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Any ideas on peroneal subluxation, I am looking for nonsurgical options. Patient with history of chronic ankle sprains now experiencing subluxation with running. Thanks!
Any ideas on peroneal subluxation, I am looking for nonsurgical options. Patient with history of chronic ankle sprains now experiencing subluxation with running. Thanks!
I have tried all nonsurgical options. Surgery is a predictable means of curing the problem and will be the only thing, in my clinical experience, that does any useful good.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
I have tried all nonsurgical options. Surgery is a predictable means of curing the problem and will be the only thing, in my clinical experience, that does any useful good.
The orthopedic surgeon I work with and I have done a few of these with excellent results and the more gifted podiatric surgeons I know do these also much more frequently than I do with excellent results. Generally, and briefly, the retinaculum is tied down by bone anchors to prevent the peroneal tendons from subluxing anteriorly on the lateral fibula without regrooving the posterior fibula.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
The orthopedic surgeon I work with and I have done a few of these with excellent results and the more gifted podiatric surgeons I know do these also much more frequently than I do with excellent results. Generally, and briefly, the retinaculum is tied down by bone anchors to prevent the peroneal tendons from subluxing anteriorly on the lateral fibula without regrooving the posterior fibula.
Kevin, thanks for your reply . Do you have a reference for a detailed account of this I can study?
Kevin, thanks for your reply . Do you have a reference for a detailed account of this I can study?
Dieter:
I still have all my surgery reference books in boxes from my recent home move. However, if I remember correctly, I think that both Ken Johnson's color atlas of foot surgery and Tom Chang's book on foot surgery have sections on this procedure and with their color photos greatly help visualizing the procedure. The surgery textbooks by Jahss and McGlamry also have sections on this procedure if I'm not mistaken. Here's a good internet reference http://www.wheelessonline.com/ortho/...on_dislocation
You would probably get some excellent replies by some of the more respected podiatric surgeons in the States if you asked the same question in Barry Block's PM News e-mail newsletter. http://podiatrym.com/pmnews.cfm
Hope this helps.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Any ideas on peroneal subluxation, I am looking for nonsurgical options. Patient with history of chronic ankle sprains now experiencing subluxation with running. Thanks!
Strapping the lower leg (clockwise for right leg; anti for left) with an elastic adhesive, so that the tendon is encouraged to stay behind the distal fib, does help with clicking/pain etc.
Strapping the lower leg (clockwise for right leg; anti for left) with an elastic adhesive, so that the tendon is encouraged to stay behind the distal fib, does help with clicking/pain etc.
Ron:
I have tried this technique but have been unsuccessful in having it make much difference. Have you found it is able to reduce the pain and clicking during running and can it be tolerated enough to be used on a daily basis for chronic sufferers?
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
I have tried this technique but have been unsuccessful in having it make much difference. Have you found it is able to reduce the pain and clicking during running and can it be tolerated enough to be used on a daily basis for chronic sufferers?
As you know, the skin does not tolerate tape too well on a daily basis; and skin-sensitivity does vary from person to person, and region (plantar v. dorsal) to region.
Hence, what I do is instruct the patient to prioritise their week. For instance, do their aggravating activities skewed to one part of the week; or (run) on alternate days. At least that way the skin can settle.
I have found that it does make enough of a difference. Obviously, the limiting factor in this type of taping technique is neuro-vascular compromise. If the latter is catered for, and if the tape is applied when the tendon is in its 'proper' position re-assessment testing should improve. I don't think the tape is magically holding the tendon specifically. It may be that the increased compression between the dermis and the distal fibula, restrain the tendon from slipping over. With that in mind, I might fiddle with an ankle air cast next time????
I am not advocating a long-term solution from the tape by any stretch. But, if applied properly, the patient can enjoy less discomfort with previously provocative activity.
As you know, the skin does not tolerate tape too well on a daily basis; and skin-sensitivity does vary from person to person, and region (plantar v. dorsal) to region.
Hence, what I do is instruct the patient to prioritise their week. For instance, do their aggravating activities skewed to one part of the week; or (run) on alternate days. At least that way the skin can settle.
I have found that it does make enough of a difference. Obviously, the limiting factor in this type of taping technique is neuro-vascular compromise. If the latter is catered for, and if the tape is applied when the tendon is in its 'proper' position re-assessment testing should improve. I don't think the tape is magically holding the tendon specifically. It may be that the increased compression between the dermis and the distal fibula, restrain the tendon from slipping over. With that in mind, I might fiddle with an ankle air cast next time????
I am not advocating a long-term solution from the tape by any stretch. But, if applied properly, the patient can enjoy less discomfort with previously provocative activity.
Unfortunately, most of the athletes I treat would not accept being relegated to only every other day workouts. I suppose I will continue to recommend surgical treatment since, I have found it to be very successful, allowing the patient to resume normal, daily, aggressive physical activity generally within 3 months after the surgery.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Is it always necessarily to diagnose subluxation with MRI or US or is clinical diagnosis sufficient enough?
cheers
The problem with MRI and US is that, in some patients, the peroneal tendon doesn't sublux until the ankle is dorsiflexed and the peroneal muscles are actively contracting. Therefore, clinical diagnosis is not only sufficient but, as far as I'm concerned, the preferred method of diagnosis since MRI scans and US scans have the potential to have false-negatives, unless they are done with the peroneals under tension and with the tendon in the subluxed position.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Is it always necessarily to diagnose subluxation with MRI or US or is clinical diagnosis sufficient enough?
cheers
I always get a DYNAMIC ultrasound before planning surgery. This test is very operator dependent and we are lucky to have a wiz of an ultrasound specialist at our institution. Static MRI is worthless IMHO.
Background: Several techniques are published for the treatment of peroneal tendon instability.
Hypothesis: The fibular retromalleolar groove impaction technique is a simple and reliable surgical procedure with low morbidity for the treatment of peroneal tendon instability.
Study Design: Case series; Level of evidence, 4.
Methods: Twenty-three consecutive patients (average age, 34.2 years; range, 16-57 years) with a symptomatic subluxation of the peroneal tendons but no other peroneal tendon injuries were included in the study. All patients were severely limited in sports participation by their symptoms. The mean preoperative American Orthopedic Foot and Ankle Society score was 68.5 (range, 47-78). The reconstruction of the peroneal retromalleolar groove was performed by removing the cancellous bone behind the groove with a 3.5-mm drill. Then the entire peroneal rim was mobilized with small osteotomes at its edges and impacted into the fibula. Using this technique, it was possible to deepen the peroneal retromalleolar groove and to preserve the smooth surface of the peroneal rim at the same time. After the procedure, the patients were kept in a boot cast for 6 weeks with partial weight-bearing of 20 kg. The ankle joint was then mobilized under the supervision of a physical therapist. Linear sports activities were allowed after 7 weeks and unlimited sports after 12 weeks.
Results: No local wound problems were observed, and no further symptomatic subluxation or dislocation of the peroneal tendons was encountered during the 2-year follow-up. The mean American Orthopedic Foot and Ankle Society score improved to 96.3 (range, 85-100).
Conclusion: Groove impaction offers a simple, quickly done procedure with low morbidity, relatively quick return to sports, and successful elimination of peroneal tendon instability
BACKGROUND: The surgical treatment methods for recurrent dislocation of peroneal tendons are controversial. A simpler and more effective treatment method is valuable for these patients. HYPOTHESIS: A new rerouting operation designed by the authors will have satisfactory results and avoid disadvantages of the old rerouting methods.
STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Seventeen consecutive male patients with unilateral recurrent peroneal tendon dislocations were treated by transposition of the calcaneofibular ligament from the tubercle of calcaneofibular ligament with a 1 x 1 x 1 cm(3) bone block and elevation of this tubercle with another 1 x 1 x 1 cm(3) calcaneal bone block, which were fixed by a 3.5-mm cancellous screw with a washer. All patients received clinical and radiographic follow-up for at least 2 years. The preoperative and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scales were used for functional results assessment.
RESULTS: All bone transposition sites healed radiographically at 6 weeks after surgery. Four patients had transient numbness over the lateral aspect of the injured foot, and 3 patients had swelling and pain involving the operative sites. All complications resolved by 3 to 5 months after the operation. No recurrent dislocation of the peroneal tendons was noted. The mean AOFAS ankle-hindfoot scale improved significantly, from 73.4 +/- 5.5 preoperatively to 100 at 2- to 5-year follow-up (P < .001). Normal ankle stability and no tightening of the lateral side of the injured ankles in the inversion position were noted.
CONCLUSION: This method is a simple, reliable, and reproducible operation to treat recurrent dislocation of the peroneal tendons. It allows early return to daily, working, and sports activities with satisfactory results
BACKGROUND: Dislocation or subluxation of the peroneal tendons out of the peroneal groove under a torn or avulsed superior peroneal retinaculum has been well described. We identified a new subgroup of patients with intrasheath subluxation of these tendons within the peroneal groove and with an otherwise intact retinaculum. METHODS: The cases of fifty-seven patients with painful snapping of the peroneal tendons posterior to the fibula were reviewed. Of these, forty-three had tendons that could be reproducibly subluxated out of the groove with a dorsiflexion-eversion maneuver of the ankle. Fourteen patients who could not subluxate the tendons out of the groove underwent a dynamic ultrasound examination of the tendons. While the same dorsiflexion and eversion maneuver was being performed, the tendons were seen to switch their relative positions (the peroneus longus came to lie deep to the peroneus brevis tendon) with a reproducible painful click. All fourteen patients underwent a peroneal groove-deepening procedure with retinacular reefing. Intraoperatively, thirteen patients were found to have a convex peroneal groove and all fourteen had an intact peroneal retinaculum. All patients subsequently underwent a follow-up dynamic ultrasound examination and an American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score evaluation at a minimum of twenty-four months after surgery. RESULTS: All fourteen patients were female, with an average age of thirty-five years. Two subtypes of intrasheath subluxation were found. Type A (ten patients) involved intact tendons with relative switching of their anatomic alignment. Type B (four patients) involved a longitudinal split within the peroneus brevis tendon through which the longus tendon subluxated. Intraoperative confirmation of the ultrasound findings was 100%. At an average follow-up interval of thirty-three months, the average AOFAS score had improved from 61 points preoperatively to 93 points, and the average score on the 10-cm visual analog pain scale had improved from 6.8 to 1.2. Follow-up ultrasound evaluation revealed healed tendons without persistent subluxation in thirteen patients. Nine patients rated the result as excellent, four rated it as good, and one rated it as fair. CONCLUSIONS: Patients with retrofibular pain and clicking of the peroneal tendons may not have demonstrable subluxation on physical examination and may have an intact superior peroneal retinaculum. They may have an intrasheath subluxation of the peroneal tendons, which can be confirmed with use of a dynamic ultrasound. Surgical repair of tendon tears combined with a peroneal groove-deepening procedure with retinacular reefing is a reproducibly effective procedure for this condition.
A preliminary report on intra-sheath peroneal tendon subluxation: a prospective review of 7 patients with ultrasound verification.
Thomas JL, Lopez-Ben R, Maddox J. J Foot Ankle Surg. 2009 May-Jun;48(3):323-9.
Quote:
Peroneal tendon dislocation with recurrent subluxation over the lateral malleolus, both acute and chronic, is well documented in the literature. However, there remains a subset of patients who report symptoms similar to peroneal subluxation that do not actually display active or passive displacement of the tendon over the lateral malleolus. In this article, we describe 7 patients who were followed prospectively for the treatment of ultrasound-confirmed, retrofibular, intrasheath subluxation without the typical lateral subluxation or dislocation of the tendon over the malleolus. Six of the 7 patients had either a low-lying peroneal muscle belly or a peroneus quartus muscle and tendon, 6 experienced a tear of either 1 or both of the peroneal tendons, and 1 of the 7 had only a peroneus brevis tendon tear without any other muscle anomaly. Repair of concomitant tendon pathology and resection of the low-lying muscle belly to a point proximal to the fibro-osseous tunnel of the retromalleolar space resulted in elimination of the subluxation symptoms and improvement in American College of Foot and Ankle Surgery ankle scores in 3 patients who were treated operatively
Background
Recurrent peroneal tendon subluxation is an uncommon condition which is usually the result of sports related trauma. This injury may be misdiagnosed resulting in long-term disability. Most authors would recommend surgical treatment for patients who have a long history or in patients in whom conservative treatment has failed. Surgical treatment can also be considered in the acute phase when managing young athletic individuals.
Methods
We report the outcome in four patients who underwent the Singapore operation for chronic peroneal tendon subluxation. All patients were operated on by the same surgeon and followed up at regular intervals with a minimum follow-up of two years.
Results
In all four patients a Bankart type lesion was found in association with subluxation solely of the peroneus longus tendon. Following repair all patients returned to pre-injury activity levels within six months.
Conclusion
In our experience the Singapore operation is technically easy to perform and offers excellent results with high patient satisfaction levels
Subluxed peroneals fall into one of two categories - acute and chronic.
Depending on the age and activity level of the patient, I have had several acute subluxed peroneals not require repair simply because of the lack of long term symptoms.
The diagnosis is a clinical one, no studies are needed unless one wants to rule out a linear tear preoperatively.
Surgical repair is usually just a matter of repairing the ligament, however, I have found that patients with rear foot cavus and/or shallow peroneal grooves at the posterior distal fibula require a bit more if long term results are to be appreciated.
Deepening of the peroneal groove is a relatively simple matter. A window is removed encompassing the groove, the subcortical bone curretted and the window replaces, thus deepening the groove and at the same time maintaining the rather smooth cortical area.
The size and health of the small fibrocartilagenous "beak" at the tip of the fibula is also important in maintaining the peroneals in there correct position.
Good luck
Steve
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA
Few studies describe the results of surgical treatment of peroneal retinaculum in athletic populations. Thirty-one athletic patients with symptomatic subluxating peroneal tendons were treated surgically by one surgeon with isolated subluxation repair, subluxation repair plus peroneus brevis tendon repair, or subluxation repair plus lateral ankle stabilization. As a group, the average time to return to activity was 3.2 +/- 0.8 months with a postoperative AOFAS score of 97.0 +/- 5.3. Patients with tendon tears were older in age (P < .01) and took longer to return to activity than the rest of the cohort (P = .02). There were a total of 4 patients with postoperative complications, although all were able to return to sports. The patients with peroneal subluxation in this study were able to return to their sport in approximately 3 months. Those with concomitant tendon tears took longer. Further study is needed to see if this is associated with longer-standing symptoms
Preliminary results of calcaneofibular ligament transfer for recurrent peroneal subluxation in children and adolescents.
Boykin RE, Ogunseinde B, McFeely ED, Nasreddine A, Kocher MS. J Pediatr Orthop. 2010 Dec;30(8):899-903.
Quote:
BACKGROUND: Subluxation of the peroneal tendons over the lateral malleolus is an uncommon condition in both pediatric and adult populations. The primary dislocation is thought to occur with rupture of the superior peroneal retinaculum and may be associated with marginal fractures of the lateral malleolus or a preexisting shallow groove inferiorly. Various operative techniques have been reported earlier, but little data exists regarding surgical management and outcome in a pediatric and adolescent population with open physes.
METHODS: A retrospective review of patients presenting to our institution over a 5-year period yielded 9 cases of recurrent peroneal subluxation refractory to nonoperative management in 7 children or adolescents (mean age 12 y). Both traumatic and atraumatic etiologies were represented. All patients failed nonoperative treatment and were treated operatively with calcaneofibular ligament (CFL) transfer to reroute the peroneal tendons underneath the CFL. All patients were observed in follow-up and sent validated outcomes questionnaires, including the Foot and Ankle Ability Measure and the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale.
RESULTS: Mean clinical follow-up was 20.9 months (range: 12 to 35 mo). At follow-up, all patients had returned to sports and activity and there were no instances of recurrence of subluxation. Complications included 1 postoperative infection and 1 patient requiring revision surgery for fibrosis. Six of 9 ankles (66.6%) returned the outcomes surveys. The average Foot and Ankle Ability Measure activities of daily living score was 90.8 (±4.4) and the sports subscale was 62.5 (±9.3). The mean American Orthopaedic Foot and Ankle Society score was 86 (±3.2).
CONCLUSIONS: Peroneal subluxation is an uncommon condition in pediatric and adolescent athletes. CFL transfer over the peroneal tendons should be considered as it provides excellent stability, a low rate of recurrent subluxation, and good functional outcomes without risk of injury to the distal fibular physis which can occur with distal fibular osteotomy or groove deepening procedures.
Tendoscopic Groove Deepening for Chronic Subluxation of the Peroneal Tendons.
Vega J, Batista JP, Golanó P, Dalmau A, Viladot R. Foot Ankle Int. 2013 Mar 19
Quote:
INTRODUCTION:
Recurrent subluxation of the peroneal tendons over the lateral malleolus is an uncommon disabling condition in young people involved in sports. Injury to the superior peroneal retinaculum, sometimes in association with a shallow fibular groove, can lead to this condition. There are several surgical treatments for recurrent peroneal tendon subluxation, but no tendoscopy technique has been reported to date. The aim of this study was to describe a tendoscopic groove-deepening technique and its results for treating patients with recurrent subluxation of the peroneal tendons.
METHODS:
Seven patients (3 women and 4 men; mean age 26.4 [21-32] years) with chronic subluxation of the peroneal tendons were treated with a tendoscopic procedure. All patients experienced pain at the lateral retromalleolar area and recurrent subluxation of the peroneal tendons. The right ankle was affected in 4 patients. Mean follow-up was 15.4 (8-25) months.
RESULTS:
On tendoscopic examination, all patients had a flat fibular groove, and the superior peroneal retinaculum was found to be detached in 4 cases. Three patients had a superficial injury of the peroneus brevis tendon which was debrided. Tendoscopic deepening of the peroneal groove without superior peroneal retinaculum repair was performed in all cases. None of the patients experienced recurrent subluxation during follow-up. The AOFAS score increased from 75 preoperatively to 93 at final follow-up. No complications were reported in any case.
CONCLUSION:
Tendoscopic deepening of the fibular groove was a reproducible, minimally invasive technique that provided a favorable outcome for recurrent subluxation of the peroneal tendons in our limited number of patients.
Peroneal Subluxation
Linear Mode
