Treatment of tendon pathology of the peroneal muscles

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The causes of the pathology of the tendons of the peroneal muscles

Tendon diseases (tendinopathies) or their damage are most often caused by mechanical irritation and chronic overload. The tendon overloads of the sagittal muscles occur most often during sports activity in the conditions of repeated inversion of the ankle joint. The pathologies of the peroneal muscles can affect the entire length of the tendon, the most common places of conflict and irritation of the tendon are:

1. The upper reticulum of the fibula muscles
   The upper reticulum of the fibula muscles is stretched between the fibula and the lateral surface of the calcaneus. This retinaculum delimits the canal in which the tendons of the fibula muscles run, which are situated in the groove of the fibula. Mechanical conflict within the superior reticulum may result from increased tissue volume in the sagittal canal. Under normal conditions, the abdomen of the short fibula should merge into the tendon above the upper cord. When the belly descends too low, the muscle mass takes up too much volume in the sagittal canal, leading to mechanical friction between the tendons. The presence of an extra peroneal fourth muscle, which is some kind of anatomical anomaly, may have a similar effect. The sagittal fourth muscle also runs within the superior cord of the fibula muscles, then attaches to the lateral surface of the calcaneus.
2. Sagittal lump
   The sagittal lump is located on the lateral surface of the calcaneus. Above the tubercle there is the tendon of the short fibula and under the tubercle the tendon of the long fibula. The overgrown sagittal nodule can mechanically irritate the tendon.
3. The furrow of the cubic bone
   The tendon of the long fibula passes to the plantar side of the foot in the area of ​​the cubic bone. This is where the tendon is where a small navicular bone called the additional fibula is woven. In most people, the secondary fibula is made up of cartilage, but in some it is made up of a bone structure. Repeated foot inversion movements can lead to local irritation of the tendon in the vicinity of the accessory fibula or lead to a sharp rupture of the sesamoid.

Compression of the fibula tendons may also occur in conditions of excessive valgus hindfoot, where the space between the calcaneus and fibula is reduced. Chronic conflict can lead to tendon damage.

Tendinopathy of the fibula tendons

In most cases, the pain is caused by degeneration (tendinosis) of the peroneal tendons or inflammation of the tendon (parateononitis). Tendinosis is the degeneration of collagen that builds the tendon, with accompanying overgrowth of blood vessels and the possible formation of calcification foci. On examination, the tendon is thickened with the presence of local nodules. Importantly, in the course of tendinosis, there is no presence of intra-tendinitis, therefore the term "tendinitis" should not be used to describe this pathology. Tendinosis leads to a weakening of the mechanical strength of the tendon, increasing the risk of its delamination or complete disruption.

On the other hand, inflammation occurs in the case of "paratenonitis", that is, inflammation of the tendon and adjacent connective tissue. Inflammation of the tendon does not significantly affect the strength of the tendon itself, but it is responsible for generating pain.

Conservative treatment

Conservative treatment consists in reducing training loads and wearing hindfoot pronation inserts, which allows for temporary relief of the muscle tendons. Rehabilitation includes physical therapy procedures (e.g. cryotherapy), deep transverse tendon massage and myofascial relaxation. In the final phase of the therapy, it is recommended to train the eccentric work of the fibula muscles.

In the case of severe symptoms, non-steroidal anti-inflammatory drugs (NSAIDs) are used. Administration of a steroid block to the tendon is contraindicated as it may further weaken the tendon structure and increase the risk of an acute rupture.

Surgery

Surgical treatment of tendinosis is considered when conservative treatment is not effective and consists in excising a fragment of the tendon affected by degeneration. Tendon stumps are sutured to the adjacent peroneal tendon (tenodesis procedure) or, less frequently, the continuity of the tendon is restored using a graft. The cause of the tendon irritation should also be removed - resection of the too low abdominal part of the short sagittal muscle or removal of the additional fourth sagittal muscle. If necessary, an overgrown sagittal tubercle is developed. In the event of irritation by a damaged additional fibula, it is restored, and if this procedure cannot be performed, the long fibular tendon is joined (tenodesis) with the short fibula tendon.

Damage to tendons of the fibula muscles

Longitudinal dissection of the tendon

 The most common is dissection of the short fibula in the furrow of the fibula. During movement of the foot, the fibula tendon is pinched between the tendon of the long fibula and the substrate of the fibula. If the tendon tear does not exceed 50% of its diameter, the surgeon sutures the lesion with absorbable sutures. Larger lesions are treated as the equivalent of a tendon rupture.

Tendon rupture

Rupture of the tendons of the peroneal muscles is manifested by a significant reduction in the foot conversion movement and an inability to actively lateral stabilize the ankle joint while walking. Surgical management depends on the extent of damage to a single or both tendons:

If only one tendon is torn, tenodesis is performed, i.e. sewing of the torn tendon stumps to the second fibular tendon with the same continuity;
If both tendons of the fibular muscles are broken or remain ineffective, a flexor digitorum longus (FDL) or flexor hallucis longus (FHL) tendon is transplanted. In some cases, it is sometimes necessary to perform a two-stage procedure, which in the first step involves implanting a silicone tendon implant, and in the second, replacing it with a natural FDL or FHL graft. Allogeneic transplants, i.e. tissues obtained from deceased donors (e.g. Achilles tendon), are also used.

Dislocation of the tendons of the fibula muscles

The tendon subluxation of the peroneal muscles is most often chronic. People have an increased risk of subluxation:

- with a shallow groove of the fibula where the fibular tendons run,
- with a deformed hindfoot,
- with chronic lateral instability of the ankle joint.
Repeated subluxation causes the tendons to rub against the posterior edge of the fibula, leading to their dissection. Less commonly, acute tendon dislocation occurs.

The main stability of the sagittal tendons in the sagittal groove is provided by the superior retractor of the sagittal muscles. The tendon dislocations of the fibula muscles are associated with damage to its structure and the forward displacement of the tendons of the fibula muscles:

1st degree: elevation of the periosteum of the fibula (the dislocated tendon lies between the fibula and the periosteum),
2nd degree: detachment of the cartilaginous fibrous edge from the fibula,
3rd degree: avulsion fracture of the sagittal attachment,
Stage IV: Avulsion fracture of the heel cord attachment.

There are also the so-called Tendon "intrasheath subluxation", in which the peroneal tendon swaps with the tendon of the short fibula, moving closer to the bottom of the bone. Both tendons remain within the fibula groove, but nevertheless subluxation may be accompanied by partial damage to the tendons.

The choice of treatment method depends on the anatomical classification of the lesion and the patient's level of activity. Conservative treatment consisting in immobilizing the ankle in a cast is inadvisable due to low effectiveness and recurrence of subluxations. In justified cases, immobilization can be used in type I and III damage due to the chance of healing the periosteum or adhesion of a bone fragment. In most cases, however, surgical treatment is undertaken, which includes the following procedures:

1. Direct repair of the upper reticulum of the fibula muscles
   After a few centimeters of the incision of the lateral ankle is made, the tendons are assessed with possible treatment for their injuries. After the tendons are repositioned in their proper place, the sagittal muscle cord is folded and sewn with the technique of "pants-over-vest". The surgeon attaches the tissues to the fibula with special sutures or anchors, paying attention to obtaining the appropriate tension of the repaired strap.
2. Reconstruction of the cord using a graft
   The most recommended method is the reconstruction of the strand with the use of allogeneic transplants, that is, obtained from a tissue bank and obtained from a deceased donor. The Achilles tendon or the plantar muscle are most often used to replace or strengthen the structure of the cord.
3. Deepening of the fibula groove
   One technique involves temporarily sawing off the posterior edge of the fibula, deepening the bone bed, and then reattaching the posterior edge of the arrowhead with the reposed tendons of the fibula muscles.
4. Placement of bone blocks on the fibula
   Bone blocks are intended to be an additional barrier to the tendons, protecting them from being dislocated again.
5. Tendon displacement under the calcaneofibular ligament
   Currently, a rarely used technique due to the high risk of complications.

Surgical correction of ankle axis disorders should also be performed, when they are the cause of strains or collapses of the sagittal muscles. In the case of hindfoot varus setting, one possible procedure is a lateral calcaneal osteotomy in combination with a posterior metatarsal osteotomy. This allows you to restore a stable support for the foot and relieve the tendons. Sagittal tendon repair procedures are often performed together with reconstruction of the lateral ligaments of the ankle joint. In the case of valgus position of the tarsus, an osteotomy mediating the calcaneus can be performed.

Proceedings after repair procedures of tendons of peroneal muscles

 For the first two weeks after the procedure, the patient moves on crutches to relieve the operated limb. Then a special orthosis is put on, the role of which is to protect the joint against excessive inversion and eversion movements until the tendons are fully healed. Rehabilitation will be aimed at mobilizing the postoperative scar, gradually restoring the range of motion in the joint, learning to properly load the lower limb while walking and practicing deep feeling (proprioception). This will allow the lateral muscular stabilization of the ankle to be restored and a safe return to normal activity.

Frequently asked questions about the treatment of tendon injuries of the fibula muscles: