C h ro n i c R u p t u re o f th e

P e ro n e a l Ten d o n s
a, b
Kamran S. Hamid, MD, MPH *, Annunziato Amendola, MD

KEYWORDS
 Chronic rupture  Peroneal tendons  Surgical solutions

KEY POINTS
 Chronic rupture of the peroneal tendons can be a functionally limiting condition with a
multitude of causes.
 Conservative and operative interventions are heterogenous and tailored to the functional
demands of the patient.
 Surgical plans are based on muscle viability, patient preference, and surgeon expertise.
 Clinical outcomes evidence remains limited in this domain, and further well-designed
studies are warranted to guide treatment.

INTRODUCTION

Chronic rupture of the peroneal tendons may be the result of a neglected injury,
chronic inflammatory changes, or the sequela of longstanding tension or friction
that subjects the peroneal tendons to excessive stress leading to tendinopathy and
subsequent discontinuity.13 Abnormality can occur at the peroneus longus, peroneus
brevis, or both tendons. A meticulous history, thorough physical examination, and
appropriate diagnostic testing are imperative to identify the cause of this condition.
Conservative and operative interventions are heterogenous and tailored to the func-
tional demands of the patient.
Clinical Presentation
Patients with chronic ruptures of the peroneal tendons present with difficulty in hind-
foot eversion, pain, swelling, and functional instability. Plantarflexion of the first ray or
pivoting or ankle and dorsiflexion at the ankle may prove difficult as well. Pain along
the plantar aspect of the foot may indicate peroneus longus rupture or tendinopathy.
History taking should attempt to elicit possible pathologic causes, including history of
fluoroquinolone usage, steroid injection, prior trauma, infection, antecedent pain and
swelling, chronic dislocating tendons, wearing out of lateral border of shoes due to

The authors have nothing to disclose.

a
Rush University Medical Center, 1611 West Harrison Street, Chicago, Illinois 60612, USA;
b
Duke University Medical Center, 4709 Creekstone Dr, Durham, NC 27703, USA
* Corresponding author.
E-mail address: kamranhamid@gmail.com

Foot Ankle Clin N Am - (2017) --

http://dx.doi.org/10.1016/j.fcl.2017.07.011 foot.theclinics.com
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2 Hamid & Amendola

foot position, and previous surgery.2 Chronicity of symptoms is important to ascertain

as prolonged disuse of lateral compartment musculature may lead to fatty atrophy and
less utility of operative tendon salvage. History taking may have sensitivity but lacks
specificity because there is a great amount of overlap with chronic peroneal tendinop-
athy without rupture. Severity of weakness is the most notable distinguishing factor,
although this may be confounded by pain.
Physical examination should begin with visual assessment of lower extremity align-
ment. Visual assessment requires observing the patient preferably in shorts with knees
visible. Varus tensioning is commonly the underlying factor and may be secondary to
ankle or subtalar malalignment, supramalleolar deformity, or varus angulation at the
level of the knee. Tenderness and edema may be noted over the trajectory of the pe-
roneals. In addition to standard strength testing, special attention should be paid to
discern weakness in resisted ankle eversion and resisted first ray plantarflexion as
compared with the contralateral limb. During resisted strength testing, the peroneals
should be palpated for continuity. Single-leg balance and heel raise often prove painful
and challenging. The patient may concomitantly have abnormality of the lateral ankle
ligamentous complex with generalized instability in this region.

Diagnostic Imaging
Plain film assessment should be undertaken to identify any confounding abnormalities,
such as arthritic disease, fracture, or nonunion. A lateral radiograph can prove valuable
for identifying a proximally migrated os peroneum in the case of peroneus longus
rupture or os peroneum fracture.4 In addition to foot films, ankle radiographs and hind-
foot alignment films are necessary to identify malalignment in the supramalleolar, ankle,
or subtalar locations. Similarly, knee radiographs may be indicated when knee mala-
lignment is suspected. MRI has limitations in peroneal tendon assessment because
the tendons have a curvilinear course at the level of the distal fibula, subjecting them
to magic angle phenomenon, which can belie the true integrity of these tendons.5
With advanced disease, MRI will be useful to demonstrate the extent of abnormality.
There may be a role for MRI in plantarflexion to mitigate the effect of this phenomenon
and lessen artifact. The authors advocate for proximal extension of the MRI beyond the
ankle so as to identify any fatty infiltration of the peroneal muscle belies in cases of sus-
pected chronic rupture. Ultrasound is a powerful tool for assessment of the peroneal
tendons, although its utility is correlated with operator skill and familiarity.6

TREATMENT OPTIONS
Conservative Management
Treatment plans should be decided upon after engaging in the shared decision-
making process with the patient and germane family members. Functional demands,
pain level, and the patients risks of surgery should all be considered. Nonoperative
management may have a limited role in true chronic peroneal rupture but can be indi-
cated in the appropriate patient. Patients with lower functional demands and higher
relative risk of surgical complications may be candidates for a period of immobilization
followed by physical therapy and bracing.1 If flexible heel varus exists secondary to a
dropped first ray, then custom orthoses with lateral forefoot posting to maintain the
heel in neutral may prove helpful.

Two-Cable Surgical Solutions

In cases with limited muscular fatty infiltration and preserved motor function, the
impetus to proceed with surgery is heightened in order to optimize outcomes.
 Chronic Rupture of the Peroneal Tendons 3

Tenodesis between the peroneals is a time-tested procedure with satisfactory

results7; however, there has been a contemporary push toward preservation of native
kinematics by conserving the independence of both peroneus longus and brevis ca-
bles. Multiple techniques have been described to facilitate this end.
The use of a Hunter rod was originally described in 1971 for 2-stage reconstruction
of tendons in the hand.8 A similar method in the ankle uses the temporary Hunter rod
implant to generate a healthy peroneal tendon sheath to host a flexor hallucis longus
(FHL) tendon transfer. This method of creating a healthy biologic membrane using a
foreign body is akin to the Masquelet technique espoused by traumatologists for
2-stage segmental bone loss management.9 Because of the rarity of this abnormality,
clinical outcomes research is limited and often relegated to case series. Wapner and
colleagues10 demonstrated good results with the 2-stage reconstruction in 6 out of 7
patients undergoing the procedure at an average of 8.5-years follow-up.
Although the aforementioned technique avoids tenodesis, FHL transfer limits a true
attempt at preserving natural kinematics. Spanning the gap between tendon ends af-
ter debridement may be conducted in multiple ways. Rapley and colleagues11 used an
acellular dermal matrix to span the tendinous gap and found improvement in American
Orthopaedic Foot & Ankle Society score, pain, and function in a cohort of 7 patients
requiring a gap jump. Per the investigators, eversion strength improved to within
half a motor grade as compared with the contralateral limb on average. Four additional
patients underwent debridement with acellular dermal matrix wrapped as an augment
but did not have true chronic rupture gap abnormality. Follow-up averaged
16.9 months in this series; thus long-term functionality is uncertain.
Mook and colleagues12 evaluated 14 patients with peroneus longus and tendon rup-
tures requiring reconstruction of both. Mean follow-up was similar to Rapley and col-
leagues11 at 17 months. The average length of the intercalary segment reconstructed
was 10.8 cm, and average postoperative visual analogue score decreased to 1.0.
Average postoperative eversion strength as categorized by the Medical Research
Council grading scale improved to 4.8  0.5 (P 5 .001). The average Short Form-12
score improved to 48.8  7.8 (P 5 .02). Four patients experienced sural nerve sensory
numbness, and 2 of these were transient. There were no postoperative wound healing
complications, infections, tendon reruptures, or reoperations. No allograft-associated
complications were identified. All 14 patients returned to their preinjury activity levels.
A similar technique with autologous free graft from the peroneus brevis to longus with
plantaris augment has been described in a case report13.

One-Cable Surgical Solutions

In instances of chronic rupture-induced muscular atrophy and fatty degeneration,
preservation of both peroneus longus and brevis function may not be feasible, and
tenodesis is preferred. Patient and surgeon preference may also be indications for
tenodesis because it is a time-tested procedure. Tenodesis involves debridement of
nonviable tissue and anastomosis of the discontinuous tendon to the healthy tendon.
Although tenodesis is a commonly used procedure in the setting of chronic peroneal
rupture, this technique is extrapolated from its usage for large peroneal tears.14,15 The
external validity of these studies as related to this distinct abnormality is unvalidated.
There are no case-control or cohort studies comparing allograft reconstruction to
tenodesis in the literature at this time. Pellegrini and colleagues16 demonstrated in a
cadaveric model that allograft reconstruction of a peroneus brevis tendon restored
distal tension when the peroneal tendons and their antagonists were loaded to 50%
and 100% of physiologic load. In contradistinction, tenodesis of the brevis to the per-
oneus longus tendon did not effectively restore peroneus brevis tension under
4 Hamid & Amendola

comparable tested conditions. The investigators hypothesized that tenodesis may

thus result in an imbalanced foot, although this assertion has not been clinically veri-
fied. Tenodesis takedown and conversion to dual allograft reconstructed peroneals
have been promoted as a technique but without objective outcome measures as
evidence.17

CLINICAL CASE

A 63-year-old male surgeon presented with several months of left posterolateral ankle
pain and swelling that had worsened recently and is now functionally limiting in ever-
sion and dorsiflexion. He denies fluoroquinolones, steroid usage, or an injury mecha-
nism. Upon examination in the clinic, the patient has genu varum bilaterally that is
more pronounced on the left and reflected in standing leg length radiographs
(Fig. 1). The patient has 1/5 strength in eversion, 3/5 strength in dorsiflexion, inability
to plantarflex the first ray, and tenderness over the peroneals. MRI demonstrated
chronic rupture abnormality of the peroneus longus tendon, attrition of the peroneus
brevis, with peroneal sheath edema (Fig. 2).
After exhausting conservative treatment modalities, the patient opted for surgical
intervention in a staged manner to correct his mechanical alignment and address
his rupture abnormality. After high tibial osteotomy to correct genu varum, the patient
underwent peroneal exploration. Intraoperatively, a ruptured and edematous pero-
neus longus tendon was identified. There was significant attrition of the peroneus bre-
vis (Fig. 3). The nonviable portion of the ruptured ends was debrided, leaving an 8-cm
gap distance (Fig. 4). A tibialis anterior allograft was used to bridge the gap in some

Fig. 1. Standing leg length films demonstrate pronounced left lower extremity genu varum
and deviation from the mechanical axis.
 Chronic Rupture of the Peroneal Tendons
Fig. 2. Coronal MRI sequences demonstrating ruptured left peroneus longus rupture (A) and edema as compared with brevis (B). Arrows point to the
diseased peroneus longus and brevis tendons.

5
6 Hamid & Amendola

Fig. 3. Edematous remnant of chronic ruptured peroneus longus.

Fig. 4. Peroneus longus debrided and left with 8-cm gap distance.

Fig. 5. Tenodesis of peroneus longus to brevis tendon.

 Chronic Rupture of the Peroneal Tendons 7

Fig. 6. Repair of sheath and retinaculum to prevent subluxation and facilitate gliding.

tension, and the longus tendon and graft were tenodesed to the brevis tendon (Fig. 5).
The peroneal sheath and retinacular layers were tightly repaired to facilitate gliding
and prevent subluxation or dislocation (Fig. 6). At long-term follow-up, the patients
pain and function both improved to allow excellent function as a surgeon and in his
recreational life.

SUMMARY

Chronic rupture of the peroneal tendons can be a functionally limiting condition with a
multitude of causes. Conservative and operative interventions are heterogenous and
tailored to the functional demands of the patient. Surgical plans are based on muscle
viability, patient preference, and surgeon expertise. Clinical outcomes evidence re-
mains limited in this domain, and further well-designed studies are warranted to guide
treatment.

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