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The Pesky Peroneal Tendons & Tales of Subluxation

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The Pesky Peroneal Tendons & Tales of Subluxation The Pesky Peroneal Tendons & Tales of Subluxation Jason R. Miller, DPM, FACFAS Residency Director, Phoenixville Hospital PMSR/RRA Director, PA Intensive Lower Extremity Fellowship Program Adjunct Associate Professor, Dept. of Surgery, TUSPM Chief, Foot & Ankle Surgery, Pennsylvania Orthopaedic Center/Premier Orthopedics Presentation • Overall, peroneal tendon disorders are reportedly rare, with peroneal brevis involvement being more common than peroneus longus involvement, and with both longus and brevis involvement being the least common • Associated with lateral ankle sprain or insult, but occasionally no traumatic event is noted in patient’s history • Frequently overlooked and misdiagnosed due to assumption the injury is to the lateral ankle ligaments Molloy, R. et al (2003). Failed Treatment of Peroneal Tendon Injuries. Foot and Ankle Clinics of North America, 8, pp. 115-129. Becker, H.P. et al (1996). Functional Disorders of the Foot After Tenodesis: Is the Method Still Currently Acceptable? Sportverletz Sportschanden, 10:4, pp. 94-99. Presentation • Tears are generally degenerative in nature, look for history of repetitive lateral ankle sprains/lateral ankle instability • More commonly associated with a cavus foot type, hindfoot varus, and peroneal subluxation • Swelling along the peroneals is the most consistent clinical finding on exam (as much as 90%) Molloy, R. et al (2003). Failed Treatment of Peroneal Tendon Injuries. Foot and Ankle Clinics of North America, 8, pp. 115-129. Slater, H.K (2007). Acute Peroneal Tendon Tears. Foot and Ankle Clinics of North America, 12, pp. 759-674. Squires, N. et al (2007). Surgical Treatment of Peroneal Tendon Tears. Foot and Ankle Clinics of North America, 12, pp. 675-695. Diagnosis of Injury (Acute Injury) • Diagnosis made by clinical presentation • Dorsiflexion and eversion in ski boot • Lateral collateral injury via: • 1) plantarflexion • 2) inversion • Tenderness to palpation: • Posterior aspect of the fibular along the peroneal retinaculum • ATFL would present with pain anterior to the fibula (+AD) • Patient rarely presents with subluxed peroneals • Patient apprehensive to DORSIFLEX and EVERT foot (instability) Diagnosis of Injury (Chronic Injury) • Patient presents with: • Feeling of instability in lateral ankle • Feeling clicking posterior to the lateral malleolus • With finger pressed posterior to the lateral malleolus rotate ankle in circular fashion and feel for tendon subluxation • Always compare tightness of retinaculum to uninvolved side. • Longitudinal fissure of peroneal tendon may be noted: • Clicking with dorsiflexion and plantarflexion of foot along peroneals may be indicative of fissure often mimicking subluxation. Imaging • Xray: rule out fx, avulsion, Os Peroneum. Look for anatomy causing mechanical insult to tendons • MRI: high chance of false positive and false negative, as well as over/under estimating extent of damage • MSK U/S: probably best when looking for subluxation or subtle tears. • While prudent to obtain, open surgical visualization is the gold standard Squires, N. et al (2007). Surgical Treatment of Peroneal Tendon Tears. Foot and Ankle Clinics of North America, 12, pp. 675-695. Imaging Arrow showing “valgus erosion”, possibly contributing to peroneal impingement/dege neration Slater, H.K (2007). Acute Peroneal Tendon Tears. Foot and Ankle Clinics of North America, 12, pp. 759-674. Brief Anatomical Review: • Peroneal Brevis Muscle • O: Distal ½ of the Lateral Surface of Fibular Shaft • I: Styloid Process of 5 th Metatarsal Laterally • Peroneus Longus Muscle • O: Fibular Head and Proximal ½ of Lateral Fibular Shaft • I: 1) Lateral and Plantar Aspects of Medial Cuneiform 2) 1 st Metatarsal Tuberosity • Both in Lateral Compartment of Foot • Arterial Supply: Peroneal (Fibular) Artery • Nerve Innervation: Superficial Peroneal (Fibular) Nerve Anatomical Review of Peroneals • Peroneus Longus is POSTERIOR to the Peroneus Brevis Posterior to the Lateral Malleolus • Peroneal Tendons Retained by 3 Tunnels: • 1) Retromalleolar Tunnel (PB and PL) • Formed by Superior Peroneal Retinaculum (SPR) • At the level of distal fibular • 2) Inferior Tunnel (PB and PL Split) • Formed by Inferior Peroneal Retinaculum • At the level of Process Trochlearis (Peroneal Tubercle) • 3) Plantar Tunnel (PL) • Cuboid and Base of 5 th Metatarsal Anatomical Review of Peroneals • Peroneal Brevis Muscle • O: Distal ½ of the Lateral Surface of Fibular Shaft • I: Styloid Process of 5 th Metatarsal Laterally • Peroneus Longus Muscle • O: Fibular Head and Proximal ½ of Lateral Fibular Shaft • I: 1) Lateral and Plantar Aspects of Medial Cuneiform 2) 1 st Metatarsal Tuberosity • Both in Lateral Compartment of Foot • Arterial Supply: Peroneal (Fibular) Artery • Nerve Innervation: Superficial Peroneal (Fibular) Nerve Anatomical Review of Peroneals • Peroneal Synovial Sheath • Extends from level just superior to lateral malleolus to the level of the cuboid • Passes deep to both superior and inferior peroneal retinaculum • Peroneal Tubercle (Lateral Calcaneal Body) • Inferior peroneal retinaculum has fibers that attach to tubercle • Synovial sheath splits at this level • Peroneus Brevis travels SUPERIOR • Peroneus Longus travels INFERIOR Anatomical Review of the Peroneals • Posterior Fibular Retromalleolar Groove • Posterior aspect of the fibular head • Both Peroneal tendons travel distal within groove • Superior Peroneal Retinaculum • O: Lateral Border of Retromalleolar groove and Tip of the Lateral malleolus • I: In the aponeurosis of Achilles Tendon Retromalleolar Groove Tunnel • Fibro-osseous Tunnel which maintain the peroneals • Medial Border: PTFL and CFL • Anterior Wall: Posterior Lateral Malleolus • Posterior Wall: Superior Peroneal Retinaculum • Lateral Border: Superior Peroneal Retinaculum Peroneal Tendons (Lateral Ankle View) Actions of the Peroneal Muscles • Peroneus Longus • Eversion and Plantarflexion of foot • Pronates Subtalar and Midtarsal Joint • Plantarflexes Ankle Joint • Stabalizes 1st Met during Propulsive phase of Gait • Peroneus Brevis • Eversion and Plantarflexion of foot • Prontation of Subtalar Joint • Flexes Ankle Joint • **Hintermann et el 1994 found to be strongest everter of foot My God my Lateral Ankle !!!! What are Subluxing Peroneals? • Described as a rupture of Superior Peroneal Retinaculum which is the sling that holds the peroneal tendons stable within the retromalleolar groove • Weakest Attachment of SPR at fibula *** • Without stabilization the peroneals may sublux out of the groove with activity • Monteggia et al first described the injury in 1803 with Ballet Dancers in Italy • Most common sporting injury = Skiing (Clanton et al – 71% of 265 cases) Are Subluxing Peroneals in your Future? • Edwards et al in 1928 states some are more prone to superior peroneal retinaculum injury (cadaveric study 110 cadavers): • 1) Retromalleolar groove is concave in shape but he found that 7% convex and 11% are flat • Width of sulcus varies from 5-10 mm • 2) Fibrous ridge noted on posterolateral aspect of fibula that aids in peroneal stabilization, ABSENT in 30% • Deepens sulcus by 1-2 mm • Factored in during Eckert Classification Mechanism of Injury • Most Common: Sudden dorsiflexion stress at ankle coupled with violent contraction of Peroneals • In skiers happens when: • 1) When tip of ski is lodged in snow • 2) Sudden deceleration of ankle in dorsiflexed position • 3) Which causes forceful contraction of Peroneals to stabilize • Been reported with forceful eversion to edge down mountain • Places extra force on CFL which narrows fibo-osseous tunnel • Pushes peroneals into retinaculum Lesson: Careful Skiing Eckert and Davis Classification (1976 JBJS) • Grade 1: SPR stripped off fibular (51%) • Grade 2: Fibrous rim avulsed off fibular with SPR (33%) • Grade 3: Boney Avulsion of PL fibula by SPR (16%) • Grade 4: Added by Oden 2003*** Rupture of SPR • Key: • 1 = PB • 2 = PL Imaging for Diagnosing Peroneal Sheath Injury • Plain Radiograph • Can see posterior fleck at the distal fibular indicative of avulsion. (Grade 3 Eckert and Davis) • Rare injury and plain radiograph usually non-diagnostic • CT Scan • Precise definition of retromalleolar sulcus and position of peroneal tendons • MRI (***Gold Standard***) • Shows soft tissue structures • Often shows pouch between periosteum and fibula that contain peroneal tendons Imaging of Peroneal Sheath Injury MRI CT MRI Findings Correlation w/MRI Findings Conservative Treatment • When diagnosed patient should be placed in NWB molded cast • A piece of felt is placed posterior to the lateral malleolus for pressure • The pressure on the peroneals will hopefully help periosteum to re-adhere • McLennan, Stover, and Bryan et al reported 50% success with this method • 3 weeks NWB and 3 weeks WB in cast • Escalas et al reported 73% treated initially with conservative had re-occurrence and had surgical repair • High Lateral flange or heel lift also could be utilized by some authors Surgical Intervention for Subluxing Peroneals • Clanton et al states there are 5 categories for surgical repair: • 1) Reattachment of retinaculum and reinforcement with local tissue • 2) Bone block procedures • 3) Reinforcement of Superior Peroneal Retinaculum with transfer tissue (Achilles tendon, palmaris, etc.) • 4) Re-routing procedures (e.g. under CFL) • 5) Groove deepening procedures *Adults vs. Kids? Soft Tissue Reconstructions • Aimed to obliterate pouch between periosteum and fibula • Longitudinal incision made 1 cm superior to SPR to the distal fibula
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