eMedicine Specialties > Orthopedic Surgery > Foot & Ankle

Peroneal Tendon Pathology: Treatment

Author: Kurtis Hort, MD, Foot and Ankle Surgery Fellow, Department of Orthopedic Surgery, Orthopaedic Associates of St. Augustine, Florida
Coauthor(s): James K DeOrio, MD, Director of Foot and Ankle Fellowship Program, Assistant Professor of Orthopedic Surgery, Orthopedic Surgery, St Lukes Hospital, Jacksonville, Florida
Contributor Information and Disclosures

Updated: Mar 27, 2008

Treatment

Medical Therapy

Nonsteroidal anti-inflammatory medication to reduce pain and inflammation often is used. Any underlying medical problem (eg, diabetes, rheumatoid arthritis) should be medically controlled.15

After medical therapy is initiated, nonoperative treatment usually is attempted. In general, conservative therapy may include activity modification, footwear changes, temporary immobilization, and corticosteroid injection. Lateral heel wedges can take stress off of the peroneal tendons to allow healing. Nonoperative treatment of tenosynovitis alone often is successful, whereas a complete or partial tendon rupture often leads to surgery. Likewise, an acute injury is more likely to respond to conservative care than is a chronic process. Several authors have reported a high percentage of patients with tendon ruptures or subluxation that eventually require surgery.

As with other disorders of the foot and ankle, the use of corticosteroid injection must be undertaken with extreme caution to avoid iatrogenic rupture.

Surgical Therapy

Surgical treatment is best considered under the specific pathology being addressed. With any procedure, it is important to remove abnormal-appearing synovium or tenosynovium, which can cause persistent pain if not removed. This can be accomplished easily with the use of a rongeur. For surgical repair, see Image 3, Image 4, Image 5, Image 6, and Image 7.

Tenosynovitis

Tenosynovitis may be treated surgically with simple division of the tendon sheath. Coughlin's description of the procedure is as follows16 :

A tourniquet is used. The tendons are exposed through an incision that curves from the posterior aspect of the fibula toward the base of the fifth metatarsal. Care must be taken to protect the sural nerve. The tendon sheath is opened longitudinally, and each tendon is examined. Any degenerated area of tendon generally is removed. A peroneus quartus can be excised. If the peroneal tubercle is proud, it may be smoothed or leveled. The tendon sheath is left unrepaired.

Postoperatively, the patient is placed in a short leg cast. Weightbearing in the cast may begin after 2 weeks. Range of motion and strengthening are started after casting is discontinued at 4 weeks.

Primary peroneus longus tendinopathy

This disorder may be approached in a manner similar to that described above with subsequent debridement of the tendon, release of the inferior peroneal retinaculum, and smoothing of the peroneal tubercle. Brandes and Smith advocate adding a lateral closing wedge calcaneal osteotomy (Dwyer) if the patient has a cavus or varus deformity of the hindfoot.3

Postoperatively, a short leg cast may be used for up to 6 weeks to allow for the osteotomy to heal. Weightbearing in a protective boot is recommended for an additional 6 weeks.

Os peroneum excision

If symptoms are directly referable to the os peroneum due to fracture or fragmentation, it may simply be excised as follows.

The inferior portion of the typical peroneal tendon approach is used. With pathology limited to the os peroneum, this may consist only of the portion from the tip of the fibula to the base of the fifth metatarsal. The tendon sheath is incised, and the os is sharply removed from the tendon in a shelling out fashion. The tendon may be repaired with interrupted absorbable or nylon suture if only a longitudinal defect is present. If the tendon has lost continuity, it may be repaired with a modified Kessler or similar stitch or tenodesed to the intact peroneus brevis tendon.

Postoperatively, a short leg cast is applied for a total of 6 weeks, with weightbearing beginning after 3-4 weeks. A removable boot then is used for an additional 4 weeks with normal shoe wear to follow. Activity is advanced to tolerance following boot removal.

Peroneus brevis repair

The patient is placed supine with a sandbag under the ipsilateral hip. A thigh-high tourniquet is used. A curved longitudinal incision along the course of the peroneal tendons is extended from several centimeters above the lateral malleolus to the base of the fifth metatarsal. The superior peroneal retinaculum is incised sharply, leaving a small tag on the fibula for later repair. The tendons are inspected. The peroneus brevis will lie closer to the fibula.

If a single longitudinal tear is noted, it simply may be repaired with a running Ethibond suture. If the tendon split represents less than 30% of the normal tendon width, it can be excised. If a peroneus quartus muscle is encountered, it simply may be resected. If multiple degenerative tears are present, they are debrided with an eventual attempt to tubularize the remaining tendon. Coughlin and Mann recommend tenodesis to the peroneus longus if less than one third of the tendon remains.16 After tendon pathology is addressed, the superior peroneal retinaculum is repaired over the tendons. The skin is closed in a routine fashion.

Postoperatively, a short leg cast is applied for 6 weeks, with weightbearing started after 4 weeks. A boot is then used for an additional 4 weeks with daily range-of-motion exercises.

Peroneal tendon subluxation

Surgical treatment often is necessary to correct subluxing or dislocating peroneal tendons. If the problem is diagnosed early, acute repair of the peroneal retinaculum may be undertaken, though most often, intervention occurs later.17,18,19,20

Acute repair of superior peroneal retinaculum

A thigh tourniquet is used. The incision is in line with the peroneal tendons from 6 cm proximal to the tip of the fibula to 2 cm distal to it. The superior peroneal retinaculum is identified and sharply removed from the fibula 1 cm posterior to the fibula. A bony trough  is then created on the posterolateral fibula parallel with the remaining edge of the retinaculum just posterior to it. This can be performed with an osteotome or with a burr. Three to four drill holes then are created in the fibula along the trough. An Ethibond suture is used to approximate the retinaculum to the fibula by passing it through both of the holes and the retinaculum. The retinaculum is then further imbricated to the portion that is still attached to the fibula with an absorbable suture. The skin is closed in a routine manner.

If a large piece of the fibula has been avulsed, it may be internally fixed with a small fragment bone screw, making true repair of the retinaculum unnecessary.

Postoperatively, a short leg cast is applied for 6 weeks, with weightbearing allowed after 4 weeks.

Surgical options for chronic dislocation

Surgical options for chronic dislocation have been grouped into 5 categories.21,22

  • Superior peroneal retinaculum repair: The direct retinacular repair is the most anatomic in nature and probably the easiest to perform with the least chance of complications. It is gaining popularity. The procedure is identical to the one described for acute repairs.
  • Tissue transfer to reinforce the superior peroneal retinaculum: Transfers have been described using the Achilles tendon, as well as the plantaris and peroneus brevis tendons. They all basically involve taking a strip of free tissue (eg, plantaris) or a strip of tendon in continuity (eg, Achilles) and reconstructing a portion of the retinaculum to prevent subluxation. These procedures are mentioned only for completeness and are not currently recommended.
  • Tendon rerouting: The tendons may be rerouted beneath the calcaneofibular ligament. This procedure involves cutting the peroneal tendons with subsequent repair after rerouting.
  • Bone block procedures: Numerous bone block type procedures have been described. They involve sagittal osteotomy of the fibula, whether partially or in whole, with posterior displacement or rotation of the more lateral fragment to serve as a mechanical block to prevent anterior subluxation of the tendons. Bone displacement usually is secured with screws.
  • Groove-deepening procedures
    • The patient is placed in a supine position with a bump under the ipsilateral hip. A thigh tourniquet is used. A 10-cm incision in line with the peroneal tendons is centered over the distal posterior border of the fibula. The superior peroneal retinaculum is incised, and the tendons are dislocated anteriorly and inspected.
    • A sharp osteotome is used to raise a bony flap from the posterolateral corner of the distal fibula of approximately 3 cm in length. Care is taken to keep the posteromedial border of the flap intact so that it may act as a hinge. A burr then is used to remove cancellous bone from beneath the flap in order to deepen the peroneal groove. The flap then is reduced and impacted with a bone tamp. A screw may be used for added stability. (see Image 1)
    • The superior peroneal retinaculum then is repaired, and the skin is closed in a routine fashion.
    • Postoperatively, a short leg nonweightbearing cast is applied for 2 weeks in a position of slight eversion and plantarflexion. After 2 weeks, sutures are removed, and the patient is placed in a removable boot or short leg cast in a more neutral position. Weightbearing to tolerance is allowed at that time. All immobilization is discontinued after 6 weeks.
  • ***

Follow-up

For excellent patient education resources, visit eMedicine's Foot, Ankle, Knee, and Hip Center and Sprains and Strains Center. Also, see eMedicine's patient education article Ankle Sprain.

Complications

Recurrence of symptoms following surgical treatment is possible. Patients may complain of stiffness or tightness of the ankle following surgical repair. Surgical treatment also may be complicated by injury to the sural nerve or to the superficial peroneal nerve. The sural nerve may be more at risk due to its variable position. Infections may complicate any surgical procedure. The potential for blood clots or pulmonary embolus, while uncommon with foot and ankle surgery, must not be underestimated.

More on Peroneal Tendon Pathology

Overview: Peroneal Tendon Pathology
Workup: Peroneal Tendon Pathology
Treatment: Peroneal Tendon Pathology
Follow-up: Peroneal Tendon Pathology
Multimedia: Peroneal Tendon Pathology
References
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References

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  3. Brandes CB, Smith RW. Characterization of patients with primary peroneus longus tendinopathy: a review of twenty-two cases. Foot Ankle Int. Jun 2000;21(6):462-8. [Medline].

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Further Reading

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Keywords

disorders of the peroneal tendons, peroneal tendon subluxation, peroneus brevis disorders, disruptions of the peroneus longus, disruptions of the peroneus brevis, fractured os peroneum, fragmented os peroneum, longitudinal tears of the peroneus longus, peroneus brevis tears, longitudinal tears of the peroneus brevis tendon, ankle sprain, primary peroneus longus tendinopathy, peroneus longus rupture, ankle pain, foot pain, tendon rupture, tenosynovitis

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Contributor Information and Disclosures

Author

Kurtis Hort, MD, Foot and Ankle Surgery Fellow, Department of Orthopedic Surgery, Orthopaedic Associates of St. Augustine, Florida
Kurtis Hort, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Foot and Ankle Society, AO Foundation, and Florida Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

James K DeOrio, MD, Director of Foot and Ankle Fellowship Program, Assistant Professor of Orthopedic Surgery, Orthopedic Surgery, St Lukes Hospital, Jacksonville, Florida
James K DeOrio, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Foot and Ankle Society, Florida Medical Association, and German Society of Neurology
Disclosure: Nothing to disclose.

Medical Editor

Heidi M Stephens, MD, MBA, Associate Professor, Department of Surgery, Division of Orthopedic Surgery, University of South Florida College of Medicine; Courtesy Joint Associate Professor, Department of Environmental and Occupational Health, University of South Florida College of Public Health
Heidi M Stephens, MD, MBA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Foot and Ankle Society, and Florida Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Shepard R Hurwitz, MD, Executive Director, American Board of Orthopaedic Surgery
Shepard R Hurwitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for the Advancement of Science, American College of Rheumatology, American College of Sports Medicine, American College of Surgeons, American Diabetes Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Association for the Advancement of Automotive Medicine, Eastern Orthopaedic Association, Orthopaedic Research Society, Orthopaedic Trauma Association, and Southern Orthopaedic Association
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Jason H Calhoun, MD, FACS, Frank J Kloenne Chair in Orthopedic Surgery, Professor and Chair, Department of Orthopedics, The Ohio State University Medical Center
Jason H Calhoun, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Diabetes Association, American Medical Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Missouri State Medical Association, Musculoskeletal Infection Society, Southern Medical Association, Southern Orthopaedic Association, Texas Medical Association, and Texas Orthopaedic Association
Disclosure: Nothing to disclose.

 
 
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