Peroneus Tendon Rupture

Fig. 41 Peroneus tendon strength can be tested by asking the patient to do a resisted plantar flexion and eversion. Compare with the other side

Fig. 40 Surgical presentation of peroneus tendon rupture

SYMPTOMS The patient presents with a history of sharp pain over the lateral posterior part of the ankle joint, often mistaken for a sprain. Sometimes the athlete refers to a 'pop' when the tendon ruptures or dislocates. Two snaps are typical for dislocation-repositioning.

AETIOLOGY Peroneus tendon rupture is uncommon in young athletes but can occur if previous cortisone injections have weakened the tendon. A complete rupture is usually associated with degeneration in systemic diseases such as diabetes with arthropathy or after cortisone treatment. Usually one of the two tendons (brevis or longus) is intact, which makes the diagnosis even more difficult.

CLINICAL FINDINGS There is tenderness on palpation over the peroneus retinaculum or along the peroneus tendon and weakness on a resistance test with active plantar flexion-inversion. Compare with the other ankle.

INVESTIGATIONS MRI or ultrasound may show localised swelling and can often identify a rupture.

Fig. 41 Peroneus tendon strength can be tested by asking the patient to do a resisted plantar flexion and eversion. Compare with the other side

TREATMENT In the acute phase RICE is advocated. Surgery is usually required to repair a ruptured tendon followed by eight to twelve weeks partial immobilisation.

REFERRALS Refer to orthopaedic surgeon for consideration of surgery.

EXERCISE PRESCRIPTION Rest will not help so allow all kinds of sporting activities using well-fitting shoes and avoiding impact. A brace restricting plantar flexion and eversion-inversion can be used, allowing weight bearing but protecting the repair. EVALUATION OF TREATMENT OUTCOMES Monitor decrease of clinical symptoms and signs. Regained strength in plantar flexion-inversion and proprioception should be monitored. Compare with other ankle.

DIFFERENTIAL DIAGNOSES Syndesmosis ligament tear (positive syndesmosis test), dislocation of peroneus tendons; MT V fracture or lateral malleoli fracture (positive X-ray). PROGNOSIS Excellent-Good, but the delay in diagnosis is often substantial leading to a long convalescence.

SYMPTOMS There is a gradually increasing stiffness of the ankle and exercise-induced pain around the posterior part of the ankle joint, sometimes after previous sprain. This injury often affects footballers and ballet dancers.

AETIOLOGY Impingement syndrome is not a diagnosis but a symptom and may be caused by repetitive injury to the posterior ankle joint, for example from repetitive plantar flexions striking footballs or dancing on tiptoe thus compressing the posterior compartment. Several underlying pathoanatomical factors can cause posterior impingement, including fibrosis, synovitis or an Os Trigonum. CLINICAL FINDINGS There is sometimes effusion and localised tenderness on palpation over the posterior ankle deep in front of the Achilles tendon. It is provoked during forced plantar-flexion. INVESTIGATIONS X-ray can show an Os Trigonum. MRI may show soft tissue oedema sometimes around the Os Trigonum.

Fig. 42 Posterior impingement of the ankle can be caused by an inflamed area around the Os Trigonum

TREATMENT Orthotics and adjustment in techniques may be tried. NSAID can give short-term relief, as can a local cortisone injection. If there are persistent or severe symptoms, surgery with excision of impinged structures is recommended and curative.

REFERRALS Refer to orthopaedic surgeon in difficult cases.

EXERCISE PRESCRIPTION Rest will not help so allow all kinds of sporting activities using well-fitting shoes. If there is pain on impact suggest low-impact activities such as cycling and swimming.

EVALUATION OF TREATMENT OUTCOMES

Monitor decrease of clinical symptoms and signs. DIFFERENTIAL DIAGNOSES Several underlying problems can cause posterior impingement, including loose bodies, fibrosis, chondral flap tears, synovitis or impinging soft tissue flaps or conditions around the Achilles tendon such as bursitis or tendinosis.

PROGNOSIS Excellent if treated properly.

Fig. 42 Posterior impingement of the ankle can be caused by an inflamed area around the Os Trigonum

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