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Ankle Specialist

Examining the Relationship Between Pathologies of the Peroneal, Achilles, and Posterior Tibial
Tendons: An MRI Review in an Asymptomatic Lateral Ankle Population
Melissa M. Galli, Nicole M. Protzman, Eiran M. Mandelker, Amit D. Malhotra, Garrett M. Wobst, Edward Schwartz and
Stephen A. Brigido
Foot Ankle Spec 2014 7: 277 originally published online 7 July 2014
DOI: 10.1177/1938640014537298
The online version of this article can be found at:
http://fas.sagepub.com/content/7/4/277

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research-articleXXXX

FASXXX10.1177/1938640014537298Foot & Ankle SpecialistFoot & Ankle Specialist

vol. 7 / no. 4

Foot & Ankle Specialist

Clinical

Research
Examining the Relationship
Between Pathologies of
the Peroneal, Achilles, and
Posterior Tibial Tendons

Melissa M. Galli, DPM, MHA, AACFAS,

Nicole M. Protzman, MS, Eiran M.
Mandelker, MD, Amit D. Malhotra, MD,
Garrett M. Wobst, DPM, AACFAS, Edward
Schwartz, DPM, and Stephen A.
Brigido, DPM

An MRI Review in an
Asymptomatic Lateral Ankle
Population
Abstract: The hindfoot and ankle
are dynamic structures to which the
interplay of tendinous pathologies is
scarcely understood. Five hundred
consecutive ankle magnetic resonance
imaging examinations, obtained
between December 27, 2011 and
April 9, 2013, were reviewed. Patients
without a history of hindfoot or ankle
trauma or lateral ankle pain were
included. The 108 MRIs that met the
inclusion and exclusion criteria were
then re-evaluated by 2 musculoskeletal
radiologists. Of these, 55.56%
demonstrated pathology of the Achilles
tendon (AT), 44.44% demonstrated
pathology of the posterior tibial
tendon (PTT), 35.19% demonstrated
pathology of the peroneus brevis (PB),
and 37.96% demonstrated pathology
of the peroneus longus (PL). In our

individual anatomic structures may

asymptomatic patient population,
have underappreciated functional
16 (14.81%) patients demonstrated
relationships that could lead to future
concomitant pathology of the AT,
investigations.
PTT, and peroneal tendons. There
were positive, moderate
correlations between
To definitively assess causation, the
graded pathology of the
AT and the PTT, rs(106)
clinical evolution of radiologic findings,
= 0.32, P = .001; the AT
and PB, rs(106) = 0.38,
and future symptoms and outcomes,
P = 0.001; and the AT
and PL, rs(106) = 0.46,
prospective, longitudinal cohort studies
P = .001. However, there
are necessary.
were no statistically
significant correlations
between pathology of
Level of Clinical Evidence: Level IV
the PTT and PB, rs(106) = 0.17, P =
Keywords: Achilles tendon;
.08, or the PTT and PL, rs(106) = 0.14,
anatomy; magnetic resonance
P = .15. These findings suggest an
imaging; peroneal tendon; posterior
intimate relationship between the AT,
tibial tendon
PTT, and the peroneal tendons. These

DOI: 10.1177/1938640014537298. From the Foot and Ankle Reconstruction Fellowship, Coordinated Health, Bethlehem, Pennsylvania (MMG, GMW); Foot and Ankle
Department, Coordinated Health, Bethlehem, Pennsylvania (ES, SAB); Clinical Education and Research Department, Coordinated Health, Bethlehem, Pennsylvania (NMP);
Imaging Department, Coordinated Health, Allentown, Pennsylvania (EMM, ADM). Address correspondence to: Stephen A. Brigido, DPM, FACFAS, Fellowship Director, Foot
& Ankle Reconstruction, Coordinated Health, 2775 Schoenersville Road, Bethlehem, PA 18017; e-mail: drsbrigido@mac.com.
For reprints and permissions queries, please visit SAGEs Web site at http://www.sagepub.com/journalsPermissions.nav.
Copyright 2014 The Author(s)

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Introduction
Tendons transmit force generated from
muscle to bone while also absorbing
external forces to limit muscle damage.1
In the foot and ankle, tendons function
under the weight of the human body.
Despite the excessive stress, these
tendons assist with the complex tasks of
standing and locomotion. The peroneal
tendons, the Achilles tendon (AT), and
the posterior tibial tendon (PTT) are 3
significant tendinous structures within
the hindfoot and ankle.
The peroneal tendons run side-by-side
along the lateral ankle, behind the lateral
malleolus, and beside the lateral surface
of the calcaneus.2 The peroneus longus
(PL) descends and inserts on the plantar
surface of the foot, whereas the
peroneus brevis (PB) inserts on the
tuberosity at the proximal base of the
fifth metatarsal.2 These 2 tendons are
responsible for everting the foot and
providing dynamic stabilization.2 While
peroneal tendon injuries are commonly
caused by acute trauma, overuse, and
inflammation,3,4 tendon damage is not
always symptomatic.
The AT, on the other hand, is the
strongest tendon in the body, supporting
loads up to 12.5 times body weight.5,6
The thick fibrous band is a conjoint
tendon of the soleus and gastrocnemius
muscles, inserting posteriorly on the
calcaneus.2 It is this highly specialized
insertion that permits the AT to transmit
extreme tensile loads. Be that as it may,
during walking, running, jumping,
sudden acceleration, and sudden
deceleration, the AT is repetitively
strained, making it vulnerable to injury.7
As logic would dictate, overuse injuries
are most common in athletes, but can
also occur in less physically active
individuals.8-11 Although these posterior
and lateral tendons are not always
linked, anatomic variants have been
described in which the superficial
peroneal retinaculum (SPR) inserts onto
the aponeurosis of the AT and has an
isolated attachment to the AT.12
Of the medial ankle tendons, the PTT is
the largest. The PTT courses around the
medial malleolus to its insertions on the

plantar surface of the medial side of the

foot.2 While this tendon assists with
inversion of the foot and plantar flexion
of the ankle, its primary function is to
support and stabilize the medial arch of
the foot.2 Injury to the PTT commonly
results in PTT dysfunction. Dysfunction
of the PTT is a progressive condition that
can result in the arch slowly collapsing
over time, leading to adult acquired
flatfoot deformity.13 A number of PTT
dysfunction etiologies have been
proposed, including trauma,
degeneration, inflammatory conditions,
and functional deficits, and in some
cases, the condition was thought to arise
spontaneously.14 While acute trauma to
the PTT can initiate this progression,
oftentimes, it develops insidiously.
The feet and ankles provide the
foundation of the human body. On a
daily basis, these dynamic structures are
subjected to tremendous stress.15
Consequently, the tendons of the
hindfoot and ankle are predisposed to a
wide range of acute and chronic injuries.
While incidental findings of pathologic
features within the lateral ankle have
been demonstrated in asymptomatic
patients,12,16,17 there has been little focus
regarding the interplay between
tendinous pathologies within the
hindfoot and ankle in an asymptomatic
patient population.
The purpose of the present study was
threefold: (1) to review ankle magnetic
resonance imaging (MRI) examinations in
patients without a history of ankle trauma
or lateral ankle pathology and determine
the prevalence of pathology of the
peroneal tendons, AT, and PTT; (2) to
assess the relationship between pathology
of the AT, PTT, and peroneal tendons; and
(3) to examine the relationship between
general pathologic features and pathology
of the AT and PTT. We hypothesized that
pathology of the AT and PTT would be
positively correlated with increasing
pathology of the peroneal tendons and
increasing general pathology. Given the
reported variations in SPR insertion, we
specifically hypothesized that there would
be a statistically significant correlation
between pathology the SPR and
pathology of the AT.

Table 1.
Inclusion and Exclusion Criteria.
Inclusion Criteria
Asymptomatic lateral ankle
MRI was read by an
institutional musculoskeletal
radiologist
No history of trauma
Exclusion Criteria
Comparison exam
Current infection of the foot or
ankle
History of acute or chronic
dislocation
History of spina bifida
History of neuropathy
History of trauma
Lateral ankle pain
MRI was obtained at an outside
institution
MRI was procured with the use
of gadolinium enhancement
Previous surgery
The inclusion and exclusion criteria used
for patient selection.

Patients and Methods

According to our Institutional Review
Board, this investigation met the
conditions for exemption. The protocol
was approved, and the informed consent
was waived. Via our electronic imaging
system, 500 ankle MRI examinations
ordered by attending orthopaedic and
podiatric physicians from December 27,
2011 to April 9, 2013 were identified. A
single fellowship trained surgeon
reviewed all 500 ankle MRIs, their
ordering criteria, the associated radiology
reports, and the clinic note that
immediately preceded the ordering of
the MRI to determine if the inclusion and

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Foot & Ankle Specialist

exclusion criteria were met (Table 1).

Data were recorded into a passwordprotected, secure database. The
confidentiality and privacy of individuals
was ensured and maintained.
Contributory patient demographics were
recorded. These consisted of patient age
(years), gender (male/female), and
imaged side (right/left). The MRIs that
met the inclusion and exclusion criteria
were then re-evaluated by 2 institutional
musculoskeletal trained radiologists with
19 years of combined experience. When
a disagreement occurred, the 2
musculoskeletal radiologists reviewed the
images simultaneously via telephone.
Consensus on the presence and nature
of pathology was reached and recorded.
Statistical analyses were performed by
the research associate at our institution.
All images were obtained on the same
magnet (ONI 1.0T OrthOne Extremity
MRI, Block Imaging, Holt, Michigan) with
an identical protocol, except in cases
requiring additional image sequences. The
standard protocol included axial proton
density, axial T2, axial short tau inversion
recovery (STIR), coronal proton density,
coronal STIR, sagittal T1, and sagittal STIR
images.
The AT was evaluated to determine if
thickening/tendinosis/tendinitis or a tear
was present.18 Axial and sagittal
sequences were used to most accurately
assess the AT. Thickening/tendinosis/
tendonitis was defined as loss of the
expected concave shape as seen on the
axial images. Intrasubstance intermediate
or high signal on the fluid-sensitive
images was indicative of delamination.
Fluid extending to the surface or a
partial deformity characterized by
morphologic distortion was defined as a
partial thickness tear. Complete
disruption/separation of the tendon with
a gap between the torn tendon ends was
indicative of a full thickness tear.19
The PTT was evaluated to determine if
fusiform enlargement, intrasubstance
degeneration, or longitudinal tears were
present.20 Fusiform enlargement was
defined as hypertrophy and rounding of
the tendon without definitive separation
of fibers. For the purpose of the present
report, fusiform enlargement was not

characterized as a type 1 partial tear, as

previously described.20 Axial proton
density images were used to assess
intrasubstance degeneration and
longitudinal tears. Intrasubstance
degeneration was evidenced by an
increased intrasubstance signal. Linear
fluid in the substance of the tendon or
separation of the tendon fibers along the
long axis of the tendon was indicative of
a longitudinal tear. When necessary, the
coronal plane was used as a supplement.
The peroneal tendons were evaluated
for tendinopathy and tears.21
Tendinopathy was graded as mild,
moderate, or severe, and tears were
categorized as partial or full. Peroneal
tendinopathy was defined as the
appearance of fluid collection within the
common peroneal sheath, increased
signal intensity within the tendon, or
hypertrophy of the tendon on
T2-weighted sagittal and axial images.21
Partial tears included longitudinal and
interstitial tears. A longitudinal split tear
of the PB was present when fluid was
noted in the substance of the tendon or
there was subluxation of the components
of the tendon medial and lateral to the
PL.22 A longitudinal split tear of the PL
was present when fluid was noted in the
substance of the tendon with separation
of the fibers. On T1- and fat-suppressed
T2-weighted images, an interstitial tear
was indicated by an intermediate or
uniform intermediate signal intensity
within the tendon.23 Full tears were
defined as a complete discontinuity of
the tendon with a fluid gap.
The presence or absence of general
pathophysiology was also noted. Both
the ankle and the subtalar joint were
examined for arthritic change and if
evident, the extent of the arthritic
change was classified as effusion/
synovitis or arthritis. Effusion was
defined by a fluid signal distending the
joint capsule, synovitis was indicated
when a complex or nodular signal was
recognized within an effusion, and
arthritis was evident based on the size of
the osteophytes, the extent of cartilage
loss, subchondral cystic changes, and
peri-articular edema. The navicular was
classified as anatomic or possessing an

accessory or prominent tuberosity. When

present, osteophytes were classified as
mild or moderate to severe. If present,
SPR pathology was classified as acute or
chronic. Acute injuries demonstrated
disrupted retinacular fibers and
extensive surrounding soft tissue
swelling, whereas chronic injuries
demonstrated a thickened and
heterogeneous SPR with little or no
surrounding soft tissue swelling. Lastly,
the presence or absence of talar
osteochondral lesions was recorded.
Talar osteochondral lesions were
evidenced by a defect in the cartilage of
the talar dome with underlying bony
deformity and/or signal changes
manifested as low signal on the
T1-weighted images and intermediate or
high signal on the fluid sensitive images.

Statistical Methods
All analyses were conducted using IBM
SPSS Statistics (Software Version 20).
Sample size was determined for
correlations based on a 90% power, an
alpha of 0.05, and a correlation coefficient
of 0.30, which required a minimum of 92
MRI examinations. Statistical analyses
were performed to investigate the
relationships between pathology of the
peroneal tendons, AT, and PTT.
Furthermore, we investigated the
relationship between general pathology
and pathology of the AT and PTT.
For the purposes of data analysis, the
severity of tendinous pathology was
graded on a scale ranging from 0 to 2,
with 0 representing no pathologic features,
1 representing mild to moderate pathology
(tendon thickening, tendinosis/tendinitis,
tendinopathy, fusiform enlargement), and
2 representing severe pathologic change
(intrasubstance degeneration and tears of
varying severity). The presence or absence
of general pathology was coded as 0 or 1,
with 0 representing the absence of
pathology and 1 representing the presence
of pathology.
Spearmans rank order correlations
were used to determine the strength and
direction of the relationship between 2
ordinal variables as well as ordinal and
dichotomous variables.

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Table 2.

Table 3.

Patient Demographics.

Tendinous Pathology.

Demographic

Value

Patients (no.)

108

Age (years)

Tendinous Pathology

41.90 20.42

Gender

Outcome Prevalence

Achilles tendon

60 (55.56)

None

48 (44.44)

Thickening/tendinosis/tendinitis

53 (49.07)

Female

71 (65.74)

Achilles tear

Male

37 (34.26)

Posterior tibial tendon

48 (44.44)

None

60 (55.56)
37 (34.26)

Injury side

7 (6.48)

Left

54 (50.00)

Fusiform enlargement

Right

54 (50.00)

Intrasubstance degeneration

5 (4.63)

Primary MRI indications

Long tear

6 (5.56)

Nonlateral
ankle pain

101 (93.52)

Peroneus brevis tendon

38 (35.19)

None

70 (64.82)

Soft tissue
mass

2 (1.85)

Mild tendinopathy

32 (29.63)

Stress fracture

5 (4.63)

Abbreviation: MRI, magnetic resonance

imaging.
Patient demographics are reported for
the study population (n = 108). Data are
presented as mean standard deviation
or count (%).

The significance level for all statistical

tests was set at P = .05. Data are reported
as means standard deviation.

Moderate tendinopathy

2 (1.85)

Severe tendinopathy

0 (0.00)

Partial tear

3 (2.78)

Full tear

1 (0.93)

Peroneus longus tendon

41 (37.96)

None

67 (62.04)

Mild tendinopathy

37 (34.26)

Moderate tendinopathy

4 (3.70)

Severe tendinopathy

0 (0.00)

Results

Partial tear

0 (0.00)

A total of 500 consecutive MRI reports

were reviewed. Of which, 108 (21.60%)
met the inclusion criteria. Patient
demographics are summarized in Table 2.
Of the lateral asymptomatic patients
included in the present study, 60 (55.56%)
demonstrated pathology of the AT, 48
(44.44%) demonstrated pathology of the
PTT, 38 (35.19%) demonstrated pathology
of the PB, and 41 (37.96%) demonstrated
pathology of the PL (Table 3). When a
tendon tear was evidenced
radiographically, the location of the tear
was recorded (Table 4).

Full tear

0 (0.00)

Tendinous pathology observed in the study population (n = 108). Data are presented as count (%).

Further evaluation revealed that 16

(14.81%) patients demonstrated
concomitant pathology of the PB, PL, AT,
and PTT. Twenty-seven (25.00%) patients
demonstrated concomitant pathology of
the PB and the PL tendons, and 35
(32.41%) patients demonstrated
concomitant pathology of the AT and the
PTT. In terms of concomitant pathology

associated with the PB, 28 (25.93%)

patients demonstrated concomitant
pathology of the PB and the AT, 21
(19.44%) patients demonstrated
concomitant pathology of the PB and the
PTT, and 19 (17.59%) patients
demonstrated concomitant pathology of
the PB, AT, and the PTT. In terms of
concomitant pathology associated with

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Table 4.
Tear Location.
No.

Tendon

Type of Tear

Tear Location

Posterior tibial

Long tear

Inframalleolar segment

Posterior tibial

Long tear

Retromalleolar and inframalleolar segments

Peroneus brevis

Longitudinal split

At the base of the fifth metatarsal

Peroneus brevis

Full-tear

Involving the inframalleolar portion of the tendon

Posterior tibial

Long tear

Inframalleolar segment

Achilles

Tear

Watershed segment

Achilles

Tear

Watershed segment and lateral insertional fibers

Posterior tibial

Long tear

Inframalleolar from the tarsus to the insertion point on the medial

cuneiform

Posterior tibial

Long tear

Retromalleolar and inframalleolar to the tarsus

10

Achilles

Tear

Watershed

11

Achilles

Tear

Watershed

12

Peroneus brevis

Longitudinal split

Retromalleolar

13

Achilles

Tear

Watershed

14

Achilles

Tear

Watershed

15

Achilles

Tear

Insertional

16

Posterior tibial

Long tear

Inframalleolar segment

17

Peroneus brevis

Longitudinal split

Retromalleolar and inframalleolar segments

The approximate location of partial- and full-thickness tears is provided for patients demonstrating tears of the Achilles tendon, posterior tibial tendon, and/
or peroneus brevis tendon (n = 17).

the PL, 34 (31.48%) patients demonstrated

concomitant pathology of the PL and the
AT, 23 (21.30%) patients demonstrated
concomitant pathology of the PL and the
PTT, and 20 (18.52%) patients
demonstrated concomitant pathology of
the PL, AT, and the PTT. The prevalence
of general pathophysiology is
summarized in Table 5.
Correlations were run to determine the
strength and direction of the association
between pathology of the AT, PTT, and
peroneal tendons (Table 6). There was a
positive, moderate correlation between
pathology of the AT and pathology of
the PTT, which was statistically
significant, rs(106) = 0.32, P = .001; a

positive, moderate correlation between

pathology of the AT and pathology of
the PB, which was statistically
significant, rs(106) = 0.38, P = .001; and
a positive, moderate correlation between
pathology of the AT and pathology the
PL, which was statistically significant,
rs(106) = 0.46, P = .001. Upon
examination of peroneal tendon
pathology, there was a positive, strong
correlation between the PB and the PL,
which was statistically significant, rs(106)
= 0.55, P < .001. However, there were no
statistically significant correlations
between pathology of the PB tendon
and pathology of the PTT, rs(106) = 0.17,
P = .08; or pathology of the PL tendon

and pathology of the PTT, rs(106) = 0.14,

P = .15.
Correlations were run to determine the
strength and direction of the association
between the presence of general
pathology and the graded pathology of
the AT and the PTT (Table 7). There was
a moderate, positive correlation between
pathology of the AT and the presence of
general pathology, rs(106) = 0.44, P <
.001, and there was a moderate, positive
correlation between pathology of the
PTT and the presence of general
pathology, rs(106) = 0.34, P < .001.
Upon further inspection of each
general pathologic condition, there were
a number of statistically significant

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Table 5.
General Pathology.
General Pathology

Outcome Prevalence

Ankle arthritis

58 (53.70)

None

50 (46.30)

Effusion/synovitis

33 (30.56)

Arthritis

25 (23.15)

Navicular

23 (21.30)

Anatomic

85 (78.70)

Accessory

14 (12.96)

Prominent tuberosity

9 (8.33)

Osteophytes

53 (49.07)

None

55 (50.93)

Mild

48 (44.44)

Moderate to severe

5 (4.63)

Subtalar arthritis

47 (43.52)

None

61 (56.48)

Effusion/synovitis

33 (30.56)

Arthritis

14 (12.96)

Superior peroneal retinaculum injury

29 (26.85)

None

79 (73.15)

Acute

0 (0.00)

Chronic

29 (26.85)

Talar lesions

16 (14.81)

None

92 (85.19)

General pathology observed in the study population (n = 108). Data are presented as count (%).

correlations. There was a moderate,

positive correlation between pathology
of the AT and arthritic change of the
ankle joint, rs(106) = 0.42, P < .0010, and
between pathology of the AT and
arthritic change of the subtalar joint,
rs(106) = 0.39, P < .001. Similarly, there
was a moderate, positive correlation
between pathology of the PTT and
arthritic change of the ankle joint, rs(106)
= 0.33, P < .001, and between pathology
of the PTT and arthritic change of the

subtalar joint, rs(106) = 0.32, P = .001.

There were statistically significant
correlations between pathology of the
AT and pathology of the SPR, rs(106) =
0.20, P =.04, and between pathology of
the PTT and pathology of the SPR,
rs(106) = 0.30, P = .002. Twenty
(18.52%) patients demonstrated
concomitant pathology of the SPR and
the AT, 21 (19.44%) patients
demonstrated concomitant pathology of
the SPR and the PTT, and 16 (14.81%)

demonstrated pathology of the SPR, AT,

and PTT. Lastly, there was a moderate,
positive correlation between pathology
of the AT and the presence of
osteophytes within the peroneal groove,
rs(106) = 0.27, P = .004, and a weak,
positive correlation between pathology
of the PTT and the presence of
osteophytes within the peroneal groove,
rs(106) = 0.22, P = .02.

Discussion
The present study demonstrated that
approximately 15% of patients with
asymptomatic lateral ankles display
concomitant pathology of the peroneal
tendons, the AT, and the PTT. Evaluating
the tendinous components separately,
35% demonstrated pathology of the PB
tendon, 38% demonstrated pathology of
the PL tendon, 56% demonstrated
pathology of the AT, and 44%
demonstrated pathology of the PTT.
Furthermore, utilizing a tendinous
pathology grading scale, AT pathology
was moderately correlated with
pathology of the PTT and pathology of
both the PB and PL tendons. Meanwhile,
no statistically significant correlations
were noted between the PTT and the PB
or the PL. These preliminary findings
confirm the interrelatedness of certain
tendinous pathology within the hindfoot
and ankle.
Magnetic resonance imaging plays an
important role in diagnosing tendinous
disorders. Over the past several decades,
a number of radiology reports have
surfaced, describing imaging protocols to
facilitate the detection of pathologic
conditions.18-23 To further improve MR
image interpretation, radiologists have
also identified osseous injuries and
abnormalities associated with specific
tendon disorders.18,24,25 In an MRI review
of AT disorders, the most common
abnormality was the presence of a bony
spur or enthesophyte at the insertion of
the AT into the calcaneus.18 Additional
abnormalities included AT ossification,
insertional tendinosis associated with
retrocalcaneal bursitis or degenerative
cystic change, and osseous injury to the
calcaneus.18,24,25 Although imaging

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Table 6.
Tendinous Pathology Correlations.
Achilles
Tendon

Posterior
Tibial
Tendon

Peroneus
Brevis
Tendon

Peroneus
Longus
Tendon

Achilles Tendon

1.00

Posterior Tibial Tendon

0.32*

1.00

Peroneus Brevis Tendon

0.38*

0.17

1.00

Peroneus Longus Tendon

0.46*

0.14

0.55*

1.00

Correlations between the graded pathology of the Achilles tendon, posterior tibial tendon, and
peroneal tendons are provided for the study population (n = 108). Correlation coefficients are
provided.
*P .05.

Table 7.
Correlations With General Pathology.
Achilles
Tendon

Posterior Tibial
Tendon

General Pathology

0.44*

0.34*

Arthritic Change Ankle Joint

0.42*

0.33*

Arthritic Change Subtalar Joint

0.39*

0.32*

Superior Peroneal Retinaculum Pathology

0.20*

0.30*

Accessory/Prominent Tuberosity of Navicular

0.02

0.18

Osteophytes within Peroneal Groove

0.27*

0.22*

Talar Lesions

0.18

0.16

Correlations between the presence of general pathologic conditions and graded pathology of the
Achilles tendon and the posterior tibial tendon are provided for the study population (n = 108).
Correlation coefficients are provided.
*P .05.

protocols and knowledge of incidental

pathology can assist in the identification
of disorders, there are potential pitfalls.
The magic angle phenomenon refers to
the presence of intermediate signal
intensity within normal tendons, which
can be misconstrued as tendinopathy.
The effect is most pronounced on short
echo time images.12 Purportedly, the
peroneal tendons are particularly
susceptible as they descend down the

ankle.12 Although Wang and colleagues

recommend imaging the foot in mild
plantar flexion (approximately 20) to
avoid the magic angle effect,12 the
radiologist at our institution refrain from
using proton density images when
diagnosing tendinopathy and tears and
predominantly rely on T2 and STIR
images, which are not as predisposed to
the magic angle effect. Furthermore, the
diagnostic criteria consisted of

morphologic distortion or a fluid signal.

By employing these measures, the
magic angle phenomenon can also be
avoided. With accurate image
interpretation, MR MRI is a valuable tool
for understanding and detecting
tendinous disorders.
Utilizing MRI, tendinous pathologies
have been identified in asymptomatic
patients.12,16,17 In 2011, Saxena and
colleagues examined pathologic
abnormalities in asymptomatic lateral
ankles.16 The study evaluated 102 MRI
examinations from 100 patients.16 The
most common pathologic features were
Achilles tendinopathy (40; 39%) and PTT
dysfunction (26; 25%).16 Regarding the
peroneal tendons, the PB was intact in
67 (66%) patients and the PL was intact
in 68 (67%) patients.16 Similarly, in the
present report, 49% of the patients
demonstrated thickening/tendinosis/
tendinitis of the AT, followed by 44% of
patient demonstrating PTT dysfunction.
However, the PB was intact in 104
(96.30%) patients and the PL was intact
in 108 (100.00%) patients. The notable
difference in the prevalence of peroneal
pathology between the present study
and the previous report may be
attributable to methodological
differences, particularly differences in the
patient populations. Although Saxena et
al excluded any patients with a lateral
ankle injury in the previous 10 years,
34% of the patients included in the study
had a history of lateral ankle sprains.16 In
the present study, however, all patients
with a history of lateral ankle trauma
were excluded. This difference in
inclusion and exclusion criteria may
explain the discrepancy observed in the
incidence peroneal tendon tears. The
authors support Saxena and colleagues
and recommend caution when
considering surgery based solely on MRI
findings, especially in an asymptomatic
patient.16
The present study sought to examine
the relationships between tendinous
pathology within the hindfoot and ankle.
Consistent with the authors expectations,
there were a number of moderate
correlations with the AT, suggesting an
intimate relationship with both the

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Foot & Ankle Specialist

peroneal tendons and the PTT. During

routine activities of daily living, such as
standing and walking, tendons of the
feet and ankles are repetitively
strained.1,15 The 4 tendons examined all
have dynamic responsibilities. For
example, the AT transmits extreme forces
while the PTT and peroneal tendons
provide stabilization.2 Meanwhile, these
tendons are in close proximity to one
another and in some cases have direct
anatomic connections. Therefore,
pathology in 1 tendon is likely to drive
pathology elsewhere. However, in our
atraumatic, asymptomatic lateral ankle
population, statistically significant
relationships were not always observed
between the tendinous pathologies
evaluated. This was true for the PTT and
the peroneal tendons, despite the
agonist-antagonist relationship of the
PTT and the PB. While it is known that
acquired flatfoot deformity secondary to
PTT dysfunction causes increased stress
on the spring ligament and the sinus
tarsi, prospective longitudinal studies are
needed to determine if PTT dysfunction
propagates additional tendinous
pathologies. These significant
correlations suggest that functional
relationships exist and appear to
contribute to concurrent pathologic
degeneration. However, this paradigm
does not appear to extend to the PTT
and the peroneal tendons in the
asymptomatic lateral population.
Perhaps, a significant relationship was
not observed between these tendons
because patients with PTT dysfunction
and peroneal pathologies are likely to be
symptomatic, and thus, those patients
were excluded from the present review.
Additional investigation is necessary to
further elucidate the progressive
influence of various pathologies within
the hindfoot and ankle.
To better understand the relationships
between pathologic conditions, tendon
disorders were recorded as well as tear
location. While knowing the location of
a tear may infer the likelihood of
concomitant tendon pathology, such as
severe posterior tibial tendinopathy
leading to an inframalleolar peroneal
tendon tear, due to the retrospective

study design, direct causality cannot be

determined. Future studies should be
prospectively designed to determine if
anatomic anomalies and/or hindfoot and
ankle position predispose patients to
tendinous and ligamentous pathology
and, ultimately, generate tears.
In addition to evaluating tendinous
pathology, the present report also
investigated the association between
tendinous pathology and general
pathologic features. We hypothesized
that the presence of general pathologic
conditions would be correlated with the
graded pathology of the AT and PTT,
which was confirmed. The tendinous
pathology observed in the AT and PTT
was correlated with degenerative change
within the ankle and subtalar joints and
the presence of osteophytes within the
peroneal groove. Collectively, these
findings suggest that the degeneration of
the hindfoot and ankle are interrelated.
Unfortunately, given the cross-sectional
design of this report, it is not possible to
determine if one pathologic process was
driving another; for example, if
tendinous pathology was driving joint
degeneration.
Additionally, approximately 15% of our
asymptomatic patients demonstrated
concomitant pathology of the SPR, AT,
and PTT. The SPR is a fibrous band that
creates the posterolateral border of the
fibro-osseous tunnel that keeps the
peroneal tendons within the fibular
groove. Given the intimate relationship
between the SPR and the peroneal
tendons, the SPR is often injured when
the foot is dorsiflexed and the peroneal
tendons are forcefully and suddenly
contracted. Considering the anatomic
variations in which the SPR inserts onto
both the aponeurosis of the AT and the
lateral calcaneus and has an isolated
attachment directly onto the AT,12 we
hypothesized that there would be a
statistically significant correlation
between the SPR and the AT, which was
confirmed. Roughly 19% of patients
demonstrated concomitant pathology of
the SPR and the AT. While this study did
not correlate our observed pathologies to
the insertions of retinacula, the intimate
relationship between these structures

could play a large role in the

asymptomatic population and should be
the subject of future investigations.
Despite no relationship between the PTT
and the peroneal tendons, there was a
statistically significant correlation
between pathology of the PTT and
pathology of the SPR. Approximately
19% of patients demonstrated
concomitant pathology of the SPR and
the PTT. Collectively, these findings
suggest a relationship between the AT,
the PTT, and the SPR.
Recent evidence suggests that there is a
pathologic continuum in which a healthy
tendon progresses to tendinopathy.26
However, there is no definitive point
along this proposed continuum in which
pathology becomes symptomatic.
Consequently, the source of pain in
symptomatic individuals remains
uncertain. Considering the asymptomatic
nature of our patient population, the
noted pathologic features are presumably
attributable to frequent micro-trauma or
excessive loading over time, but
unfortunately, given the cross-sectional
design of the present study, we are
unable to definitively confirm our
suspicions or determine if degenerative
change in one aspect of the hindfoot and
ankle drove additional pathologic
change. To determine if gait alterations
and compensatory strategies play a role
in the progression of pathology, both
symptomatic and asymptomatic ankles
should be included in future
investigations.
Certainly, there are limitations that
could threaten the validity of our
conclusions. The most substantial
methodological shortcoming of this
investigation was its retrospective
observational design, which inherently
increases the likelihood of bias. In an
effort to minimize misinterpretation of
MR images, 2 musculoskeletal
radiologists with 19 years of combined
experience were elected to review the
included studies. While our patient
population was comprised of
asymptomatic lateral ankles, to accurately
compare the relationship between
asymptomatic patients and pathologic
features, patients would have to be truly

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vol. 7 / no. 4

Foot & Ankle Specialist

asymptomatic. In all patients, an MRI was

indicated. Therefore, symptomatology in
one area of the foot may have driven
pathology elsewhere. Although our study
described associations between MRI
noted pathologies, causal relationships
between these findings cannot be
established nor can the nature of their
summative presence. Moreover, this
study did not correlate observed
pathologies with the insertions of the
retinacula and did not examine
pathologies of the smaller tendons of the
posterior compartment, namely, the
flexor digitorum longus and the flexor
hallucis longus. The authors recognize
that these relationships could play a
large role in the asymptomatic lateral
ankle population and should be the
subject of future investigations. Despite
these limitations, we believe that the
results of the present investigation are a
valuable addition to the literature and
could be used in the development of
future, multicenter prospective cohort
studies that could identify patients at risk
for developing symptomatic tendinous
pathology.
This is the first study to show the
statistically significant interrelatedness of
the PB, PL, AT, and PTT. Adding to the
existing evidence, approximately 15% of
patients with asymptomatic lateral ankles
displayed concomitant pathology of the
peroneal tendons, the AT, and the PTT.
Additionally, the present study
investigated relationship between the
tendinous pathology and general
pathophysiology. Pathology of the AT
and PTT were also correlated with
degenerative change within the ankle
and subtalar joints, the presence of
osteophytes within the peroneal groove,
and chronic damage of the SPR.
Collectively, these findings support our
presumption that these pathologic
features are likely due to progressive
damage over time. To definitively assess
causation, the clinical evolution of
radiologic findings, and future symptoms

plantar fasciitis on MR imaging. AJR Am J

Roentgenol. 2001;176:1137-1143.

and outcomes, prospective, longitudinal

cohort studies are necessary.

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