Peroneus brevis tear
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Peroneus brevis tendon tears are acute or chronic, and may be asymptomatic or associated with lateral ankle pain and/or instability. They commonly occur at the level of the retromalleolar groove.
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Small published case series include patients ranging from 13 to 65 years of age 2,4. Cadaveric studies have shown a prevalence of ~25% (range 11-37%) 6.
Injuries of the peroneus brevis are more common than those of peroneus longus 4,5. Tears of both peroneus tendons simultaneously are less common 5,7.
Small studies suggest that ~50% of peroneus brevis tears diagnosed by imaging are asymptomatic 4.
Most symptomatic tears (~60%) occur following a reported trauma, most often a lateral ankle sprain (60%) 2. However, injury may also occur slowly as a degenerative process without isolated episode 5.
Symptoms can include pain, swelling, and erythema at the lateral ankle which worsens with activity. There is a suspected high rate of peroneal tendon injury in those with chronic ankle instability. There is also an association with systemic conditions e.g. rheumatoid arthritis, diabetes, or local steroid injection 1.
The peroneus brevis tendon is positioned between the peroneus longus tendon and the retromalleolar groove of the fibula, likely predisposing it to injury from mechanical wear, particularly in dorsiflexion.
Traumatic episodes and tendon dislocation can lead to degeneration. Other anatomical variants can predispose to injury:
- insufficiency of the overlying superior peroneal retinaculum
- low-lying peroneus brevis muscle belly or variant peroneus quartus muscle
As the brevis tear develops, the longus tendon moves anteriorly, which further antagonises the injury and prevents healing.
One surgical review stated 40% of those undergoing brevis repair had longus tears at surgery, which are likely secondary to degenerative change following migration 2.
Ultrasound has a high sensitivity (100%) and specificity (85%) for identifying tendon tears 3:
- partial tear: discontinuity and partial retraction of affected tendon fibers with fluid in the sheath, normal appearance proximal and distal to the tear
- longitudinal fissures: two "hemi-tendon" appearance at the apex of the malleolus affecting the deep fibers first
- full-thickness: typical appearance of a rupture
MRI has variable reported accuracy for clinically or surgically confirmed injury, with positive predictive value as low as 48% 2 and sensitivity/specificity as high as 83% and 75%, respectively 7.
MR findings that suggest peroneus brevis tear include:
- morphologic abnormality of peroneus brevis tendon 4:
- complete discontinuity: should be confirmed on at least two planes
- C-shape or "boomerang" appearance: tendon enveloping adjacent peroneus longus tendon
- focal tendon caliber change: should be confirmed on at least two planes
- separation into discrete subtendons
- abnormal tendon positioning: anterior dislocation or subluxation most common 4
- +/- tenosynovitis: most (54%) peroneus brevis tears are associated with fluid signal the tendon sheath, which should be confirmed on multiple planes 4
Treatment and prognosis
Management of symptomatic peroneal tendon tears is initially non-operative, often using anti-inflammatories and rest/immobilization 2,5.
Operative treatment may be considered in those with persistent symptoms or for those with ankle instability with debridement or if required tenodesis to the adjacent peroneus longus tendon.
- normal variant bifurcated peroneus brevis tendon: differentiate by identifying muscle fibers attaching to the tendon slips
- peroneus quartus tendon insertion simulating a tear on imaging
- 1. Wang XT, Rosenberg ZS, Mechlin MB, Schweitzer ME. Normal variants and diseases of the peroneal tendons and superior peroneal retinaculum: MR imaging features. Radiographics : a review publication of the Radiological Society of North America, Inc. 25 (3): 587-602. doi:10.1148/rg.253045123 - Pubmed
- 2. Dombek MF, Lamm BM, Saltrick K, Mendicino RW, Catanzariti AR. Peroneal tendon tears: a retrospective review. The Journal of Foot and Ankle Surgery. 42 (5): 250-258. doi:doi:10.1016/S1067-2516(03)00314-4 - Pubmed
- 3. Molini L, Bianchi S. US in peroneal tendon tear. Journal of ultrasound. 17 (2): 125-34. doi:10.1007/s40477-014-0072-y - Pubmed
- 4. Giza E, Mak W, Wong SE, Roper G, Campanelli V, Hunter JC. A clinical and radiological study of peroneal tendon pathology. (2013) Foot & ankle specialist. 6 (6): 417-21. doi:10.1177/1938640013501544 - Pubmed
- 5. Roster B, Michelier P, Giza E. Peroneal Tendon Disorders. (2015) Clinics in sports medicine. 34 (4): 625-41. doi:10.1016/j.csm.2015.06.003 - Pubmed
- 6. Sobel M, Bohne W, Levy M. Longitudinal Attrition of the Peroneus Brevis Tendon in the Fibular Groove: An Anatomic Study:. (2016) Foot & Ankle. 5 (5): 371. doi:10.1177/1756283X10363751 - Pubmed
- 7. Lamm BM, Myers DT, Dombek M, Mendicino RW, Catanzariti AR, Saltrick K. Magnetic resonance imaging and surgical correlation of peroneus brevis tears. (2004) The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons. 43 (1): 30-6. doi:10.1053/j.jfas.2003.11.002 - Pubmed
- 8. Tiwari M, Singh V, Bhargava R. Peroneus Brevis Attrition & Longitudinal Split Tear without Subluxation and Associated Hypertrophy of Peronal Tubercle" - Treatment of an Uncommon Lesion. (2015) Journal of orthopaedic case reports. 5 (1): 34-6. doi:10.13107/jocr.2250-0685.250 - Pubmed