Peroneal Tendon Dislocation/Subluxation
Orlando V. Gonzalez
Jeffrey Rosenberg
BasicsDescription
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The peroneus longus and brevis tendons pass through a single tendon sheath in the fibular groove in the posterior fibula. They are fixed in place by the superior peroneal retinaculum.
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The peroneals' primary actions are plantar flexion, foot eversion, and to provide dynamic lateral stability to the lateral ankle.
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Elevation of the posterior periosteal attachment of the superior peroneal retinaculum off the fibula allows the peroneal brevis tendon to sublux over the posterior ridge of the fibula.
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Injury occurs from a forceful contraction of the peroneal muscles, usually with the ankle in forced plantarflexion with inversion.
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Subluxation can be a chronic overuse injury.
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Subluxation of the tendon is temporary and quickly reduced, but a dislocated tendon remains permanently out of the posterior fibular groove.
Epidemiology
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Generally a rare injury in most sports
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Nontraumatic
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Usually occurs with quick stopping or cutting movement
Risk Factors
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Field sports with tackling or regular body contact
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Ice skating with excessive pushing off during jumps
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Gymnastics and ballet with excessive plantarflexion and plié
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Generalized ligamentous laxity
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Gait abnormalities such as excessive eversion
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Severe pes planus or hindfoot deviation (valgus or varus)
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Equinus or restricted ankle dorsiflexion
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Anterolateral ankle impingement, particularly immediately following acute ankle sprain, which can lead to peroneal overcompensation
Etiology
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A sudden dynamic reflexive contraction during foot inversion with ankle dorsiflexed
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A forced dorsiflexion on the everted foot, often occurring when being tackled
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Classically occurs in athletes participating in sports such as skiing, football, ice skating, soccer, basketball, rugby, and gymnastics
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Nontraumatic subluxations associated with anatomically shallow, flat, or absent retrofibular groove, neuromuscular disease, calcaneovalgus foot type, chronic lateral ankle instability
Commonly Associated Conditions
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Neuromuscular diseases such as cerebral palsy
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Generalized ligamentous laxity
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Congenital absence of superior peroneal retinaculum
Diagnosis-
Any trauma to the ankle while falling to ground, tripping, or being tackled
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Athlete of above-mentioned sports with lateral, painful snapping of the ankle
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Recurrent ankle instability or snapping after prior ankle injury
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Ankle instability on uneven ground
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Chronic posterolateral ankle pain in setting of prior ankle injury
History
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Snapping or popping at time of injury over lateral ankle (1)
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Intensely painful posterior or inferior to the lateral malleolus and above the joint line
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Snapping and/or popping sensation with ambulation
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Unable to continue play or bear weight
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In recurrent dislocations, snapping or clicking in distal fibula
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Often misdiagnosed as ankle sprain
Physical Exam
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Acute injury:
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Very difficult to distinguish from ankle sprain especially, because of the swelling and pain (2)
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Ecchymosis, swelling, and pain posterior and/or distal to lateral malleolus and along path of tendons (vs tenderness over the anterior talofibular ligament in ankle sprain)
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Locate and palpate the peroneals. These tendons may palpably sublux out of their groove and over the fibula with eversion against resistance on a dorsiflexed ankle.
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Limited dorsiflexion or plantarflexion
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Assess lateral ligament stability: Anterior drawer test and inversion tilt test.
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Pain elicited with active eversion with the foot held in dorsiflexion
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Chronic injury;
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Examiner may be able to reproduce subluxation with dorsiflexion and eversion against resistance.
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Possible tenderness or swelling over the lateral malleolus
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Chronic instability
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Diagnostic Tests & Interpretation
Lab
No laboratory tests
Imaging
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Plain radiographs:
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After acute injury, anteroposterior view of ankle to rule out other bony lesion
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Pathognomonic is a thin rim of avulsed cortical bone from the lateral aspect of the lateral malleolus, best seen on mortise view (15–20 degrees of internal rotation).
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MRI:
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Tearing of the retinaculum, fluid in the peroneal sheath, or a longitudinal tear (split) of the peroneus brevis
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Rules out other ligamentous or cartilage lesions
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Peroneals may switch position within the sheath.
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Diagnostic US: Dynamic real-time imaging of ankle can reveal fluid distending the tendon sheath, tendinopathy, longitudinal peroneal splits, and frank subluxation of peroneal tendon.
Pathological Findings
Findings at time of surgery:
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Tears of superior retinaculum
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Unroofing of retinaculum from lateral fibular edge
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Tendinosis
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Midsubstance tendon tears
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Longitudinal split
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Adhesions of synovial sheath
Differential Diagnosis
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Lateral ankle ligament tear
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Shallow or absent peroneal groove
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Lateral ankle instability
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Varus hindfoot alignment
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Ankle fracture
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Talar osteochondral lesion
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Talofibular ligament injury
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Calcaneofibular ligament injury
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Achilles tendinitis
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Tarsal coalition
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Sural neuritis
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Sinus tarsi syndrome
P.459
Treatment-
Acute treatment:
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Analgesia
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Ice
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NSAIDs
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Crutches to aid with ambulation and prevent need for weight-bearing, which is very painful acutely
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Conservative treatment: 5–6 wks
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Immobilization may relieve symptoms and reduce inflammation.
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RICE (rest, ice, compression and elevation) and NSAIDS
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Ankle bracing may limit the excursion of the foot and may decrease the episodes of painful subluxation.
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Activity modification may reduce the occurrence of subluxation in certain patients if the subluxation is activity-specific.
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Options include non-weight-bearing cast for 5–6 wks with the ankle in midplantar flexion (to relax the tendons), strapping the ankle with lateral crescent- or J-shaped pads, or compression bandages.
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Nonoperative approach: Always should be the initial intervention, although elite and high-level athletes likely will need surgical intervention to return to preinjury level of athletics.
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Algorithm for nonsurgical treatment is not well established; 50% failure of nonsurgical treatment with persistent pain, instability, and redislocation.
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No studies to compare surgical vs nonsurgical treatment in any population
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Repeat dislocations and chronic pain are indications for surgical intervention.
Additional Treatment
Additional Therapies
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Surgery should be considered in all cases secondary to the high incidence of recurrence with nonoperative treatment.
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Repeated dislocations cause bone changes that further exacerbate recurrent instability.
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Surgery allows a quick return to normal lifestyle and athletics with no instability.
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Surgical procedure has very low morbidity.
Surgery/Other Procedures
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Surgery should be considered in all high-level athletes with acute injury and is the only appropriate management in chronic dislocations.
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Many techniques exist; all attach the superior peroneal retinaculum and the periosteum back to the bone when repositioning the peroneal tendon. Tendon dèbridement and repair of longitudinal split tears also are accomplished (3,4).
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Retromalleolar groove impaction with reattachment of peroneal retinaculum provided complete return to activity by 1 yr in a case series of 23 active athletes (average age 34 yrs) with acute peroneal subluxation. No functional differences were noted between the ankles, and there were no further subluxation episodes (5).
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Postoperative below-the-knee cast in relaxed plantar flexion and slight eversion for 6 wks; physical therapy once cast is removed
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No studies comparing differing surgical techniques
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10–20% failure rate of surgical repair may require further salvage procedure.
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Can take 6–9 mos to return to preinjury level of activity
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Many now questioning need for deepening of fibular groove because the fibrocartilagous periosteal cushion is now thought be the attachment of the retinaculum.
Ongoing Care-
Some chronic cases are minimally symptomatic and do not significantly alter athletic performance.
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J-shaped pad with compression and lateral heel wedge occasionally useful
Follow-Up Recommendations
Immediate referral for surgical evaluation is appropriate for most athletes.
Prognosis
Full return to high-level athletics may not be possible with conservative treatment, but operative repair has 10–20% failure rate.
References
1. Omey ML, Micheli LJ. Foot and ankle problems in the young athlete. Med Sci Sports Exerc. 1999;31:S470–S486.
2. Safran MR, O'Malley D, Fu FH. Peroneal tendon subluxation in athletes: new exam technique, case reports, and review. Med Sci Sports Exerc. 1999;31:S487–S492.
3. Cerrato RA, Myerson MS. Peroneal tendon tears, surgical management and its complications. Foot Ankle Clin. 2009;14:299–312.
4. Oliva F, Del Frate D, Ferran NA, et al. Peroneal tendons subluxation. Sports Med Arthrosc. 2009;17:105–111.
5. Walther M, Morrison R, Mayer B. Retromalleolar groove impaction for the treatment of unstable peroneal tendons. Am J Sports Med. 2008.
Additional Reading
Mason RB, Henderson JP. Traumatic peroneal tendon instability. Am J Sports Med. 1996;24:652–658.
Philbin TM, Landis GS, Smith B. Peroneal tendon injuries. J Am Acad Orthop Surg. 2009;17:306–317.
CodesICD9
845.09 Other ankle sprain
Clinical Pearls
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High recurrence rate of 50–75%.
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Nonoperative treatment can take 2–3 mos to return to play; 6–9 mos after surgical repair.
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Conservative treatment can be attempted but patient still may not return during same season. Immediate surgical repair will have a longer recovery but less likelihood of recurrent subluxations and chronic pain.
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Snapping over lateral ankle with plantar flexion or with dorsiflexion and eversion at time of initial on the field evaluation guides to peroneal subluxation as cause of injury.
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Conservatively treat with RICE and non-weight-bearing for in-season athlete; ankle taping with J-shaped pad may allow for eventual return to play prior to surgical repair.
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Surgical repair is indicated after the season or if conservative treatment fails.