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Treatment of Isolated Peroneus Longus Tears and a Review of the Literature Dariusch Arbab, Markus Tingart, Daniel Frank, Mona Abbara-Czardybon, Hazibullah Waizy and Carsten Wingenfeld Foot Ankle Spec 2014 7: 113 originally published online 30 December 2013 DOI: 10.1177/1938640013514273 The online version of this article can be found at: http://fas.sagepub.com/content/7/2/113
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FASXXX10.1177/1938640013514273Foot & Ankle SpecialistFoot & Ankle Specialist
vol. 7 / no. 2
Foot & Ankle Specialist
113
〈 Clinical Research 〉 Treatment of Isolated Peroneus Longus Tears and a Review of the Literature Abstract: Background. Isolated peroneus longus tendon tears are rare and represent a frequently overlooked source of lateral ankle pain and dysfunction. Only few cases of isolated peroneus longus tendon tears have been reported and a common treatment algorithm does not exist. The purpose of this study was to give an overview of the literature and to present our experience of 6 consecutive cases that have been treated successfully by operation and immobilizing cast. Methods. A comprehensive chart review was performed to compile each patient’s age, sex, onset of symptoms, time between first symptoms and diagnosis, surgical findings, surgical treatment, length of follow-up, and outcome. The average patient age was 48 years (range 20-63 years). Results. Acute tears occurred in 4 cases, and 2 patients reported about a chronic onset of symptoms. The cause for acute tears was an acute inversion ankle sprain in all cases. Diagnosis was made after an average of 11 months (range 0.75-24 months). There were 2 complete tears, and other 4 were incomplete. An os peroneum was present in 2 cases. In 5 of 6 cases, the results after surgical
Dariusch Arbab, MD, Markus Tingart, MD, Daniel Frank, MD, Mona Abbara-Czardybon, MD, Hazibullah Waizy, MD, and Carsten Wingenfeld, MD
common than tears of the peroneus treatment were excellent or good after brevis tendon (PBT). Only few cases of a mean follow-up of 28.6 months (range 12-78 months). Conclusion. isolated PLT tears without injury of the This study indicates that lateral ankle PBT have been reported by other pain may be due to isolated acute or authors before.1-3 Because of the low chronic peroneus longus tendon tears. incidence, it is a frequently overlooked Thorough clinical and radiological or misdiagnosed injury, which once diagnosis is necessary to detect this occurred, may become a source of uncommon injury in time. Patients chronic lateral ankle pain. with acute onset of symptoms and short Peroneal tendon tears may result from time between symptoms and diagnosis acute injury or chronic degeneration. tend to fare better than the chronic tears and delayed diagnosis. Peroneal tendon tears may result Surgical intervention from acute injury or chronic yields successful and predictable results.
“
degeneration.”
Level of Evidence: Level III: Retrospective comparative study
Keywords: peroneus longus tendon; peroneus brevis tendon; tendon tear; tendon rupture; tendon repair
Introduction Injuries of the peroneus longus tendon (PLT) have been reported in literature but significance and incidence are still ambiguous.1-5 Tears of the PLT are less
They can appear incomplete longitudinal, partial, or complete transverse.6 Acute injuries have been described after inversion ankle sprain, tendon subluxation, or laceration at the os peroneum.6-8 Chronic tears develop without initiating injury and onset of symptoms is subtle. Differential diagnosis is often difficult because of vague lateral ankle pain, edema, and swelling. Plain X-rays of the
DOI: 10.1177/1938640013514273. From the Department of Orthopaedic Surgery, University of Aachen Medical Center, Germany (DA, MT); Department of Orthopaedic, Trauma and Hand Surgery, Florence Nightingale Hospital, Düsseldorf Germany (DF, MA-C); Clinic for Foot and Ankle Surgery, Hessing Foundation, Augsburg, Germany (HW); and Department of Orthopaedic and Joint Surgery, Betaklinik Bonn, Bonn Germany (CW). Address correspondence to: Dariusch Arbab, MD, Department of Orthopaedic Surgery, University of Aachen Medical Center, 30 Pauwels Street, 52074 Aachen, Germany; e-mail: [email protected]. For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav. Copyright © 2013 The Author(s)
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foot may depict a proximally dislocated os peroneum as a devious sign of a PLT tear.8,9 Magnetic resonance imaging (MRI) scan can help assure diagnosis of PLT and PBT injuries, which is based on thorough anamnesis and physical examination. Several reports have shown that patients with peroneal tendon injuries had no relief of symptoms with conservative therapy even after long time of immobilization and antiphlogistic medication.2,10 In these cases, surgical treatment is considered depending on the type of lesion, chronicity, age, and activity level of the patient.11 The purpose of this study was to present 6 cases of isolated PLT tears and our experience with its operative treatment. A description of the symptoms, clinical and radiographic findings, differential diagnosis, treatment, and outcome are presented with a review of the current literature.
Material and Methods The 6 cases presented occurred between 2005 and 2010. All patients who underwent surgical repair of an isolated PLT tear were reviewed. PLT tears that were associated with a PBT or other injury were excluded. A retrospective review was performed to obtain objective data from patient records, surgical reports, and diagnostic imaging. A comprehensive chart review was performed to compile each patient’s age, sex, onset of symptoms, time between first symptoms and diagnosis, surgical findings, presence of an os peroneum, surgical treatment, length of follow-up, and outcome at the last follow-up (Table 1). According to Sammarco,11 an excellent outcome was noted if there was no pain or deformity and full range of motion. A good outcome consisted of minimal pain, minimal deformity, and a full range of motion. If a patient complained about moderate or severe pain, deformity or loss of range of motion it was noted as a fair outcome. Plain X-rays and MRI scan of the foot was performed in all 6 cases.
Results The average age of our patients was 47.6 years (range 20-63 years). There were 4 men and 2 women. Four had an acute PLT injury, and only 2 had a chronic onset of symptoms. All patients with acute onset of symptoms reported about an acute inversion ankle sprain. Patients with chronic complaints could relate no precipitating event or etiology. History and physical examination showed no signs of metabolic disorders or disease. Time between first symptoms and final diagnosis ranged between 0.75 and 24 months, and diagnosis was made after an average of 10.8 months. Plain X-rays showed no concomitant fracture in any case. In 4 cases, MRI diagnosis was confirmed at operation. In 1 case, MRI diagnosis was wrong reporting about a rupture of the PBT, showing a PLT tear intraoperatively (Figure 1). One scan showed no injury of the peroneal tendons at all. Preoperatively all patients had conservative treatment with cast immobilization and antiphlogistic medication without persistent relief of pain. At operation, 2 patients showed a complete tear, and 3 had an incomplete longitudinal tear ranging from 3 to 6 cm in length (Figure 2). One patient showed an incomplete partial tear involving more than 50% of the cross-sectional area. An os peroneum was present in 2 cases without any laceration or evidence for fracture. The PBT has been explored in all cases but no pathology was found. One patient with a complete tear and the shortest time between trauma and diagnosis and one with an incomplete partial tear were treated with a direct end-to-end tendon repair using a modified Kessler technique. In the other case of a complete tear and the longest time between trauma and diagnosis, a direct end-to-end tendon repair was not possible because of retraction. A PBT tenodesis was performed. Surgical treatment of longitudinal tears consisted of a debridement and suturing or a PBT tenodesis. PBT tenodesis was performed if the tear involved more than 50% of the cross-sectional area (Figure 3). Mean
follow-up was 28.2 months (range 12-78 months). One patient with an acute onset of symptoms and the shortest time between onset of symptoms and final diagnosis (3 weeks) rated his postoperative result as excellent without any pain and unrestricted activity. Four patients rated their results as good, complaining about minimal pain during long stance or walking or minimal loss of range of motion. The patient with the longest time between onset of symptoms and final diagnosis (24 months) rated his results as fair because of moderate pain and deformity. All patients were immobilized postoperatively in a short leg cast for 2 weeks, following 4 weeks in a walker boot. After 6 weeks of immobilization, a range of motion and strengthening program was recommended. One case showed transient hypoesthesia due to peritendinous calcification without functional impairment. No further complications occurred, and no reoperation has been performed.
Discussion Isolated tears of the peroneus longus tendon are rare and often misdiagnosed, thus they represent an important source of ankle pain and dysfunction. They are frequently overlooked because of more common differential diagnosis like lateral ankle ligament injuries, tenosynovitis, or fractures (see Krause and Brodsky12; table 1).2,11 PBT tears appear to be more common compared with PLT tears.6 Dombek et al2 found a PBT tear in 88% and a PLT tear in 13% of 40 patients treated operatively for peroneal tendon injuries. Only 13% of his patients showed isolated PLT tear. In cadaver specimens, the prevalence of PBT tears ranged from 11% to 37%,13,14 whereas PLT tears were less common but often associated with PBT tears.11 Alanen et al1 report about 38 patients treated operatively for peroneal tendon injuries. Fourteen (37%) showed complete or incomplete tears of the PBT, and only 4 (10%) showed PLT tears (Figure 4). The PLT originates from the proximal lateral part of the tibia and the head of
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Table 1. Comprehensive Chart Review. Case
1
2
3
4
5
6
Patient
RS
PA
JN
SP
TJ
HK
Age (years)
63
53
45
20
50
55
Gender
Male
Male
Female
Female
Male
Male
Onset
Chronic
Acute
Chronic
Acute
Acute
Acute
None
Inversion ankle sprain
Mechanism of injury
None
Inversion ankle sprain
Inversion ankle sprain
Time between symptoms and diagnosis
12 months
7 months
15 months
3 weeks
Surgical findings and localization
Incomplete longitudinal tear 4 cm, distal to cuboid notch
Incomplete longitudinal tear 6 cm, thinning, tip of fibula
Incomplete longitudinal tear 3 cm, distal to the calcaneal trochlear process
Complete tear, distal to the cuboid
Os peroneum
Present
Absent
Absent
Absent
Absent
Present
Intact
Intact
Intact
Intact
Intact
Intact
Treatment
Debridement and suturing
PBT tenodesis
Outcome
Good
Good
Good
Excellent
Fair
Good
Follow-up
14 months
19 months
25 months
21 months
12 months
78 months
Peroneus brevis tendon (PBT)
the fibula. The PBT originates from the middle third of the fibula and the intermuscular septum. Both tendons share one synovial sheath as they descend to the lateral malleolus. The retromalleolar groove describes a fibro-osseous tunnel at the posterior part of the fibula, where the PLT is lying posterior to the PBT. This groove differs in depth and shape, and tendons are mainly secured by the superior peroneal retinaculum. Distally to the ankle the sheath bifurcates and the peroneal tendons pass through the inferior peroneal retinaculum and are divided by the peroneal tubercle of the calcaneus.
Debridement and suturing
End-to-end repair
The PBT continues to insert at the base of the fifth metatarsal, whereas the PLT traverses the plantar foot and inserts onto the plantar base of the first metatarsal and the lateral aspect of the medial cuneiform.4,15,16 Petersen et al17 described avascular zones for both tendons at the turn around the lateral malleolus and a second for the PLT where the tendon turns around the cuboid. Both muscles provide main total hindfoot eversion strengths, are dynamic stabilizers of the lateral ankle ligament complex, and function as weak plantar flexors. The PLT stabilizes the medial
24 months
Inversion ankle sprain
Complete tear, distal to the cuboid
PBT tenodesis
6 months
Incomplete partial tear, distal to the cuboid
End-to-end repair
column of the foot during gait and works as a main antagonist of the tibialis posterior muscle.4 Peroneal tendon tears may be acute or chronic degenerative. They can appear incomplete longitudinal, partial, or complete transverse. Peroneus longus tendon tears have been described after acute inversion ankle sprain, tendon subluxation, traumatic tendon laceration, or avulsion at the os peroneum.5,11 Predisposing anatomic factors and variations for peroneal tendon tears have been described as a cavovarus foot type, superior peroneal retinaculum
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Figure 1.
Figure 2.
Figure 4.
Case 3: T2-weighted fat-suppressed (STIR) coronal magnetic resonance imaging scan of an isolated peroneus longus tendon tear with chronic onset of symptoms. The scan shows an enlargement of the tendon sheath and abnormal high signal intensity around and inside of the peroneus longus tendon. The peroneus brevis tendon depicts irregularity in signal intensity indicative for a tear but no injury was found intraoperatively.
Operative photograph of case 2 depicts a longitudinal tear of the peroneus longus tendon at the tip of the fibula. The peroneus brevis tear has been retracted.
Operative photograph of case 1. Thickened peroneus longus tendon sheath. The peroneus brevis tendon has been retracted and appears normal.
Figure 3. Operative photograph after debridement and repair of the longitudinal peroneus longus tendon tear with a running suture.
insufficiency, a flat fibular groove, or a peroneus quadratus muscle.12,18,19 In our series, all acute tears happened after acute inversion ankle sprain. Patients with chronic complaints could relate no precipitating event or etiology. Predisposing anatomic factors or variations could be identified neither in the acute nor in the chronic group. Brandes and Smith18 defined three anatomic zones where injuries to the PLT may occur. Zone A is the region from the tip of the lateral malleolus to the entrance of the superior peroneal retinaculum. Zone B extends from the lateral calcaneal trochlear process to the inferior peroneal retinaculum, whereas zone C is defined as the region distally to the cuboid notch. Partial tears tend to occur more often in zone B, complete tears in zone C. In our series, all complete tears occurred in zone C, 2
incomplete tears in zone B, and 2 in zone C. Acute or chronic peroneal tears present with typical pain at the lateral ankle. Pain might be present at the posterior groove of the distal fibular, the lateral collateral ligament and more distal at the calcaneal cuboid joint. Common findings are warmth, tenderness along the peroneal tendon and edema.6 Walking may be painful and activity is decreased. Muscle strength is usually decreased and manual testing of plantarflexion and eversion is painful or not possible. Pain and swelling are in general more distinct compared to tendinitis or tenosynovitis but differential diagnosis remains difficult and delayed diagnosis or wrong diagnosis is commonly reported.2,11 In our series, only 1 patient has been diagnosed within
the first month. The time between first symptoms and final diagnosis ranged between 3 weeks and 24 months, and diagnosis was made after an average of 10.8 months. Plain dorsoplantar, lateral, and oblique X-rays of the foot may depict acute osseous injuries, such as fractures of the calcaneus, lateral malleolus, or chronic conditions, such as lateral ankle impingement, hypertrophy of the peroneal tubercle, spurring of the retromalleolar groove, exostoses, arthrosis, tumors, and an os peroneum.15 The os peroneum as an accessory sesamoid at the lateral aspect of the calcaneocuboid joint is embedded in the peroneus longus tendon. It is rounded or oval and sometimes presents bi- or tripartite. Anatomic and radiographic studies showed that the os peroneum is seen in approximately 5% to 26% of patients.4 In our series, 2 os peroneum could be identified. Stress fractures of the accessory sesamoid are not uncommon and tear of the PLT associated with os peroneum fractures have been reported in the literature.7,20 Some authors propose that the presence of an os peroneum may predispose the tendon to rupture.3,5 The position of the os peroneum in serial radiographs can depict fracture of the sesamoid bone or PLT rupture in case of proximal migration as shown in one of our cases (Figure 5).5,9
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Figure 5.
Figure 6.
Case 6 with an incomplete partial rupture. (A) T2-weighted sagittal fat suppressed (SPIR) magnetic resonance imaging scan shows a high signal intensity and a tendon thinning at the cuboid notch. (B) Oblique radiograph of the same foot demonstrating a proximally dislocated os peroneum.
(A) and (B) Case 1: T1-weighted fat-suppressed and T2-weighted coronal magnetic resonance imaging scans of a longitudinal tear demonstrating an increased intrasubstance signal intensity in a thickened peroneus longus tendon under the cuboid notch. (C) and (D) Case 1: T1-weighted fat-suppressed (SPIR) axial and T2-weighted sagittal magnetic resonance imaging scan showing an increased intrasubstance signal intensity in a thickened peroneus longus tendon as it courses inferior.
Magnetic resonance imaging scan is the standard method for evaluating tendon injuries.21 It provides visualization of the tendon, synovial sheath, and surrounding structures, such as ligaments or peroneal retinaculum. PLT tears demonstrate linear or round area of increased signal alteration whereas PBT tears often appear as c-shaped or bisected (Figure 6).22 There are confusing data in literature about accuracy of MRI for diagnosis of peroneal tendon disorders. Steel and DeOrio23 reported on high specificity and sensitivity for diagnosis of PBT and PLT injuries. Some authors showed that MRI overestimates peroneal tendon disorders,18 whereas others found that MRI underestimates peroneal tendon injury, particularly PLT affection.2,12,24 In our series, 4 out of 6 MRI depicted
correct diagnosis. One scan was indicative for a PBT injury, but operative exploration showed a PLT tear without any PBT affection. One scan showed no tear at all. MRI scan should be an aid for evaluation of peroneal tendon disorders but diagnosis is mainly based on thorough anamnesis and physical examination. Peroneus brevis tendon tears have been classified by Sobel et al,13 describing 4 grades. Krause and Brodsky12 described a classification for
directing treatment on the basis of the cross-sectional area of viable tendon. A common classification for PLT tear does not exist but may be based on PBT tear classifications. If nonoperative treatment, including anti-inflammatory medications, immobilization, and physical therapy fails, surgical intervention should be considered.10 Operative treatment depends on the type of lesion, chronicity, age, and activity level of the patient.11 Different algorithms have been described. Redfern and Myerson24
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propose an algorithm for operative treatment based on intraoperative pathological findings of both tendons. Sammarco11 describes an algorithm for PLT tears depending on acute or chronic onset, presence of an os perineum, and stable or unstable feet. All recommendations and algorithms for operative treatment are based on level IV and level V studies. Surgical treatment of complete tears in our series was direct end-to-end repair and PBT tenodesis in cases of retraction. Our patients with longitudinal tears were treated with a debridement and suturing of the tendon or a PBT tenodesis if the tear involved more than 50% of the cross-sectional area. Operative treatment has been reported to be successful and demonstrates predictable results.1,2,11 In our series, 5 out of 6 patients rated their results as excellent or good. The patient with the shortest time between onset of symptoms and final diagnosis (3 weeks) rated his results as excellent, whereas the patient with the longest time (24 months) rated his results as fair. Time of diagnosis and early treatment seems to be essential for a high patient satisfaction and outcome.
Conclusion Peroneal tendon disorders are not an uncommon source of lateral ankle pain. We could demonstrate that MRI may show false positive or false negative results in existing PLT tears. Surgical exploration should therefore be considered in cases of persistent lateral ankle pain because time between onset of symptoms and diagnosis proved to be an essential factor for outcome.
References 1. Alanen J, Orava S, Heinonen OJ, Ikonen J, Kvist M. Peroneal tendon injuries. Report of thirty-eight operated cases. Ann Chir Gynaecol. 2001;90:43-46. 2. Dombek MF, Lamm BM, Saltrick K, Mendicino RW, Catanzariti AR. Peroneal tendon tears: a retrospective review. J Foot Ankle Surg. 2003;42:250-258. 3. Peacock KC, Resnick EJ, Thoder JJ. Fracture of the os peroneus with rupture of the peroneus longus tendon. A case report and review of the literature. Clin Orthop Relat Res. 1986;(202):223-226. 4. Sarrafian SK. Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional. Philadelphia, PA: J. B. Lippincott; 1983. 5. Thompsen FM, Patterson AH. Rupture of the peroneus longus tendon. Report of three cases. J Bone Joint Surg Am. 1989;71:293-295. 6. Clarke H, Kitaoka H, Ehman R. Peroneal tendon injuries. Foot Ankle Int. 1998;19:280-288.
peroneus brevis tendon splits: a proposed mechanism, technique of diagnosis, and classification of injury. Foot Ankle. 1992;13:413-422. 14. Sobel M, DiCarlo E, Bohne W, Collins L. Longitudinal splitting of the peroneus brevis tendon: an anatomic and histologic study of cadaveric material. Foot Ankle. 1991;12:165-170. 15. Heckman DS, Reddy S, Pedowitz D, Wapner KL, Parekh SG. Operative treatment for peroneal tendon disorders. J Bone Joint Surg Am. 2008;90:404-418. 16. Zgonis T, Jolly GP, Polyzois V, Stamatis ED. Peroneal tendon pathology. Clin Podiatr Med Surg. 2005;221:79-85. 17. Petersen W, Bobka T, Stein V, Tillmann B. Blood supply of the peroneal tendons: injection and immunohistochemical studies of cadaver tendons. Acta Orthop Scand. 2000;71:168-174. 18. Brandes CB, Smith RW. Characterization of patients with primary peroneus longus tendinopathy: a review of twenty-two cases. Foot Ankle Int. 2000;21:462-468.
7. Bassett FH 3rd, Speer KP. Longitudinal rupture of the peroneal tendons. Am J Sports Med. 1993;21:354-357.
19. Sobel M, Levy M, Bohne WH. Congenital variations of the peroneus quadratus: an anatomic study. Foot Ankle. 1990;11: 81-99.
8. Truong DT, Dussault RG, Kaplan PA. Fracture of the os peroneum and rupture of the os peroneus longus tendon as a complication of diabetic neuropathy. Skeletal Radiol. 1995;24:626-628.
20. Wander DS, Galli K. Surgical management of a ruptured peroneus longus tendon with a fractured multipartite os peroneum. J Foot Ankle Surg. 1994;33:124-128.
9. Waizy H, Frank D. Rupture of the m. peroneus longus. Case report and review of the literature. FussSprung. 2005;3:205-209. 10. Molloy R, Tisdel C. Failed treatment of peroneal tendon injuries. Foot Ankle Clin. 2003;8:115-129. 11. Sammarco GJ. Peroneus longus tendon tears: acute and chronic. Foot Ankle Int. 1995;16:245-253. 12. Krause JO, Brodsky JW. Peroneus brevis tendon tears: pathophysiology, surgical reconstruction, and clinical results. Foot Ankle Int. 1998;19:271-279. 13. Sobel M, Geppert MJ, Olson EJ, Bohne WH, Arnoczky SP. The dynamics of
21. Bencardino JT, Rosenberg ZS, Serrano LF. MR imaging features of diseases of the peroneal tendons. Magn Reson Imaging Clin N Am. 2001;9:493-505. 22. Rademaker J, Rosenberg ZS, Delfaut EM, Cheung YY, Schweitzer ME. Tear of the peroneus longus tendon: MR imaging features in nine patients. Radiology. 2000;214:700-704. 23. Steel MW, DeOrio JK. Peroneal tendon tears: return to sports after operative treatment. Foot Ankle Int. 2007;28:49-54. 24. 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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Treatment of Isolated Peroneus Longus Tears and a Review of the Literature Dariusch Arbab, Markus Tingart, Daniel Frank, Mona Abbara-Czardybon, Hazibullah Waizy and Carsten Wingenfeld Foot Ankle Spec 2014 7: 113 originally published online 30 December 2013 DOI: 10.1177/1938640013514273 The online version of this article can be found at: http://fas.sagepub.com/content/7/2/113
Published by: http://www.sagepublications.com
Additional services and information for Foot & Ankle Specialist can be found at: Email Alerts: http://fas.sagepub.com/cgi/alerts Subscriptions: http://fas.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
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514273
research-articleXXXX
FASXXX10.1177/1938640013514273Foot & Ankle SpecialistFoot & Ankle Specialist
vol. 7 / no. 2
Foot & Ankle Specialist
113
〈 Clinical Research 〉 Treatment of Isolated Peroneus Longus Tears and a Review of the Literature Abstract: Background. Isolated peroneus longus tendon tears are rare and represent a frequently overlooked source of lateral ankle pain and dysfunction. Only few cases of isolated peroneus longus tendon tears have been reported and a common treatment algorithm does not exist. The purpose of this study was to give an overview of the literature and to present our experience of 6 consecutive cases that have been treated successfully by operation and immobilizing cast. Methods. A comprehensive chart review was performed to compile each patient’s age, sex, onset of symptoms, time between first symptoms and diagnosis, surgical findings, surgical treatment, length of follow-up, and outcome. The average patient age was 48 years (range 20-63 years). Results. Acute tears occurred in 4 cases, and 2 patients reported about a chronic onset of symptoms. The cause for acute tears was an acute inversion ankle sprain in all cases. Diagnosis was made after an average of 11 months (range 0.75-24 months). There were 2 complete tears, and other 4 were incomplete. An os peroneum was present in 2 cases. In 5 of 6 cases, the results after surgical
Dariusch Arbab, MD, Markus Tingart, MD, Daniel Frank, MD, Mona Abbara-Czardybon, MD, Hazibullah Waizy, MD, and Carsten Wingenfeld, MD
common than tears of the peroneus treatment were excellent or good after brevis tendon (PBT). Only few cases of a mean follow-up of 28.6 months (range 12-78 months). Conclusion. isolated PLT tears without injury of the This study indicates that lateral ankle PBT have been reported by other pain may be due to isolated acute or authors before.1-3 Because of the low chronic peroneus longus tendon tears. incidence, it is a frequently overlooked Thorough clinical and radiological or misdiagnosed injury, which once diagnosis is necessary to detect this occurred, may become a source of uncommon injury in time. Patients chronic lateral ankle pain. with acute onset of symptoms and short Peroneal tendon tears may result from time between symptoms and diagnosis acute injury or chronic degeneration. tend to fare better than the chronic tears and delayed diagnosis. Peroneal tendon tears may result Surgical intervention from acute injury or chronic yields successful and predictable results.
“
degeneration.”
Level of Evidence: Level III: Retrospective comparative study
Keywords: peroneus longus tendon; peroneus brevis tendon; tendon tear; tendon rupture; tendon repair
Introduction Injuries of the peroneus longus tendon (PLT) have been reported in literature but significance and incidence are still ambiguous.1-5 Tears of the PLT are less
They can appear incomplete longitudinal, partial, or complete transverse.6 Acute injuries have been described after inversion ankle sprain, tendon subluxation, or laceration at the os peroneum.6-8 Chronic tears develop without initiating injury and onset of symptoms is subtle. Differential diagnosis is often difficult because of vague lateral ankle pain, edema, and swelling. Plain X-rays of the
DOI: 10.1177/1938640013514273. From the Department of Orthopaedic Surgery, University of Aachen Medical Center, Germany (DA, MT); Department of Orthopaedic, Trauma and Hand Surgery, Florence Nightingale Hospital, Düsseldorf Germany (DF, MA-C); Clinic for Foot and Ankle Surgery, Hessing Foundation, Augsburg, Germany (HW); and Department of Orthopaedic and Joint Surgery, Betaklinik Bonn, Bonn Germany (CW). Address correspondence to: Dariusch Arbab, MD, Department of Orthopaedic Surgery, University of Aachen Medical Center, 30 Pauwels Street, 52074 Aachen, Germany; e-mail: [email protected]. For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav. Copyright © 2013 The Author(s)
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foot may depict a proximally dislocated os peroneum as a devious sign of a PLT tear.8,9 Magnetic resonance imaging (MRI) scan can help assure diagnosis of PLT and PBT injuries, which is based on thorough anamnesis and physical examination. Several reports have shown that patients with peroneal tendon injuries had no relief of symptoms with conservative therapy even after long time of immobilization and antiphlogistic medication.2,10 In these cases, surgical treatment is considered depending on the type of lesion, chronicity, age, and activity level of the patient.11 The purpose of this study was to present 6 cases of isolated PLT tears and our experience with its operative treatment. A description of the symptoms, clinical and radiographic findings, differential diagnosis, treatment, and outcome are presented with a review of the current literature.
Material and Methods The 6 cases presented occurred between 2005 and 2010. All patients who underwent surgical repair of an isolated PLT tear were reviewed. PLT tears that were associated with a PBT or other injury were excluded. A retrospective review was performed to obtain objective data from patient records, surgical reports, and diagnostic imaging. A comprehensive chart review was performed to compile each patient’s age, sex, onset of symptoms, time between first symptoms and diagnosis, surgical findings, presence of an os peroneum, surgical treatment, length of follow-up, and outcome at the last follow-up (Table 1). According to Sammarco,11 an excellent outcome was noted if there was no pain or deformity and full range of motion. A good outcome consisted of minimal pain, minimal deformity, and a full range of motion. If a patient complained about moderate or severe pain, deformity or loss of range of motion it was noted as a fair outcome. Plain X-rays and MRI scan of the foot was performed in all 6 cases.
Results The average age of our patients was 47.6 years (range 20-63 years). There were 4 men and 2 women. Four had an acute PLT injury, and only 2 had a chronic onset of symptoms. All patients with acute onset of symptoms reported about an acute inversion ankle sprain. Patients with chronic complaints could relate no precipitating event or etiology. History and physical examination showed no signs of metabolic disorders or disease. Time between first symptoms and final diagnosis ranged between 0.75 and 24 months, and diagnosis was made after an average of 10.8 months. Plain X-rays showed no concomitant fracture in any case. In 4 cases, MRI diagnosis was confirmed at operation. In 1 case, MRI diagnosis was wrong reporting about a rupture of the PBT, showing a PLT tear intraoperatively (Figure 1). One scan showed no injury of the peroneal tendons at all. Preoperatively all patients had conservative treatment with cast immobilization and antiphlogistic medication without persistent relief of pain. At operation, 2 patients showed a complete tear, and 3 had an incomplete longitudinal tear ranging from 3 to 6 cm in length (Figure 2). One patient showed an incomplete partial tear involving more than 50% of the cross-sectional area. An os peroneum was present in 2 cases without any laceration or evidence for fracture. The PBT has been explored in all cases but no pathology was found. One patient with a complete tear and the shortest time between trauma and diagnosis and one with an incomplete partial tear were treated with a direct end-to-end tendon repair using a modified Kessler technique. In the other case of a complete tear and the longest time between trauma and diagnosis, a direct end-to-end tendon repair was not possible because of retraction. A PBT tenodesis was performed. Surgical treatment of longitudinal tears consisted of a debridement and suturing or a PBT tenodesis. PBT tenodesis was performed if the tear involved more than 50% of the cross-sectional area (Figure 3). Mean
follow-up was 28.2 months (range 12-78 months). One patient with an acute onset of symptoms and the shortest time between onset of symptoms and final diagnosis (3 weeks) rated his postoperative result as excellent without any pain and unrestricted activity. Four patients rated their results as good, complaining about minimal pain during long stance or walking or minimal loss of range of motion. The patient with the longest time between onset of symptoms and final diagnosis (24 months) rated his results as fair because of moderate pain and deformity. All patients were immobilized postoperatively in a short leg cast for 2 weeks, following 4 weeks in a walker boot. After 6 weeks of immobilization, a range of motion and strengthening program was recommended. One case showed transient hypoesthesia due to peritendinous calcification without functional impairment. No further complications occurred, and no reoperation has been performed.
Discussion Isolated tears of the peroneus longus tendon are rare and often misdiagnosed, thus they represent an important source of ankle pain and dysfunction. They are frequently overlooked because of more common differential diagnosis like lateral ankle ligament injuries, tenosynovitis, or fractures (see Krause and Brodsky12; table 1).2,11 PBT tears appear to be more common compared with PLT tears.6 Dombek et al2 found a PBT tear in 88% and a PLT tear in 13% of 40 patients treated operatively for peroneal tendon injuries. Only 13% of his patients showed isolated PLT tear. In cadaver specimens, the prevalence of PBT tears ranged from 11% to 37%,13,14 whereas PLT tears were less common but often associated with PBT tears.11 Alanen et al1 report about 38 patients treated operatively for peroneal tendon injuries. Fourteen (37%) showed complete or incomplete tears of the PBT, and only 4 (10%) showed PLT tears (Figure 4). The PLT originates from the proximal lateral part of the tibia and the head of
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Table 1. Comprehensive Chart Review. Case
1
2
3
4
5
6
Patient
RS
PA
JN
SP
TJ
HK
Age (years)
63
53
45
20
50
55
Gender
Male
Male
Female
Female
Male
Male
Onset
Chronic
Acute
Chronic
Acute
Acute
Acute
None
Inversion ankle sprain
Mechanism of injury
None
Inversion ankle sprain
Inversion ankle sprain
Time between symptoms and diagnosis
12 months
7 months
15 months
3 weeks
Surgical findings and localization
Incomplete longitudinal tear 4 cm, distal to cuboid notch
Incomplete longitudinal tear 6 cm, thinning, tip of fibula
Incomplete longitudinal tear 3 cm, distal to the calcaneal trochlear process
Complete tear, distal to the cuboid
Os peroneum
Present
Absent
Absent
Absent
Absent
Present
Intact
Intact
Intact
Intact
Intact
Intact
Treatment
Debridement and suturing
PBT tenodesis
Outcome
Good
Good
Good
Excellent
Fair
Good
Follow-up
14 months
19 months
25 months
21 months
12 months
78 months
Peroneus brevis tendon (PBT)
the fibula. The PBT originates from the middle third of the fibula and the intermuscular septum. Both tendons share one synovial sheath as they descend to the lateral malleolus. The retromalleolar groove describes a fibro-osseous tunnel at the posterior part of the fibula, where the PLT is lying posterior to the PBT. This groove differs in depth and shape, and tendons are mainly secured by the superior peroneal retinaculum. Distally to the ankle the sheath bifurcates and the peroneal tendons pass through the inferior peroneal retinaculum and are divided by the peroneal tubercle of the calcaneus.
Debridement and suturing
End-to-end repair
The PBT continues to insert at the base of the fifth metatarsal, whereas the PLT traverses the plantar foot and inserts onto the plantar base of the first metatarsal and the lateral aspect of the medial cuneiform.4,15,16 Petersen et al17 described avascular zones for both tendons at the turn around the lateral malleolus and a second for the PLT where the tendon turns around the cuboid. Both muscles provide main total hindfoot eversion strengths, are dynamic stabilizers of the lateral ankle ligament complex, and function as weak plantar flexors. The PLT stabilizes the medial
24 months
Inversion ankle sprain
Complete tear, distal to the cuboid
PBT tenodesis
6 months
Incomplete partial tear, distal to the cuboid
End-to-end repair
column of the foot during gait and works as a main antagonist of the tibialis posterior muscle.4 Peroneal tendon tears may be acute or chronic degenerative. They can appear incomplete longitudinal, partial, or complete transverse. Peroneus longus tendon tears have been described after acute inversion ankle sprain, tendon subluxation, traumatic tendon laceration, or avulsion at the os peroneum.5,11 Predisposing anatomic factors and variations for peroneal tendon tears have been described as a cavovarus foot type, superior peroneal retinaculum
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Figure 1.
Figure 2.
Figure 4.
Case 3: T2-weighted fat-suppressed (STIR) coronal magnetic resonance imaging scan of an isolated peroneus longus tendon tear with chronic onset of symptoms. The scan shows an enlargement of the tendon sheath and abnormal high signal intensity around and inside of the peroneus longus tendon. The peroneus brevis tendon depicts irregularity in signal intensity indicative for a tear but no injury was found intraoperatively.
Operative photograph of case 2 depicts a longitudinal tear of the peroneus longus tendon at the tip of the fibula. The peroneus brevis tear has been retracted.
Operative photograph of case 1. Thickened peroneus longus tendon sheath. The peroneus brevis tendon has been retracted and appears normal.
Figure 3. Operative photograph after debridement and repair of the longitudinal peroneus longus tendon tear with a running suture.
insufficiency, a flat fibular groove, or a peroneus quadratus muscle.12,18,19 In our series, all acute tears happened after acute inversion ankle sprain. Patients with chronic complaints could relate no precipitating event or etiology. Predisposing anatomic factors or variations could be identified neither in the acute nor in the chronic group. Brandes and Smith18 defined three anatomic zones where injuries to the PLT may occur. Zone A is the region from the tip of the lateral malleolus to the entrance of the superior peroneal retinaculum. Zone B extends from the lateral calcaneal trochlear process to the inferior peroneal retinaculum, whereas zone C is defined as the region distally to the cuboid notch. Partial tears tend to occur more often in zone B, complete tears in zone C. In our series, all complete tears occurred in zone C, 2
incomplete tears in zone B, and 2 in zone C. Acute or chronic peroneal tears present with typical pain at the lateral ankle. Pain might be present at the posterior groove of the distal fibular, the lateral collateral ligament and more distal at the calcaneal cuboid joint. Common findings are warmth, tenderness along the peroneal tendon and edema.6 Walking may be painful and activity is decreased. Muscle strength is usually decreased and manual testing of plantarflexion and eversion is painful or not possible. Pain and swelling are in general more distinct compared to tendinitis or tenosynovitis but differential diagnosis remains difficult and delayed diagnosis or wrong diagnosis is commonly reported.2,11 In our series, only 1 patient has been diagnosed within
the first month. The time between first symptoms and final diagnosis ranged between 3 weeks and 24 months, and diagnosis was made after an average of 10.8 months. Plain dorsoplantar, lateral, and oblique X-rays of the foot may depict acute osseous injuries, such as fractures of the calcaneus, lateral malleolus, or chronic conditions, such as lateral ankle impingement, hypertrophy of the peroneal tubercle, spurring of the retromalleolar groove, exostoses, arthrosis, tumors, and an os peroneum.15 The os peroneum as an accessory sesamoid at the lateral aspect of the calcaneocuboid joint is embedded in the peroneus longus tendon. It is rounded or oval and sometimes presents bi- or tripartite. Anatomic and radiographic studies showed that the os peroneum is seen in approximately 5% to 26% of patients.4 In our series, 2 os peroneum could be identified. Stress fractures of the accessory sesamoid are not uncommon and tear of the PLT associated with os peroneum fractures have been reported in the literature.7,20 Some authors propose that the presence of an os peroneum may predispose the tendon to rupture.3,5 The position of the os peroneum in serial radiographs can depict fracture of the sesamoid bone or PLT rupture in case of proximal migration as shown in one of our cases (Figure 5).5,9
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Figure 5.
Figure 6.
Case 6 with an incomplete partial rupture. (A) T2-weighted sagittal fat suppressed (SPIR) magnetic resonance imaging scan shows a high signal intensity and a tendon thinning at the cuboid notch. (B) Oblique radiograph of the same foot demonstrating a proximally dislocated os peroneum.
(A) and (B) Case 1: T1-weighted fat-suppressed and T2-weighted coronal magnetic resonance imaging scans of a longitudinal tear demonstrating an increased intrasubstance signal intensity in a thickened peroneus longus tendon under the cuboid notch. (C) and (D) Case 1: T1-weighted fat-suppressed (SPIR) axial and T2-weighted sagittal magnetic resonance imaging scan showing an increased intrasubstance signal intensity in a thickened peroneus longus tendon as it courses inferior.
Magnetic resonance imaging scan is the standard method for evaluating tendon injuries.21 It provides visualization of the tendon, synovial sheath, and surrounding structures, such as ligaments or peroneal retinaculum. PLT tears demonstrate linear or round area of increased signal alteration whereas PBT tears often appear as c-shaped or bisected (Figure 6).22 There are confusing data in literature about accuracy of MRI for diagnosis of peroneal tendon disorders. Steel and DeOrio23 reported on high specificity and sensitivity for diagnosis of PBT and PLT injuries. Some authors showed that MRI overestimates peroneal tendon disorders,18 whereas others found that MRI underestimates peroneal tendon injury, particularly PLT affection.2,12,24 In our series, 4 out of 6 MRI depicted
correct diagnosis. One scan was indicative for a PBT injury, but operative exploration showed a PLT tear without any PBT affection. One scan showed no tear at all. MRI scan should be an aid for evaluation of peroneal tendon disorders but diagnosis is mainly based on thorough anamnesis and physical examination. Peroneus brevis tendon tears have been classified by Sobel et al,13 describing 4 grades. Krause and Brodsky12 described a classification for
directing treatment on the basis of the cross-sectional area of viable tendon. A common classification for PLT tear does not exist but may be based on PBT tear classifications. If nonoperative treatment, including anti-inflammatory medications, immobilization, and physical therapy fails, surgical intervention should be considered.10 Operative treatment depends on the type of lesion, chronicity, age, and activity level of the patient.11 Different algorithms have been described. Redfern and Myerson24
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propose an algorithm for operative treatment based on intraoperative pathological findings of both tendons. Sammarco11 describes an algorithm for PLT tears depending on acute or chronic onset, presence of an os perineum, and stable or unstable feet. All recommendations and algorithms for operative treatment are based on level IV and level V studies. Surgical treatment of complete tears in our series was direct end-to-end repair and PBT tenodesis in cases of retraction. Our patients with longitudinal tears were treated with a debridement and suturing of the tendon or a PBT tenodesis if the tear involved more than 50% of the cross-sectional area. Operative treatment has been reported to be successful and demonstrates predictable results.1,2,11 In our series, 5 out of 6 patients rated their results as excellent or good. The patient with the shortest time between onset of symptoms and final diagnosis (3 weeks) rated his results as excellent, whereas the patient with the longest time (24 months) rated his results as fair. Time of diagnosis and early treatment seems to be essential for a high patient satisfaction and outcome.
Conclusion Peroneal tendon disorders are not an uncommon source of lateral ankle pain. We could demonstrate that MRI may show false positive or false negative results in existing PLT tears. Surgical exploration should therefore be considered in cases of persistent lateral ankle pain because time between onset of symptoms and diagnosis proved to be an essential factor for outcome.
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peroneus brevis tendon splits: a proposed mechanism, technique of diagnosis, and classification of injury. Foot Ankle. 1992;13:413-422. 14. Sobel M, DiCarlo E, Bohne W, Collins L. Longitudinal splitting of the peroneus brevis tendon: an anatomic and histologic study of cadaveric material. Foot Ankle. 1991;12:165-170. 15. Heckman DS, Reddy S, Pedowitz D, Wapner KL, Parekh SG. Operative treatment for peroneal tendon disorders. J Bone Joint Surg Am. 2008;90:404-418. 16. Zgonis T, Jolly GP, Polyzois V, Stamatis ED. Peroneal tendon pathology. Clin Podiatr Med Surg. 2005;221:79-85. 17. Petersen W, Bobka T, Stein V, Tillmann B. Blood supply of the peroneal tendons: injection and immunohistochemical studies of cadaver tendons. Acta Orthop Scand. 2000;71:168-174. 18. Brandes CB, Smith RW. Characterization of patients with primary peroneus longus tendinopathy: a review of twenty-two cases. Foot Ankle Int. 2000;21:462-468.
7. Bassett FH 3rd, Speer KP. Longitudinal rupture of the peroneal tendons. Am J Sports Med. 1993;21:354-357.
19. Sobel M, Levy M, Bohne WH. Congenital variations of the peroneus quadratus: an anatomic study. Foot Ankle. 1990;11: 81-99.
8. Truong DT, Dussault RG, Kaplan PA. Fracture of the os peroneum and rupture of the os peroneus longus tendon as a complication of diabetic neuropathy. Skeletal Radiol. 1995;24:626-628.
20. Wander DS, Galli K. Surgical management of a ruptured peroneus longus tendon with a fractured multipartite os peroneum. J Foot Ankle Surg. 1994;33:124-128.
9. Waizy H, Frank D. Rupture of the m. peroneus longus. Case report and review of the literature. FussSprung. 2005;3:205-209. 10. Molloy R, Tisdel C. Failed treatment of peroneal tendon injuries. Foot Ankle Clin. 2003;8:115-129. 11. Sammarco GJ. Peroneus longus tendon tears: acute and chronic. Foot Ankle Int. 1995;16:245-253. 12. Krause JO, Brodsky JW. Peroneus brevis tendon tears: pathophysiology, surgical reconstruction, and clinical results. Foot Ankle Int. 1998;19:271-279. 13. Sobel M, Geppert MJ, Olson EJ, Bohne WH, Arnoczky SP. The dynamics of
21. Bencardino JT, Rosenberg ZS, Serrano LF. MR imaging features of diseases of the peroneal tendons. Magn Reson Imaging Clin N Am. 2001;9:493-505. 22. Rademaker J, Rosenberg ZS, Delfaut EM, Cheung YY, Schweitzer ME. Tear of the peroneus longus tendon: MR imaging features in nine patients. Radiology. 2000;214:700-704. 23. Steel MW, DeOrio JK. Peroneal tendon tears: return to sports after operative treatment. Foot Ankle Int. 2007;28:49-54. 24. 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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