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The Basic Anatomy & Pathology Of The Peroneal Tendon
The Basic Anatomy
Within the foot is present a pair of peroneal tendons that run side by side at the rear of the outer ankle bone. One of the tendons is attached to the outer part of the midfoot while the other runs within the lower foot surface and is attached near the inside of the arch.
The primary function of the peroneal tendons is to provide stability to the foot and ankle while protecting them from sprains.
The Basic Pathology
Peroneal tendon partial or complete dislocations are relatively uncommon and often misdiagnosed. Acute dislocations often go unrecognized and misdiagnosed as ankle sprains, and lead to chronic instability. Most acute conditions are sports-related injuries stemming from high impact sports such as soccer, football, basketball, running and skiing. Violent traumas such as car accidents and falls from a height are usually associated with fractures of the fibula, talus and calcaneus. Induced subluxing peroneal tendon injuries can result from poorly performed former surgery as well.
Peroneal tendon pathology can range from simple longitudinal tears of one unit to significant compromise of one or both units, to complete rupture. Treatment techniques may differ based on the degree of tendon damage and the personal decision of the surgeon relative to their views regarding tendon augmentation.
The Underlying Causes Of Peroneal Tendon Injuries
Peroneal tendon injuries may be acute or chronic in nature. They most commonly occur in individuals who are involved in the following factors:
- High Impact Sporting Activities
- Repetitive & Continuous Ankle Motion
- Higher-than-normal Foot Arch
- Acute Wear & Tear Process
Basic Types Of Peroneal Tendon Injuries
Peroneal tendon injuries have been classified into 4 major types:
- Tendonitis which is an inflammation of one or both tendons, caused by activities involving repetitive or overuse of the tendon, or trauma (such as an ankle sprain)
- Acute Tearswhich are caused by repetitive activity or trauma
- Degenerative Tears (Tendinosis)which are caused usually due to overuse and occur over long periods of time. In these tears, the tendon acts like taffy that has been overstretched until it becomes thin and eventually frays. Having high arches also puts you at risk for developing a degenerative tear.
- Subluxationwhich indicates that one or both tendons have slipped out of their normal position. Subluxation may be congenital with a variation in the shape of the bone or muscle, or it occurs following trauma, such as an ankle sprain. Damage or injury to the tissues that stabilize the tendons (retinaculum) can lead to chronic tendon subluxation.
Grading Of The Peroneal Tendon Injury
We can grade peroneal tendon injuries as follows:
- Grade I: The retinaculum is elevated from the lateral malleolus with the tendons lying between the bone and periosteum
- Grade II: The fibrocartilaginous ridge is elevated with the retinaculum attached and the tendons are displaced beneath the ridge
- Grade III: A thin cortical fragment is avulsed from the fibula with the tendons displaced beneath the fibular fragment
- Grade IV: The retinaculum is avulsed or ruptured from the posterior attachment
The Associated Signs & Indications
All types of peroneal tendon injuries present with their own set of symptoms, listed as follows:
- Warm To The Touch
- Instability Due To The Weakness Of The Foot & Ankle
Degenerative Tears (Tendinosis)
- Sporadic Pain On The Lateral Side Of The Ankle
- Instability In The Ankle Due To Weakness
- An Increase In The Height Of The Arch
- Sporadic Pain At The Rear Of The Lateral Ankle Bone
- A Snapping Feeling Of The Tendon Around The Ankle Bone
- Ankle Instability Due To Weakness
The Diagnostic Measures
Since peroneal tendon injuries are sometimes misdiagnosed and may worsen without proper treatment, prompt evaluation by a foot and ankle specialist is advised. To diagnose a peroneal tendon injury, the specialist physician would:
- Examine the foot and evaluate the extent of pain, instability, swelling, warmth and weakness on the outer (lateral) side of the ankle
- Advice an X-ray or MRI to fully evaluate the injury
- Look for signs of an ankle sprain and other related injuries that may accompany a peroneal tendon injury
The Treatment Methodologies
The Nonsurgical Treatment
- Immobilization using a cast or splint to keep the foot and ankle from moving and allow the injury to heal
- Medications taken either oral or injected in the form of anti-inflammatory drugs that help relieve pain and inflammation
- Physiotherapy with the help of icepacks, heat or ultrasound therapy to reduce swelling and pain.
- Physical Workout can be added as symptoms improve, to strengthen the muscles and improve range of motion and balance
- Bracing by the surgeon for a short while or during activities requiring repetitive ankle motion
The Surgical Treatment
In some cases, surgery may be required to repair the torn tendon or tendons and other supporting structures of the foot. The foot and ankle surgeon will determine the most appropriate procedure based on the patient’s condition and lifestyle. In the postsurgical phase, physical therapy plays an important part in the rehabilitation process. The surgical procedure is carried out as follows:
- Incision placement for the approach for the peroneal retinacular repair is done.
- Dissection is carried down to expose the superior peroneal retinaculum and peroneal tendon sheath.
- The peroneal tendons are manipulated back into their correct anatomical position posterior to the fibula using a blunt instrument.
- The peroneal tendons are maintained behind the fibular. The over-and-over suture technique begins lateral and posterior, piercing through the distended peroneal retinaculum and sheath, and progressing anterior.
- Approximately 5 to 6 over-and-over sutures are performed and left untied until all have been placed and the final peroneal tendon position has been assessed.
- All independent suture ends are then tied down progressively, under sufficient tension, from superior to inferior to ensure maintenance of reduction.
- The ankle is then plantar-flexed and dorsi-flexed, and the repair is critically inspected for stability and sufficiency.
The approximate healing time is estimated at 16 to 18 weeks, with full weight-bearing in regular footwear. Progressive return to impact activities, agility and proprioception is usually observed.