más probabilidades de éxito (26) . Consiste en inmovilizar con botina de yeso en equino durante 6 semanas, excepto si asocia una lesión del ligamento lateral externo, que deberá inmovilizarse en neutro para no comprometer la correcta cicatrización del ligamento. ...
... The SPR originates from the posterior portion of the distal fibula at the level of the ankle joint line and attaches to the adjacent periosteum, under which the PT passes through the posterior groove of the lateral malleolus [14]. The SPR is an important stabilizing structure that restricts the peroneal tendon from subluxation [15][16][17]. The injury of SPR will cause chronic pain and subsequent instability of the ankle. ...
Pediatric ankle injuries are common; ankle epiphyseal fractures are also common in children. But isolated distal epiphyseal fibular fractures of the distal fibula are clinically rare. We describe one unusual case of an adolescent with a completely displaced Salter-Harris type II distal fibular epiphyseal fracture. The attempt of closed reduction failed, and the patient required open reduction and internal fixation. The localized periosteum and the superior peroneal retinaculum were avulsed from the distal fibular metaphysis, with the peroneal tendons underneath exposed but no obvious subluxation. To the best of our knowledge, this combination of injuries has not been previously reported.
... Injury of peroneal tendon should be always considered as the differential diagnosis after inversion ankle trauma such as ankle sprain. Peroneal tendon injuries include peroneal tendinosis, peroneal tendinitis, peroneal tendon tear following PT subluxation or inversion injuries and dislocation of PT caused by tear of peroneal retinaculum [6]. In our case report a newly discovered tear in peroneus brevis tendon was caused by chronic subluxation of peroneal tendons. ...
... In our case the first surgical treatment of SPR injury repaired with sutured SPR has reoccurred causing subluxation problems and additional tendon injuries. In the literature there are described tendon graft reconstruction techniques to reinforce the SPR with the use of the Achilles tendon, peroneus brevis or plantaris tendon [6]. The use of semitendinosus tendon for managing the peroneal retinaculum pathology has been only introduced in the literature by Frangež., et al. in a 2017 case report and has shown favourable results [9]. ...
... 16 Many studies have reported risk factors associated with peroneal tendon pathologies. 3,5,10,19 Among these risk factors, the relationship between the retromalleolar fibular groove morphology and the development of peroneal tendon disorders has been well discussed. [1][2][3] Whether the type of retromalleolar groove is a risk for peroneal tendon pathologies remains controversial. ...
... 3,5,10,19 Among these risk factors, the relationship between the retromalleolar fibular groove morphology and the development of peroneal tendon disorders has been well discussed. [1][2][3] Whether the type of retromalleolar groove is a risk for peroneal tendon pathologies remains controversial. Ayanoglu et al 2 reported that a retromalleolar groove with a concave shape was a risk factor for peroneal tendon tears; however, Adachi et al 1 found no significant difference in the shape of the retromalleolar groove between patients with and without recurrent peroneal tendon dislocations. ...
... Computed tomography (CT) would be superior to MRI for the detailed assessment of the osseous morphology. 3 However, to our knowledge, only 1 study has investigated the shape of the retromalleolar groove using CT images. 11 The purpose of the current study was to evaluate the influence of the level of axial CT scans on the assessment of retromalleolar groove morphology. ...
Background
Studies have evaluated types of retromalleolar groove using axial magnetic resonance imaging at the level of 10 mm above the tip of the lateral malleolus. However, no evidence is available to support that this level is appropriate for evaluating retromalleolar groove morphology.
Purpose
To assess the influence of the level of axial computed tomography (CT) scans on the assessment of retromalleolar groove morphology.
Study Design
Cross-sectional study; Level of evidence, 3.
Methods
The study population included 122 patients (mean age, 27.9 ± 11.8 years; 69 males, 53 female) who underwent CT scans to evaluate foot or ankle pathologies between 2020 and 2023. The shape of the retromalleolar groove (concave, flat, convex, or irregular) at 3 levels of axial CT scans (8, 10, and 12 mm above the tip of the lateral malleolus) was assessed independently by 2 orthopaedic surgeons. The length from the tip of the lateral malleolus to the proximal tip of the fossa of the lateral malleolus was also measured on coronal CT scans.
Results
The type of retromalleolar groove was significantly different according to the level of CT scans (8 vs 10 mm, P = .0001; 10 vs 12 mm, P = .0001; 8 vs 12 mm, P = .001). The type of retromalleolar groove was the same at all 3 levels in 31.1% of patients (38/122). The length from the tip of the lateral malleolus to the proximal tip of the fossa of the lateral malleolus was <10 mm in 17.2% of patients (21/122).
Conclusion
The shape of the retromalleolar fibular groove was affected by the level at which the CT scan was obtained. Approximately 70% of the patients showed different types of retromalleolar grooves among the 3 CT scan levels.
... The SPR originates from the posterior portion of the distal bula at the level of the ankle joint line and attaches to the adjacent periosteum, under which the PT passes through the posterior groove of the lateral malleolus 12 . The SPR is an important stabilizing structure that restricts the peroneal tendon from subluxation [13][14][15] . The injury of SPR will cause chronic pain and subsequent instability of the ankle. ...
Ankle injuries are the most common pediatric injury. Ankle epiphyseal fractures are also common in children, but isolated distal epiphyseal fibular fractures of the distal fibula are clinically rare. We describe one unusual case of an adolescent with a completely displaced Salter-Harris type II distal fibular epiphyseal fracture. The attempt of closed reduction failed, and the patient required open reduction and internal fixation. The localized periosteum and the superior peroneal retinaculum were avulsed from the distal fibular metaphysis, with the peroneal tendons underneath exposed but no obvious subluxation. To the best of our knowledge, this combination of injuries has not been previously reported.
... However, peroneal tendon dislocation is often misdiagnosed as an ankle sprain and may be overlooked [8,22,23]. The recurrent dislocation rate after conservative treatment has been reported as 56%-74% [3,9,20,29]; thus, surgical treatment is considered even after primary dislocation [6,26]. The predisposition to peroneal tendon dislocation has been reported to include the presence of a low-lying muscle belly of the peroneus brevis (PB) [10,14,24] and an accessory peroneal muscle (APM). ...
Purpose
The association of peroneal tendon dislocation with peroneal bone morphology and postoperative redislocation rates remains unknown. This study compared the fibula morphology in patients with peroneal tendon dislocation with that in a control population.
Methods
The study enrolled 48 patients who underwent surgery for peroneal tendon dislocation at our institution during between 2018 and 2023. Thirty‐five patients with preoperative magnetic resonance imaging of the ankle were defined as Group D and 35 with magnetic resonance imaging of the ankle for other reasons and with similar background data were selected as the control group (Group C). The posterior tilting angle of the fibula, posterolateral angle and posterolateral edge angle were evaluated at the plafond level. The posterior tilting angle, posterolateral angle and retromalleolar bone shape according to the Rosenberg classification (flat, convex, concave) were evaluated at the midpoint between the plafond and the tip.
Results
At the plafond level, the posterior tilting, posterolateral and posterolateral edge angles were 57.7 ± 11.1°, 123.8 ± 12.3° and 90.8 ± 13.7°, respectively, in Group D and 64.1 ± 15.4°, 121.1 ± 12.3° and 88.7 ± 12.2°, respectively, in Group C, with no significant differences. No significant between‐group differences existed in the posterior tilting and posterolateral angles at the midpoint level. Moreover, no significant differences existed in distribution of the bone geometry according to the Rosenberg classification.
Conclusion
There were no differences in morphology between patients with peroneal tendon dislocation and controls. This study provides useful information on the indications for primary surgery and whether bony approach is useful for peroneal tendon dislocation.
Level of Evidence
Level IV.
... Lateral ankle pain and dysfunction constitute common clinical complaints, frequently attributed to ligament injuries [5], with peroneal tendons abnormalities being a frequently overlooked source. This oversight poses a significant diagnostic challenge [5], as highlighted by Dombek et al., who reported a mere 60% accuracy in identifying peroneal tendon disorders during initial clinical evaluations [7]. ...
... Lateral ankle pain and dysfunction constitute common clinical complaints, frequently attributed to ligament injuries [5], with peroneal tendons abnormalities being a frequently overlooked source. This oversight poses a significant diagnostic challenge [5], as highlighted by Dombek et al., who reported a mere 60% accuracy in identifying peroneal tendon disorders during initial clinical evaluations [7]. These pathological anomalies, categorised into tendinopathy, subluxation/dislocation and tendon splits and tears [12] are frequently encountered in individuals presenting with chronic lateral ankle instability or cavovarus hindfoot alignment, often resulting from prolonged and repetitive athletic activities or traumatic injuries [5]. ...
... This oversight poses a significant diagnostic challenge [5], as highlighted by Dombek et al., who reported a mere 60% accuracy in identifying peroneal tendon disorders during initial clinical evaluations [7]. These pathological anomalies, categorised into tendinopathy, subluxation/dislocation and tendon splits and tears [12] are frequently encountered in individuals presenting with chronic lateral ankle instability or cavovarus hindfoot alignment, often resulting from prolonged and repetitive athletic activities or traumatic injuries [5]. Chronic peroneal subluxation can be a frequent cause of degenerative peroneus brevis tears [23]. ...
Purpose
The objective of this study was to validate a scale that could help surgeons evaluate patients' psychological readiness to return to sport (RTS) after peroneal tendon pathology surgery.
Methods
The Ankle Ligament Reconstruction‐Return to Sport after Injury (ALR‐RSI) scale, which had previously been validated in ankle ligament reconstruction patients, was adapted to evaluate the psychological preparedness for RTS in athletic patients who underwent peroneal tendinopathy surgery. The Foot and Ankle Outcome Score (FAOS) and Foot Ankle Ability Measurement (FAAM) scores were employed as patient‐related outcome measurement (PROM) instruments.
Results
This study included 57 patients. There was a strong correlation between ALR‐RSI and both FAOS and FAAM ( r = −0.68 and 0.74, respectively). ALR‐RSI was considerably higher in patients who returned to sports than in those who did not. The mean score was 72.9 ± 19.0 in patients who returned to the same preinjury level, 48.5 ± 24.0 in those who returned to a lower level and 53.6 ± 31.1 in patients who changed their athletic activity ( p < 0.0001). Furthermore, ALR‐RSI showed at least a similar discrimination ability when compared to FAOS and FAAM. The test–retest intraclass correlation coefficient was 0.95. The Cronbach's α statistic used to measure the internal consistency was high (0.95). A Youden index of 0.65 was observed for a cut‐off score of 68 points.
Conclusion
ALR‐RSI is a valid instrument for assessing psychological readiness to RTS in an athletic population following peroneal tendon surgery. When compared to the most commonly used PROMs, it was strongly correlated and demonstrated at least similar discrimination capacity. This could assist surgeons in identifying athletes who will have poor postoperative results and advising them on their capability to RTS.
Level of Evidence
Level III.
... Peroneal tendon disorders are a common cause of chronic lateral ankle pain [1], but are commonly missed initially [2]. Patients typically present with chronic lateral ankle or hindfoot pain, frequently localized to the retromalleolar or inframaleollar region that worsens with activity, occasionally accompanied by a clicking or popping sensation [3]. Potential diagnoses include peroneal tendinopathy (tendinosis/tenosynovitis), peroneal tendon tear (including longitudinal split tears), and peroneal tendon instability (subluxation/dislocation) [4]. ...
Suspected peroneal tendinopathy, tears, and subluxation are often confirmed preoperatively using magnetic resonance imaging (MRI) or diagnostic ultrasound (US). No study has directly compared the accuracy of these tests for the diagnosis of peroneal tendon pathology. The purpose of this study is to directly compare MRI and US to intraoperative findings in patients who underwent surgery for suspected peroneal pathology to determine the imaging diagnostic accuracy. Operative records and diagnostic images for 21 consecutive patients who had both MRI and US prior to surgery for suspected peroneal tendinopathy, tears, or subluxation were retrospectively reviewed. The results of this review are compared with the intraoperative findings to yield the sensitivity and specificity for each imaging modality. For the diagnosis of peroneal tendon tears, US was found to have a sensitivity of 88% and specificity of 100%, compared to 100% sensitivity and specificity for MRI. In the diagnosis of peroneal tendinopathy, both US and MRI had a sensitivity and specificity of 100%. In diagnosing peroneal subluxation, US was 100% sensitive compared to 66% for MRI, and both were 100% specific. In conclusion, US was found to be more effective in diagnosing peroneal subluxation and MRI was slightly more accurate in the diagnosis of peroneal tendon tears.
... As far as autologous tendons are concerned, the popliteus tendon and peroneus longus tendon are chosen more often [4,5]. However, there is a lack of clarity regarding the effect on foot and ankle function and gait after autologous peroneus longus tendon excision and most of the current scholars believe that this effect is minor or nonexistent, but they are relatively limited in the methods of assessment they use, such as functional scores, X-rays, and so on [6,7]. In particular, in the study by Marín et al. [8], it was noted that whether there is an effect on the foot and ankle after peroneal longissimus tendon excision needs to be further confirmed with stronger evidence using more reliable assessment tools. ...
... We used a gait analysis device wearable gait sensor to collect dynamic data from patients. In terms of dynamic function, the peroneus longus tendon has a role in plantar flexion and external rotation of the ankle joint, and the gait cycle may be affected by tendon excision [6]. The gait cycle is the process from the landing of one side of the foot to the landing of that side of the foot again, which is divided into the stance phase and the swing phase [32][33][34]. ...
... In our study, we also did not find any significant difference in the proportion of time spent in the swing phase between the operative side and the healthy side. During the touchdown phase, the heel just touches the ground with dorsiflexion of the ankle joint and simultaneous valgus due to the synergistic action of the peroneus longus tendon, which if insufficiently valgus will result in a reduction of the dorsiflexion moment [6]. In our study, we found that the average touchdown elevation angle of the affected foot during the gait cycle was reduced by approximately 2° compared to the healthy foot with a statistically significant difference (P < 0.05), which may be due to the weakening of the foot's eversion force after the anterior half of the peroneus longus tendon is cut, which is also following the study findings of Shao and Angthong et al. [26,37]. ...
Background and objectives
In anterior cruciate ligament reconstruction, the strength of the graft was found to be unsatisfactory usually the anterior half of the peroneus longus tendon was taken for supplementation, but the effect on foot and ankle function and gait in the donor area is unclear. This study aims to explore the changes in the ankle and gait after using the harvested anterior half of the peroneus longus tendon as a reconstruction graft for the anterior cruciate ligament.
Methods
A total of 20 patients, 6 males and 14 females, aged 18 to 44 years, with unilateral anterior cruciate ligament injuries, underwent reconstruction using the harvested anterior half of the peroneus longus tendon as a graft between June 2021 and December 2021. The part on which the anterior half of the peroneus longus tendon was harvested was considered the experimental group, while the contralateral foot was the control group. At the 6-month follow-up, the Lysholm knee score, AOFAS ankle score, and gait-related data (foot length, arch index, arch volume, arch volume index, and gait cycle parameters: percentage of time in each gait phase, step frequency, step length, foot strike angle, and push-off angle) were assessed using a 3D foot scanner and wearable sensors for both groups.
Results
All 20 patients completed the six-month follow-up. There were no statistically significant differences between the experimental and control groups regarding knee scores, ankle scores, foot length, arch index, arch volume, arch volume index, step frequency, and step length (P > 0.05). However, there were statistically significant differences between the experimental and control groups in terms of the gait cycle parameters, including the percentage of time in the stance, mid-stance, and push-off phases, as well as foot strike angle and push-off angle (P < 0.05).
Conclusion
Through our study of the surgical experimental group we have shown that harvesting the anterior half of the peroneus longus tendon does not affect foot morphology and gait parameters; however, it does impact the gait cycle.
... Moreover, peroneal tendon pathology has been described in 23% to 77% of patients with lateral ankle instability [1,2]. It has been estimated that the range for peroneal tendon tears is between 11% and 37% [3][4][5][6][7], and the peroneal brevis tendon is the most involved (88%) [3,8,9] The peroneal muscles form the lateral compartment of the lower leg. The peroneus longus (PL) muscle becomes tendinous 3 to 4 cm proximal to the distal fibular tip, and the peroneus brevis (PB) muscle usually extends 0.6 to 2 cm more distally [1]. ...
... Clinical presentation is usually by posterolateral ankle swelling, pain, tenderness in the peroneal track, and functional impairment, symptoms that can be confused with other causes of ankle pain [3,4,10]. Passive plantar flexion and inversion of the foot and active plantar flexion and eversion of the foot may provoke tenderness or pain [1,11]. ...
... It is important to assess the alignment of the hindfoot since the excess valgus can cause a subperoneal impingement of the peroneal tendons, and the excess varus is associated with peroneal tendon pathologies [3,4]. ...
Introduction: Peroneal disorders are a common cause of ankle pain and lateral instability and have been described in as much as 77% of patients with lateral ankle instability. Clicking, swelling, pain, and tenderness in the peroneal tendons track are frequent symptoms, but they can be confused with other causes of lateral ankle pain. The management of peroneal disorders can be conservative or surgical. When the conservative treatment fails, surgery is indicated, and open or tendoscopic synovectomy, tubularization, tenodesis or tendon transfers can be performed. The authors present a surgical technique of tendoscopy associated to minimally invasive tenodesis for the treatment of peroneal tendon tears, as well as the preliminary results of patients submitted to this procedure. Methods: Four patients with chronic lateral ankle pain who were diagnosed with peroneal brevis pathology were treated between 2020 and 2022 with tendoscopic-assisted minimally invasive synovectomy and tenodesis. Using a 2.7 mm 30° arthroscope and a 3.0 mm shaver blade, the entire length of the peroneus brevis tendon and most parts of the peroneus longus tendon can be assessed within Sammarco’s zones 1 and 2. After the inspection and synovectomy, a minimally invasive tenodesis is performed. Results: All patients were evaluated at least six months after surgery. All of them reported improvement in daily activities and in the Foot Function Index (FFI) questionnaire (pre-surgery mean FFI = 23.86%; post-surgery mean FFI = 6.15%), with no soft tissue complications or sural nerve complaints. Conclusion: The tendoscopy of the peroneal tendons allows the surgeon to assess their integrity, confirm the extent of the lesion, perform synovectomy, prepare the tendon for tenodesis, and perform it in a safe and minimally invasive way, reducing the risks inherent to the open procedure.
