AANA Lab Course 908-Foot and Ankle Arthroscopy (APEx)-Peroneal Subluxation_ How I Repair_Reconstruct_ Is Arthroscopic Approach Enough

Peroneal Subluxation_ How I Repair_Reconstruct_ Is Arthroscopic Approach Enough_-Eric Giza, M.D.

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This document by Eric Giza, MD, provides a comprehensive overview of peroneal tendon pathology and the role of peroneal tendoscopy in diagnosis and treatment. The peroneal tendons (brevis and longus) function primarily in eversion and plantar flexion of the ankle and dynamic stabilization of the ankle and subtalar joints. Anatomy details include the fibular origin of both tendons, their insertions, and noted anatomical variations, such as a slip from brevis to the 5th extensor digitorum longus tendon and the fibular groove zones prone to injury.<br /><br />Peroneal tendon pathology can occur at specific zones: Zone 1 (fibular groove, often with brevis involvement) and Zone 2 (peroneal tubercle and cuboid tunnel, often involving longus). Blood supply studies show consistent vascularization, especially to the longus tendon, arguing against avascular degeneration in brevis split tears. The superior and inferior peroneal retinacula are crucial for tendon stability, covering the tendons uniquely with fibrous tunnels and an osteosynovial sheath.<br /><br />The retromalleolar sulcus morphology (concave, flat, or convex) was studied but found not correlated with peroneal tendon dislocations. The peroneal tubercle is commonly present and varies in shape; it and the cuboid tunnel can contribute to tendon entrapment and injury.<br /><br />Injuries can be acute (e.g., sudden dorsiflexion or inversion injuries) or chronic (associated with sprains, hindfoot varus, synovitis, and SPR attenuation). Clinical signs include lateral tenderness, popping with eversion, and specific physical tests. Imaging with radiographs may reveal the "fleck sign," pathognomonic of tendon dislocation. MRI and ultrasound are important: MRI has variable predictive values and must be correlated clinically; ultrasound shows high sensitivity and specificity.<br /><br />Peroneal tendoscopy is indicated for synovitis, small tears of brevis or longus, subluxation, low-lying brevis muscle, and presence of the peroneus quartus muscle, which is often implicated in persistent pain and treated by excision and SPR repair. Tendoscopy allows direct visualization of the tendons, synovium, fibrocartilaginous tunnels, splits, and stenoses not always evident on imaging. It involves multiple portals and allows dynamic assessment and treatment (e.g., debridement).<br /><br />Arthroscopic repair of peroneal tendon subluxation includes minimally invasive repair of the superior peroneal retinaculum (SPR). Techniques described include tendoscopic visualization, cleaning tears, insertion of suture anchors at the fibula, and secure repair of the retinaculum to restore stability.<br /><br />Overall, peroneal tendoscopy is a valuable tool for both diagnosis and treatment of complex peroneal tendon disorders, offering less invasive options with good clinical outcomes.

Keywords

peroneal tendon pathology

peroneal tendoscopy

peroneus brevis

peroneus longus

superior peroneal retinaculum

peroneal tendon subluxation

fibular groove

peroneal tubercle

MRI and ultrasound imaging

arthroscopic repair