Clinical Biomechanics 34 (2016) 7–11

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Clinical Biomechanics

journal homepage: www.elsevier.com/locate/clinbiomech

The influence of the Peroneus Longus muscle on the foot under axial
loading: A CT evaluated dynamic cadaveric model study
K. Dullaert a,⁎, J. Hagen a, K. Klos b,c, B. Gueorguiev a, M. Lenz c, R.G. Richards a, P. Simons b
a
AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos, Switzerland
b
Catholic Clinic Mainz, Department of Foot and Ankle Surgery, KKM Mainz, An der Goldgrube 11, , 55131 Mainz, Germany
c
Department of Trauma, Hand and Reconstructive Surgery, University Hospital Jena, Bachstraße 18, 07743 Jena, Germany

a r t i c l e i n f o a b s t r a c t

Article history: Background: Subtle hypermobility of the first tarsometatarsal joint can occur concomitantly with other pathologies
Received 26 November 2015 and may be difficult to diagnose. Peroneus Longus muscle might influence stability of this joint. Collapse of the medial
Accepted 2 March 2016 longitudinal arch is common in flatfoot deformity and the muscle might also play a role in correcting Meary's angle.
Methods: A radiolucent frame was used to simulate weightbearing during CT examination. Eight pairs fresh-frozen
Keywords:
lower legs were imaged in neutral position under non-weightbearing (75 N), weightbearing (700 N) and with
First ray instability
15 kg weights hung from Peroneus Longus tendon. Measurements included first metatarsal rotation, intermetatarsal
Hallux valgus
Medial longitudinal arch
angle, first tarsometatarsal joint subluxation and Meary's angle.
Peroneus Longus function Findings: Weightbearing significantly increased Meary's angle and significantly decreased first tarsometatarsal joint
Biomechanical study subluxation (both P b 0.01). Pulling Peroneus Longus tendon significantly increased first metatarsal rotation
(P b 0.01), significantly decreased the intermetatarsal angle (P b 0.01) and increased non-significantly Meary's
angle (P = 0.52).
Interpretation: A considerable effect weightbearing has on the medial longitudinal arch and first tarsometatarsal joint
was observed. Pulling Peroneus Longus tendon improved first metatarsal subluxation but increased its rotation. The
study calls into question the importance of this tendon in maintaining the medial longitudinal arch and raises con-
cerns about rotational deformity of the first metatarsal following hallux valgus correction without first tarsometatarsal
arthrodesis.
Clinical relevance: Study outcomes will provide more insight in foot pathology.
What is known about the subject: Weightbearing affects anatomy of the foot. No reliable information is available
concerning the influence of the Peroneus muscle.
What this study adds to existing knowledge: This study investigates the influence of weightbearing and the impact the
Peroneus muscle on the anatomy of the foot.
© 2016 Published by Elsevier Ltd.

1. Introduction Subtle hypermobility of the first tarsometatarsal (TMT) joint can

The human foot is a complex structure able to resist great forces with
a dynamic interaction between forefoot, midfoot and hindfoot. The rest-
ing position of the foot can vary greatly from the weightbearing position
and this can be dependent on bone morphology (Knupp et al., 2011;
Sarrafian, 1993) and pathology (Hayashi et al., 2008; Johnston et al.,
1995; Rao and Joseph, 1992). Many pathologic conditions reveal
themselves only in loaded position.
⁎ Corresponding author.
E-mail addresses: koendullaert@gmail.com (K. Dullaert), hagenje@ortho.ufl.edu
(J. Hagen), k-klos@kkmainz.de (K. Klos), boyko.gueorguiev@aofoundation.org
(B. Gueorguiev), mark.lenz@med.uni-jena.de (M. Lenz), geoff.richards@aofoundation.org
(R.G. Richards), p-simons@kkmainz.de (P. Simons).
occur concomitantly with other first ray pathology, such as hallux val-
gus, and can be difficult to diagnose clinically. Controversy exists
about the role of the metatarsal instability (Dietze et al., 2013; Faber
et al., 1999; van Beek and Greisberg, 2011) and how to diagnose it
(Greisberg et al., 2010). The Peroneus Longus (PL) attaches at the base
of the first metatarsal, and it is possible that activation of this tendon
can dynamically alter the first TMT joint (Faber et al., 1999) and also in-
fluence the intermetatarsal angle (Spinner et al., 1984). By pulling the
PL, the tendon acts in conjunction with the Tibialis Posterior muscle in
plantar flexing the foot and could influence the Meary's angle.
The objective of this study was to investigate two conditions that
might reveal themselves only in loaded foot position. Therefore, ex-
vivo CT investigation was performed on the human foot in unloaded
condition and under defined axial loading to determine the impact of
weightbearing on the first tarsometatarsal joint and the medial longitu-
dinal configuration. In addition, via tendon pulleys we investigated

http://dx.doi.org/10.1016/j.clinbiomech.2016.03.001
0268-0033/© 2016 Published by Elsevier Ltd.
8 K. Dullaert et al. / Clinical Biomechanics 34 (2016) 7–11
Fig. 1. Picture of the pressure-controlled custom made frame for axial loading.
the effect PL tendon actuation has on the position of the first
tarsometatarsal joint and its ability to restore the medial longitudinal
arch.
2. Methods
Eight pairs of fresh-frozen (− 20 °C) human cadaveric lower legs
including the feet were used. The specimens with age of the donors be-
tween 59 and 91 years, mean 79.4 years, five males and three females,
all Caucasian, were visually checked for pathology or any prior surgery.
Using computer tomography (CT), all specimens were checked for
integrity of the joints. The tibia and fibula were cut at mid-tibia level
and potted in polymethylmethacrylate (PMMA; SCS-Beracryl, Suter-
Kunststoffe AG, Fraubrunnen, Switzerland).
Weightbearing was simulated by an air pressure-controlled custom
made loading frame, while a 75 N or 700 N axial load was applied (Fig.
1). The 75 N load was defined asunloaded state, chosen to simulate the
toe-touch weightbearing; this allowed the feet to sit flat and not claw.
The axial loading of 700 N, defined as loaded state, was selected to rep-
licate single-legged stance of a 70 kg person (Knupp et al., 2011;
Thordarson et al., 1995).
The PL tendons were isolated proximally and secured with a metal
tendon grasper and sutures (Fig. 2). The grasper was held by a rope
running through a pulley and pulling the tendons was simulated by
hanging a 15 kg weight on the rope. A set-up with the feet flat was de-
signed because the PL is active in foot flat position during gait
(Louwerens et al., 1995). In prototype testing, a 15 kg weight provided
enough force to visibly plantarflex the first ray during 700 N of axial
loading without causing rupture of the cadaveric tendon (Fig. 3).
Neutral foot position was defined as aligning the tibial crest and sec-
ond metatarsal with the top of the CT gantry. Clinical CT scanning was
performed in toe-touch (75 N), under 700 N loading, and with a 15 kg
weight on the PL tendon. The tendon-actuated scans were performed
under loaded condition (700 N).
Fig. 2. Picture of the isolated Peroneus Longus tendon with metal grasper and sutures.
Fig. 3. Picture of the set-up for axial loading and scanning including the weight hung from
the PL tendon.
Measurements in the coronal plane using the CT scans included the
first metatarsal rotational angle, which is a novel way of measuring and
was defined as the angle made up by the lateral cortex of the first
metatarsal and the horizon. For this purpose, the triangular base of the
first metatarsal on the coronal reformats was first identified. Then a line
was drawn parallel to the lateral cortex and another line parallel to the
horizon. The angle should open to the lateral edge of the foot (Fig. 4).
The intermetatarsal angle between the first and second metatarsal bone
was measured in the transverse plane (Fig. 5) (Spinner et al., 1984).
The measurements in the sagittal plane included first TMT joint sub-
luxation and lateral tarso-first metatarsal angle or Meary's angle. The
joint subluxation was measured by finding the CT slide in the sagittal
plane where the first TMT joint was the widest. The length of each side
of the joint was measured and its centre was marked. Then the vertical
distance between these two centre points was measured thus defining
the first tarsometatarsal joint subluxation (Fig. 6). A negative value indi-
cates dorsal translation of the metatarsal to the cuneiform bone, whereas
a positive value indicates plantar translation of the metatarsal.
To measure the Meary's angle, the sagittal planes of the images were
checked for cut(s) that demonstrated the axis of the talus and first
metatarsal best. As this was not always a single cut, the angles between
the horizon and the axis of the talus and the first metatarsal were re-
corded on the respective slices, and then these two angles were
subtracted to obtain the true talotarsal (Meary's) angle (Figs. 7 and 8).
Fig. 4. Measurement of the first metatarsal rotational angle in an exemplified specimen
(88.54°).
 K. Dullaert et al. / Clinical Biomechanics 34 (2016) 7–11
Fig. 5. Measurement of the intermetatarsal angle in an exemplified specimen (10.23°).
The images were analysed with three-dimensional Multi-Planar Re-
construction (3D-MPR) using image processing software (OsiriX MD,
Pixmeo, Geneva, Switzerland).
All measurements were done by an orthopaedic trauma resident
with attending surgeon guidance.
2.1. Statistical analysis
Statistical analysis was performed using SPSS software package
(version 22, IBM SPSS, Chicago, IL, USA). Data was screened for normal-
ity of distribution applying Shapiro–Wilk test. General Linear Model
Repeated Measures with Bonferroni post hoc test was applied to
Fig. 6. Measurement of the first tarsometatarsal joint subluxation.
9
Fig. 7. Measurement of the lateral angle of the first metatarsal in an exemplified specimen
(17.67°). Notice that the more proximal bones are not visible in this slice.
statistically compare the outcomes in the unloaded specimen's state
75 N, loaded state 700 N, and loaded state 700 N with the PL pulled.
Each measurement was performed twice to create an intra-observer
correlation coefficient by applying Pearson Correlation test. Level of
significance was set at P = 0.05 for all statistical tests.
3. Results
The intra-observer correlations had high coefficients for all measure-
ments: 0.98 (first metatarsal rotation), 0.87 (first metatarsal subluxa-
tion) and 0.92 (intermetatarsal angle). The talus-horizon angle and
the first metatarsal-horizon angle used for the calculation of the Meary's
angle both showed intra-observer correlation coefficients of 0.93.
The addition of an axial load had a significant effect on foot configu-
ration (Table 1). The first metatarsal was translated in plantar direction
in unloaded state (75 N) and weightbearing (700 N) significantly de-
creased this translation (P b 0.01). The Meary's angle, the first metatar-
sal rotational angle and the intermetatarsal angle significantly increased
during weightbearing (P b 0.01, P b 0.01 and P = 0.04, respectively).
The first metatarsal rotational angle significantly increased after
pulling on the PL tendon in loaded state (P b0.01, Table 2). There was
a trend toward significance in restoring the first tarsometatarsal sublux-
ation to the unloaded state after pulling on the PL tendon (P = 0.07).
Pulling the PL tendon was unable to restore the Meary's angle (P =
0.52). There was a significant decreasing effect of pulling the PL tendon
on the intermetatarsal angle trending toward the unloaded state
(P b 0.01).
4. Discussion
In the current study we were able to demonstrate a significant differ-
ence in the position of the medial longitudinal arch and first TMT joint
Fig. 8. Measurement of the lateral angle of the talus in an exemplified specimen (28.72°).
10 K. Dullaert et al. / Clinical Biomechanics 34 (2016) 7–11

Table 1
Effect of weightbearing on foot configuration (SD = standard deviation).
Mean foot configuration Measurement
Unloaded state Loaded state
Mean (SD) Mean (SD)
Meary's angle (°) (normal b10° 6.84 (6.11) 9.16 (7.09)
(Chi et al., 1999; Pedowitz
and Kovatis, 1995))a
First metatarsal rotation (°) 84.8 (12.49) 87.69 (11.32)
First TMT joint subluxation (mm) 2.79 (1.40) 2.21 (1.47)
Intermetatarsal angle (°) 11.33 (3.26) 12.61 (3.28)
(normal b9° (Hardy and
Clapham, 1951; Steel
et al., 1980))a
†
P values reflecting the difference between unloaded and loaded state.
a
Note: the normal values from in vivo measurements.
that was created under weightbearing. These findings are consistent
with other clinical studies where radiokinematic and pedobarographic
analyses using both radiographs and multiplanar imaging detected in-
fluence of weightbearing on such outcomes (Dietze et al., 2013;
Haleem et al., 2014). This reinforces our belief in the clinically relevant
design of the current study.
The behaviour of the first TMT joint was also interesting in this
study. There is a significant amount of translation that occurs under
weightbearing, even in a specimen without obvious first ray pathology.
Actuation of the PL did appear to pull the first TMT joint subluxation
back toward its unloaded state, although without reaching statistical
significance. The rotation worsened, however, which is not surprising
given the off-axis line of pull. The rotating effect of pulling the PL on
the medial column in the frontal plane was also described by Johnson
and Christensen (1999). These authors hypothesised that the eversion
of the PL is “locking” of the first ray against the rest of the foot.
Although none of our specimens had obvious flatfoot deformity, we
did see an increase in Meary's angle with the addition of weightbearing.
This did not decrease with PL actuation as we would expect, but showed
a tendency to further increase the angle. This is in contrast to the hy-
pothesis that the PL might be a dynamic stabilizer of the longitudinal
arch (Bierman et al., 2001). Kokubo et al. showed that activation of
the PL resulted in a decreased foot stiffness and increased the energy
stored in the foot (Kokubo et al., 2012). Otis et al. showed the effect
the PL has on both the Chopart joint and subtalar joint (Otis et al.,
2004). Taking into account this data and our results we may consider
that the PL stabilizes the TMT joint while destabilizing the hindfoot.
The lessening effect of the PL actuation on the intermetatarsal angle
was significant, appearing to correct the angle to the unloaded state.
Faber et al. found a stabilizing effect of the PL on the first TMT joint
with a much smaller amount of force (Faber et al., 1999). The implica-
tions of the findings trending toward stabilization with worsened rota-
tion, specifically regarding hallux valgus pathology, are interesting. One
of the less discussed deformities in hallux valgus is rotation of the first
metatarsal (Dayton et al., 2013). The first ray everts in this pathology,
and, according to our results, the PL actuation appears to apply a
deforming force, yet at the same time another characteristic of the
Table 2
Effect of tendon pulling on foot configuration (SD = standard deviation).
Measurement
hallux valgus, the intermetatarsal angle, is corrected by pulling the PL.
This could be an argument for concomitant first TMT joint arthrodesis
P value† during hallux valgus correction, even in patients without obvious first
TMT joint instability in the sagittal plane. The findings of Bierman
et al. support this by describing an increased efficiency of the PL acting
on the medial column in cadaveric feet treated with Lapidus arthrodesis
b0.01
(Bierman et al., 2001).
Our data suggests that when assessing the quantity of first TMT joint
b0.01 mobility in clinical daily practice the function of the PL should also be
b0.01 taken into account.
0.04
Furthermore, the findings of the current study may help in implicat-
ing a conservative treatment protocol for hallux valgus with strengthen-
ing the PL to restore medial column stability.
Our experimental design has some limitations inherent to all cadav-
eric studies. The normal values in Table 1 are from in vivo
measurements whereas our measurements are not. The role of
weightbearing imaging has already been validated in several studies
(Ananthakrisnan et al., 1999; Arangio et al., 2006; Chadha et al., 1997;
Perry et al., 1992; Saltzman et al., 1994; Younger et al., 2005) although
this was performed in clinical setting. A standardized axial load of
700 N is idealized single-legged stance weightbearing; as we had speci-
mens from just several female and male donors, this is not a true repre-
sentation of the load observed in each one individual specimen in vivo.
We did not have time-of-death weight or height of the donors, so this
could not be accommodated for. Nevertheless, the added value of this
study is the investigation of the change in foot alignment in both loaded
and unloaded states, with the addition of a selected tendon influence.
Another limitation of this study is the method of tendon actuation. A stat-
ic pull of 15 kg on the tendons in isolation is a gross underestimation of
the complex, dynamic balance of the forces seen around the foot during
ambulation. Although the deformation seen with the addition of the
weight was consistent with the known action of the PL tendon, the
benefit of the current design is that we were able to study the impact
of this tendon in isolation, which is not feasible in an in vivo study.
5. Conclusions
The current study demonstrates in an ex vivo study model the signif-
icant effect weightbearing has on the medial longitudinal arch and first
TMT joint positions. Pulling the PL tendon improved the first TMT joint
sagittal plane subluxation and intermetatarsal angle, but ‘worsened’ the
first metatarsal rotation and did not reconstitute the arch. While clinical
investigation is needed, the present study raises concern about persis-
tent rotational deformity of the first metatarsal following hallux valgus
correction that does not incorporate first TMT joint arthrodesis and calls
into question the importance of the PL tendon in maintaining the longi-
tudinal arch during stance.
Acknowledgements
The authors were fully involved in the study and preparation of the
manuscript. They are not compensated and there are no other
institutional subsidies, corporate affiliations or funding sources
supporting this work unless clearly documented and disclosed. This
investigation was performed with the assistance of the AO Foundation
via the AOTRAUMA Network (Grant No.: AR2014_02).

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