Updated: 11/30/2019 14

Peroneal Tendon Subluxation & Dislocation

Chad Krueger

TOPIC QUESTIONS EVIDENCE VIDEOS

Review Topic 21 17 2

Subluxation/Dislocations

Peroneal tedon dislocation and repetitive subluxation from behind lateral malleolus
Epidemiology
most of these injuries occur in young, active patients
Mechanism
rapid dorsiflexion of an inverted foot inversion leading to rapid reflexive contraction of
the PL and PB tendons
rapid contraction can also lead to injury to the superior peroneal retinaculum
Pathophysiology
subluxation of the peroneal tendons leads to longitudinal tears over time which usually
involves peroneus brevis at fibular groove
subfibular impingment secondary to calcaneal malunion
Associated conditions
tears of the peroneus brevis and or longus
longitudinal split tears more common than transverse
lateral ankle ligament injuries (ATFL, CFL) in up to 75% of patients with SPR injuries

Anatomy

Muscles & innervation

peroneus brevis
innervated by the superficial peroneal nerve, S1
acts as primary evertor of the foot
tendinous about 2-4cm proximal to the tip of the fibula
lies anterior and medial to the peroneus longus at the level of the lateral malleolus

peroneus longus
innervated by superficial peroneal nerve, S1
primarily a plantar flexor and foot and first metatarsal
can have an ossicle (os peroneum) located within the tendon body
Space & compartment
peroneal tendons contained within a common synovial sheath that splits at the level of
the peroneal tubercle
the sheath is runs in the retromalleolar sulcus on the fibula
peroneus longus is posterior in the sulcus (longus takes the long way around)
peroneus brevis is anterior in the sulcus (brevis is behind the bone)
deepened by a fibrocartilaginous rim (still only about 5 millimeters deep)
covered by superior peroneal retinaculum (SPR)
 originates from the posterolateral ridge of the fibula and inserts onto the
lateral calcaneus (peroneal tubercle)
the inferior aspect of the SPR blends with the inferior peroneal retinaculum
is the primary restraint the peroneal tendons within the retromalleolar sulcus
at the level of the peroneal tubercle of the calcaneus
peroneus longus is inferior
peroneus brevis is superior
both tendons covered by inferior peroneal retinaculum

Classification

Ogden Classification of Superior Peroneal Retinaculum (SPR) Tears

Grade 1 The SPR is partially elevated off of the fibula allowing for subluxation of both tendons
Grade 2 The SPR is separated from the cartilofibrous ridge of the lateral malleolus, allowing the
tendons to sublux between the SPR and the cartilofibrous ridge
Grade 3 There is a cortical avulsion of the SPR off of the fibula, allowing the subluxed tendons to
move underneath the cortical fragment
Grade 4 The SPR is torn from the calcaneous, not the fibula

Presentation

History
patients often report they felt a pop with a dorsiflexion ankle injury
Symptoms
clicking, popping and feelings of instability or pain on the lateral aspect of the ankle
Physical exam
inspection
swelling posterior to the lateral malleolus
tenderness over the tendons
'pseudotumor' over the peroneal tendons
voluntary subluxation of the tendons +/- a popping sound
provocative tests
apprehension tests
the sensation of apprehension or subluxation with active dorsiflexion and
eversion against resistance cause subluxation/dislocation and apprehension

compression test
pain with passive dorsiflexion and eversion of the ankle

Imaging

Radiographs
recommended views
best recognized on an internal rotation view
findings
may see a cortical avulsion off the distal tip of the lateral malleolus (fleck sign, rim
fracture)
needed to evaluate for varus hindfoot
MRI
best evaluated with axial views of a slightly flexed ankle
can demonstrate anatomic anomalies leading to pathology
peroneus quartus muscle
low-lying peroneus brevis muscle belly

Treatment

Nonoperative
short leg cast immobilization and protected weight bearing for 6 weeks
 indications
all acute injuries in nonprofessional athletes
technique
tendons must be reduced at the time of casting
outcomes
success rates for nonsurgical management are only marginally better than
50%.
Operative
acute repair of superior peroneal retinaculum and deepening of the fibular groove
indications
acute tendon dislocations in serious athletes who desire a quick return to a
sport or active lifestyle
presence of a longitudinal tear
groove-deepening with soft tissue transfer and/or osteotomy
indications
chronic/recurrent dislocation
technique
less able to reconstruct SPR so treatment focuses on other aspects of
peroneal stability
typically involves groove-deepening in addition to soft tissue transfers or
bone block techniques (osteotomies to further contain the tendons within the
sulcus)
plantaris grafts can act to reinforce the SPR
hindfoot varus must be corrected prior to any SPR reconstructive procedure

Peroneal Brevis Tears

Introduction
presentation and physical exam is often very similar to peroneal tendon dislocation,
however there is no instability of the tendon
Imaging
MRI is requried for diagnosis
Treatment
nonoperative
NSAIDs, activity restriction and a walking boot are often the first line of treatment
failure rate may be as high as 83%
Topics operative
Techniques QBank Evidence Cases Videos Podcasts Groups Products Help
core repair and tubularization of the tendon
indications
simple tears
debridement of the tendon with tenodesis of distal and proximal ends of the
brevis tendon to the peroneus longus or reconstruction with allograft
Foot & Ankle indications
complex tears with multiple longitudinal tears and significant tendinosis
F&A INTRODUCTION (> 50% of the tendon involved)
debridement of both tendons with interposition allograft
F&A ANATOMY indications
complex tears of both tendons with (involving over 50% of tendon
F&A EVALUATION substance) with preserved muscle excursion
debridement of both tendons with FHL transfer
F&A TRAUMA
indications
ANKLE SPRAINS complex tears of both tendons with (involving over 50% of tendon
substance) with no muscle excursion
MID & FOREFOOT hindoot osteotomy with peroneal tendon pathology
TRAUMA varus hindfoot alignment contributes to peroneal pathology
consider calcaneal osteotomy or subtalar arthrodesis in patient with hindfoot
TENDON INJURIES
varus and peroneal pathology
Achilles Tendon Rupture

Peroneal Tendon Subluxation

 & Dislocation

Anterior Tibialis Tendon

Rupture

INFECTION Please rate topic. Average 4.0 of 51 Ratings

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HALLUX DISORDERS

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VIDEOS & PODCASTS (3)

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 Login to View Community Videos 2018 Orthopaedic Summit Evolving Techniques 9/12/2019

Chronic Peroneal Subluxation Treating with a 223 views

Fibular Osteotomy - Troy S. Watson, MD (OSET
2018)
Troy Watson

Foot & Ankle - Peroneal Tendon Subluxation & Dislocation

Upgrade to View Premium Videos 3/2/2013

Peroneal tendon subluxation
4877 views
Chad Krueger

Foot & Ankle - Peroneal Tendon Subluxation & Dislocation

Foot & Ankle Peroneal Tendon Subluxation & 10/16/2019

Dislocation
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Team Orthobullets (5)

Foot & Ankle - Peroneal Tendon Subluxation & Dislocation

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