eMedicine Specialties > Sports Medicine > Lower Limb

Peroneal Tendon Syndromes: Differential Diagnoses & Workup

Author: Steven Karageanes, DO, Director, Primary Care Sports Medicine Fellowship, Director, Sports Medicine Education, Center for Orthopedics and Neuroscience; Department of Medical Education, Oakwood Healthcare System
Coauthor(s): Kathleen Sharp, MD, Sports Medicine Fellow, Department of Family Practice, Henry Ford Hospital
Contributor Information and Disclosures

Updated: Sep 2, 2008

Differential Diagnoses

Achilles Tendonitis
Calcaneofibular Ligament Injury
Ankle Fracture
Talofibular Ligament Injury
Ankle Impingement Syndrome
Ankle Sprain
Athletic Foot Injuries

Other Problems to Be Considered

Ankle arthritis
Calcaneus bone injuries
Distal fibula fracture
Fifth metatarsal styloid fracture
Os trigonum
Osteochondritis dissecans
Peroneal nerve palsy
Sinus tarsus syndrome

Workup

Imaging Studies

  • Radiography is the first-line study for excluding fractures of the lateral malleolus or calcaneus, arthritis, or loose bodies. Radiography is also useful to observe a migration of the os peroneum in a peroneus longus tendon rupture. Most importantly, radiographs are used to identify a rim fracture, which is an avulsion of the superior peroneal retinaculum from the lateral malleolus. A talar stress view is helpful; if more than 15° of tilt is seen, talar instability that can lead to peroneal instability may be present.
  • Magnetic resonance imaging (MRI) is the criterion standard for identifying peroneal tendon injuries, which are demonstrated by the high signal intensity within the affected tendon on T2-weighted axial views.6,16,17  Kijowski et al found that the presence of uniform or predominantly intermediate signal intensity within the peroneal tendons on 3 consecutive axial proton density-weighted images is a highly sensitive and moderately specific indicator of symptomatic peroneal tendinopathy, as well as the presence of circumferential fluid greater than 3 mm in maximal width.16
  • Ultrasonography is useful for detecting all types of peroneal lesions. In particular, real-time ultrasonography can be performed to assess dynamic stability.7,11,18 This approach is institution dependent because not all facilities are proficient with musculoskeletal ultrasonography. However, Neustadter et al found the positive predictive value of dynamic ultrasonography for peroneal tendon subluxation was 100% in 13 patients.11
  • Computed tomography (CT) scanning is useful for evaluating bony irregularities and suspected fractures, particularly in the calcaneus.19  Heterotopic ossifications can also be identified more accurately with CT scans.
  • Tenography is useful for assessing large lesions of the tendons but is rarely used in practical settings.

Related Medscape topic:
Specialty Site Radiology

Other Tests

  • Electromyelography (EMG) may be useful in difficult cases with profound weakness and no significant damage to the peroneal tendons.
  • EMG should be used in instances of drop foot.

More on Peroneal Tendon Syndromes

Overview: Peroneal Tendon Syndromes
Differential Diagnoses & Workup: Peroneal Tendon Syndromes
Treatment & Medication: Peroneal Tendon Syndromes
Follow-up: Peroneal Tendon Syndromes
Multimedia: Peroneal Tendon Syndromes
References
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References

  1. Fallat L, Grimm DJ, Saracco JA. Sprained ankle syndrome: prevalence and analysis of 639 acute injuries. J Foot Ankle Surg. Jul-Aug 1998;37(4):280-5. [Medline].

  2. Heckman DS, Reddy S, Pedowitz D, Wapner KL, Parekh SG. Operative treatment for peroneal tendon disorders. J Bone Joint Surg Am. Feb 2008;90(2):404-18. [Medline]. [Full Text].

  3. Rosenfeld P. Acute and chronic peroneal tendon dislocations. Foot Ankle Clin. Dec 2007;12(4):643-57, vii. [Medline].

  4. van Dijk CN, Kort N. Tendoscopy of the peroneal tendons. Arthroscopy. Jul-Aug 1998;14(5):471-8. [Medline].

  5. Slater HK. Acute peroneal tendon tears. Foot Ankle Clin. Dec 2007;12(4):659-74, vii. [Medline].

  6. Major NM, Helms CA, Fritz RC, Speer KP. The MR imaging appearance of longitudinal split tears of the peroneus brevis tendon. Foot Ankle Int. Jun 2000;21(6):514-9. [Medline].

  7. Diaz GC, van Holsbeeck M, Jacobson JA. Longitudinal split of the peroneus longus and peroneus brevis tendons with disruption of the superior peroneal retinaculum. J Ultrasound Med. Aug 1998;17(8):525-9. [Medline].

  8. Sammarco GJ. Peroneal tendon injuries. Orthop Clin North Am. Jan 1994;25(1):135-45. [Medline].

  9. Sobel M, Geppert MJ, Warren RF. Chronic ankle instability as a cause of peroneal tendon injury. Clin Orthop Relat Res. Nov 1993;296:187-91. [Medline].

  10. Raikin SM, Elias I, Nazarian LN. Intrasheath subluxation of the peroneal tendons. J Bone Joint Surg Am. May 2008;90(5):992-9. [Medline].

  11. Neustadter J, Raikin SM, Nazarian LN. Dynamic sonographic evaluation of peroneal tendon subluxation. AJR Am J Roentgenol. Oct 2004;183(4):985-8. [Medline]. [Full Text].

  12. Mendicino RW, Orsini RC, Whitman SE, Catanzariti AR. Fibular groove deepening for recurrent peroneal subluxation. J Foot Ankle Surg. Jul-Aug 2001;40(4):252-63. [Medline].

  13. Schweitzer ME, Eid ME, Deely D, Wapner K, Hecht P. Using MR imaging to differentiate peroneal splits from other peroneal disorders. AJR Am J Roentgenol. Jan 1997;168(1):129-33. [Medline]. [Full Text].

  14. DiGiovanni BF, Fraga CJ, Cohen BE, Shereff MJ. Associated injuries found in chronic lateral ankle instability. Foot Ankle Int. Oct 2000;21(10):809-15. [Medline].

  15. Karageanes SJ. Principles of Manual Sports Medicine. Philadelphia, Pa: Lippincott Williams & Wilkins; 2005.

  16. Kijowski R, De Smet A, Mukharjee R. Magnetic resonance imaging findings in patients with peroneal tendinopathy and peroneal tenosynovitis. Skeletal Radiol. Feb 2007;36(2):105-14. [Medline].

  17. Campbell SE, Warner M. MR imaging of ankle inversion injuries. Magn Reson Imaging Clin N Am. Feb 2008;16(1):1-18, v. [Medline].

  18. Waitches GM, Rockett M, Brage M, Sudakoff G. Ultrasonographic-surgical correlation of ankle tendon tears. J Ultrasound Med. Apr 1998;17(4):249-56. [Medline].

  19. Ho RT, Smith D, Escobedo E. Peroneal tendon dislocation: CT diagnosis and clinical importance. AJR Am J Roentgenol. Nov 2001;177(5):1193. [Medline]. [Full Text].

  20. Squires N, Myerson MS, Gamba C. Surgical treatment of peroneal tendon tears. Foot Ankle Clin. Dec 2007;12(4):675-95, vii. [Medline].

  21. Omey ML, Micheli LJ. Foot and ankle problems in the young athlete. Med Sci Sports Exerc. Jul 1999;31(7 suppl):S470-86. [Medline].

  22. Safran MR, O'Malley D Jr, Fu FH. Peroneal tendon subluxation in athletes: new exam technique, case reports, and review. Med Sci Sports Exerc. Jul 1999;31(7 suppl):S487-92. [Medline].

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Further Reading

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Keywords

peroneal tendon syndromes, peroneal tendon, ankle sprain, ankle instability, peroneal tendonitis, peroneal tendinitis, peroneal tendon tears, peroneal tendon subluxation, peroneal tendon dislocation, peroneal tendon strain, peroneal tenosynovitis, peroneal retinaculum tear, peroneal tendon pathology, 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,  primary peroneus longus tendinopathy, peroneus longus rupture, ankle pain, foot pain, tendon rupture, lateral ankle ligament tear, inversion injury

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Contributor Information and Disclosures

Author

Steven Karageanes, DO, Director, Primary Care Sports Medicine Fellowship, Director, Sports Medicine Education, Center for Orthopedics and Neuroscience; Department of Medical Education, Oakwood Healthcare System
Steven Karageanes, DO is a member of the following medical societies: American Medical Association, American Osteopathic Association, and Michigan State Medical Society
Disclosure: Nothing to disclose.

Coauthor(s)

Kathleen Sharp, MD, Sports Medicine Fellow, Department of Family Practice, Henry Ford Hospital
Kathleen Sharp, MD is a member of the following medical societies: American Academy of Family Physicians and National Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Gerard A Malanga, MD, Founder and Director, New Jersey Sports Medicine Institute; Director of Pain Management, Overlook Hospital; Director of Sports Medicine, Sports Medicine Fellowship Director, Mountainside Hospital; Clinical Chief, Rehabilitation Medicine and Electrodiagnosis, St Michael's Medical Center; Medical Director, Consultant, Horizon Healthcare Worker's Compensation Services, Blue Cross and Blue Shield Worker's Compensation
Gerard A Malanga, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, North American Spine Society, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Russell D White, MD, Professor of Medicine, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center Lakewood
Disclosure: Nothing to disclose.

CME Editor

Jon B Whitehurst, MD, Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner and Executive Board Member, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital
Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD, Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago
Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

 
 
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