Peroneal Tendon Debridement

Tenosynovitis of the peroneal tendons is a common lower extremity problem that is often mistaken for other ankle pathology. Diagnosis is suggested with thorough history and physical examination and confirmed with radiographic studies when necessary. Patients with less acute or more severe presentation may improve with rest and physical therapy alone. When conservative management fails, surgical intervention is aimed at excising inflamed synovium with debridement and repair of any tears in the peroneal tendons. Recent literature has emphasized the increased use of tendoscopic approaches to peroneal pathology, although most studies to date have been too underpowered to suggest superiority to an open approach. We present a case of acute tenosynovitis treated by open surgical debridement and irrigation. Tendoscopy was deferred as the size and nature of this patient’s injury warranted an open repair.

Tenosynovitis; tendon injury; peroneal tendon; tendon debridement; foot and ankle.

Tenosynovitis of the peroneal tendons is a common lower extremity problem that can be difficult to diagnose and treat. Injury to the peroneal tendon is often mistaken for an ankle sprain or other lower extremity pathology, and it is estimated that only 60% of peroneal tendon disorders are accurately diagnosed by the initial evaluation.¹ We present a case of acute tenosynovitis treated by open surgical debridement and irrigation. While injury to the peroneal tendons can sometimes be managed surgically with a tendoscopic approach, the size and nature of this patient’s injury warranted an open repair.

Tenosynovitis also presents as chronic disease, and a detailed history and examination can elucidate the presence of injury or entrapment of the peroneal tendons and give clues to suggest the etiology.² Peroneal tenosynovitis tends to occur both in active, younger populations with repetitive inversion injuries as well as middle-aged or elderly patients with injury to the peroneus longus at the cuboid tunnel.^2,3 Pertinent details in the history include a pattern of pain along the trajectory of the peroneus longus that is worsened by activity, and the presence of swelling, grating, tenderness, or crepitus. Peroneal tendon injuries are more commonly seen in individuals with cavus or high-normal medial longitudinal arches.²

This 40-year-old female patient presented with tenosynovitis of the left peroneal tendons. She has no significant past medical history. Both of her feet have normal arches, and she reports minimal daily physical activity, with a BMI of 31 kg/m². An associated infection was suspected due to the acute onset of the patient’s symptoms, which included pain and swelling with limited range of motion at the ankle. The patient had received conservative treatment prior to surgery, including empirical antibiotic therapy with peroral cephalosporins, ice, rest, and NSAIDs, which mostly alleviated the symptoms and clinical signs of acute inflammation. On the day of surgery, her chief complaint was limited range of motion and pain with passive inversion and plantarflexion in her left ankle.

Swelling (especially posterolateral ankle effusion in line with the course of the peroneal tendon) is often present on physical examination, particularly proximal to the base of the fifth metatarsal. Limited range of motion and tenderness are seen, particularly pain with passive inversion and plantarflexion or active eversion and dorsiflexion. The peroneals also serve to plantarflex the ankle, in addition to dorsiflexion and eversion. Therefore, circumduction of the ankle provides a full range of motion and activation to the peroneal tendons during a clinical exam. In rare cases, tenosynovitis may be caused by a pseudotumor created by fibrotic degeneration of the tendon sheath that is palpable at the lateral edge of the foot.²

Physical examination is usually sufficient to confirm the diagnosis of peroneal tenosynovitis, but a variety of radiologic studies may be performed to further characterize the etiology and severity of disease to guide treatment planning.^2,4,5 Plain radiographs are used primarily to exclude ankle fractures or small fibular avulsion fractures. They can also be used to identify enthesopathy, which may be an indication of more chronic tendinopathy. A medial oblique view of the foot may reveal an os peroneum at the peroneal groove of the cuboid bone. A calcaneal axial view may demonstrate hypertrophy of the peroneal tubercle. MRI can be used to characterize tendon ruptures or demonstrate fluid collection associated with tenosynovitis. Peroneal tenography may demonstrate anatomical compression of the tendons by the tendon sheath using dye whose course is tracked along the tendon by multiple fluoroscopic films. CT is historically used to identify bony abnormalities, but more recently has been used to identify tendinopathy such as tenosynovitis, as peritendinous fat planes are distorted and the tendons are surrounded in a soft tissue mass on imaging. Finally, ultrasound has some utility in diagnosing tendonitis as hypoechoic regions and tendon thickening will often be seen, and complete ruptures may also be identified. Effusion within tendon sheath can be evaluated sonographically. The ESSKA-AFAS international consensus statement on peroneal pathologies has suggested ultrasound and MRI to be the preferred adjunct imaging studies when diagnosis is unclear.⁴

Patients may experience resolution or significant improvement in symptoms with conservative management.² However, patients with stenosis at the tendon sheath, large tears in the tendons, or abnormal bony pathology are unlikely to see improvement, and surgical intervention is advised upon failure of conservative therapies.

Conservative treatment may be attempted for acute or chronic tenosynovitis upon initial presentation and is often associated with improvement, particularly in acute cases.² Rest, ice, immobilization, and NSAIDs are employed along with physical therapy aimed at stretching and developing strength in the peroneal tendons. Patients with stenosis at the tendon sheath causing compression of the tendons can undergo tenography as a diagnostic and therapeutic measure; their symptoms will persist beyond conservative management but may respond to the dye injection as the added volume can sometimes release the constriction.² Corticosteroid injections may be used as a supplementary treatment in these patients with continuing symptoms. Refractory or severe disease is best managed using a surgical approach.

Surgical intervention is employed in more severe cases of tenosynovitis to excise any synovitis, relieve any compression on the peroneal tendons by the tendon sheath, repair or excise medium to large tears in the tendon, and to correct any bony pathology that may lead to recurrence. Patients will undergo 2–4 weeks of non-weight bearing, followed by a strengthening protocol that should lead to resolution of symptoms and return to activity.

This patient underwent open surgical debridement to resolve infection and tenosynovitis of the peroneal tendons. The tenosynovium within the retinaculum was found to be inflamed at various points and was debrided. Additionally, the muscle belly of the peroneus brevis was found to extend down through the retinaculum to the inferior fibular groove and was also debrided  to above the level of the fibular groove. Finally, peroneus quartus was identified and debrided. The tendons were found to be stable within the groove with dorsiflexion and eversion. The retinaculum was reconstructed using woven sutures passed through bone and subsequently oversewn with 2-0 Vicryl sutures. Free excursion of the tendons was noted following reconstruction. The patient’s foot was placed in a posterior short leg plaster splint in neutral position for postoperative immobilization. The patient was expected to undergo an uneventful recovery and return to full function following physical therapy. The patient was seen 6 months postoperatively, and she had no complaints, with full range of motion in her left ankle.

De Quervain was the first to describe stenosing tenosynovitis of the wrist in 1895,⁶ and Hildebrand described tenosynovitis in the lower extremity 12 years later.⁷ The first procedures to relieve the obstruction in stenosing tenosynovitis were described by Hackenbroch in 1927.⁸ Since this time, the preferred surgical management of the vast majority of cases of peroneal tenosynovitis refractory to conservative therapy has been via an open approach at the posterolateral aspect of the fibula, with debridement, repair of tendons, reconstruction, or other procedures performed as necessary to resolve the cause of the tendinopathy.⁹

The majority of outcomes from peroneal surgery are good to excellent, although most studies to date on peroneal debridement are underpowered and varying in scope, therefore further research is needed to evaluate the outcomes. Demetracopoulos et al. (2014) studied 34 patients undergoing peroneal debridement and tendon repair and noted that 17 of 18 follow-up patients returned to full activity and did not require reoperation.¹⁰ Another study of 11 patients with stenosing peroneal tenosynovitis demonstrated significant improvements in 4 out of the 5 Foot and Ankle Outcomes Score measures (pain, daily activities, sports activities, quality of life) in all patients.¹¹

More recently, Wertheimer was the first to propose posterior tibial tendoscopy,¹² and van Dijk and Kort (1998) described the first tendoscopic procedure of the peronei, an approach that has now increased in popularity in selected cases.¹³ In a study of 9 patients, tendoscopy was successfully performed, and 3 of 4 patients with identified adhesions were symptom free at a mean follow up of 19 months. A more recent 2018 meta-analysis of 96 tendoscopic procedures of the peroneal tendons reported an overall success rate of 95% with minimal complications.¹⁴ Studies aimed at comparing the open and tendoscopic approaches to treating peroneal tenosynovitis are lacking in the literature, although two studies of open debridement for tendon tears have suggested that complication rates may be higher with open surgery (9–54%).^15,16 Thus, there is a need for further research examining both approaches to correcting selected and specified peroneal pathology, including tenosynovitis and/or associated tendon tears. Panchbhavi and Trevino have also promoted tendoscopy as a diagnostic tool in a study that uniquely identified peroneal pathology not evident on preoperative MRI.¹⁷ However, at this time there is insufficient evidence to suggest that tendoscopic approaches to peroneal disorders are superior to open due to the lack of higher-powered studies.

Peroneal tenosynovitis may be associated with tears of the peroneal tendon. The treatment algorithm developed by Redfern and Myerson has been utilized to direct intraoperative decision making for tendon repairs.¹⁶ For type I tears with both tendons grossly intact but with a tear present, excision of the longitudinal tear is performed followed by tubularization of the tendon. Type II tears in which one tendon is torn are managed via tenodesis. For type III tears in which both tendons are torn and unusable, the surgeon evaluates whether excursion of the proximal muscle is present. When present, the surgeon may attempt a one-stage allograft or tendon transfer assuming there is no scarring of the tissue bed. If scarring is present, a staged allograft with silicone rod may be a preferable alternative. When there is no excursion of the proximal muscle a tendon allograft is unlikely to be successful, and a tendon transfer would be indicated. Overall, this system has been well-received as a diagnostic tool for tendon injuries, as their study reported return to activity within 12 weeks in 70–80% of patients following tenodesis.¹⁶

Postoperative rehabilitation is an essential component of recovery from peroneal surgery. The optimal postoperative protocol is determined by whether the superior peroneal retinaculum was repaired during the surgery.⁴ When repair of the retinaculum is performed, two weeks of non-weight bearing in a lower leg cast followed by four weeks of weight bearing in a cast or boot is appropriate. The peroneal tendons should not be active until six weeks postoperatively. When the retinaculum is not repaired, rehabilitation should be guided by individualized patient-directed goals for recovery with early mobilization being encouraged, rather than a time-based recovery protocol. The presented recommendations are based on our experience and, to our knowledge, there are currently no published studies concluding on the optimal duration of immobilization following peroneal tendon debridement for tenosynovitis.

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This article is the companion to the following JOMI articles by Dr. Eric Bluman, MD, PhD:

• Brostrom-Gould Procedure for Lateral Ankle Instability
  
• Deltoid Ligament Repair
  
• Five-Month Patient Follow-Up following Ankle Ligament Reconstruction