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Ankle & Foot
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Peroneal Tendons
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The peroneii are a pair of set of tendons arising from the peroneal muscles in the posterolateral calf. Peroneus longus is a larger and more posterior of the two main tendons, peroneus brevis is the smaller and anterior. In the mid foot, peroneus longs passes beneath the cuboid and traverses the plantar aspect of the tarsal bones to insert in the base of the first metatarsal. Peroneus brevis lies more anteriorly at the level of the lateral malleolus and follows a more direct course to insert at the base of the fifth metatarsal. They are positioned posterior to the lateral malleolus is maintained by a combination of concavity in the distal fibula and the peritoneal retinaculum. Just below the lateral malleolus, the two tendons are separated by a bony prominence lateral aspect of the os calcis called the peroneal tubercle. Injuries to the peoneii are most commonly related to misuse. Peroneus brevis is affected more than peroneus longs possibly reflecting is position as it lies between peroneus longs and the fibula. The presence of an accessory tendon, a low musculotendinous junction and a prominent peroneal tubercle may all contribute to the development of peroneal tendinopathy. The peroneal tubercle has a variable appearances which should not be elevated more than 5mm from the underlying bone. The most common manifestation of injuries the development of tendinopathy and longitudinal splits. Tendon splitting can result in apparent division of peroneus brevis into two tendons which can become displaced to lie in the medial and lateral aspect of peroneus longs. The identification of three structures within the peroneal sheath should raise suspicion of this injury.
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The differential diagnosis of three structures within the tendon sheath includes the presence of an accessory slip of peroneus quadratus. In association with tendon splits ganglion cysts may form and may extend some distance along and around the tendon usually proximal to the lateral malleolus. Peroneus brevis tendinopathy may also occur close to its insertion at the base of the fifth metatarsal. The most common injury is of course an avulsion fracture called the Jones fracture. Fractures of an accessory ossicle in peroneus longs may simulate tendon rupture.
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