World Journal of Orthopedics

Peroneus longus tendon rupture: A case report

Don Koh, Lincoln Liow, Joseph Cheah, Kevin Koo

Abstract
BACKGROUND

Peroneal tendinopathies are an under-diagnosed and potentially under-treated

pathology. If left untreated it can be a cause of chronic lateral hindfoot pain. Its
diagnosis is challenging owing to its low incidence and vague clinical presentation.

CASE SUMMARY

We share a case of a patient who experienced a chronic lateral ankle pain

exacerbated after alighting from a bus. This patient came to our attention only after
failing conservative management on two separate occasions. Plain radiographs and
magnetic resonance imaging revealed rupture of the peroneus longus tendon (PLT).
Findings were confirmed intra-operatively and tenodesis of the PLT to the peroneus
brevis was performed. Patient was kept non-weight-bear with his foot everted and in
plantarflexion before being converted to an offloading boot at two weeks. Patient
was started on a progressive rehabilitation programme at six weeks and was able to
return to work shortly after with excellent outcomes.

CONCLUSION

We aim to share our experience in managing this patient and propose some pointers
guided by available literature to avoid missing this commonly overlooked pathology.

Key words: Chronic lateral ankle pain; Peroneus longus rupture; Peroneal
tendinopathy; Tenodesis; Diagnostic challenge; Case report
INTRODUCTION

Ruptures of the peroneus longus tendon (PLT) are rare. The mechanism of injury is
due to a combination of mechanical and anatomical factors. The peroneus longus
undertakes a tortuous course from its origin at the proximal tibia and fibula to its
insertion at the first metatarsal and medial cuneiform. The tendon travels within the
posterior fibula groove, passes under the peroneal tubercle of the calcaneus and
bends sharply along the cuboid groove before inserting medially at the base of the
first metatarsal. These sites are potential sources of attrition[ 1] and avascularity[ 2- 4].
Incompetence of the superior peroneal retinaculum over the fibula groove can
[1,3]
predispose PLT subluxation . Varus deformities of the hindfoot or lateral ankle
ligamentous laxity can subject the PLT to increased tension and frictional forces at
transitional points described above[3]. In addition, anatomical variability such as the
presence of an os peroneum in approximately 20% of the population may predispose
to PLT rupture[5-9].

PLT pathologies can present acutely or insidiously, typically presenting with chronic
pain. Patients who are able to relate an initiating injury are defined as acute; whilst
patients who were unable to are classified as chronic[ 6, 10]. Non-surgical management
rarely yield acceptable outcomes[11,12]. Due to the PLT’s role in mid and hindfoot
stability, surgical correction is often warranted with most authors achieving
reproducible results. Timely intervention yields best results[6,10].

Its incidence remains ill-defined and the condition has only been described in case
series or cadaveric studies. Dombek et al[12] documented 5 cases of isolated peroneus
longus tears in their series of 40 patients with peroneus tendon pathologies. In
contrast, Sobel et al[13] did not report any PLT ruptures in a cadaveric study of 124
ankles. Due its low incidence, peroneus tendon pathologies are often overlooked and
often misdiagnosed. The duration between injury and diagnosis of PLT tear ranges
from 6 to 48 mo[ 6, 10, 12]
. In addition, the ambiguity of its symptoms makes PLT
pathologies a diagnostic challenge. In the largest retrospective study available, only
60% of peroneal tendon injuries were accurately diagnosed on initial consult [12].
Prudent history-taking, adequate examination and appropriate investigations cannot
be overemphasized. We aim to share our experience managing a case of PLT rupture
and strive to highlight the diagnostic challenges involved in this unique case.

CASE PRESENTATION

Chief complaints

A 51-year-old male flight attendant complained of chronic lateral ankle pain without
prior trauma or twisting injury.

History of present illness

Three-month history of left lateral ankle pain. He sought treatment at other

Orthopaedic centres but failed conservative management on two separate occasion.
He subsequently presented to our care after he exacerbated his lateral ankle pain and
heard a “click” whilst alighting from a bus. He denied any traumatic or inversion
injury.

History of past illness

Known history of gout and previous left total hip replacement secondary to left hip
avascular necrosis.

Personal and family history

None.

Physical examination

On clinical examination, he presented with an antalgic gait, swelling and tenderness

over the posterolateral hindfoot. He demonstrated weakness in eversion
Laboratory examination

Not performed.

Imaging examination

Radiograph of the left foot showed a proximally displaced os peroneum compared to

contralateral foot (Figures 1 and 2). Peroneal tendon pathology was suspected and
magnetic resonance imaging (MRI) of the left foot revealed a full-thickness rupture
of the PLT distal to the os peroneum with underlying tenosynovitis (Figure 3).

FINAL DIAGNOSIS

Full-thickness rupture of the PLT with underlying tenosynovitis.

TREATMENT

Surgical repair of the PLT was performed 4 wk after injury. Patient was positioned
lateral with a thigh tourniquet applied. Incision was centred over the os peroneum
and made from the left fibula tip to the base of the fifth metatarsal (Figure 4). The os
peroneum was identified and excised. Unhealthy portions of the PLT and devitalized
synovium were debrided. Proximal and distal ends of the PLT was mobilised and the
defect was measured (Figure 4F). During surgery, a 1.5 cm longitudinal split of the
peroneus brevis was noted and was repaired viatubularisation using vicryl sutures
(Figure 4G). Side-to-side tenodesis of the PLT to the peroneus brevis tendon was
performed using size 2-0 braided polyethylene sutures (ULTRABRAID Suture,
Smith and Nephew, York, United Kingdom). The wound was irrigated with normal
saline and hemostasis was performed. Layered closure was performed and a backslab
was applied over the operated foot, keeping it in plantarflexion and eversion.

OUTCOME AND FOLLOW-UP

Patient was discharged on post-operative day one and was kept non-weight bear on
the operated leg. Follow up was done in the outpatient setting at two weeks and six
weeks post-operatively. At two weeks, the wound was inspected, skin sutures
removed. The backslab was converted to a tall-aircast with heel wedges for the next
four weeks and the patient was allowed to perform partial weight-bearing. At six
weeks after surgery, patient was allowed full weight-bearing on the aircast and
started on a rehabilitation programme aimed at improving range of motion and
strength through stretching and isometric exercises.

At three months after surgery, patient demonstrated excellent clinical outcomes

(Table 1) with significant improvements in American Orthopedic Foot and Ankle
Score, visual analogue pain score as well as the Physical Component Score. He was
allowed full weight bearing on normal footwear and returned to ground duties at the
airport. At 6 mo, he had returned to sport and was allowed to return to flying duties.
This patient continued to demonstrate excellent clinical outcomes at 12 mo post op
(Table 1).

DISCUSSION

In a patient with posterolateral hindfoot tenderness and swelling refractory to

conservative management, peroneal tendon pathology should be considered. A
thorough history detailing the initial injury, exacerbating symptoms, evidence of
instability or clicking should be elicited. Associated conditions such as rheumatoid
arthritis, neuropathies, gout, local steroid injections and known ankle pathologies
(e.g., enlarged peroneal tubercle) can predispose peroneal tendinopathy[14-18].

The presence of cavovarus or hindfoot varus may increase peroneal tendon tension
and increase risk of rupture due to the unopposed action of the posterior tibialis.
Physical examination, in particular, palpation should be focused along the course of
the peroneal tendons. Common sites of discomfort and swelling include
posterolateral hindfoot, cuboid groove and insertion site over at the plantar and
medial aspect of the Foot[3]. Eversion weakness should increase clinical suspicion of
PLT pathology as the peroneal tendons contributes to 63% of eversion strength - with
the peroneus longus contributing more than peroneus brevis[19] . However, it must be
noted that the absence of weakness doesn’t preclude peroneal tendinopathy.
Tenderness on active eversion, passive inversion or during plantarflexion of first ray
may also suggest peroneal tendinopathy with the latter specific for the peroneus
longus. Lateral ankle ligamentous laxity should also be assessed to rule out
concomitant anterior-talofibular ligament (ATFL) incompetence.

Despite having a known history of gout, our patient did not require pharmacological
control for his condition and denied any previous local steroid injections. Extra-
articular tophaceous gout can predispose to PLT tendinopathy but rarely involves
peroneal tendons. To date, there have only been two documented cases of PLT
tendinopathy secondary to gout. De Yoe et al[17] described a patient with peroneus
brevis tendon rupture and ATFL attenuation secondary to gouty infiltration. Radice
et al[16] reported longitudinal tears of both peroneus longus and brevis tendons caused
by urate crystal deposition. In our patient, intra-operative findings revealed no gouty
infiltration.

Imaging investigations should be guided by clinical findings. Appropriate initial

investigations involves weight-bearing anteroposterior, lateral and oblique views of
affected foot (Figure 1). Although not routinely performed, the contralateral foot
should be imaged in suspected PLT pathologies as it will be helpful in detecting
subtle anatomical differences (Figure 2). In our patient, fracture of the os peroneum
resulting in proximal migration of the os is pathognomonic of PLT ruptures. This is
best seen on oblique and lateral views. There are numerous cases documenting the
association of an os peroneum with PLT tears[5-9]. Some authors however disagree,
reporting the lack of association in their series [3,6]. In addition, the oblique foot view
also enables assessment of the peroneal tubercle. Enlargement of the peroneal
tubercle alters biomechanics of the peroneus longus and is associated with tears of
the PLT [20,21]. In our patient, the peroneal tubercle was not enlarged.

Ultrasound of the peroneal tendons allow for dynamic assessment, particularly useful
in examining peroneal tendon subluxation. It has been shown to provide 90% to 94%
diagnostic accuracy of peroneal tendon tears with excellent sensitivity and specificity
[22,23]
. MRI is also widely employed, especially since the clinical presentation of PLT
can be difficult to diagnose initially[6]. T2-weighted images allow detection of
tendinosis or oedema within the tendons. However, there are a high rate of false
positives and false negatives attributed to signal artefacts[10,24,25]. O’Neil et al[26]
believes that the magic angle effect takes place as the PLT curves postero-inferiorly
around the lateral malleolus - mitigatable through plantarflexion of the foot[26].

In minimally symptomatic patients without ankle instability or loss of function, a

trial of conservative management can be offered. Non-surgical treatment protocols
are poorly defined but consist of non-steroidal anti-inflammatory medication, rest,
orthosis or immobilisation with a short leg cast. Graded rehabilitation programs
aiming to increase flexibility and strength are normally started two to four weeks
post-immobilisation[6,19]. Outcomes with non-surgical management remains poor -
especially for PLT ruptures[6,25]. In a series involving 40 patients with peroneal
tendon tears, 36 patients reported undergoing unsuccessful non-surgical treatment[12].

Surgery is the mainstay of treatment for PLT ruptures. Sammarco proposed surgery
when a trial of non-operative management has been unsuccessful or when an
unstable or varus foot is noted. In the presence of an os peroneum, excision is
indicated before repair is attempted. In the absence of an os peroneum, an MRI is
indicated to identify cause of rupture or concomitant ligamentous or bony injuries[6].

Redfern and Myerson’s algorithm of treatment considers the condition of the

peroneus brevis[25]. Type I lesions occur when both tendons appear grossly intact;
Type II lesions on the other hand occurs when one tendon is torn, whilst the other
tendon remains intact and finally Type III lesions occur when both tendons are torn.
In the case of a PLT rupture with a usable PBT, this is classified as a Type II lesion
in the algorithm and can be managed by tenodesis. Similarly in our patient, the
postdebridement gap was too large (four centimetres) (Figure 4F) and did not allow
for a direct repair despite maximal mobilization of the proximal and distal ends of
the PLT. The use of tendon transfers and autografts have been proposed within
literature, but evidence is limited and mostly employed in concomitant PBT
ruptures[27, 28]. At present, all studies surrounding the management of peroneal tendon
tears or ruptures evolve around Level IV or V evidence and the consensus is that
surgical intervention yields the most consistent and reproducible results.

Rehabilitation post-operatively is crucial in achieving positive outcomes. Most

authors kept patients non-weight bearing for at least two weeks. During this period, a
backslab or hinged boot can be employed to prevent inversion/dorsiflexion which
may disrupt the tendon repair. Between two to eight weeks post-surgery, early
mobilisation is encouraged through the use of an off-loading walker boot. Redfern
and Myerson employs the use of stirrup brace for an additional six weeks and have a
low threshold to extend the use of the boot should there be concerns regarding the
repair or patient compliance[25]. It is at this point that most patients are started on a
range of motion and strengthening rehabilitation programme[3,10,12,19,25].

Peroneal tenosynovitis, tendinosis, subluxation or dislocation, stenosing

tenosynovitis, os peroneum fracture, acute and chronic tendon tears are part of a
spectrum of peroneal tendinopathies. These conditions may co-exist or precipitate
one another. In the case discussed, peroneal tendinosis likely precipitated PLT
rupture. Peroneal tendinopathy was not considered and therefore, inadequate
conservative treatment was prescribed.

We can appreciate the difficulties faced in arriving at this diagnosis. Many other
authors have described similar challenges[6,10,12]. Common differential diagnosis such
as lateral ankle ligament injury, base of 5th metatarsal fractures and sinus tarsi
syndrome are often considered before investigating for peroneal tendinopathy. In
their series of 6 cases, Arbab et al[10] reported requiring an average of 10.8 mo to
achieve diagnosis. Sammarco shared similar findings, with a series of 14 cases
symptomatic between 7 to 48 mo before definitive diagnosis[6]. Patients who present
acutely and receive timely surgical intervention, achieve the best outcomes. It is
therefore essential to diagnose these peroneal tendinopathies early so that appropriate
treatment can be commenced promptly. We propose an investigation pathway when
reviewing patients with lateral ankle discomfort (Figure 5). Paramount to this is an
astute clinical history and examination as well as focused radiographic investigations
of the affected ankle and foot. Most differential diagnosis of lateral ankle pain can be
ruled out at this juncture. In the event of raised clinical suspicion, radiographic
presence or displacement of the os peroneum, persistent symptoms or the absence of
a clear diagnosis - early MRI is warranted.

Tenodesis of the proximal stump of the ruptured peroneus longus to the intact
peroneus brevis is a useful technique allowing for early return to activity as well as
excellent post-operative clinical outcome (Table 1). More studies are required to
further evaluate this technique as well as compare clinical outcomes against other
techniques available within literature.

CONCLUSION

PLT ruptures are rare and form part of a spectrum of peroneal tendon pathologies
that is being increasingly recognized today. This case demonstrates how elusive
diagnosing peroneal tendon pathology is - especially when it is rarely considered. We
shared our experience in promptly diagnosing and surgically treating this patient.
Tenodesis of the peroneus longus to the peroneus brevis is a useful technique in the
management of peroneus longus ruptures. We achieved excellent early clinical
outcome measures that remained excellent 12 mo after surgery.
Figure 1 Initial weight bearing radiographs of the injured foot.A: Weight-bearing
dorsoplantar view of left foot showing well-defined bony fragment (white arrow)
lateral to the anterior left calcaneum; B: Left lateral weight-bearing views shows a
bony fragment at the level of the calcaneum; C: Left oblique view. White arrow
shows the absence of the os peronuem at its usual anatomical. Instead, it was
displaced proximally to the level of the anterior calcaneum process.

Figure 2 Comparing radiographs of bilateral oblique foot views.A: Weight-bearing

oblique view of left foot show a bony fragment lateral to the anterior left calcaneum;
B: Shows the position of the undisplaced os peroneum on the right foot. The
displaced os peroneum over the left foot is better appreciated when compared against
the contralateral foot

Figure 3 Magnetic resonance imaging of left foot.A: (Coronal) Peroneal

tenosynovitis; B: (Coronal) Both peroneal tendons run within a flat peroneal groove
with intact superior peroneal retinaculum. No fixed lateral subluxation of the
peroneal tendons; C, D: (Sagittal view). Five millimeter os peroneum within the
peroneus longus tendon (PLT), with full-thickness rupture of the PLT. The tear
measures 2 cm in length, with proximal migration of the tendon at the level of the
cuboid bone.

Figure 4 Intra-operative images. A: Lateral position adopted with a thigh tourniquet

applied; B: Incision was made from the left fibula tip to the base of the fifth
metatarsal - centred around the os peroneum; C: The os peroneum was identified and
excised and unhealthy tendon and devitalised synovium were debrided; D: The sural
nerve was identified and protected during the surgery; E and F: Proximal and distal
ends of the peroneus longus tendon (PLT) was mobilised and defect gap measured;
G: The longitudinal split tear in the peroneus brevis was repaired; H: Sideto-side
tenodesis of the PLT to the peroneus brevis tendon was performed.
Table 1 Significant improvement in clinical outcome scores at 6 mo after surgery
(excellent results were maintained at 12 mo after surgery)

AOFAS: American Orthopedic Foot and Ankle Score

Figure 5 Investigative pathway when approaching patients with lateral ankle

discomfort.a At this juncture, most differential diagnosis can be ruled out with astute
b
clinical and radiological findings; Early magnetic resonance imaging ankle is
warranted should there remain a strong clinical suspicion, persistently symptomatic
patient and even the absence of a definitive diagnosis.

REFERENCES

1. Brandes CB, Smith RW. Characterization of patients with primary peroneus

longus tendinopathy: a review of twenty-two cases. Foot Ankle Int2000; 21:
462-468 [PMID: 10884103 DOI: 10.1177/107110070002100602]
2. Petersen W, Bobka T, Stein V, Tillmann B. Blood supply of the peroneal
tendons: injection and immunohistochemical studies of cadaver tendons. Acta
Orthop Scand2000; 71: 168-174 [PMID: 10852323DOI: 10.1080/0001647
00317413148]
3. Selmani E, Gjata V, Gjika E. Current concepts review: peroneal tendon
disorders. Foot Ankle Int 2006; 27: 221-228 [PMID: 16539908DOI:
10.1177/107110070602700314]
4. van Dijk PA, Madirolas FX, Carrera A, Kerkhoffs GM, Reina F. Peroneal
tendons well vascularized: results from a cadaveric study. Knee Surg Sports
Traumatol Arthrosc2016; 24: 1140-1147 [PMID: 26740089DOI:
10.1007/s00167-015-3946-4]
5. Cachia VV, Grumbine NA, Santoro JP, Sullivan JD. Spontaneous rupture of the
peroneus longus tendon with fracture of the os peroneum. J Foot Surg1988; 27:
328-333 [PMID: 3225393]
6. Sammarco GJ. Peroneus longus tendon tears: acute and chronic. Foot Ankle
Int1995; 16: 245-253 [PMID: 7633579DOI: 10.1177/107110079501600501]
7. Patterson MJ, Cox WK. Peroneus longus tendon rupture as a cause of chronic
lateral ankle pain. Clin Orthop Relat Res1999; 365: 163-166 [PMID:
10627700DOI: 10.1097/00003086-199908000-00021]
8. Blitz NM, Nemes KK. Bilateral peroneus longus tendon rupture through a
bipartite os peroneum. J Foot Ankle Surg2007; 46: 270-277 [PMID:
17586440DOI: 10.1053/j.jfas.2007.03.006]
9. Stockton KG, Brodsky JW. Peroneus longus tears associated with pathology of
the os peroneum. Foot Ankle Int2014; 35: 346-352 [PMID: 24505044DOI:
10.1177/1071100714522026]
10. Arbab D, Tingart M, Frank D, Abbara-Czardybon M, Waizy H, Wingenfeld C.
Treatment of isolated peroneus longus tears and a review of the literature. Foot
Ankle Spec2014; 7: 113-118 [PMID: 24381076DOI: 10.1177/193864001351
4273]
11. Smith JT, Johnson AH, Heckman JD. Nonoperative treatment of an os peroneum
fracture in a high-level athlete: a case report. Clin Orthop Relat Res2011; 469:
1498-1501 [PMID: 21328020DOI: 10.1007/s11999-011-1812-3]
12. Dombek MF, Lamm BM, Saltrick K, Mendicino RW, Catanzariti AR. Peroneal
tendon tears: a retrospective review. J Foot Ankle Surg2003; 42: 250-258
[PMID: 14566716DOI: 10.1016/S1067-2516(03)00314-4]
13. Sobel M, Bohne WH, Levy ME. Longitudinal attrition of the peroneus brevis
tendon in the fibular groove: an anatomic study. Foot Ankle1990; 11: 124-128
[PMID: 2131804DOI: 10.1177/107110079001100302]
14. Truong DT, Dussault RG, Kaplan PA. Fracture of the os peroneum and rupture
of the peroneus longus tendon as a complication of diabetic neuropathy. Skeletal
Radiol1995; 24: 626-628 [PMID: 8614867DOI: 10.1007/bf00204867]
15. Goodwin MI, O’Brien PJ, Connell DG. Intra-articular fracture of the calcaneus
associated with rupture of the peroneus longus tendon. Injury1993; 24: 269-271
[PMID: 8325689DOI: 10.1016/0020-1383(93)90186-a]
16. Radice F, Monckeberg JE, Carcuro G. Longitudinal tears of peroneus longus and
brevis tendons: a gouty infiltration. J Foot Ankle Surg2011; 50: 751-753 [PMID:
21816636DOI: 10.1053/j.jfas.2011.06.004]
17. De Yoe BE, Ng A, Miller B, Rockett MS. Peroneus brevis tendon rupture with
tophaceous gout infiltration. J Foot Ankle Surg1999; 38: 359-362 [PMID:
10553550DOI: 10.1016/s1067-2516(99)80008-8]
18. Borland S, Jung S, Hugh IA. Complete rupture of the peroneus longus tendon
secondary to injection. Foot (Edinb)2009; 19: 229-231 [PMID: 20307484DOI:
10.1016/j.foot.2009.07.001]
19. Davda K, Malhotra K, O’Donnell P, Singh D, Cullen N. Peroneal tendon
disorders. EFORT Open Rev2017; 2: 281-292 [PMID: 28736620DOI:
10.1302/2058-5241.2.160047]
20. Burman M. Subcutaneous tear of the tendon of the peroneus longus; its relation
to the giant peroneal tubercle. AMA Arch Surg1956; 73: 216-219 [PMID:
13354112DOI: 10.1001/archsurg.1956.01280020030006]
21. Palmanovich E, Laver L, Brin YS, Kotz E, Hetsroni I, Mann G, Nyska M.
Peroneus longus tear and its relation to the peroneal tubercle: A review of the
literature. Muscles Ligaments Tendons J 2012; 1: 153-160 [PMID: 23738264]
22. Waitches GM, Rockett M, Brage M, Sudakoff G. Ultrasonographic-surgical
correlation of ankle tendon tears. J Ultrasound Med1998; 17: 249-256 [PMID:
9544608DOI: 10.7863/jum.1998.17.4.249]
23. Grant TH, Kelikian AS, Jereb SE, McCarthy RJ. Ultrasound diagnosis of
peroneal tendon tears. A surgical correlation. J Bone Joint Surg Am2005; 87:
1788-1794 [PMID: 16085620DOI: 10.2106/JBJS.D.02450]
24. Erickson SJ, Cox IH, Hyde JS, Carrera GF, Strandt JA, Estkowski LD. Effect of
tendon orientation on MR imaging signal intensity: a manifestation of the
 “magic angle” phenomenon. Radiology 1991; 181: 389-392 [PMID:
1924777DOI: 10.1148/radiology.181.2.1924777]
25. Redfern D, Myerson M. The management of concomitant tears of the peroneus
longus and brevis tendons. Foot Ankle Int2004; 25: 695-707 [PMID:
15566700DOI: 10.1177/107110070402501002]
26. O’Neil JT, Pedowitz DI, Kerbel YE, Codding JL, Zoga AC, Raikin SM.
Peroneal Tendon Abnormalities on Routine Magnetic Resonance Imaging of the
Foot and Ankle. Foot Ankle Int 2016; 37: 743-747 [PMID: 26941162DOI:
10.1177/1071100716635645]
27. Borton DC, Lucas P, Jomha NM, Cross MJ, Slater K. Operative reconstruction
after transverse rupture of the tendons of both peroneus longus and brevis.
Surgical reconstruction by transfer of the flexor digitorum longus tendon. J Bone
Joint Surg Br1998; 80: 781-784 [PMID: 9768886DOI: 10.1302/0301-
620x.80b5.0800781]
28. Seybold JD, Campbell JT, Jeng CL, Short KW, Myerson MS. Outcome of
Lateral Transfer of the FHL or FDL for Concomitant Peroneal Tendon Tears.
Foot Ankle Int2016; 37: 576-581 [PMID: 26912032DOI:
10.1177/1071100716634762]