Qué está sintiendo¶
Los tendones peroneos son dos cordones que discurren detrás del hueso externo del tobillo, justo por encima y por debajo de esa protuberancia ósea que puede sentir en el lateral de su tobillo. Cuando uno de ellos se irrita o se desgarra, el dolor se localiza precisamente allí, a lo largo del borde externo del tobillo y del retropié. Con frecuencia aparece después de que el tobillo se invierta hacia adentro, aunque también puede desarrollarse lentamente con el tiempo.
Esa zona puede presentar hinchazón y ser sensible al tacto. Empujar con el pie, apoyarse en el borde externo del pie o girar el pie hacia afuera contra resistencia pueden empeorar los síntomas. Caminar sobre terreno irregular, subir escaleras y practicar deportes que requieren movimientos laterales rápidos suelen desencadenar el dolor. Algunas personas notan el dolor más intensamente después de hacer ejercicio o a la mañana siguiente al despertar. El descanso y la reducción de la actividad suelen aliviarlo, hasta que vuelve a aparecer.
Si un tendón se desplaza de su posición normal, es posible sentir o ver un movimiento brusco o un chasquido detrás del hueso del tobillo, a veces acompañado de un dolor agudo. Esto ocurre al girar el tobillo o al mover el pie desde una posición de puntas hacia abajo e inclinadas hacia adentro a una posición de levantamiento hacia arriba y hacia afuera. En algunas personas el tendón se desplaza repetidamente, lo que hace que caminar en pendientes o subir escaleras resulte inseguro.
En caso de desgarro completo del tendón, girar el pie hacia afuera se vuelve débil y difícil. Las actividades cotidianas que implican carga en el lateral del tobillo, como empujar para caminar, subir escaleras o mantenerse de pie sobre una sola pierna para vestirse, pueden resultar complicadas. La hinchazón y la sensibilidad son muy similares a las que se observan en una simple irritación; por eso, al principio los desgarros suelen confundirse con problemas menos graves.
Estos problemas son poco frecuentes y fácilmente se confunden con un simple esguince de tobillo que no mejora. Si el dolor en el lado externo del tobillo persiste a pesar del descanso, merece ser evaluado adecuadamente.
¿Qué está ocurriendo realmente?¶
Los dos tendones situados detrás del maléolo lateral discurren por un surco poco profundo de dicho hueso. Una banda de tejido llamada retináculo los mantiene en ese surco, de forma similar a como un cinturón de seguridad sujeta los cables en su lugar. Al actuar, los tendones se doblan bruscamente alrededor de la punta del hueso, por lo que quedan bajo tensión cada vez que usted empuja con el pie o lo gira.
Varios factores pueden alterar este mecanismo. Si el surco es naturalmente poco profundo, o si hay tejido adicional que reduce el espacio disponible, los tendones quedan sueltos y pueden desplazarse. Cuando el retináculo se desgarra, generalmente durante una torsión en la que el tobillo gira hacia adentro, los tendones se desplazan repetidamente sobre el borde del hueso. Las personas suelen describir una sensación de “pop” o chasquido, seguida de dolor e hinchazón. Cada desplazamiento puede desgastar el tendón; este desgaste suele extenderse longitudinalmente a lo largo del tendón, como si una cuerda se deshilachara hebra por hebra.
El tendón más afectado es el que se inserta en el borde lateral del pie, en parte porque queda comprimido entre el otro tendón y el hueso situado detrás del tobillo. Además, justo detrás del maléolo existe una zona donde estos tendones tienen un aporte sanguíneo escaso por naturaleza; por eso, cualquier lesión en ese punto cicatriza lentamente. Algunas personas nacen con un tendón adicional o con un vientre muscular situado más abajo de lo habitual en el surco, lo cual reduce el espacio disponible y aumenta la tensión sobre los tendones.
Estos problemas suelen ir acompañados de inestabilidad del tobillo. Si los ligamentos laterales se han estirado a causa de un esguince, los tendones deben trabajar más para estabilizar la articulación, quedando en una posición en la que una torsión repentina puede lesionarlos. Por eso el dolor, el chasquido y la debilidad mencionados anteriormente se deben a un mismo proceso: tendones que se desplazan, rozan o se desgastan en un surco que ya no los protege.
Qué podemos hacer al respecto¶
Estudios como la ecografía pueden mostrar si algún tendón se desplaza de su posición al mover el tobillo, mientras que la resonancia magnética permite detectar desgarros longitudinales en el propio tendón.
En casos de irritación acumulada con el tiempo, normalmente empezamos sin recurrir a la cirugía. Esto implica modificar las actividades que provocan el dolor, usar una tobillera con cordones y trabajar con un fisioterapeuta para calmar el tendón y recuperar la fuerza. Cuando la irritación se concentra en una zona pequeña e inflamada, puede ser recomendable mantener el tendón en reposo mediante un yeso durante un tiempo, acompañado del uso de antiinflamatorios por vía oral. Es aconsejable darle tiempo a estas medidas antes de concluir que no han surtido efecto.
Si estos pasos no logran mejorar la situación, la cirugía podría ser el siguiente paso. La intervención dependerá del estado del tendón: un tendón deshilachado o parcialmente desgarrado puede ser limpiado y reparado; tratar a tiempo un desgarro longitudinal reduce el riesgo de que se convierta en una rotura total. Un tendón que se ha roto por completo, o que está tan deteriorado que no admite reparación, puede ser extirpado y el tendón restante reorientado para asumir su función. Si ambos tendones están muy deteriorados, una opción es utilizar tejido tendinoso de donante para reconstruirlos. Cuando los tendones tienden a salirse del surco situado detrás del hueso del tobillo, la cirugía puede reparar o reconstruir la estructura que los mantiene en su lugar, así como profundizar dicho surco para que los tendones queden bien fijos. La operación tiene su propia página informativa; antes de tomar cualquier decisión, analizaremos con usted qué opción se adapta mejor a su tobillo.
Qué esperar¶
Estos problemas suelen persistir en lugar de desaparecer por sí solos. El descanso y reducir la actividad pueden aliviar cada episodio de dolor, pero este suele reaparecer al volver a practicar deporte o al caminar sobre terrenos irregulares. Si un tendón se sale repetidamente de su posición, el fenómeno de “clic” o desplazamiento continúa hasta que se trata. Si se deja sin intervención, la irritación y el desgaste del tendón pueden empeorar gradualmente; por eso es fundamental obtener un diagnóstico correcto lo antes posible.
Con tratamiento, la mayoría de las personas experimentan una mejora constante. En casos de irritación que responden a órtesis y fisioterapia, se espera primero recuperar la capacidad de caminar y realizar tareas cotidianas; posteriormente, al fortalecerse el tendón, se podrá volver al deporte. Para tendones que “clican” o se desplazan, la cirugía destinada a reparar o reconstruir la estructura que los mantiene en su sitio presenta una baja tasa de recurrencia; incluso quienes se sometieron a ella hace años conservan un tobillo estable y sin dolor. La cirugía artroscópica, que emplea una pequeña cámara dentro de la vaina tendinosa, es menos invasiva y puede acelerar el regreso al deporte; sin embargo, requiere más tiempo quirúrgico y mayor pericia del cirujano.
Es importante ser realistas respecto a los límites del tratamiento. Aproximadamente uno de cada cuatro pacientes tratados por inestabilidad crónica del tobillo vuelve a sufrir esguinces. Cerca de la mitad no recupera su nivel deportivo previo; esto ocurre con mayor frecuencia en atletas y en personas con lesión simultánea del ligamento lateral del tobillo. Conocer estos datos antes del tratamiento ayuda a fijar objetivos realistas en el trabajo y el deporte; además, el cirujano podrá ofrecerle una estimación más precisa de su cronograma de recuperación una vez analizadas las imágenes diagnósticas.
Si una rotura tendinosa se deja sin tratar, el daño suele avanzar; además, la mayoría de quienes presentan rotura tendinosa también tienen lesiones dentro de la articulación del tobillo que requieren atención por separado. La conclusión es clara: el dolor en la zona externa del tobillo que no cede merece una evaluación exhaustiva, pues cuanto antes se identifique la causa, más opciones de tratamiento tendrá usted.
¿Cuándo consultar a un especialista?¶
Acuda a su médico de cabecera si el dolor en el borde externo del tobillo reaparece una y otra vez a pesar del reposo, o si continúa después de un esguince que no mejora. Solicite una evaluación especializada si el dolor en esa zona no disminuye, ya que un desgarro tendinoso en ese lugar es fácil de pasar por alto y a menudo se confunde con un simple esguince. Busque atención médica cuanto antes si al intentar girar el pie hacia afuera contra resistencia el tendón se desplaza o “salta” de su posición, o si esa acción se ha vuelto débil. Estos síntomas indican que el tendón está desplazado, desgastado o completamente roto; cuanto antes se identifique la causa, más opciones de tratamiento tendrá usted.
Evidence & references
This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.
Anatomy & Pathophysiology¶
Bony and Soft Tissue Anatomy¶
- The peroneus longus (PL) and peroneus brevis (PB) tendons are innervated by the superficial peroneal nerve (S1) [4].
- The peroneus longus and peroneus brevis originate from the fibula and interosseous membrane [4].
- The peroneal tendons run in a sulcus called the peroneal groove formed posteriorly in the fibula [4].
- The peroneal groove is further stabilized by a fibrocartilaginous rim and the superior peroneal retinaculum (SPR) [4].
- Within the peroneal groove, the PB tendon is anterior and medial to the PL tendon [4].
- Both peroneal tendons curve anteriorly around the tip of the fibula [4].
- The peroneal tubercle separates the PL and PB tendons at the level of the calcaneus [4].
- The PB tendon runs distally to insert onto the tuberosity of the fifth metatarsal [4].
- The PL tendon makes a 90° turn medially at the cuboid groove before inserting into the base of the first metatarsal and medial cuneiform [4].
- The peroneus brevis originates from the distal half of the lateral fibula [14].
- The peroneus longus originates more proximally on the lateral fibula [14].
- The peroneus longus inserts into the medial cuneiform and the first metatarsal base [14].
- The SPR runs from the posterolateral ridge of the fibula to the lateral calcaneus [14].
- The SPR functions as the primary restraint to peroneal tendon subluxation within the retromalleolar sulcus [14].
- The retromalleolar sulcus is deepened by a fibrocartilaginous rim which provides moderate inherent stability to the tendons [14].
- Within the retromalleolar sulcus, the peroneus longus is found posterior to the peroneus brevis [14].
- The low-lying muscle belly of the peroneus brevis typically terminates approximately 3 cm from the tip of the fibula [14].
Vascular Supply and Watershed Zones¶
- A vascular watershed region just posterior to the fibula is the most common area of peroneal tendon injury [4].
- Compression from the PL on the PB is implicated in the vascular watershed region posterior to the fibula [4].
Anatomic Variations¶
- A low-lying PB muscle belly is an anatomic variation implicated in tendon tears and instability [4].
- The presence of a peroneus quartus muscle is an anatomic variation implicated in tendon tears and instability [4].
- The peroneus quartus muscle is present in 13% to 22% of individuals [4].
- The peroneus quartus muscle may be seen in the fibular groove and contributes to crowding of the fibro-osseous tunnel [4].
Pathophysiology of Injury¶
- Peroneal tendon injuries occur when there is rapid dorsiflexion of the inverted foot [14].
- Anatomic studies demonstrate that peroneal tendons are perched along the distal fibula at 15° to 25° of plantar flexion, making them susceptible to inversion injury at this position [14].
- Rapid dorsiflexion of the inverted foot causes reflexive contraction of the peroneus brevis and longus [14].
- Reflexive contraction of the peroneal tendons can lead to frank tendon injury or injury to the superior peroneal retinaculum [14].
- Chronic symptoms develop when peroneal tendons are not anatomically located in their retromalleolar position and subsequently subluxate abnormally with ankle motion [14].
- Disruption of the SPR leads to repeated subluxation of the peroneal tendons [14].
- Repeated subluxation often leads to longitudinal tears, most frequently in the peroneus brevis where it runs within the fibular groove [14].
- Acute tendinitis may result from overuse, predisposition from a varus hindfoot, or stenosis within the peroneal tunnel [4].
- Stenosis within the peroneal tunnel can be caused by a peroneus quartus muscle or a low-lying PB muscle belly [4].
- Tendon tears may result from inversion injuries or injury causing tendon subluxation or dislocation [4].
- Most peroneal tendon tears occur in the PB tendon at the level of the fibular groove [4].
- Tears of the PL tendon are less common and usually occur at the peroneal tubercle [4].
- PB and PL tendon tears are often longitudinal and typically seen in chronic situations [4].
- Compression of the PB between the PL tendon and the posterior fibula is an etiologic factor for tendon tears [4].
- Subluxation or dislocation of the tendons is an etiologic factor for tendon tears [4].
- Diminished blood supply in the watershed region is an etiologic factor for tendon tears [4].
- An acute change in direction around the fibula is an etiologic factor for tendon tears [4].
- Ankle instability or varus heel is an etiologic factor for tendon tears [4].
- A shallow peroneal groove and overcrowding of the fibular groove are predisposing factors for dislocation or subluxation [4].
- Dislocation or subluxation occurs during an inversion injury to a dorsiflexed ankle with rapid reflexive contraction of the PL and PB tendons [4].
- Dislocation or subluxation results in a disruption of the SPR or fibrocartilage ridge [4].
- Acute longitudinal tendon tears may occur in the setting of dislocation or subluxation [4].
- Patients with dislocation or subluxation describe a “pop” or snapping sensation, followed by pain and swelling [4].
- Peroneal tendon injuries at the level of the ankle should be differentiated from Iselin disease, which is a traction apophysitis seen in the pediatric population [14].
- Iselin disease results from repetitive traction of the peroneus brevis at its attachment at the base of the fifth metatarsal [14].
- Symptomatic os vesalianum is a rare accessory bone adjacent to the fifth metatarsal in the substance of the peroneus brevis tendon that is included in the differential diagnosis of lateral fifth metatarsal pain in the pediatric population [14].
SPR Injury Classification¶
- Grade I SPR injuries are characterized by partial avulsion of the SPR from the distal fibula, allowing subluxation of the tendons [14].
- Grade II SPR injuries involve separation of the SPR from the distal fibrocartilaginous rim, causing the tendons to pass between the SPR and the rim [14].
- Grade III SPR injuries are characterized by a frank cortical avulsion of the SPR from the distal fibula, forming a classic rim fracture [14].
- Grade IV SPR injuries are characterized by SPR failure at the calcaneus instead of the fibula [14].
Classification¶
- Peroneal tendon abnormalities are identified on routine magnetic resonance imaging of the foot and ankle [1].
- A low-lying peroneus brevis muscle belly is a potential source of tendon subluxation in patients with peroneal tendon pathologic features [1].
- Peroneus longus tears are associated with pathology of the os peroneum [1].
- Peroneal tendon dislocation can coexist with medial and lateral ligamentous laxity in the ankle joint [1].
- Peroneal tendon tears can be concomitant, involving both the peroneus longus and brevis tendons [1].
- Peroneal tendon tears can be classified as mid-substance defects [1].
- Peroneal tendon tears can be classified as irreparable [1].
- Peroneal tendon instability can be managed via repair of the superior peroneal retinaculum [1].
- Recurrent dislocation of the peroneal tendons is a distinct clinical presentation from primary dislocation [1].
- Peroneal tendon tears can be treated with debridement and primary repair [1].
- Peroneal tendon tears can be treated with allograft reconstruction [1].
- Peroneal tendon tears can be treated with tenodesis [1].
- Peroneal tendon tears can be treated with flexor tendon transfer [1].
- Peroneal tendon tears can be treated with sliding fibular graft repair [1].
- Peroneal tendon tears can be treated with staged reconstruction using a Hunter rod [1].
- Peroneal tendon tears can be treated with tendoscopic repair [1].
- Peroneal tendon tears can be treated with peroneal tendoscopy [1].
- Peroneal tendon tears can be treated with retinaculum repair with or without fibular groove deepening [1].
- Peroneal tendon tears can be treated with augmentation using an acellular dermal matrix allograft [1].
- Peroneal tendon tears can be treated with lateral transfer of the flexor hallucis longus or flexor digitorum longus [1].
- Peroneal tendon tears can be treated with single-stage flexor tendon transfer [1].
- Peroneal tendon tears can be treated with allograft reconstruction versus tenodesis in a cadaveric model [1].
- Peroneal tendon tears can be treated with mid-substance defect augmentation [1].
- Peroneal tendon tears can be treated with sliding fibular graft repair for recurrent subluxation [1].
- Peroneal tendon tears can be treated with treatment of coexisting medial and lateral ligamentous laxity [1].
- Peroneal tendon tears can be treated with long-term results of debridement and primary repair [1].
- Peroneal tendon tears can be treated with outcome after retinaculum repair with and without fibular groove deepening [1].
- Peroneal tendon tears can be treated with comparison of outcome after retinaculum repair with and without fibular groove deepening [1].
- Peroneal tendon tears can be treated with long-term results of debridement and primary repair of peroneal tendon tears [1].
- Peroneal tendon tears can be treated with single-stage flexor tendon transfer for severe concomitant peroneus longus and brevis tendon tears [1].
- Peroneal tendon tears can be treated with prevalence and role of a low-lying peroneus brevis muscle belly [1].
- Peroneal tendon tears can be treated with tendoscopic repair of the superior peroneal retinaculum via 2 portals [1].
- Peroneal tendon tears can be treated with allograft reconstruction of peroneal tendons: operative technique and clinical outcomes [1].
- Peroneal tendon tears can be treated with peroneal tendon abnormalities on routine magnetic resonance imaging [1].
- Peroneal tendon tears can be treated with effectiveness of allograft reconstruction vs tenodesis for irreparable peroneus brevis tears [1].
- Peroneal tendon tears can be treated with use of a Hunter rod for staged reconstruction of peroneal tendons [1].
- Peroneal tendon tears can be treated with mid-substance peroneal tendon defects augmented with an acellular dermal matrix allograft [1].
- Peroneal tendon tears can be treated with results of treatment of posterior ankle impingement syndrome and flexor hallucis longus tendinopathy in dancers [1].
- Peroneal tendon tears can be treated with outcome of lateral transfer of FHL or FDL for concomitant peroneal tendon tears [1].
- Peroneal tendon tears can be treated with patient-reported outcomes and return to activity after peroneus brevis repair [1].
- Peroneal tendon tears can be treated with peroneus longus tears associated with pathology of the os peroneum [1].
- Peroneal tendon tears can be treated with endoscopic repair of posterior ankle impingement syndrome due to os trigonum in soccer players [1].
- Peroneal tendon tears can be treated with ankle injuries in dancers [1].
- Peroneal tendon tears can be treated with sliding fibular graft repair for the treatment of recurrent peroneal subluxation [1].
- Peroneal tendon tears can be treated with treatment of peroneal tendon dislocation and coexisting medial and lateral ligamentous laxity in the ankle joint [1].
Clinical Presentation¶
Acute Tendinitis¶
- Patients with acute peroneal tendinitis report swelling and pain in the lateral hindfoot or ankle [4].
- Physical examination for acute peroneal tendinitis reveals swelling and pain with palpation [4].
- Physical examination for acute peroneal tendinitis may reveal reduced strength [4].
- MRI evaluation of acute peroneal tendinitis reveals fluid within the peroneal tendon sheath [4].
Tendon Tears or Ruptures¶
- Symptoms of peroneal tendon tears are similar to those of acute tendinitis [4].
- Physical examination results for peroneal tendon tears are similar to those of acute tendinitis [4].
- Subluxation or dislocation associated with peroneal tendon tears may be provoked during physical examination with eversion against resistance [4].
- MRI evaluation of peroneal tendon tears reveals longitudinal tears in the tendon [4].
- MRI findings of longitudinal peroneal tendon tears can be confused with a peroneus quartus muscle [4].
- Patients with complete peroneal tendon rupture present with severe limitation of eversion strength [4].
Dislocation or Subluxation¶
- Patients with peroneal tendon dislocation or subluxation describe a “pop” or snapping sensation [4].
- Patients with peroneal tendon dislocation or subluxation experience pain and swelling following the initial sensation [4].
- Physical examination for peroneal tendon dislocation reveals variable pain and swelling depending on the acuteness of the injury [4].
- Dislocation or subluxation of the peroneal tendons may be elicited during physical examination with ankle rotation [4].
- Dislocation or subluxation of the peroneal tendons may be elicited during physical examination by forcing the foot from a position of inversion and plantar flexion to a position of eversion and dorsiflexion [4].
- Radiographs for peroneal tendon dislocation may reveal an avulsion fracture of the distal fibula at the insertion of the superior peroneal retinaculum [4].
Investigations¶
Imaging¶
- Plain radiographs may demonstrate a rim fracture of the lateral aspect of the distal fibula [9].
- Plain radiographs may demonstrate a retraction or fracture of the os peroneum in cases of acute rupture of the peroneus longus tendon [9].
- MRI may demonstrate displacement of peroneal tendons anterolateral to the retrofibular region [9].
- MRI reveals fluid within the peroneal tendon sheath in acute tendinitis [4].
- MRI reveals longitudinal tears in the tendon, but these can be confused with a peroneus quartus muscle [4].
- False-positive results showing longitudinal tears are common with MRI [9].
- Radiographs are usually negative for peroneal tendon subluxation, though a "fleck" of bone may be seen off the posterior distal fibula with a grade 3 injury [11].
- MRI can be used to identify injury to the superior peroneal retinaculum [11].
- MRI can be used to identify anomalous structures such as the peroneus quartus or a low-lying peroneal brevis muscle belly [11].
- Kinematic MRI of the ankle moving from dorsiflexion to plantar flexion has been suggested to be superior to static imaging because the pathologic process is position dependent [11].
- Ultrasonography has been reported to be effective for dynamically evaluating peroneal tendon subluxation [11].
- Ultrasound is useful as a dynamic tool to evaluate subluxation/dislocation [9].
- Dynamic ultrasound imaging has been used for intrasheath instability of peroneal tendons [3].
- Computed tomography assessment has been used for peroneal tendon displacement and posteromedial structure entrapment in pilon fractures [3].
- CT analysis has been used for peroneal tendon injuries [2].
- Ultrasound diagnosis of peroneal tendon tears has been correlated with surgical findings [2].
- Cadaver correlation of peroneal tendon changes with magnetic resonance imaging has been performed [2].
Physical Examination¶
- Physical examination reveals swelling and pain with palpation in acute tendinitis [4].
- Physical examination may reveal reduced strength in acute tendinitis [4].
- Subluxation or dislocation may be provoked during examination with eversion against resistance [4].
- Dislocation or subluxation may be elicited with ankle rotation or with forcing the foot from a position of inversion and plantar flexion to a position of eversion and dorsiflexion [4].
- Patients may have evidence of apprehension with resistant eversion, which may be relieved with manual stabilization of the peroneal tendons [9].
- Assessment for intratendinous subluxation is needed during physical examination [9].
- Tenderness in peroneal tendon subluxation is proximal to the tip of the fibula, whereas in lateral ankle ligament sprain it is distal to the tip of the fibula [11].
- Swelling in peroneal tendon subluxation is posterolateral, whereas in lateral ankle ligament sprain it is anteroinferior [11].
- The history for peroneal tendon subluxation includes snapping, whereas for lateral ankle ligament sprain it includes giving way [11].
- Peroneal tendon subluxation is worse with circumduction, whereas lateral ankle ligament sprain is not [11].
- Peroneal tendon subluxation is not worse on flexion-inversion, whereas lateral ankle ligament sprain is [11].
Treatment¶
Non-Operative¶
- Chronic peroneal tendinosis or tenosynovitis is initially treated with activity modification, NSAIDs, a lace-up ankle brace, and physical therapy [9].
- Prolonged immobilization in a cast and oral anti-inflammatory medication are recommended for localized inflammation and tendinitis at the peroneus longus tendon associated with the os peroneum [16].
- Ultrasound is useful as a dynamic tool to evaluate peroneal tendon subluxation or dislocation [9].
Operative: Tendon Repair and Debridement¶
- Tenosynovectomy, débridement, and repair of degenerative tears are indicated for peroneal tendon pathology, usually involving the peroneus brevis [9].
- Early treatment of longitudinal splits reduces the risk of progression to a full tear [9].
- Excision and tenodesis are required when there is a complete rupture or a severely degenerative tendon (>50%) that prohibits repair [9].
- Debridement of the peroneus longus tendon, removal of the os peroneum, and tenodesis of the peroneus longus to the peroneus brevis are indicated for chronic reproducible tenderness in the plantar-lateral aspect of the lateral midfoot despite conservative treatment [16].
- If the cuboid tunnel is constricted during os peroneum removal, it may be enlarged with a small osteotome and rasp [16].
- Postoperative care for os peroneum removal involves a non-weight-bearing cast for 4 weeks, followed by protected weight bearing in a walking boot [16].
- Formal physical therapy is started at 8 weeks after surgery for os peroneum removal [16].
Operative: Subluxation and Dislocation¶
- Acute peroneal subluxation or dislocation requires repair or reconstruction of the superior peroneal retinaculum (SPR) [9].
- Chronic peroneal subluxation or dislocation requires repair or reconstruction of the SPR and fibular groove deepening [9].
- Fibular groove deepening is indicated if there is a shallow fibular groove [9].
- Peroneal retinacular repair is indicated if there is evidence of tendon subluxation [9].
- Assessment for intratendinous subluxation is needed during evaluation for peroneal tendon disorders [9].
- Patients may exhibit apprehension with resistant eversion, which may be relieved with manual stabilization of the peroneal tendons [9].
Operative: Reconstruction and Transfer¶
- More than 50% degeneration of both the peroneus longus and brevis requires excision of both tendons [9].
- Good results are reported with lateral transfer of the flexor hallucis longus (FHL) or flexor digitorum longus (FDL) for concomitant peroneal tendon tears [9].
- Allograft reconstruction may be used if peroneal muscles demonstrate adequate excursion at the time of surgery with minimal atrophic change to the muscle [9].
- In younger, more active patient populations, allograft reconstruction can be considered for peroneal tendon disorders [9].
- If there is no viability of the proximal musculature, a tendon transfer of the FHL is a salvage operation that can restore some active function without expectation of normal function [9].
- Tendon transfer is typically directed to the fifth metatarsal [9].
Operative: Adjunctive Procedures¶
- A Dwyer osteotomy (lateral closed-wedge osteotomy of the calcaneus) is used for hindfoot varus to limit the risk of recurrent tears and continued pain [9].
Complications¶
- Recurrent dislocation of the peroneal tendons is a recognized complication treated with retinaculum repair, with or without fibular groove deepening [1].
- Peroneal tendon tears may require debridement and primary repair [1].
- Severe concomitant peroneus longus and brevis tendon tears may be treated with single-stage flexor tendon transfer [1].
- Peroneal tendon instability can be treated with tendoscopic repair of the superior peroneal retinaculum via 2 portals [1].
- Allograft reconstruction is an operative option for peroneal tendons [1].
- Allograft reconstruction and tenodesis are compared as treatments for irreparable peroneus brevis tears [1].
- Staged reconstruction of peroneal tendons can utilize a Hunter rod [1].
- Mid-substance peroneal tendon defects can be augmented with an acellular dermal matrix allograft [1].
- Lateral transfer of FHL or FDL is an option for concomitant peroneal tendon tears [1].
- Sliding fibular graft repair is a treatment for recurrent peroneal subluxation [1].
References¶
[1] Campbell S Operative Orthopaedics 4 Volume Set. MULTIPLE Z-PLASTY RELEASE OF A CONGENITAL RING > PERONEAL TENDONS.
[2] Campbell S Operative Orthopaedics 4 Volume Set. MULTIPLE Z-PLASTY RELEASE OF A CONGENITAL RING > DISORDERS OF TENDONS > PERONEAL TENDONS.
[3] Campbell S Operative Orthopaedics 4 Volume Set. ACHILLES TENDON AUGMENTATION OF SUPERIOR PERONEAL RETINACULUM REPAIR > DISPLACEMENT OF PERONEAL TENDONS.
[4] Aaos Comprehensive Orthopaedic Review 3. Tendon Disorders of the Foot and Ankle > III. Disorders of the Peroneal Tendons.
[9] Miller S Review Of Orthopaedics. PERONEAL TENDONS.
[11] Campbell S Operative Orthopaedics 4 Volume Set. SUTURE ANCHOR REPAIR OF PATELLAR TENDON RUPTURE > REPAIR OF THE SUPERIOR PERONEAL RETINACULUM > FIBULAR GROOVE DEEPENING WITH TISSUE TRANSFER (PERIOSTEAL FLAP) FOR RECURRENT PERONEAL TENDON DISLOCATION.
[14] Orthopaedic Knowledge Update. Ankle Injuries* > Peroneal Tendon Injuries.
[16] Campbell S Operative Orthopaedics 4 Volume Set. MULTIPLE Z-PLASTY RELEASE OF A CONGENITAL RING > DISTAL PERONEAL LONGUS TENDINITIS ASSOCIATED WITH OS PERONEUM: THE PAINFUL OS PERONEUM SYNDROME.