In this article, we will discuss a case of peroneus longus tendon injury.
The peroneus longus tendon is one of the muscles located on the outside of the foot and is one of the most common muscles to be injured, for example by spraining the ankle.Injuries to this area are common and not uncommon, but depending on the severity of the injury, they can be rare.
In clinical practice, we often see inflammation and dislocation of tendons due to partial injuries, but I have never heard of a complete rupture of a tendon. (I have).
In this case, we will see a complete tear of the peroneus longus tendon, so let's learn how the tear occurred and how it was treated.
Case
A 50-year-old woman working as a nursing assistant at a public hospital came to see the doctor complaining of severe pain and swelling in her right rear foot along the course of her peroneal tendon (PT) after an ankle sprain.
The patient had come to the outpatient clinic to address pain and swelling in the lateral aspect of her right hind foot that had persisted for a month after spraining her ankle while walking down the street.
The patient's medical history consisted of hypertension only.
On physical examination, the pain on palpation and swelling was PT location and obvious.Under stress maneuvers (anterior drawer and talar tilt test), no clinical signs of ankle instability are observed.
Imaging studies included simple radiographic series images of the foot and ankle and magnetic resonance imaging (MRI) of the foot and ankle
MRI T2-weighted images showed complete rupture of the PLT surrounded by extensive synovitis).
Using the anteroposterior simple radiographs of the ankle and the MRIT1 and T2-weighted images, we were able to identify a sharp hypertrophic peroneal nodule.
(Figure 2). An MRI scan of the leg was performed to assess the condition of the peroneal muscle and to determine if there was evidence of fatty infiltration and/or muscle atrophy.Based on the various tests, a diagnosis of a full layer tear of the PLT associated with a hypertrophic peroneal nodule was made.
Treatment and Results
Conservative treatment (physical therapy, rest, anti-inflammatory medications, and ankle stabilizers to limit inversion-inversion motion) was implemented, but was deemed to have failed after 6 months and surgical treatment was presented.
Preoperatively, the VAS and AOFAS ankle-hindfoot scores were applied.
The patient's VAS score was 9 and the AOFAS ankle-hindfoot score was 39.
The surgical procedure was performed under local anesthesia and the patient was placed in the lateral position using a well-padded, non-sterile femoral tourniquet inflated to 300 mmHg.
The minimally invasive approach consisted of two short incisions.
The anatomical reference was marked with a Codman skin marking pen and included the lateral ankle and the base of the fifth metatarsal.
Proximally, a longitudinal incision approximately 3 cm in length was made 1 cm posterior to the posterior border of the distal fibula and 1.5 cm above the tip of the lateral ankle.
The PT sheath was opened through the incision to expose the proximal portion of the PLT, but the superior peroneal muscle branch remained intact.Distally, a 3 cm long longitudinal incision was made parallel to the ground and posterior to the tip of the base of the fifth metatarsal.
In the distal incision, the distal end of the remaining PLT was incised and released in a rectangular groove.
Because of the presence of an enlarged peroneal muscle tubercle, a short central incision of 2 cm was made for its resection.
The PLT was then removed from the sheath through the proximal incision and the nonviable portion was excised.After wound excision of the PLT, the remaining proximal fragment of the native PLT was sutured to the PBT on both sides with two U-shaped transverse sutures using No.1 Vicryl.
This suture was placed on the superior peroneal retinaculum to prevent volumetric effects due to increased pressure within the flexor strut (Figure (Figure (Figure 5)).
Finally, the three incisions were closed in layers.
In the proximal incision, the PT sheath was closed with No. 1 Vicryl, the subcutaneous tissue was closed with No. 3 Monocryl, and the skin was closed with No. 4 Nylon.
For the central and distal incisions, the subcutaneous tissue was closed with No. 3 Monocryl and the skin was closed with No. 4 Nylon.
After closing the surgical wound, sterile soft bandages and collaterals were applied with the foot in a neutral position.
Postoperatively, the patient wore a cast and avoided weight bearing for two weeks.
After two weeks, the sutures were removed and full weight-bearing was applied as tolerated by the CWB.
No complications from healing were noted, and the sensitivity of the lateral skin of the hind leg was maintained, similar to that of the contralateral leg.Physical therapy was initiated, focusing on dorsiflexion/plantar flexion range of motion to prevent adhesions.
During physical therapy, inversion/reversal movements were prohibited to prevent rupture of the tendon fixation sutures.Patients were instructed to maintain CWB at all times, except for hygiene purposes and dorsiflexion/plantar flexion exercises.
At 6 weeks postoperatively, the patient was out of the CWB with minimal swelling and inversion/flip motion was allowed.
The patient was then transitioned to an ankle stabilization brace.
The physical therapy program targeted inversion/inversion exercises and aimed to gradually restore intrinsic receptive sensation and muscle strength, and with rehabilitation, the use of the ankle stabilizing orthosis was gradually reduced.
At 12 weeks follow-up, physical examination revealed no pain on palpation or restriction of inversion.The surgical incision had completely healed and the swelling had decreased significantly.
The patient showed a VAS score of 0 and an AOFAS ankle hindfoot score of 90.
At the 6-month follow-up, the patient completed physical therapy and returned to her previous level of activity.On physical examination, the patient was still pain free and had a peroneal muscle strength of 5/5.
The VAS score was 0 and the AOFAS hindfoot ankle score was 98. At the 14-month follow-up, the patient reported that she felt good, had no complaints, and was fully active.
Nishikawa DRC, Duarte FA, Saito GH, et al. Minimally invasive tenodesis for peroneus longus tendon rupture: A case report and review of literature. J Orthop. 2020;11(2):137-144. published 2020 Feb 18. doi:10.5312/wjo.v11.i2.137
Conclusion
When the peroneal tendon is injured, the generally indicated treatment is often conservative therapy, but when it is a complete tear, as in this case, it is different, and the method may be considered depending on the patient's daily lifestyle.
In this case, the patient had chosen conservative treatment because he was resting, but that method failed and he switched to a surgical method.
However, it seems that surgical methods can also cause invasive damage to other tissues, unless they are minimally invasive like this one, so the procedure described above was effective.Although only a surgeon can reproduce the procedure, I introduced it because there are many things that can be learned, such as the fact that 14 months have passed as a result and the rehabilitation process.
