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Hi Steve. I’m struggling with identifying where the neovascularisation actually is on this guys peroneal tendon area. X ray shows he has an os peroneum, which may or may not be what that bony structure is on my images. There looks like there is some in the tendon sheath, is this a sesamoiditis of that os peroneum? Is there a longitudianl split tear? Is the retinaculum also inflamed with tenosynovitis? Increased blood flow seems to be also under the tendons. Any help would be greatly appreciated. Thanks Mike
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Tricky one Mike,
There is no doubt there is some peroneal tenosynovitis,
But this never happens without an underlying pathological cause!
Most commonly peroneus brevis compression from longus at the medial malleolus and progressing to a longitudinal split.
Second most common: peroneal tubercle syndrome stenosing tenosynovitis of peroneus longus. This happens a little further distal at the level of the peroneal tubercle.
Third option: Os peroneum which is an accessory tubercle in the peroneus longus at the high compression point as the tendon passes around the cuboid before passing into the plantar foot.
In your case there is a bone that is not standard anatomical and it appears to be in the peroneus longus tendon.
The os peroneum is certainly in peroneus longus, however this ossicle looks like it is more proximal than I would normally expect.
Os peroneum is typically at the level that the peroneus longus wraps around the cuboid,
This ossicle looks more proximal, closer to where I expect the peroneal tubercle to be,
What level was this ossicle at?
The ossicle is also somewhat irregular,
I have no doubt this ossicle is a culprit!
From the images provided I would suggest there is an irregular os peroneum setting up a localised tendinosis and associated peroneal tenosynovitis.
I am uncertain as to the exact anatomical location of the ossicle and am wondering if it is a little more proximal to the usual location (at the “cuboid corner”).
This raises questions about the distal peroneus longus insertion.
It also raises the question as to if the peroneal tubercle is normal
The lateral band of the plantar fascia insertion onto the base of 5th MT is really nicely imaged and normal.
Let’s continue the conversation.
Steve.
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Ahhh,
Those radiographs and extra images make all the difference to me,
It is as I suspected,
The peroneal tubercle is normal,
To find it , follow the peroneal tendons around the lateral malleolus,
At this level the peron L and B sit on top of each other.
When you see the CFL passing under the persons you are getting close.
Just distal to this level you see the peron tendons sit side by side and this is the level of the tubercle.
It can be a large, small or absent tubercle, but there is ALWAYS a retinaculum over the tendons which you have imaged perfectly.
In your case there is not much tubercle, however the accessory ossicle is in an unusual location half way between the tubercle and the normal site for the ossicle at the cuboid corner.
The combination of the unusual location, large size and sclerotic shape is causing the tendinopathy and associated synovitis.
It is still worth checking the peroneus longus insertion to ensure the ossicle has not slipped back proximally due to a distal tear.
Lovely work Mike,
Steve
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Hi Son,
Great images and clip,
In my opinion the primary pathology in this case is a compressive tendinosis of peroneus brevis that has developed into a longitudinal split.
We had a great protection at the Melbourne anatomy day past weekend where the old cadaver had exactly the same pathology and we could see how the peroneus brevis had become thin and wrapped around peroneus longus at the level of the lateral malleolus and then had developed a longitudinal split that I could put my examination stick through.
Your case is exactly this pathology.
I also agree that there is a large peroneal tubercle.
BUT
In my view the large peroneal tubercle is not the primary problem here (it may be a secondary point of irritation for peroneus brevis) but the primary pathology is the compression of brevis by longus proximal to the tubercle and the longitudinal split.
I would not refer to this as a peroneal tubercle syndrome stenosing tenosynovitis.
When it is true peroneal tubercle syndrome stenosing synovitis (in my view) it most commonly affects the peroneus longus and the peroneus brevis is relatively spared. There would be a thick inferior peroneal retinaculum at the level of the tubercle (which is absent in this case.
So in my view this is a compression tendinosis and split tear of brevis and an incidental large peroneal tubercle.
Great case.
Steve
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Nice video Son,
I think it is multifactorial.
The first and obvious point is that the peroneus brevis tendon is in a disadvantaged position squashed between the peroneus longus tendon and the lateral malleolus (fibula).
Other than the obvious unlucky position there are several predisposing factors that leave to compression of peroneus brevis.
Diabetes
High BMI
Biomechanics factors
Smoking2 weeks ago we had the Canon anatomy day in Melbourne and one of the prosecution cadaver specimens we had was a perfect example,
The peroneus longus tendon was almost round / slightly oval shaped and the peroneus brevis tendon was paper thin and wrapped completely around it. When we lifted the peroneus longus tendon out of the cup shaped brevis tendon we could see a longitudinal split that had formed in the brevis tendon.
It is a mechanical compression phenomenon,
B grade engineering !
I have always said peroneus brevis is a Cheap as Chips, Cunninghams Warehouse quality tendon design.
Steve.
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