Review Article

Peroneal Tendon Injuries

Abstract
Terrence M. Philbin, DO Geoffrey S. Landis, DO Bret Smith, DO

Peroneal tendon injuries are underdiagnosed and should be considered in every patient who presents with chronic lateral ankle pain. Ankle sprains are common, and up to 40% of affected individuals experience subsequent chronic ankle pain. Identifying the source of chronic ankle pain can be difficult because of the large number of possible causes. The peroneal tendons are the primary evertors of the foot and function as lateral ankle stabilizers. A careful physical examination, along with a thorough patient history and imaging studies, are critical in arriving at an accurate diagnosis. Understanding the anatomy of the peroneal tendons and knowledge of current treatment approaches for peroneal tendon tears, subluxation and dislocation of the tendons, and peroneal tenosynovitis are of great importance in achieving a favorable outcome. Low-demand patients do well with a nonsurgical approach; high-demand patients may benet from surgery.

P
Dr. Philbin is Fellowship Director, Orthopedic Foot and Ankle Center, Columbus, OH. Dr. Landis is Attending Surgeon, Tucson Orthopaedic Institute, Tucson, AZ. Dr. Smith is Attending Surgeon, Moore Orthopaedic Clinic, Columbia, SC. None of the following authors or a member of their immediate families has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Philbin, Dr. Landis, and Dr. Smith. Reprint requests: Dr. Philbin, Orthopedic Foot and Ankle Center, 6200 Cleveland Avenue, Columbus, OH 43235. J Am Acad Orthop Surg 2009;17: 306-317 Copyright 2009 by the American Academy of Orthopaedic Surgeons.

eroneal tendon disorders are a significant but often overlooked cause of lateral ankle pain. These injuries are more common than typically realized and must be considered in every person who presents with lateral ankle pain, particularly in those who report a history of ankle sprain. Ankle sprains are common athletic injuries. It is not uncommon for persons with ankle sprains to experience subsequent chronic lateral ankle pain. The differential diagnosis of lateral ankle pain is extensive.

Anatomy
The perforating branches of the anterior tibial and peroneal arteries supply blood to the lateral compartment of the leg. The superficial peroneal nerve, a branch of the common peroneal nerve, innervates the peroneus brevis and the peroneus longus muscles. The primary action of these muscles is, respectively, eversion and pronation of the foot, with a second-

ary action of weak plantar flexion. Together, the peroneal tendons provide supplemental lateral ankle stability, especially during the midstance and heel-raise portions of gait. The peroneus brevis becomes tendinous 2 to 3 cm proximal to the tip of the fibula. The tendon lies anterior and medial to the peroneus longus tendon at the level of the lateral malleolus and inserts onto the dorsal-lateral surface of the tuberosity of the fifth metatarsal base. Here the rare os vesalianum pedis is found in <1% of the population.1 This is important to consider because the ossicle must be differentiated from an acute fracture of the base of the fifth metatarsal. The peroneus brevis muscle functions as the primary evertor of the foot. The peroneus longus muscle courses down the spiral twist of the fibula, becoming lateral at midtibia and posterior to the peroneus brevis at the lateral malleolus. The tendon passes beneath the peroneal troch-

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Figure 1

A, Lateral view of the ankle demonstrating the peroneal tendons beneath the superior and inferior peroneal retinacula. B, Superior view demonstrating the position of the peroneus brevis tendon anterior to the peroneus longus tendon. (Reproduced with permission from Coughlin MJ, Schon LC: Disorders of tendons, in Coughlin MJ, Mann RA, Saltzman CL [eds]: Surgery of the Foot and Ankle, ed 8. Philadelphia, PA: Mosby Elsevier, 2007, vol 1, p 1210.)

lear process on the lateral side of the calcaneus, over the peroneal tubercle, and then turns to the cuboid tunnel, where it runs obliquely across the plantar aspect of the foot. It inserts on the plantar proximal surface of the first metatarsal and the lateral border of the medial cuneiform.2 The peroneus longus is a plantar flexor of the ankle joint and a primary plantar flexor of the first metatarsal. Located within the substance of the peroneus longus, the os peroneum is found in 20% of the population and is usually located plantar to the cuboid, lateral to the calcaneus, or at the calcaneocuboid articulation.3

Peroneal Tendons and Retinacula

The peroneus brevis and longus tendons share a common synovial sheath from a point 4 cm above the distal fibula. This sheath bifurcates at the level of the peroneal tubercle distally. The sheath passes through a fibro-osseous tunnel that is reinforced by the superior peroneal retinaculum (SPR), the posterior talofibular ligament, the calcaneofibular ligament, and the posterior inferior tibiofibular ligament4 (Figure 1). Anteriorly, the sheath is bordered by the
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fibula in the area of the retromalleolar sulcus. The peroneal retinaculum consists of superior and inferior portions. The SPR is a fibrous band of tissue that travels from the posterior ridge of the fibula to the lateral wall of the calcaneus. It acts as the primary restraint to subluxation and dislocation of the tendons as they course around the tip of the fibula. Davis et al5 reported five anatomic variations of the insertion of the SPR. The inferior peroneal retinaculum is distal to the tip of the lateral malleolus. The fibers forming the inferior peroneal retinaculum are blended from the fascia overlying the anterior ankle joint and are known as the cruciate crural ligament anteriorly. The sulcus in the posterior aspect of the distal fibula is typically concave, with a width of 5 to 10 mm and a depth of up to 3 mm.2 The lack of concavity of the posterior distal fibula, as seen in a cadaveric study, may predispose to tendon dislocation.6 This same study reported an absence of a fibular groove in 11% of the specimens and a convexity in 7%. In addition to the fibular groove, a fibrocartilaginous rim, which deepens the groove by 2 to 4

mm, provides additional stability to the tendons.

Anomalous Anatomy
Anomalous anatomy that may be involved in peroneal pathology includes a low-lying muscle belly of the peroneus brevis, presence of a peroneus quartus muscle, and a hypertrophied peroneal tubercle. The peroneus quartus has a varied origin but most commonly arises on the peroneus brevis and inserts in the retrotrochlear eminence of the calcaneus.7 It has a reported incidence of 13% in the general population.8 Sobel et al9 found it to be present in 27 of 124 cadaver dissections (21.8%). The peroneus quartus muscle was identified on magnetic resonance imaging (MRI) in 10% of patients in one report10 and, more recently, in 6.6% of evaluations.7 Other anomalous peroneal musculature has been described, most notably the peroneus digiti quinti muscle of Testut and the peronealcalcaneus muscle of Hecker.11 The presence of a low-lying muscle belly or a peroneus quartus might increase the risk of SPR laxity, with resultant peroneal pathology.12,13 Hyer et al14 performed a cadaveric

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Figure 2

Anteroposterior radiograph demonstrating eck avulsion of the distal bula.

study of 114 calcanei and identified three main anatomic variants of the peroneal tubercle: flat, 42.7%; prominent, 29.1%; and concave, 27.2%. Their study demonstrated the possibility of a bony tunnel in one specimen (1%) that could easily result in peroneal disease.

tendons to increased forces that predispose the tendons to injury.15 Patients with hindfoot varus should be evaluated for underlying neuromuscular disorders, such as CharcotMarie-Tooth disease and related motor neuropathies. This subset of patients may have a unique pathology, and a missed diagnosis may result in unpredictable outcomes. Peroneal disorders include swelling posterior to the fibula or along the lateral wall of the calcaneus; tenderness to palpation along the course of the peroneal tendons; the presence of a pseudotumor; and pain with resisted eversion, passive inversion stretch, or resisted plantar flexion of the first metatarsal.16 Sobel et al13 described the peroneal compression test, which is used to assess pain, crepitus, and popping at the posterior edge of the distal fibula during forceful eversion and dorsiflexion of the ankle.

Physical Examination
A complete, well-organized history and physical examination of the affected foot and ankle, as well as of the contralateral foot and ankle, is essential. A thorough history can provide direction in forming differential diagnoses, especially in regard to long-term issues such as chronic lateral ankle pain. The examination for lateral ankle pain should be focused primarily on the ankle and its function. Overall function and strength of the peroneal tendons, as well as the integrity of the lateral ligamentous complex, are evaluated. Signs and symptoms of subluxated tendons and ligamentous instability of the ankle should be assessed. Specific attention should be given to the hindfoot in both static and dynamic positioning. Individuals with hindfoot varus may subject the peroneal

Imaging Studies
Standard three-view, weight-bearing radiographs of the foot and ankle are mandatory for proper evaluation. Radiographs can reveal avulsions around the base of the fifth metatarsal, which can indicate an eversion type of ankle injury; this subjects the peroneus brevis tendon to increased stress and possible injury. Similarly, injury to the peroneus longus tendon is suspected in the presence of a fracture of an os peroneum. It is frequently necessary to obtain radiographs of the contralateral extremity for comparison. Tendon subluxation and dislocation should be suspected when radiographs show a fleck avulsion of the distal fibula (Figure 2); this is indicative of an injury to the SPR and is best recognized on an internal rotation view. Hypertrophy of the peroneal tubercle can raise suspicion of tendinosis and tears of the

peroneal tendons.17 Ultrasonography may be useful as an imaging modality for peroneal tendon evaluation. In homogeneous regions with hypoechoic areas, >1 mm of fluid collection and/or tendon thickening indicates tendinosis. Ultrasonography is helpful in diagnosing subluxation of peroneal tendons, and it has shown promise as a dynamic imaging modality; it was used to correctly diagnose 12 patients with positional subluxation of the peroneal tendons.18 Grant et al19 reported 90% accuracy for ultrasonography in diagnosing peroneal tendon tears. Computed tomography is best suited for visualizing detailed osseous anatomy. It is used to delineate bony abnormalities associated with peroneal tendon disorders, such as peroneal tubercle hypertrophy, calcaneal fractures, and convexity of the distal fibular groove. MRI offers an adjunctive imaging technique for diagnosing peroneal tendon disorders.20 The transaxial plane with the foot in slight plantar flexion is the most useful view for evaluating the integrity of the peroneal tendons.21,22 Normal tendons should exhibit homogeneous lowsignal intensity on T1- and T2weighted and short tau inversion recovery (STIR) images.22 It is normal for T2-weighted and STIR images to exhibit a thin area of high signal intensity surrounding the tendon in the tendon sheath.22 Areas of increased signal on T2-weighted and STIR images, as well as loss of homogenous signal, may indicate tenosynovitis, tendinosis, or a tear.21 Tendinosis and tenosynovitis are best visualized on T2-weighted or axial proton densityweighted images and are characterized by increased intermediate signal intensity.23 Circumferential fluid within the common peroneal tendon sheath wider than 3 mm is highly specific for peroneal tenosynovitis.23

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Consideration must be given to the magic angle effect. This phenomenon is seen as variations in signals, especially T1-weighted images, from tendons that have acute angulations (approximately 55 to the magnetic field)that is, the peroneal tendons as they proceed behind the lateral mallelous.21,22,24 In addition to imaging tendinosis and tears, MRI can be used to evaluate the possibility of tendon subluxation and dislocation. MRI scans can also show variations in normal anatomy, such as a low-lying muscle belly of the peroneus brevis, presence of a peroneus quartus muscle, and hypertrophied peroneal tubercle.22

boot or a short leg cast for 3 to 4 weeks. Corticosteroid injections into the tendon sheath should be used judiciously, if at all. Nonsurgical treatment of peroneal tenosynovitis is usually successful. When symptoms persist, surgical intervention may be indicated. It is imperative that a surgical plan address both the tendon pathology (ie, repair, dbridement) and any underlying disorder such as instability or varus positioning. If present, a low-lying peroneus brevis muscle belly (in the retromalleolar region) or a peroneus quartus should be dbrided. A hypertrophied peroneal tubercle should be excised. A complete tenolysis and tenosynovectomy should also be done.

Peroneal Tendon Pathology

Tenosynovitis of the peroneal tendons is usually the result of a repetitive or prolonged activity, although it can also occur after direct trauma. Additionally, anatomic variations, such as a hypertrophied peroneal tubercle or osseous calcaneal tunnel, may predispose an individual to stenosis and development of this tenosynovitis.11,12 Affected patients report pain, swelling, and point tenderness over the peroneal tendons at the posterolateral aspect of the ankle. The patient history may reveal a recent inversion injury or a recent increase in athletic endeavors. Commonly, pain is exacerbated by forced plantar flexion and inversion or by resisted dorsiflexion and eversion. MRI can be useful in differentiating tendinosis and tenosynovitis from longitudinal or complete tendon tears. Treatment begins with rest, ice, nonsteroidal anti-inflammatory drugs, physical therapy, and, possibly, use of an ankle brace and a lateral heel wedge orthosis. Further nonsurgical treatment can include an orthotic rocker-bottom
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Peroneus Brevis Tears

Peroneus brevis tears were first described by Meyer25 in 1924. Studies exploring the causes of peroneus brevis tears have focused primarily on hypovascularity, lateral ankle instability, and extrinsic compression phenomenon. Sobel et al26 reported that hypovascularity did not play a role in peroneus brevis tears. Their cadaveric study showed an ample source of blood supply in the region of the tear, leading the authors to conclude that the primary mechanism was a mechanical disruption. Sammarco and DiRaimondo27 reported on several athletes who displayed peroneus brevis tears while being treated for lateral ankle instability. Krause and Brodsky28 reported on 20 patients who all had redundancy of the SPR. The level of the tears all corresponded to the distal 3 cm of the fibula, where the tendon appeared to be compressed over the edge of the fibula. Sobel et al13 performed a cadaveric study in which tension on the peroneus longus with the foot in inversion resulted in compression of the peroneus brevis in the fibular groove. The flattening and splaying of the peroneus brevis over

the anterior lip of the fibula led the authors to conclude that longitudinal tears or splits in the peroneus brevis tendon were caused by acute or repetitive mechanical trauma. Geller et al12 recently described the effect of the low-lying muscle belly with resulting pressure on the SPR, subsequent instability, and peroneal tear. Extrinsic compression has been noted to come from sources other than the peroneus longus tendon, including anomalous anatomy. The patient who presents with peroneus brevis tear may report a specific traumatic event, failure to improve after treatment for tenosynovitis, repeated ankle sprains, and chronic lateral ankle pain and swelling. On examination, the patient has swelling and pain with palpation over the peroneal tendons, pain with resisted eversion, and weakness. A bulbous pseudotumor in the area of the peroneus brevis has been described by Webster.29 Mizel et al30 injected bupivacaine into the sheath to aid in diagnosis. MRI scans in addition to plain radiography aid in the diagnosis of peroneus brevis tears. Treatment of this condition may initially be nonsurgical, but surgical procedures should be considered when symptoms are recalcitrant to nonsurgical management. Krause and Brodsky28 reported an 83% failure rate with the use of nonsteroidal anti-inflammatory drugs, activity modification, lateral heel wedges, and a walking boot or cast to treat peroneus brevis tears in the presence of ankle instability. Because the outcome of nonsurgical treatment of a known peroneus brevis tear may be less than satisfactory, surgical intervention should be considered. Given the likelihood that nonsurgical management of peroneus brevis tear will be unsatisfactory, serious consideration should be given to surgical intervention as the initial course of action. Surgical treatment of peroneus

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Figure 3

Surgical techniques for managing single longitudinal tears of the peroneus brevis tendon (A). Steps may include dbridement (B), repair (C), and tubularization (D) of the tendon. (Reproduced from Chiodo CP: Acute and chronic tendon injury, in Richardson EG [ed]: Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL: American Academy of Orthopaedic Surgeons, 2003, pp 81-89.)

brevis tears depends on the type of tear found at exploration. Single longitudinal tears can undergo dbridement, repair, and tubularization of the tendon31 (Figure 3). We use a 3-0 absorbable suture for a core repair, then tubularize with 3-0 monofilament absorbable suture. Multiple longitudinal tears with significant tendinosis (ie, >50% of the cross section of the tendon) and fibrillation may undergo dbridement and either direct repair of or, more commonly, tenodesis to the peroneus longus tendon. Tenodesis consists of excising the degenerated portion of the tendon and suturing the proximal and distal ends of the brevis tendon to the peroneus longus. Krause and Brodsky28 graded peroneus brevis tears according to the cross-sectional area of involvement. Grade 1 tears were those with <50% involvement, and grade 2 tears had >50% involvement. Grade 1 tears underwent direct repair, and grade 2 lesions underwent tenodesis. When the tear is peripheral, up to 50% of the outer tendon can be excised. Steel and DeOrio32 reported that 9 of 10 patients treated with surgical re-

pair were able to return to work (90%), but only 46% were able to return to sports at their preoperative level. Other studies have shown an 85% to 95% return to athletic and fitness activities with surgical repair of peroneal tendon tears.33,34

Peroneus Longus Tears

Tears of the peroneus longus are uncommon. Diabetes mellitus, hyperparathyroidism, rheumatoid arthritis, and psoriasis can predispose individuals to peroneus longus tears. Other conditions associated with peroneus longus tears include ankle instability, hindfoot varus, and a hypertrophied peroneal tubercle. Peroneus longus tears are most commonly related to direct trauma or sports injuries. Chronic tears are associated with mechanical irritation, most commonly occurring at the cuboid tunnel, and longstanding tenosynovitis. Patient history usually reveals either an acute traumatic event or a slow, progressive, insidious course. In addition to swelling and tenderness over the lateral ankle, individu-

als with peroneus longus tears have weakness and pain with resisted eversion, tenderness distal to the fibula, and pain with resisted plantar flexion of the first metatarsal. Fracture of the os peroneum can be an indicator of peroneal pathology. Hypertrophy of the peroneal tubercle can also be seen on plain radiographs and is commonly believed to be a contributing factor to peroneus longus tenosynovitis, tears, and rupture. Boles et al17 recommend the use of Harris-Beath views to evaluate for tubercle enlargement. MRI is recommended when confirmation of the pathology is indicated because it allows easier evaluation of injury to the tendon. Treatment is based on the type of the tear and factors such as patient age, activity level, and duration of symptoms. Nonsurgical management may be considered for patients with minimal symptoms and no loss of function. When symptoms persist, surgical options to consider for longitudinal tears and acute ruptures include dbridement, tubularization, and end-to-end repair. For distal ruptures near the insertion at the base of the first metatarsal, and chronic injuries with persistent symptoms and in which the tear is not amenable to end-to-end repair, tenodesis to the peroneus brevis tendon is recommended. Commonly, the diseased portion of the tendon is excised, and the proximal and distal ends of the peroneus longus tendon are sutured side-to-side with the peroneus brevis.

Painful Os Peroneum Syndrome

Sobel et al3 described painful os peroneum syndrome in 1994. Clinical entities involving the os peroneum and the peroneus longus tendon include an acute fracture of the os peroneum or an acute diastasis of a multipartite os peroneum; chronic os

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Figure 4

Algorithm for the intraoperative assessment of peroneal tendon tear. (Adapted with permission from Redfern D, Myerson M: The management of concomitant tears of the peroneus longus and brevis tendons. Foot Ankle Int 2004;25:695-707.)

peroneum fracture resulting in stenosing tenosynovitis; a partial or overuse rupture of the peroneus longus tendon; gross discontinuity of the peroneus longus tendon; and a hypertrophied peroneal tubercle that entraps the peroneus longus tendon during its excursion.3 Patients with acute painful os peroneum syndrome have a history of direct trauma or a supination-inversion injury. Symptoms include tenderness along the tendon distal to the fibula and paresthesias along the course of the sural nerve distal to the lateral wall of the calcaneus. On examination, resisted plantar flexion or inversion stress of the first ray will exacerbate the symptoms. There may also be weakness and pain on active eversion. Diagnostically, radiographs show migration of the os peroneum, the presence of a multipartite os, and/or
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an enlarged peroneal tubercle. The images should be compared with radiographs of the contralateral foot. Treatment may be nonsurgical; however, Sobel et al3 found that only 20% of patients treated nonsurgically had acceptable results. Surgical treatment includes excision of the os with dbridement and repair of the tendon, depending on the severity of the peroneus longus disorder.

Concomitant Tears of the Peroneal Tendons

The diagnosis and treatment of concomitant tears of the peroneal tendons is a relatively new topic, and little has been written about these injuries. Tears of both tendons can be attributed to steroid injection, diabetes mellitus, rheumatoid arthritis, and injuries associated with peroneal tendon subluxation, dis-

location, and instability. Diagnosis of these injuries can be made through history, physical examination, and imaging studies. Redfern and Myerson35 developed a treatment algorithm for concomitant tears of the peroneal tendons (Figure 4). The tears are classified as type I, in which both tendons are repairable; type II, in which only one tendon is repairable and usable; and type III, in which both tendons are unusable. Type III tears are subdivided into types IIIa and IIIb. Type IIIa tears have no proximal muscle excursion and, therefore, are candidates for tendon transfer. Type IIIb tears have proximal peroneal muscle excursion and can be treated with either single-stage or delayed allograft repair. Treatment results depend on the treatment of simultaneous injury, such as a cavovarus deformity, ankle

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instability, and peroneal dislocation. These same disorders can occur with all peroneal pathology and must be considered. Redfern and Myerson35 treated 29 feet for tears of both tendons, reporting a mean postoperative American Orthopaedic Foot and Ankle Society score of 82, compared with a preoperative mean of 61. Wapner et al33 recently reported the results of treating concomitant tears with a Hunter rod and a flexor hallucis longus (FHL) transfer as a salvage procedure. They concluded that patients with failed previous surgery present several surgical challenges, including the need to create a viable tendon sheath for free movement and to reestablish a restraint to tendon dislocation, to reestablish tendon stability, and to provide a viable motor to replace the atrophied peroneal tendons. The surgeons performed a two-stage procedure in seven patients, with initial placement of a Silastic rod attached distally to the free end of the tendon to establish a synovial sheath. The second surgery occurred 3 months later, with an FHL harvest and Pulvertaft weave to reconstruct the peroneal tendons. At an average 8.5-year follow-up, six of the seven patients were pain-free.33 Hansen36 has advocated a singlestage FHL transfer to the peroneus brevis. Flexor digitorum longus transfer and free gracilis tendon autograft have been described for concomitant peroneal tears.

Subluxation and Dislocation

Peroneal tendon subluxation and dislocation are often differentiated as acute or chronic injury. Although subluxation and dislocation are uncommon causes of lateral ankle pain, both can be significantly disabling. Also, because they may be associated with lateral ankle instability, these injuries are easily misdiagnosed.

Quite often they occur in athletes;37 skiing has frequently been cited as one of the sports in which they occur.38,39 The mechanism for subluxation and dislocation is commonly a history of a forceful dorsiflexion and eversion injury.39 Injured patients report a snapping and popping or giving way in the ankle and often have a history of previous ankle injury. Active circumduction of the foot starting in plantar flexion and eversion may recreate the symptoms. Recreation of subluxation can also be done via forced dorsiflexion or resisted plantar flexion with eversion.40 Fullness or swelling and tenderness just posterior to the distal fibula are good indicators of peroneal tendon pathology. Hindfoot alignment should be evaluated for varus, and the examiner should assess lateral ankle stability. Many patients have ligamentous injury in conjunction with peroneal tendon injuries.41 In 1976, Eckert and Davis39 evaluated 73 patients with injury to the SPR and classified three types of injury. Grade I injuries (51%) were those resulting in elevation of the retinaculum from the lateral malleolus, with the tendons lying between the bone and periosteum. Grade II injuries (33%) were characterized by the fibrocartilaginous ridge elevated with the retinaculum attached and the tendons subluxated between the fibrocartilaginous ridge and the fibula. Grade III injuries (16%) represented a thin cortical fragment of bone avulsed from the fibula, with the tendons displaced beneath the fibular fragment. In 1987, Oden42 added grade IV to this classification system to describe an injury in which the SPR is torn from its posterior attachment to the calcaneus and deep investing fascia of the Achilles tendon, with the retinaculum lying deep to the dislocating tendon (Figure 5).

Treatment
Treatment should be based on several factors: whether the injury is acute or chronic, the timing of the injury, the associated clinical findings, and the age and activity level of the patient.31 Treatment in acute cases may consist of placing the foot and ankle in a plantarflexed, inverted, below-knee cast for 6 weeks. It is essential that the tendons be in a reduced position before casting is done. Nonsurgical treatment has demonstrated a significant failure rate in patients with chronic injury. Eckert and Davis,39 as well as Stover and Bryan,43 consider nonsurgical treatment futile; they report a <50% success rate with nonsurgical management in patients with chronic disorders. Surgical treatment is usually preferred in these patients. Most patients are young, athletic, and active, and they desire a rapid return to an active lifestyle. Direct repair of the SPR is used most commonly for acute subluxation or dislocation injuries. Excellent results and rapid recovery have been reported with direct repair.37,44 Many surgical treatments have been discussed for chronic injuries, such as tissue transfer, bone block procedures, and groove deepening. These can be classified into several categories, which address primary repair of the SPR versus the need for additional support to the SPR repair.

Tissue Transfer Tissue transfer techniques can be used to reinforce the SPR. Jones45 and Escalas et al38 used Achilles tendon tissue to reinforce their repair (Figure 6). Other tissues used include the plantaris,46 and the peroneus brevis or quartus.47 The authors preferred method of SPR repair begins with sharp excision of retinacular tissue from the

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Figure 5

Figure 6

The Ellis-Jones technique for reconstructing the peroneal retinaculum, using a portion of Achilles tendon. The inset shows the bony tunnel that is created to pass the harvested section of Achilles tendon, recreating a restraint for the peroneal tendons. (Reproduced with permission from Coughlin MJ, Schon LC: Disorders of tendons, in Coughlin MJ, Mann RA, Saltzman CL [eds]: Surgery of the Foot and Ankle, ed 8. Philadelphia, PA: Mosby Elsevier, 2007, vol 1, p 1215.)

act as reinforcement. During primary repair of the SPR, a thorough evaluation of the retromalleolar groove is appropriate (Figure 7). Many techniques have rerouted the tendons and used other structures to stabilize the tendons. Platzgummer48 used the calcaneofibular ligament to reinforce the tendons (Figure 8).
Classication of injuries to the superior peroneal retinaculum (SPR). Grade I, injury resulting in elevation of the retinaculum from the lateral malleolus, with the tendons lying between the bone and periosteum. Grade II, the brocartilaginous ridge is elevated, with the retinaculum attached and the tendons subluxated between the brocartilaginous ridge and the bula. Grade III, a thin cortical fragment of bone is avulsed from the bula, with the tendons displaced beneath the bular fragment. Grade IV, the SPR is torn from its posterior attachment to the calcaneus and deep investing fascia of the Achilles tendon, with the retinaculum lying deep to the dislocating tendon. (Adapted with permission from Coughlin MJ, Schon LC: Disorders of tendons, in Coughlin MJ, Mann RA, Saltzman CL [eds]: Surgery of the Foot and Ankle, ed 8. Philadelphia, PA: Mosby Elsevier, 2007, vol 1, p 1211.)

Bone Block Procedures Bone block procedures that involve osteotomies of the fibula attempt to provide a bony lip at the distal fibula to help prevent subluxation and dislocation of the peroneal tendons (Figure 9). Despite good results in most patients, these procedures have high complication rates because of the internal fixation that is used.47 Groove Deepening Groove deepening has also been proposed as a mechanism for providing increased stability to the peroneal tendons (Figure 10). In 1979, Zoell-

fibula. The tendons are evaluated, and repair or dbridement of the tendons is performed. When the retinaculum is amenable to primary repair,
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the edge of the fibula is shaved down to a fresh bleeding bed, and a pantsover-vest repair is performed, allowing the excess retinacular tissue to

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Figure 7

Primary repair of acute peroneal tendon dislocation. A, A curvilinear incision is made over the peroneal tendons (arrows). The dislocated peroneal tendons are identied along with the tear in the superior peroneal retinaculum (SPR). B, Placement of the incision in the SPR. Inset, View of the position of the peroneal tendons in a dislocated position. C, The peroneal tendons are then relocated, and the SPR is primarily repaired. Inset, Primary repair of the SPR and repair of the avulsed retinacular sleeve. (Reproduced with permission from Coughlin MJ, Schon LC: Disorders of tendons, in Coughlin MJ, Mann RA, Saltzman CL [eds]: Surgery of the Foot and Ankle, ed 8. Philadelphia, PA: Mosby Elsevier, 2007, vol 1, p 1214.)

ner and Clancy49 described the first groove-deepening procedure with the goal of increasing the depth of the groove by 6 to 9 mm. They advocated plication of the SPR to augment the repair. However, despite the success of this procedure, McGarvey and Clanton50 reported a 30% complication rate with groove-deepening procedures. A newer technique has been described by Shawen and Anderson.51 The fibula is sequentially reamed out from the tip in line with the peroneal

groove; then the thinned cortical rim is impacted. This allows the smooth posterior surface of the fibula to remain undisturbed. Porter et al52 recently described a groove-deepening procedure that involves removing a bone flap, excavating the subchondral bone from the distal posterior fibula, and reattaching the flap within the deepened groove and reconstructing the SPR. The authors reported good results with an accelerated rehabilitation protocol. Their preferred method is to ream the tip

of the fibula, then impact the posterior surface as described by Shawen and Anderson.51 All patients are carefully evaluated for any underlying disease of the foot before any operation is performed to repair the retinaculum or the tendons. Any evidence of hindfoot varus must be surgically corrected. We perform a lateralizing Dwyer calcaneal osteotomy. In the presence of lateral ligament instability, a lateral ligament reconstruction, such as a Brostrm procedure, is completed.

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Figure 8

Figure 10

Platzgummer method of tendon rerouting. A, The dislocated peroneal tendons are identied, and the calcaneobular ligament is divided. B, The peroneal tendons are relocated, and the calcaneobular ligament is reattatched to the distal bula (arrow), keeping the tendons in position. (Reproduced with permission from Coughlin MJ, Schon LC: Disorders of tendons, in Coughlin MJ, Mann RA, Saltzman CL [eds]: Surgery of the Foot and Ankle, ed 8. Philadelphia, PA: Mosby Elsevier, 2007, vol 1, p 1215.) Figure 9

Groove-deepening procedure with osteoperiosteal aps. The osteoperiosteal ap is created on the posterior aspect of the bula at the retromalleolar groove. The ap is elevated (inset a), and the cancelleous bone is removed (inset b). The osteoperiosteal ap is then tamped into the created void (arrow) and the peroneal tendons relocated (inset c). Note the repair of the superior peroneal retinaculum in the nal inset (*). (Reproduced with permission from Coughlin MJ, Schon LC: Disorders of tendons, in Coughlin MJ, Mann RA, Saltzman CL [eds]: Surgery of the Foot and Ankle, ed 8. Philadelphia, PA: Mosby Elsevier, 2007, vol 1, p 1217.)

Bone block procedures for repairing subluxating peroneal tendons. A, A sagittal cut is made in the distal portion of the bula, and the bone is rotated back, creating a block to prevent the peroneal tendons from disclocating. B, In an alternative technique, a small wedge of bula is displaced posteriorly (arrow) so as to create a similiar block. (Reproduced with permission from Coughlin MJ, Schon LC: Disorders of tendons, in Coughlin MJ, Mann RA, Saltzman CL [eds]: Surgery of the Foot and Ankle, ed 8. Philadelphia, PA: Mosby Elsevier, 2007, vol 1, p 1217.)

Postoperative Care
Most of the SPR and peroneal tendon repair procedures have a similar postoperative course. In the operating room, a Jones dressing with posterior splint is applied. The foot is placed in neutral to a slightly inMay 2009, Vol 17, No 5

verted position and the ankle at 90. The patient is nonweight bearing, and sutures are removed 10 days postoperatively. The leg is then placed in a nonweight-bearing, below-knee fiberglass cast, with the foot in neutral to slight inversion and the ankle at 90, for 4 to 6 weeks, after which the patient is transitioned

out of the cast into a high-top walking boot. The patient may begin weight bearing at 4 to 6 weeks in the walking boot. This may be modified when an additional procedure (eg, osteotomy) has been performed. Physical therapy focusing on range of motion is started under the guidance of the therapist when the patient is placed in the walking boot at 8 weeks postoperatively. We recommend three 2-week phases of physical therapy. The initial phase focuses on progressive weight bearing in a regular shoe as well as joint mobilization. We often fit our patients for a functional athletic ankle brace to use during activities. The second phase focuses on improving range of motion and proprioception, with normal gait pattern. The final phase of physical therapy focuses on increasing strength and returning to activity.

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At approximately 3 months after surgery, the patient is evaluated for return-to-activity status. Prior to return to activity, the patient is evaluated for orthoses. For dbridement of tenosynovitis only, without repair, an accelerated postoperative protocol is used. The patient is transitioned out of the postoperative dressing directly into a removable walking boot, and physical therapy is started approximately 3 to 4 weeks after surgery, with a similar prescription of three 2-week phases.

Citation numbers printed in bold type indicate references published within the past 5 years.
1. Coughlin MJ: Sesamoids and accessory bones of the foot, in Coughlin MJ, Mann RA, Saltzman CL (eds): Surgery of the Foot and Ankle, ed 8. Philadelphia, PA: Mosby Elsevier, 2007, vol 1, pp 531610. Mann RA, Haskell A: Biomechanics of the foot and ankle, in Coughlin MJ, Mann RA, Saltzman CL (eds): Surgery of the Foot and Ankle, ed 8. Philadelphia, PA: Mosby Elsevier, 2007, vol 1, pp 3-44. Sobel M, Pavlov H, Geppert MJ, Thompson FM, DiCarlo EF, Davis WH: Painful os peroneum syndrome: A spectrum of conditions responsible for plantar lateral foot pain. Foot Ankle Int 1994;15:112-124. Coughlin MJ, Schon LC: Disorders of tendons, in Coughlin MJ, Mann RA, Saltzman CL (eds): Surgery of the Foot and Ankle, ed 8. Philadelphia, PA: Mosby, 2007, vol 2, pp 1149-1277. Davis WH, Sobel M, Deland J, Bohne WH, Patel MB: The superior peroneal retinaculum: An anatomic study. Foot Ankle Int 1994;15:271-275. Edwards M: The relations of the peroneal tendons to the fibula, calcaneus and cuboideum. Am J Anat 1988;42: 213-253. Zammit J, Singh D: The peroneus quartus muscle: Anatomy and clinical relevance. J Bone Joint Surg Br 2003;85: 1134-1137. Hecker P: Study on the peroneus on the tarsus. Anat Rec 1923;26:79-82. Sobel M, Levy ME, Bohne WH: Congenital variations of peroneus quartus muscle: An anatomic study. Foot Ankle 1990;11:81-89. Cheung YY, Rosenberg ZS, Ramsinghani R, Beltran J, Jahss MH: Peroneus quartus muscle: MR imaging features. Radiology 1997;202:745-750. Sarrafian SK: Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional, ed 2. Philadelphia, PA: Lippincott Williams & Wilkins, 1993, p 218. Geller J, Lin S, Cordas D, Vieira P: Relationship of a low-lying muscle belly to tears of the peroneus brevis tendon. Am J Orthop 2003;32:541-544. Sobel M, Geppert MJ, Olson EJ, Bohne WH, Arnoczky SP: The dynamics of peroneus brevis tendon splits: A proposed mechanism, technique of diagnosis, and classification of injury. Foot Ankle 1992;13:413-422.

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Hyer CF, Dawson JM, Philbin TM, Berlet GC, Lee TH: The peroneal tubercle: Description, classification, and relevance to peroneus longus tendon pathology. Foot Ankle Int 2005;26:947950. Manoli A II, Graham B: The subtle cavus foot: The underpronator. Foot Ankle Int 2005;26:256-263. Safran MR, OMalley D Jr, Fu FH: Peroneal tendon subluxation in athletes: New exam technique, case reports, and review. Med Sci Sports Exerc 1999;31(7 suppl):S487-S492. Boles MA, Lomasney LM, Demos TC, Sage RA: Enlarged peroneal process with peroneus longus tendon entrapment. Skeletal Radiol 1997;26:313-315. Neustadter J, Raikin SM, Nazarian LN: Dynamic sonographic evaluation of peroneal tendon subluxation. AJR Am J Roentgenol 2004;183:985-988. Grant TH, Kelikian AS, Jereb SE, McCarthy RJ: Ultrasound diagnosis of peroneal tendon tears: A surgical correlation. J Bone Joint Surg Am 2005; 87:1788-1794. Crim JR, Cracchiolo A, Bassett LW, Seeger LL, Soma CA, Chatelaine A: Magnetic resonance imaging of the hindfoot. Foot Ankle 1989;10:1-7. Major NM, Helms CA, Fritz RC, Speer KP: The MR appearance of longitudinal split tears of the peroneus brevis tendon. Foot Ankle Int 2000;21:514-519. Wang XT, Rosenberg ZS, Mechlin MB, Schweitzer ME: Normal variants and diseases of the peroneal tendons and superior peroneal retinaculum: MR imaging features. Radiographics 2005; 25:587-602. Kijowski R, De Smet A, Mukharjee R: Magnetic resonance imaging findings in patients with peroneal tendinopathy and peroneal tenosynovitis. Skeletal Radiol 2007;36:105-114. Erickson SJ, Cox IH, Hyde JS, Carrera GF, Strandt JA, Estkowski LD: Effect of tendon orientation on MR imaging signal intensity: A manifestation of the magic angle phenomenon. Radiology 1991;181:389-392. Meyer A: Further evidences of attrition in the human body. Am J Anat 1924;34: 241-267. Sobel M, Geppert MJ, Hannafin JA, Bohne WH, Arnoczky SP: Microvascular anatomy of the peroneal tendons. Foot Ankle 1992;13:469-472. Sammarco GJ, DiRaimondo CV: Chronic peroneus brevis tendon lesions. Foot Ankle 1989;9:163-170. Krause JO, Brodsky JW: Peroneus brevis

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Summary
The diagnosis of peroneal tendon disorders is often missed in the evaluation of the patient with lateral ankle pain. Understanding the functional expectations of the patient is useful in selecting the best course of treatment. Persons with minimal symptoms and loss of function often do well with a nonsurgical approach. In contrast, higher-demand patients with more loss of function, especially those involved in athletic activities, may benefit from surgical treatment. A thorough history and physical examination, combined with judicious use of imaging techniques, should aid in making the correct diagnosis. Awareness of these disorders, their characteristics, and treatment options provides a more rapid diagnosis for the patient and a more effective management algorithm for the physician.
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References
Evidence-based Medicine: There are no level I or level II studies cited. References 19, 23, 26, and 28 are level III case-control studies. References 5-10, 12-14, 16-18, 20-22, 24, 25, 27, 29, 30, 32-35, and 37-51 are level IV case series. References 3 and 15 are level V expert opinion.
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tendon tears: Pathophysiology, surgical reconstruction, and clinical results. Foot Ankle Int 1998;19:271-279. 29. Webster FS: Peroneal tenosynovitis with pseudotumor. J Bone Joint Surg Am 1968;50:153-157. Mizel MS, Michelson JD, Newberg A: Peroneal tendon bupivacaine injection: Utility of concomitant injection of contrast material. Foot Ankle Int 1996; 17:566-568. Chiodo CP: Acute and chronic tendon injury, in Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL: American Academy of Orthopaedic Surgeons, 2003, pp 81-89. 37. 36. Hansen ST: Transfer of the flexor hallucis longus to peroneus brevis, in Hansen ST: Functional Reconstruction of the Foot and Ankle, Philadelphia, PA: Lippincott Williams & Wilkins, 2000, pp 462-466. Arrowsmith SR, Fleming LL, Allman FL: Traumatic dislocations of the peroneal tendons. Am J Sports Med 1983;11:142146. Escalas F, Figueras JM, Merino JA: Dislocation of the peroneal tendons: Long-term results of surgical treatment. J Bone Joint Surg Am 1980;62:451-453. Eckert WR, Davis EA Jr: Acute rupture of the peroneal retinaculum. J Bone Joint Surg Am 1976;58:670-672. Marti R: Dislocation of the peroneal tendons. Am J Sports Med 1977;5:19-22. Saxena A, Pham B: Longitudinal peroneal tendon tears. J Foot Ankle Surg 1997;36:173-179. Oden RR: Tendon injuries about the ankle resulting from skiing. Clin Orthop Relat Res 1987;216:63-69. Stover CN, Bryan DR: Traumatic dislocation of the peroneal tendons. Am J Surg 1962;103:180-186. Das De S, Balasubramaniam P: A repair operation for recurrent dislocation of peroneal tendons. J Bone Joint Surg Br 1985;67:585-587. 50. 45. Jones E: Operative treatment of chronic dislocation of the peroneal tendons. J Bone Joint Surg Am 1932;14:574-576. Miller JW: Dislocation of peroneal tendons: A new operative approach. A case report. Am J Orthop 1967;9:136137. Ogawa BK, Thordarson DB: Current concepts review: Peroneal tendon subluxation and dislocation. Foot Ankle Int 2007;28:1034-1040. Platzgummer H: On a simple procedure for the operative therapy of habitual peroneal tendon luxation [German]. Arch Orthop Unfallchir 1967;61:144150. Zoellner G, Clancy W Jr: Recurrent dislocation of the peroneal tendon. J Bone Joint Surg Am 1979;61:292-294. McGarvey WC, Clanton TO: Peroneal tendon dislocations. Foot Ankle Clin 1996;1:325-342. Shawen SB, Anderson RB: Indirect groove deepening in the management of chronic peroneal dislocation. Tech Foot Ankle Surg 2004;3:118-125. Porter D, McCarroll J, Knapp E, Torma J: Peroneal tendon subluxation in athletes: Fibular groove deepening with retinacular reconstruction. Foot Ankle Int 2005;26:436-441.

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32. Steel MW, DeOrio JK: Peroneal tendon tears: Return to sports after operative treatment. Foot Ankle Int 2007;28:4954. 33. Wapner KL, Taras JS, Lin SS, Chao W: Staged reconstruction for chronic rupture of both peroneal tendons using Hunter rod and flexor hallucis longus tendon transfer: A long-term followup study. Foot Ankle Int 2006;27:591-597. 34. Saxena A, Wolf SK: Peroneal tendon abnormalities: A review of 40 surgical cases. J Am Podiatr Med Assoc 2003;93: 272-282. Redfern D, Myerson M: The management of concomitant tears of the peroneus longus and brevis tendons. Foot Ankle Int 2004;25:695-707.

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