25/12/2020 at 7:55 am #8889Ray Chien-Hsing ChenParticipant
in video 1 and II , I can see the PB tendinosis at proximal and distal side of peroneal tubercle.
Do you agree this is PB tendinosis? is this secondary to peroneal tubercle syndrome?
I see PL more often in this situation, How about your opinion?
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29/12/2020 at 7:30 pm #8968Stephen BirdKeymaster
I am interested in this case,
My thoughts are that peroneus longus tendinosis is usually associated with peroneal tubercle syndrome where there is a stenosing tenosynovitis event caused by the congenitally large tubercle and the tight inferior peroneal retinaculum.
My default setting it to suspect peroneal tubercle syndrome for peroneus longus tenosynovitis and tendinosis and compression around the lateral malleolus for peroneus brevis tenosynovitis and tendinosis.
In this case the peroneal tubercle is normal and the retinaculum is not thick and peroneus longus is normal.
So I don’t think it is tubercle related.
The tendinosis does however extend to the inferior retinaculum, but this is not the cause of the problem.
You didn’t quite show me the problem but you showed me enough to have a good idea of the pathology.
If you look at the most proximal part of the peroneus brevis tendon that you show in the video you can see the tendinosis is much worse.
Also the relationship with the lateral malleolus is unusual,
I think the superior peroneal retinaculum is weak or damaged and there is some migration of peroneus brevis onto the lateral malleolus.
This will cause some dynamic instability.
You can also see this with the tibialis posterior tendon.
So it is a peoneus brevis instability and compression issue at the level of the lateral malleolus that is the primary pathology and the tendinosis simply extends to the level of the tubercle.
I have recently loaded a new lesson on the website “current concepts” where I discuss such pathology in the tibialis posterior tendon.
Another thing I have seen recently Ray is a case of obvious peroneus longus tenosynovitis and tendinosis exactly at the level of the peroneal tubercle but with only a tiny tubercle. Most times I see this the tubercle is hypertrophic. In this case it was small but the inferior retinaculum was very thick. It has convinced me that you can have a peroneal tubercle stenosing tenosynovitis without necessarily having a large tubercle. All you need is a thick and compressing retinaculum.
This is a lovely case you have shares with us Ray
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