Peroneal Tendon Tear M66.88 727.69



Peroneal tendons

Fleck sign 

synonyms: peroneal tendon tear, peroneal tendon disruption, peroneus longus tendon tear, peroneus brevis tendon tear

Peroneal Tendon Tear ICD-10

Peroneal Tendon Tear ICD-9

  • 727.69: Nontraumatic rupture of other tendon

Peroneal Tendon Tear Etiology / Epidemiology / Natural History

  • Often associated with ankle sprains in athletes: ballet dancers, skiers, soccer, tennis, football, running, basketball, ice-skating.

Peroneal Tendon Tear Anatomy

  • Superior peroneal retinaculum: primary retaining structure for the perneal tendons. Origin: posterior margin of the distal 1-2cm of the fibula. Travels posteriorly to the lateral calcaneus with extensions into the paratenon of the Achilles tendon. Most commonly avulses from the fibula often with a small fleck of bone.  (Maffuli N, AJSM 2006;34:986).
  • Deficient posterior distal fibular groove may contibute to peroneal instability.  Approximately 25% of people have a flattened or convex peroneal groove.
  • Hindfoot varus alignment is a predisposition to peroneal tendon injury.
  • Os peroneum is a sesamoid bone present in 10% to 20% of people located along the peroneus longus near the peroneal groove of the cuboid. (Sobel M, Foot Ankle Int 1994;15:112)
  • Anatomic varients in peroneal tendon sheath: low-lying peroneal brevis muscle belly; anomalous peroneal quartus tendon.

Peroneal Tendon Tear Clinical Evaluation

  • Lateral ankle pain, swelling and ecchymosis.
  • Tenderness posterioly along the peroneal tendons.
  • Pain and weakness with active ankle dorsiflexion and external rotation.
  • Lateral tenderness, no medial tenderness.
  • Ankle Circumduction Test: indicates peroneal tendon instability

Peroneal Tendon Tear Xray / Diagnositc Tests

  • A/P, Lateral and Mortise views of the ankle are normal.  May demonstrate a "fleck" sign: small avulsion fracture of the lateral malleolus which is pathognomonic for acute dislocation of the peroneal tendons and indicates Grade III injury to the superior peroneal retinaculum.
  • MRI: demonstrates disruption of the peroneus brevis +/- peroneus longus. Partial thickness tears will demonstrate fluid accumulation (high intensity signal) within the tendon
  • Dynamic ultrasound: may be indicated to evaluated for pseudosubluxation of the peroneal tendons. (Grant TH, JBJS 2005;87A:1788).

Peroneal Tendon Tear Classification / Treatment

  • Acute Partial Thickness Peroneous brevis tear: brief period of immobilization followed by focused physical therapy to maintain ROM, strengthen and restore proprioception. May return to sports in ankles taped / athletic ankle brace when pain is minimal and full motion and strength have been restored.
  • Chronic unrepairable peroneus brevis/longus tears with lack of foot eversion: FDL transfer (Wapner KL, Foot Ankle Int 2006;27:591)  Other options: VDL transfer or autograft/allograft tendon repair. 

Peroneal Tendon Tear Associated Injuries / Differential Diagnosis

Peroneal Tendon Tear Complications

  • Recurrent Tear
  • Continued pain
  • Stiffness
  • CRPS

Peroneal Tendon Tear Follow-up Care

  • Outcomes of peroneal tendon tear operative treatment:  90% return to employment at the same level. 58% scar tenderness; 54% lateral ankle swelling; 46% successfully return to sports.(Steel MW, Foot Ankle Int 2007;28:49)

Peroneal Tendon Tear Review References

  • Cerrato RA, Foot and Ankle Clinics of North America, 2009;14:299
  • Philbin TM, JAAOS 2009;17:306
  • Murr S: Dislocation of the peroneal tendon with marginal fracture of the lateral malleolus.  J Bone Joint Surg 1965;43B:563-565.
  • Eckert WR, Davis EA Jr: Acute rupture of the peroneal retinaculum.  J Bone Joint Surg 1976;58A:670-672.
  • Zoellner G, JBJS 1979;61A:292
  • Steel MW, Foot Ankle Int, 2007;28:49