Based on the clinical history and physical exam findings this patient likely has chronic peroneal longus tendinopathy. The optimal treatment is a tendon debridement and tenodesis to the peroneus brevis. As the pathology often occurs near the cuboid tunnel, the diseased portion distally is excised. Proximal side-to-side tenodesis should occur just proximal to fibula. Distal side-to-side tenodesis occurs proximal to the cuboid.
The peroneal muscles are the primary evertors of the hindfoot. The peroneal longus is located posterior to the fibula and traverses posterior to the peroneal tubercle to enter the cuboid tunnel. It attaches distally at the base of the first metatarsal and medial cuneiform. Injuries to the peroneal longus are uncommon and may be associated with diabetes, RA, hindfoot varus and a enlarged peroneal tubercle. Treatment for chronic injuries (which usually occur in the cuboid tunnel) involve tendon debridement and tenodesis to the peroneal brevis
Philbin et al. review the etiology, diagnosis and management of peroneal tendon injuries. They indicate that peroneus longus injuries are often related to direct trauma and that chronic tears occur secondary to mechanical irritation as the tendon enters the cuboid tunnel. In chronic cases, for which end to end repair is not possible, the diseased tendon should be removed followed by tenodesis to the peroneus brevis.
Figure A is a coronal MRI sequence at the level of the cuboid as the peroneus longus enters the cuboid tunnel. Increased signal on this T2 weighted sequence is consistent with a tear.
Illustration A is an axial MRI sequence at the just distal to the ankle joint demonstrative of the relationship of the peroneal tendons at the level of the fibula. The peroneus brevis (labeled A) is located anterior to the peroneal longus (labeled B).
A video is provided that reviews management of peroneus longus injuries.
Answers 1, 2: Given the chronicity of this injury and limited excursion of the affected tendon, repair is likely not possible
Answers 3, 4: The peroneal brevis tendon is not implicated here
Feinblatt J, Graves SC. Disorders of the anterior tibial, peroneal and achilles tendons. In: Pinzur MS, ed. Orthopaedic Knowledge Update: Foot and Ankle 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008:115-133
Coughlin MJ, Schon LC. Disorders of Tendons. In: Coughlin MJ, Mann RA, Saltzman CL,eds. Surgery of the Foot and Ankle. 8th ed. St Louis, MO: Mosby Elsevier; 2007:1149-1275.
Philbin TM, Landis GS, Smith B. Peroneal tendon injuries. Philbin TM, Landis GS, Smith B.