In this issue, we will discuss hypertrophic peroneal tuberosities and impingement of the peroneus longus muscle.
There was an interesting disease from a case report.
It is a case of hypertrophic peroneal nodules which can cause tendinopathy of the peroneus longus muscle.
What is a hypertrophic peroneal muscle nodule?
Hypertrophic peroneal nodules (HPTs) are abnormal growths of the peroneal muscles on the lateral aspect of the hindfoot that can cause tendinopathy of the peroneus longus tendon.Os peroneum (OP) is an accessory bone present in the peroneus longus tendon on the lateral aspect of the peroneal muscular joint.
Both HPT and OP can cause pain on the outside of the foot and in some cases require surgical treatment.
Cases
A 63-year-old man.
He had been complaining of pain on the lateral aspect of his right rear foot while walking for 6 years.
During his initial examination, a bony prominence was palpated on the lateral aspect of his right hind foot.
The patient complained of pain in the same area while walking.
Simple radiographs and computed tomography images of his right foot showed HPT, abnormal bony proliferation around the peroneus brevis muscle, and OP, lateral anterolateral ossicle of the calcaneus.
Magnetic resonance imaging showed hypointense lesions on T1-weighted images and hyperintense lesions on short T1 inversion recovery images around the HPT.
Bone marrow involvement of the HPT was suggested, but the OP showed no signs of inflammation.
Dynamic ultrasound imaging confirmed that the HPT and OP were causing impact with active abduction of the foot, and lidocaine injection between the HPT and OP provided pain relief.Based on these findings, we hypothesized that the lateral foot pain was not caused by POPS, but by inflammation around the HPT caused by the impact between the HPT and the OP.
Therefore, we decided to perform only an HPT resection without removing the OP.
A transverse incision was made parallel to the peroneus longus tendon.
During surgery, it was observed that the HPT and OP impinged on each other due to traction of the peroneus longus tendon.
There was no apparent fracture or diastasis of the OP during the examination.
The prominence of the HPT was excised with a chisel.
The resection of the HPT freed the OP and allowed it to glide smoothly along the peroneal tendon track.
A 3 cm longitudinal tear of the peroneus longus tendon between the HPT and the OP was identified and sutured with 3-0 PDS using tubularization.
The wound was cleaned and closed, and sterile bandages were applied.
Full weight bearing was allowed postoperatively as tolerated.The postoperative course was good and the patient returned to normal activities without functional impairment.Foot (JSSF) scale, the Objective Standardized Assessment System, and the Self-Administered Foot Evaluation Questionnaire (SAFE-Q), the SAFE-Q consists of six subcategories (i.e., pain and pain-related, physical functioning and daily living, social functioning, shoe-related, general health and well-being, and sports activities).
The patient had a preoperative JSSF score of 71/100, which improved significantly to 100 after one year.
Compared to the preoperative status, all subscale scores of the SAFE-Q improved after one year.
Pain: 48 to 72 points
Physical function and daily life: 41 to 82 points
Social functioning: 62 to 88 points
Shoe-related: 50 to 74 points
Health and well-being: 58 to 76 points
Simple radiographs taken one year after the surgery showed no signs of HPT recurrence.
Takada R, Chang SH, Kasai T, et al. Lateral Heel Pain Caused by Impingement of Hypertrophic Peroneal Tubercle and Os Peroneum. Case Rep Orthop. 2021;2021: Published 2021 Jan 8. doi:10.1155/2021/6621539
Conclusion
HPT is thought to occur around 20~30% of the time, and is caused by congenital, traumatic, or exertional factors.
I may have overlooked HPT before! But I also realized that the outcome of the symptoms itself can be improved by taking appropriate measures.
It was discovered by proper examination, and the healing process would have been prolonged if it had been treated only for simple muscle or tendon reasons.
Thank you for your study.
