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Sports Med 2006; 36 (10): 839-846REVIEW ARTICLE 0112-1642/06/0010-0839/$39.95/0

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Recurrent Subluxation of thePeroneal TendonsNicholas A. Ferran,1 Francesco Oliva2 and Nicola Maffulli1

1 Department of Trauma and Orthopaedic Surgery, Keele University School of Medicine,Hartshill, Stoke-on-Trent, UK

2 Department of Orthopaedics and Traumatology, Faculty of Medicine and Surgery, Universityof Rome ‘Tor Vergata’, Rome, Italy

ContentsAbstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8391. Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8402. Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8403. Clinical Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8414. Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8415. Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8416. Preferred Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8437. Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8448. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 844

Recurrent peroneal tendon subluxation is an uncommon sports-related injury.AbstractThe retrofibular groove is formed not by the concavity of the fibula itself, but by arelatively pronounced ridge of collagenous soft tissue blended with the perioste-um that extends along the posterolateral lip of the distal fibula. The shape of thegroove is primarily determined by this thick fibrocartilagenous periosteal cushion,and not by the bone itself. The superior peroneal retinaculum is extremely variablein width, thickness and insertional patterns. Peroneal tendon subluxation iscommonly associated with longitudinal splits in the peroneus brevis tendon andlateral ankle instability. Disruption of the lateral collateral ankle ligaments placesconsiderable strain on the superior peroneal retinaculum. This explains why thetwo conditions commonly coexist. In recurrent subluxation, patients usually givea history of previous ankle injury, which may have been misdiagnosed as a sprain.An unstable ankle that gives way or is associated with a popping or snappingsensation is another common complaint. The peroneal tendons may actually beseen subluxing anteriorly on the distal fibula during ambulation. The role ofimaging has been debated, and the diagnosis and management plan are based onclinical evidence. Conservative management may be attempted in acute disloca-tions, and can be successful in up to 50% of patients, although there is a trend foroperative management in athletes. Recurrent dislocations should be managedsurgically. Five basic categories of repair have been described: (i) anatomicalreattachment of the retinaculum; (ii) bone-block procedures; (iii) reinforcement ofthe superior peroneal retinaculum with local tissue transfers; (iv) rerouting the

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840 Ferran et al.

tendons behind the calcaneofibular ligament; and (v) groove deepening proce-dures. However, it is impossible to determine from the relatively small serieswhich procedure is superior. If an anatomical approach to treating the pathology isutilised, reattachment of the superior retinaculum seems a most appropriatetechnique. Randomised controlled trials may be the way forward in determiningthe best surgical management method. However, the relative rarity of the condi-tion and the large number of techniques described make such study difficult.

Recurrent subluxation of the peroneal tendons is lateral lip of the distal fibula.[5] The shape of therare.[1] First described in a ballet dancer in 1803 by groove is primarily determined by this thick fibro-Monteggia,[2] acute peroneal subluxation is com- cartilagenous periosteal cushion, and not by themonly associated with skiing,[1] ice skating, soccer, bone itself.[4] Edwards,[8] examining 178 fibulae,basketball, rugby and gymnastics.[3] Acute subluxa- noted that a sulcus was present in the bone in 82% oftion usually occurs while the foot is dorsiflexed with cases, the bone was flat in 11%, and 7% had convexthe peroneal muscles strongly contracted.[4] Con- surfaces.servative management of acute subluxation is asso- The two peroneal tendons are bound to the lateralciated with a high rate of recurrence, and acute malleolus by the superior peroneal retinaculum, de-peroneal subluxation in high-demand individuals scribed as a band of deep fascia that extends fromshould probably be primarily managed surgically.[5] the posterior aspect of the lateral malleolus to theUntreated or misdiagnosed acute injury predisposes lateral surface of the calcaneus.[7] The superior pero-a patient to recurrent peroneal dislocation.[6] neal retinaculum is extremely variable in width,

thickness and insertional patterns, with most speci-1. Anatomy mens having insertions on both the calcaneus and

the Achilles tendon.[9]

Peroneus longus originates from the head and The sural nerve is a branch of the tibial nerve. Itupper two-thirds of the peroneal surface of the fibula descends between the heads of gastrocnemius,and from the intermuscular septa. Peroneus brevis pierces the deep fascia proximally in the leg and isoriginates from the lower two-thirds of the fibula. In joined by a sural communicating branch of the com-the middle third of the fibula, its origin lies in front mon peroneal nerve. It descends lateral to the Achil-of that of the peroneus longus, and the two muscles les tendon, near the small saphenous vein, to theand their tendons maintain this relationship. The region between the lateral malleolus and the calca-broad tendon of peroneus brevis lies immediately neus. It supplies the posterior and lateral skin of theposterior to the lateral malleolus. The narrower ten- distal third of the leg, proceeding distal to the lateraldon of peroneus longus lies on that of peroneus malleolus along the lateral side of the foot and littlebrevis. The peroneus brevis tendon passes above the toe.[10] Its proximity to the peroneal groove needs toperoneal trochlea to insert into the tubercle at the be considered when planning surgery, as transectionbase of the fifth metatarsal. The tendon of peroneus results in loss of sensation to the lateral aspect of thelongus passes below the peroneal trochlea and pass- foot.es obliquely to insert into the lateral aspect of thebase of the first metatarsal and the medial cunei- 2. Pathologyform.[7]

The retrofibular groove is formed not by the The superior peroneal retinaculum is the primaryconcavity of the fibula itself but by a relatively restraint to subluxation of the peroneal tendons inpronounced ridge of collagenous soft tissue blended the fibular groove. There are four grades of acutewith the periosteum that extends along the postero- tears of the superior retinaculum (figure 1). In grade

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Recurrent Subluxation of the Peroneal Tendons 841

1, the retinaculum is separated from the collagenous flexion and eversion against resistance to make thelip and lateral malleolus. In grade 2, the collagenous dynamic instability of the tendons apparent.[13]

lip is elevated with the retinaculum. In grade 3, a4. Imagingthin sliver of bone, visible on radiographs, is avulsed

with the collagenous lip and the retinaculum.[5] InWhile radiographs are helpful in diagnosing

grade 4 injury, the retinaculum is torn away from itsgrade 3 injuries to the superior peroneal retinacu-

posterior attachment on the calcaneus.[1] The superi-lum,[14] the roles of ultrasound, CT and magnetic

or peroneal retinaculum itself generally remains in-resonance imaging (MRI) have been debated. These

tact.[5] It is impossible to determine the grade of theimaging modalities are not widely used. Dynamic

injury clinically, except for grade 3 injuries, whichhigh-resolution ultrasound is effective in demon-

can be diagnosed on radiographs.strating subluxation and associated tendon

Peroneal tendon subluxation is commonly asso- splits.[15,16] CT may be helpful in assessing the re-ciated with longitudinal splits in the peroneus brevis trofibular groove prior to, and postoperatively in,tendon and lateral ankle instability. Disruption of groove deepening procedures.[17] Static MRI is use-the lateral collateral ankle ligaments places consid- ful in grading superior peroneal retinaculum inju-erable strain on the superior peroneal retinaculum. ries, identifying splits in the peroneal tendons, diag-This explains why the two conditions commonly nosing abnormality in the lateral collateral anklecoexist.[11]

ligament complex and demonstrating morphologicalabnormalities of the fibular groove (flat, convex or

3. Clinical Features irregular).[18] When there is clinical suspicion ofperoneal tendon subluxation, static MRI with active

In recurrent subluxation, patients usually give a dorsiflexion of the foot may demonstrate displacedhistory of previous ankle injury, which may have tendons. Kinematic MRI may also demonstrate po-been misdiagnosed as a sprain. An unstable ankle sition-dependent dislocation in cases where sponta-that gives way or is associated with a popping or neous relocation may make clinical assessment dif-snapping sensation is another common complaint. ficult.[19]

The peroneal tendons may actually be seen sublux-ing anteriorly on the distal fibula during ambula- 5. Managementtion.[12] A recently described examination technique

Conservative management may be attempted insuggests positioning the patient prone with the kneesacute dislocations; however, recurrent dislocationsflexed at 90°, with active dorsiflexion and plantarshould be managed surgically.[20-27] Various surgicaltechniques have been described, with no randomisedstudies to determine which method is superior. Theavailable literature is limited to case reports and caseseries.

Five basic categories of repair have been de-scribed: (i) anatomical reattachment of the retinacu-lum; (ii) bone-block procedures; (iii) reinforcementof the superior peroneal retinaculum with local tis-sue transfers; (iv) rerouting the tendons behind thecalcaneofibular ligament; and (v) groove deepeningprocedures.[3]

Anatomical reattachment of the retinaculum aimsat restoring the primary restraint to the peronealtendons. Several authors[5,28-32] described reattach-

Normal

Fibula

Collagenouslip

SPR

Fig. 1. Schematic of classification of acute tears of the superiorperoneal retinaculum (SPR). PBT = peroneus brevis tendon; PLT =peroneus longus tendon.

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842 Ferran et al.

ment with sutures brought through drill holes in the prompted several authors to design procedures todistal fibula. As an alternative, Beck[22] brought the augment or reinforce the retinaculum with tissueretinaculum through a slit created in the distal fibula transfers consisting of either tendon or periostealand fixed this with a screw. None of his nine patients flaps. Jones[40] first described restraining the perone-with recurrent subluxation had recurrences or com- al tendons with a strip of Achilles tendon anchoredplications. In a 9-year follow-up of the ‘Singapore through a drill hole in the fibula. There were nooperation’ with 18 of 21 patients having excellent recurrences in a long-term follow up of a series of 15results and three patients who experienced postoper- patients treated with an Ellis-Jones repair.[41]

ative pain and neuromas, no recurrence was not- Thomas et al.[6] described a modification to thised.[33] Karlsson et al.[32] reported 13 patients with procedure, which allowed the use of a smaller stripgood to excellent results that were able to return to of Achilles tendon, reducing the risk of weakeningfull activity, and two patients whose activity was the tendon. The tendon of peroneus brevis,[42-44]

limited by pain; no recurrence was noted at follow- plantaris[45,46] and peroneus quartus[47] can be usedup. They did, however, employ groove deepening in for the same purpose. Zoellner and Clancy[48] andconjunction with reattachment if the posterior sur- Gould[49] used periosteal flaps to restrain the perone-face of the fibula was flat or convex. al tendons in a deepened peroneal grove with satis-

factory results. A periosteal flap from the retrofibu-Bone-block procedures attempt to deepen thelar grove can be used on its own or incorporatedretrofibular groove using a bone graft as a physicalwith groove deepening,[26] with no postoperativerestraint to the peroneal tendons. In 1920, Kelly[34]

complications in ten patients in whom this proce-described a bone-block procedure. He initially useddure has been used.[50]

screw fixation for the sliding veneer graft but laterdesigned a wedge-shaped graft that avoided the use Platzgummer[51] divided the calcaneofibular liga-of screws near the ankle joint. DuVries[35] and Wat- ment and transposed the tendons behind it to restrainson-Jones[36] described modifications to the Kelly the peroneal tendons. Sarmiento and Wolf[52] latertechnique. Watson-Jones[36] used an osteoperiosteal divided the peroneal tendons and reattached themflap anchored by a soft tissue pedicle and secured it after rerouting them behind the calcaneofibular liga-posteriorly with sutures. DuVries[35] anchored a pos- ment. Both methods potentially weakened theseteriorly displaced wedge with a screw. Other authors structures, although the 13 patients operated withreported on patients with chronic subluxation treat- Platzgummer’s technique showed good or excellented with a modified Kelly technique with no recur- results with no evidence of recurrence or instabili-rence.[21,23,37] Larsen et al.[24] and Lowy et al.[38] ty.[53] The 11 patients of Sarmiento and Wolf[52]

reported on the DuVries technique. Larsen et al.[24] showed no evidence of recurrence or instability atreported many complications including re-disloca- follow-up, although two patients experienced suraltion and pain associated with a screw, but Lowry et nerve injury.[54] A bone-block of the ligamentousal.[38] noted no complications in a single case report. insertion on the fibula[55] or the calcaneus[25] isIn 1989, Micheli et al.[39] employed an inferiorly mobilised, the tendons are transposed and the bonedisplaced fibula bone graft fixed with screws. Of 12 block is reattached with a screw. Both methodspatients with chronic subluxation to undergo the preserve the integrity of both the calcaneofibularprocedure, one experienced a traumatic fracture of ligament and the peroneal tendons. Pozo and Jack-the graft and two required exploration for pain with son[55] reported no complications and return to fullno recurrences of the subluxation.[39] Adhesion of level of activity in a single patient. Poll andthe tendons to the fresh bone wound may prove to be Duijfjes[25] reported ten patients with no recurrencea disadvantage of bone-block procedures.[22] or instability.

In some patients with recurrent subluxation, the The depth of the retrofibular sulcus was thoughtsuperior peroneal retinaculum is attenuated. This to play an important role in the restraint of the

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Recurrent Subluxation of the Peroneal Tendons 843

groove is defined by the fibrocartilagenous perioste-al cushion and not the bony sulcus add weight to thisargument.[4]

6. Preferred Surgical Technique

Under general or spinal anaesthetic, the patient isplaced supine on the operating table with a sandbagunder the buttock of the operative side to internallyrotate the affected leg. A tourniquet is applied to thethigh, the leg exsanguinated and the cuff inflated to250mm Hg.

A 5cm longitudinal incision is made along thecourse of the peroneal tendons. The incision startsFig. 2. Exposure and sectioning of the common peroneal tendon

sheath. posterior to the tip of the lateral malleolus, andprogresses proximally, staying well anterior to the

peroneal tendons leading to the development of pro- sural nerve. The incision is deepened to the peronealcedures to deepen the sulcus when it was flat or tendon sheath, which is incised longitudinally 3mmconvex. Zoellner and Clancy[48] described a proce- posterior to the posterior border of the fibula (figuredure in which an osteoperiosteal flap is elevated 2). The superior peroneal retinaculum is normallyposteriorly on the distal fibula and cancellous bone thin and deficient, especially anteriorly. The perone-is removed with a gauge. The flap is then reduced al tendons are identified by blunt dissection, andinto the deepened sulcus and the tendons are re- protected. The lateral aspect of the lateral malleolusplaced into this. The nine patients they treated had is exposed (figure 3), and the ‘pouch’ formed be-excellent results with no recurrence or instability.[48] tween the bony surface of the lateral malleolus and

the superior peroneal retinaculum, where the ten-Slatis et al.[56] reported on four patients with excel-dons sublux becomes visible.lent results with this method. Kollias and Ferkel[27]

The bony surface of the lateral malleolus isreported that 10 of 11 patients treated with thisroughened up with a periosteal elevator to produce amethod had excellent results, with one patient hav-bleeding surface (figure 4) and three or four anchorsing a poor result due to decreased ankle mobility.are inserted along the posterior border of the lowerHutchinson and Gustafson[57] described a similar

method in combination with retinaculum reattach-ment. In their 20 patients, three had poor results withre-subluxation and one of these developed reflexsympathetic dystrophy. Gould[49] reported a patientin whom groove deepening was incorporated withrestraint of the peroneal tendons by reflection of andelevated osteoperiosteal flaps. Mendicino et al.[58]

used intramedullary drilling and cortical impactionto achieve groove deepening. The need for groovedeepening has been questioned. Although 18% ofthe fibulae in the anatomical study of Edwards[8] hada flat or convex sulcus, the low incidence of perone-al tendon subluxation would suggest that the bonysulcus is not a predisposing factor to subluxation.Histological studies demonstrating that the peroneal

Fig. 3. The lateral aspect of the lateral malleolus with the deficientsuperior peroneal retinaculum exposed by anterior retraction.

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844 Ferran et al.

7. Postoperative Care

Patients were discharged the day after surgery,after having been taught to use crutches by anorthopaedic physiotherapist. No thrombo-prophy-laxis is used. Patients were allowed to bear weighton the operated leg as tolerated, but were told tokeep the leg elevated as much as possible for thefirst two postoperative weeks. Patients were seen onan outpatient basis at the second postoperativeweek, and the cast was removed 4 weeks from theoperation. Patients then mobilised the ankle withphysiotherapy guidance. They were allowed to par-tially weight bear, and commenced gradual stretch-Fig. 4. The lateral malleolus is roughened up with a periostal eleva-

tor.ing and strengthening exercises over 8–10 weeksafter surgery. Cycling and swimming were started 2fibula (figure 5). After manual testing that theweeks after removal of the cast. Patients were al-

anchors cannot be dislodged, the superior peroneallowed to return to their sport on the fifth postopera-

retinaculum is reconstructed in a ‘vest over pants’ tive month.fashion (figure 6), making sure that the pouch be-tween the bony surface of the lateral malleolus and 8. Conclusionsthe superior peroneal retinaculum is totally obliter-

Recurrent peroneal tendon subluxation is a rela-ated. The ankle is kept in eversion and slight dor-tively rare sports-related injury that occurs when thesiflexion so that the peroneal tendons are in theacute injury is misdiagnosed or not adequately man-‘worst possible position’. The strength of the repairaged. The primary pathology is failure of the superi-

is tested moving the ankle through the whole rangeor peroneal retinaculum, the principal restraint to the

of motion. peroneal tendons. While diagnosis remains depen-If a tear of the peroneal tendons was found (two dent on clinical suspicion and clinical examination,

there is an emerging role for imaging to determinepatients, both showing a tear of peroneus brevis),this was repaired with fine absorbable sutures.

The wound is closed in layers with 2/0 Vicryl 1

(Ethicon, Edinburgh, UK) for the subcutaneous fat,subcuticular undyed 3/0 Vicryl (Ethicon, Edin-burgh, UK) and Steristrips (3M, Loughborough,UK). Dressing swabs, dressing and crepe bandageare applied. A below-knee walking synthetic cast isapplied with the ankle in neutral and slight eversion.Weight bearing is allowed from the day after theoperation, and the plaster is removed 4 weeks afterthe procedure, when rehabilitation is started. Gradu-al return to activities and to sport is allowed over thecourse of 3–4 months from the procedure. Fig. 5. The anchors in situ.

1 The use of trade names is for product identification purposes only and does not imply endorsement.

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Recurrent Subluxation of the Peroneal Tendons 845

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