Peroneal Tendon Syndromes Workup

  • Author: Steven J Karageanes, DO; Chief Editor: Sherwin SW Ho, MD   more...
 
Updated: Dec 5, 2011
 

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, 15, 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.[15]
  • 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.
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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.
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Contributor Information and Disclosures
Author

Steven J 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 J 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, CAQSM  Medical Director, CareNow-Duncanville

Kathleen Sharp, MD, CAQSM is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, and National Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Gerard A Malanga, MD  Director of Pain Management, Overlook Hospital; Director of PM&R Sports Medicine Fellowship, Atlantic Health; Clinical Professor, Department of Physical Medicine and Rehabilitation, UMDNJ-New Jersey Medical School; Clinical Chief, Rehabilitation Medicine and Electrodiagnosis, St Michael's Medical Center; Fellow, American College of Sports Medicine

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, American Institute of Ultrasound in Medicine, International Spine Intervention Society, and North American Spine Society

Disclosure: Cephalon Honoraria Speaking and teaching; Endo Honoraria Speaking and teaching; Genzyme Honoraria Speaking and teaching; Prostakan Honoraria Speaking and teaching; Pfizer Consulting fee Speaking and teaching

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Russell D White, MD  Professor of Medicine, Professor of Orthopedic Surgery, Director of Sports Medicine Fellowship Program, Medical Director, Sports Medicine Center, Head Team Physician, University of Missouri-Kansas City Intercollegiate Athletic Program, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center-Lakewood

Russell D White, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Family Physicians, American Association of Clinical Endocrinologists, American College of Sports Medicine, American Diabetes Association, and American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Jon B Whitehurst, MD  Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner, 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 Division of the Biological Sciences, The Pritzker School of Medicine

Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, and Herodicus Society

Disclosure: Breg, Inc. Consulting fee Consulting; Biomet, Inc. Consulting fee Consulting; GMV, Inc. Arthroscopy Simulator Evaluation and teaching; Smith and Nephew Grant/research funds Fellowship funding; DJ Ortho Grant/research funds Course funding; Athletico Physical Therapy Grant/research funds Course, research funding

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. 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].

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

  17. Saxena A, Luhadiya A, Ewen B, Goumas C. Magnetic resonance imaging and incidental findings of lateral ankle pathologic features with asymptomatic ankles. J Foot Ankle Surg. Jul-Aug 2011;50(4):413-5. [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. Kramer D, Solomon R, Curtis C, Zurakowski D, Micheli LJ. Clinical results and functional evaluation of the Chrisman-Snook procedure for lateral ankle instability in athletes. Foot Ankle Spec. Feb 2011;4(1):18-28. [Medline].

  22. Saxena A, Ewen B. Peroneal subluxation: surgical results in 31 athletic patients. J Foot Ankle Surg. May-Jun 2010;49(3):238-41. [Medline].

  23. Muir JJ, Curtiss HM, Hollman J, Smith J, Finnoff JT. The accuracy of ultrasound-guided and palpation-guided peroneal tendon sheath injections. Am J Phys Med Rehabil. Jul 2011;90(7):564-71. [Medline].

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

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

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Lateral ankle anatomy demonstrates the peroneal tendons as they course beneath the superior retinaculum. The anterior talofibular, calcaneofibular, and posterior talofibular ligaments are also shown.
Anterior drawer test, which assesses anterior talofibular ligament stability. The top hand stabilizes, while the lower hand translates the calcaneus and talus directly toward the operator. From Karageanes SJ. Principles of Manual Sports Medicine, Lippincott Williams & Wilkins, 2005.
Tilt test. The operator tilts the talus and calcaneus, not the forefoot. This assesses the integrity of the calcaneofibular ligament. From Karageanes SJ. Principles of Manual Sports Medicine, Lippincott Williams & Wilkins, 2005.
Dislocated peroneal tendons. Left, Note the course of the tendons anterior to the lateral malleolus. Right, Image demonstrates manual relocation of the displaced tendons.
Peroneal stability test. The patient pushes the foot laterally against resistance, while the operator monitors the tendon. From Karageanes SJ. Principles of Manual Sports Medicine, Lippincott Williams & Wilkins, 2005.
 
 
 
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