History

The patient with peroneal tendon pathology typically complains of laterally based ankle or hindfoot pain. The pain usually worsens with activity. However, presentation and diagnosis often are delayed. Patients may or may not recall a specific episode of trauma. Brandes and Smith reported that only nine of 22 patients with primary peroneus longus tendinopathy recalled an inciting event and that the event was an average of 4.3 months prior to presentation.^[5]

Peroneal tendon subluxation or dislocation may present acutely following a traumatic injury to the ankle. However, it is not uncommon for these to present later with an uncertain history of trauma. Patients also may complain of snapping or popping in the ankle.

Physical Examination

On physical examination, there usually is tenderness to palpation along the course of the peroneal tendons. Edema also may be present. These disorders require a high level of suspicion. Even frank dislocations may be missed if not specifically evaluated. (see the image below.)

Ganglion arising from peroneal tendon sheath as cause of painful swelling. Left image shows palpable tender swelling behind lateral malleolus; center image shows ganglion as seen intraoperatively; right image is view after excision.

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A provocative test for peroneal pathology has been described. The patient's foot is examined hanging in a relaxed position with the knee flexed 90^º. Slight pressure is applied to the peroneal tendons posterior to the fibula. The patient is then asked to forcibly dorsiflex and evert the foot. Pain may be elicited, or subluxation of the tendons may be felt.

Circumduction of the ankle may reveal dislocation of the tendons with dorsiflexion and eversion and relocation with inversion and plantarflexion. Chronic dislocation of the tendons may be associated with chronic swelling and a palpable ridge along the posterolateral fibula (the "secondary pseudogroove” of the lateral fibular cortex).

A complete examination of the ankle must always be performed to rule out pathologic conditions such as lateral ankle instability, syndesmotic injuries, and painful os trigonum, as well as fractures at the posterior process of the talus, the lateral process of the talus, the anterior process of the calcaneus, and the fifth metatarsal base.

Differential Diagnoses

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Media Gallery

Lateral view of ankle, with marking of distal fibula, base of fifth metatarsal, and intended incision.
Peroneus brevis degeneration forming ganglion-type mass.
Peroneus longus tendon next to peroneus brevis tendon.
Peroneus brevis above after resection of degenerative mass and peroneus longus below.
Partial repair of peroneal tendon sheath.
Repaired peroneal tendon sheath.
Skin closed over peroneal tendon repair.
Cystic mass (ganglion) on right arising from peroneal tendon (×40).
Ganglion with myxoid degeneration and connective tissue with myxoid material pools with cystic change (×400).
Appearance of normal peroneal tendons on MRI. Axial turbo spin-echo (TSE) T1-weighted image (left) shows peroneus brevis (short arrow). TSE proton density (PD)-weighted fat-suppressed (FS) image (center) shows peroneus longus (arrowhead). Sagittal TSE T2-weighted FS image (right) shows peroneus longus (arrowhead).
Turbo spin-echo (TSE) T1-weighted MRI shows hypointense peroneus quartus tendon (arrow) with muscle belly seen posterior to peroneus longus and peroneus brevis tendon.
Plain lateral radiograph (left) shows os peroneum. Axial CT (right) shows os peroneum adjacent to cuboid bone .
Axial turbo spin echo (TSE) T1-weighted and TSE T2-weighted fat-suppressed (FS) MRI shows split of peroneus brevis tendon into two subtendons.
Coronal short TI inversion recovery (STIR)-sequence MRI shows hyperintense calcaneofibular ligament at fibular attachment (left) and calcaneal attachment (right).
Ganglion arising from peroneal tendon sheath as cause of painful swelling. Left image shows palpable tender swelling behind lateral malleolus; center image shows ganglion as seen intraoperatively; right image is view after excision.

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Author

Rajesh Malhotra, MBBS, MS Professor and Head, Department of Orthopedics, All India Institute of Medical Sciences; Chief, JPN Apex Trauma Centre, India

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Vinod K Panchbhavi, MD, FACS, FAOA, FABOS, FAAOS Professor, Department of Orthopedic Surgery, Chief, Division of Foot and Ankle Surgery, Director, Foot and Ankle Fellowship Program, Department of Orthopedic Surgery, University of Texas Medical Branch School of Medicine

Vinod K Panchbhavi, MD, FACS, FAOA, FABOS, FAAOS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Orthopaedic Trauma Association, Texas Orthopaedic Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Styker.

Additional Contributors

James K DeOrio, MD Professor of Orthopedics, Director, Duke Foot and Ankle Fellowship, Duke University Medical Center, Duke University School of Medicine; Associate Professor, Mayo Clinic College of Medicine; Clinical Assistant Professor, F Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences

James K DeOrio, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Foot and Ankle Society, Association of Graduates, United States Air Force Academy, Doctors Mayo Society, Mayo Clinic Alumni Association, Society of Air Force Clinical Surgeons, Society of Military Orthopaedic Surgeons

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Exactech; Treace Medical; Additive; Mirus; Crossroads Orthopedics<br/>Serve(d) as a speaker or a member of a speakers bureau for: Exactech; Treace Medical; Additive; Mirus; WoultersKluwer; Crossroads Orthopedics<br/>Received income in an amount equal to or greater than $250 from: Exactech; Treace Medical; Additive; Mirus; WoultersKluwer; Crossroads Orthopedics.

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, Florida Medical Association

Disclosure: Nothing to disclose.

Peroneal Tendon Pathology Clinical Presentation

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