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(Radiology. 2000;214:700-704.)
© RSNA, 2000

Musculoskeletal Imaging

Tear of the Peroneus Longus Tendon: MR Imaging Features in Nine Patients1

Jürgen Rademaker, MD, Zehava Sadka Rosenberg, MD, Emanuelle M. Delfaut, MD, Yvonne Y. Cheung, MD 2 and Mark E. Schweitzer, MD

1 From the Department of Radiology, Charite, Virchow Hospital Campus, Humboldt University of Berlin, Germany (J.R.); the Department of Radiology, Hospital for Joint Diseases Orthopaedic Institute, 301 E 17th St, New York, NY 10003 (Z.S.R., E.M.D.); the Department of Radiology, St Vincent's Hospital and Medical Center, New York, NY (Y.Y.C.); and the Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, Pa (M.E.S.). From the 1998 RSNA scientific assembly. Received December 14, 1998; revision requested January 1, 1999; final revision received July 1; accepted August 18. Address reprint requests to Z.S.R.


   Abstract
TOP
 Abstract
Introduction
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 
PURPOSE: To determine the magnetic resonance (MR) imaging features that characterize tear of the peroneus longus tendon at the midfoot.

MATERIALS AND METHODS: Medical records and MR images in nine patients with a tear of the middle segment of the peroneus longus tendon were retrospectively reviewed. All nine patients had undergone routine ankle MR imaging; three had undergone additional oblique coronal MR imaging. Surgical proof of a tear was available for three patients.

RESULTS: Partial tear was present in four patients, and complete tear was present in five. Partial tears were characterized by heterogeneous signal intensity and thickening of the tendon. Complete tears were characterized by discontinuity of the tendon. Additional findings included fluid in the tendon sheath (n = 6), marrow edema of the lateral calcaneal wall (n = 3), enlarged peroneal tubercle (n = 3), and tear of the peroneus brevis tendon (n = 2). The extent of the tear was better assessed with oblique coronal MR images.

CONCLUSION: The characteristic MR imaging appearance of complete or partial tear of the middle portion of the peroneus longus tendon includes foci of increased signal intensity in the distal tendon, morphologic alterations, and/or discontinuity of tendon. Bone marrow edema along the lateral calcaneal wall may be suggestive of the diagnosis. Additional oblique coronal midfoot MR images may help in assessment of the extent of the tear.

Index terms: Foot, MR, 464.121411, 464.121413 • Tendons, injuries, 464.486


   Introduction
TOP
 Abstract
 Introduction
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 
Numerous magnetic resonance (MR) imaging findings have been described (1–3) in patients with injury to the peroneal tendons (peroneal "tendinopathy"). These reports, however, have dealt with injuries to the proximal segments of the tendons, in the region of the lateral malleolus. Little attention has been paid to abnormalities affecting the peroneus longus tendon in the midfoot. Although some reports (2–5) included single cases of such lesions, to our knowledge there has been no focused imaging description of such tears in the radiology literature.

Diagnosis of tear of the peroneus longus tendon in the midfoot is clinically important, particularly because the patients tend to have nonspecific findings and are usually thought to have other conditions, such as ligamentous tears. The purpose of this study was to determine the MR imaging findings that are characteristic of a tear of the peroneus longus tendon at the midfoot. In this article, we describe the MR imaging features and discuss the clinical aspects of such tears.


   MATERIALS AND METHODS
TOP
 Abstract
 Introduction
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 References
 
Anatomy
The peroneus longus muscle arises from the posterior and lateral aspects of the fibula. The muscle has a long musculotendinous junction that ends above the level of the distal portion of the fibula. The tendon changes direction at the level of the lateral malleolus. Passing below the peroneal tubercle of the calcaneus, the peroneus longus tendon enters a fibro-osseous tunnel beneath the cuboid bone and transverses the sole of the foot to attach to the medial cuneiform bone and the base of the first metatarsal bone. About 25% of all patients have a sesamoid bone, or os peroneum, within the tendon in the region of the cuboid tunnel. The bone is ossified in 20% of cases (Fig 1) (6).



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  		Figure 1a. (a) Drawing shows the normal course of the peroneus longus tendon (open arrow). The tendon passes beneath the peroneal tubercle (arrowhead) to enter the cuboid tunnel (solid arrow). (b) Oblique coronal T1-weighted spin-echo MR image (600/25 [repetition time msec/echo time msec]) of the foot depicts a normal peroneus longus tendon (arrow) beneath the cuboid bone (C).

 


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  		Figure 1b. (a) Drawing shows the normal course of the peroneus longus tendon (open arrow). The tendon passes beneath the peroneal tubercle (arrowhead) to enter the cuboid tunnel (solid arrow). (b) Oblique coronal T1-weighted spin-echo MR image (600/25 [repetition time msec/echo time msec]) of the foot depicts a normal peroneus longus tendon (arrow) beneath the cuboid bone (C).

 
Patient Population
Nine patients (seven men, two women) aged 37–62 years (mean age, 51.9 years) were included in this study. An MR imaging diagnosis of partial or complete tear of the middle portion of the peroneus longus tendon had been established in all patients in our retrospective analysis. Symptoms ranged from ache to swelling and tenderness along the posterolateral portion of the foot or along the plantar surface of the midfoot.

Two patients had a history of inversion injury. Two others had a history of trauma, but the exact mechanism of injury was unclear. The other five patients denied a precedent trauma. One of these five reported waking up in the morning with pain under the arch of his foot. In another patient, an old anterior talofibular ligament tear was found at MR imaging, but the patient did not recall any trauma or injury. None of the patients had undergone prior foot or ankle surgery, and none had received a local injection of steroids. Three of the nine patients underwent surgical repair of the peroneus longus tendon.

MR Imaging Technique
Routine ankle MR examinations were performed in all nine patients by using 1.5- and 0.5-T units (Signa; GE Medical Systems, Milwaukee, Wis) equipped with a transmit-receive extremity coil. Patients were placed in the supine position with the ankle in mild (20°) plantar flexion. Imaging protocols were slightly different, but axial, coronal, and sagittal acquisitions of the ankle were performed in all patients. Three patients also underwent imaging of the midfoot in an oblique coronal plane (obtained perpendicular to the long axis of the metatarsal bones). The latter images provide a true cross section of the peroneal tendons in the midfoot.

Axial images were obtained with either T1-weighted spin-echo (400–600/13–16) or intermediate-weighted (5,266–5,466/38 [repetition time msec/effective echo time msec]) and T2-weighted (2,000–9,000/53–95 [effective]) fast spin-echo sequences. Coronal T1-weighted spin-echo (400–600/13–16) sequences also were performed.

In the oblique coronal plane, T1-weighted spin-echo (400–500/16–25) and/or T2-weighted fast spin-echo (5,416–9,983/68–105 [effective]) or inversion recovery (7,600/150/35 [repetition time msec/echo time msec/inversion time msec]) sequences were performed. In the sagittal plane, T1-weighted spin-echo (500–666/16–20) or T2-weighted fast spin-echo (3,200–6000/78–105 [effective]) sequences were performed.

For all MR sequences, the other parameters were 12–20 x 9–20-cm field of view, 256–512 x 128–256 matrix, 4–5-mm section thickness with 1.0–1.5-mm intersection gap, one to two signals acquired, and echo train length of four to eight.

The medical records, MR studies, and surgical reports were retrospectively analyzed by two of the authors (J.R., Z.S.R.), and a consensus was reached in cases of disagreement. The MR studies were evaluated for the following features: complete or partial tear of the tendon, proximal extension of the tear, marrow edema, fluid in the tendon sheath, prominence of the peroneal tubercle, presence of an os peroneum, and associated injuries to ankle ligaments and the peroneus brevis tendon.

Tear of the peroneus longus tendon was defined as a lesion in the midfoot if the tear was at the level of the peroneal tubercle or in the region of the cuboid fibro-osseus tunnel. Complete rupture of the peroneus longus tendon was defined as a discontinuity and gap in the tendon. Partial tear was defined as continuity of the damaged tendon with morphologic and signal intensity alterations on T1-weighted MR images with or without signal intensity alterations on T2-weighted images. There was no attempt to distinguish partial tear from chronic tendinopathy.


   RESULTS
TOP
 Abstract
 Introduction
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 References
 
Complete tear was diagnosed in five patients. Four patients had a partial tear of the peroneus longus tendon (Fig 2). All ruptures occurred at or slightly proximal to the cuboid fibro-osseus tunnel. In patients with a complete rupture, MR studies revealed an empty peroneus longus tendon sheath at the cuboid tunnel, with retracted proximal and distal segments of the tendon (Fig 3).



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  		Figure 2a. Nontraumatic partial tear of the peroneus longus tendon in a 48-year-old man. (a) Oblique coronal T1-weighted spin-echo MR image (600/25) of the foot reveals intermediate signal intensity in a thickened peroneus longus tendon (arrow). (b) Oblique coronal T2-weighted spin-echo MR image (5,000/930) of the foot depicts a fluid-filled, distended tendon sheath (arrow) and a thickened tendon.

 


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  		Figure 2b. Nontraumatic partial tear of the peroneus longus tendon in a 48-year-old man. (a) Oblique coronal T1-weighted spin-echo MR image (600/25) of the foot reveals intermediate signal intensity in a thickened peroneus longus tendon (arrow). (b) Oblique coronal T2-weighted spin-echo MR image (5,000/930) of the foot depicts a fluid-filled, distended tendon sheath (arrow) and a thickened tendon.

 


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  		Figure 3a. Nontraumatic complete tear of the peroneus longus tendon in a 62-year-old man. (a, b) Sequential oblique coronal intermediate-weighted MR images (2,400/17) of the foot reveal (a) a large central area of increased signal intensity in the peroneus longus tendon (arrow) at the calcaneocuboid joint and (b) more distally, at the cuboid tunnel, absence of the peroneus longus tendon and presence of a fluid-filled sheath (arrow). (c) Sagittal intermediate-weighted fast spin-echo MR image (3,500/93 [effective]) depicts the retracted distal portion of the peroneus longus tendon (arrow) surrounded by fluid under the head of the first metatarsal bone (m).

 


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  		Figure 3b. Nontraumatic complete tear of the peroneus longus tendon in a 62-year-old man. (a, b) Sequential oblique coronal intermediate-weighted MR images (2,400/17) of the foot reveal (a) a large central area of increased signal intensity in the peroneus longus tendon (arrow) at the calcaneocuboid joint and (b) more distally, at the cuboid tunnel, absence of the peroneus longus tendon and presence of a fluid-filled sheath (arrow). (c) Sagittal intermediate-weighted fast spin-echo MR image (3,500/93 [effective]) depicts the retracted distal portion of the peroneus longus tendon (arrow) surrounded by fluid under the head of the first metatarsal bone (m).

 


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  		Figure 3c. Nontraumatic complete tear of the peroneus longus tendon in a 62-year-old man. (a, b) Sequential oblique coronal intermediate-weighted MR images (2,400/17) of the foot reveal (a) a large central area of increased signal intensity in the peroneus longus tendon (arrow) at the calcaneocuboid joint and (b) more distally, at the cuboid tunnel, absence of the peroneus longus tendon and presence of a fluid-filled sheath (arrow). (c) Sagittal intermediate-weighted fast spin-echo MR image (3,500/93 [effective]) depicts the retracted distal portion of the peroneus longus tendon (arrow) surrounded by fluid under the head of the first metatarsal bone (m).

 
The tears were all visualized on routine MR examinations of the ankle, particularly on routine axial images. Optimal depiction of the tears was noted in patients with additional studies of the midfoot (obtained in the oblique coronal plane). In one patient, the additional images of the midfoot aided in determining that the tear was partial.

There were a few soft-tissue and bone MR imaging findings associated with the tears. Fluid in the sheath of the peroneus longus tendon was noted in six (67%) of nine patients (Fig 2b). In one patient, a tear of the anterior talofibular ligament was noted. Two patients had an associated split of the peroneus brevis tendon. Marrow edema along the calcaneal wall adjacent to the site of the tear was seen in three patients (Fig 4). Two of these three patients had an enlarged peroneal tubercle, and edema was noted in the peroneal tubercle, as well as along the lateral wall of the calcaneus (Fig 5). The third patient with an enlarged peroneal tubercle did not have calcaneal marrow edema. None of the patients in our series were found to have an os peroneum.



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  		Figure 4a. Nontraumatic complete tear of the peroneus longus tendon in a 56-year-old man. (a, b) Sequential axial fat-saturated T2-weighted fast spin-echo MR images (5,983/105 [effective]) of the ankle reveal marrow edema (*) along the anterolateral aspect of the calcaneus. (a) Residual peroneus longus tendon fibers (arrow) are seen. (b) More distally, there is a large amount of fluid (arrow) replacing the tendon. Minimal debris is noted lateral to the site of the injury.

 


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  		Figure 4b. Nontraumatic complete tear of the peroneus longus tendon in a 56-year-old man. (a, b) Sequential axial fat-saturated T2-weighted fast spin-echo MR images (5,983/105 [effective]) of the ankle reveal marrow edema (*) along the anterolateral aspect of the calcaneus. (a) Residual peroneus longus tendon fibers (arrow) are seen. (b) More distally, there is a large amount of fluid (arrow) replacing the tendon. Minimal debris is noted lateral to the site of the injury.

 


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  		Figure 5a. Traumatic partial tears of the peroneus longus and brevis tendons, associated with hypertrophied peroneal tubercle in a 37-year-old woman. (a) Oblique coronal T1-weighted spin-echo MR image (600/16) of the foot depicts hypertrophied peroneal tubercle (*) and marrow edema (arrowheads). The peroneus longus tendon (open arrow) is barely visible and has heterogeneous signal intensity. The peroneus brevis tendon is not well depicted. Scar and debris (solid arrows) surround both tendons. (b) Axial intermediate-weighted MR image (2,500/20) of the ankle depicts splits of the peroneus longus (open arrow) and peroneus brevis (solid white arrow) tendons. Marrow edema (arrowheads) is visible along the lateral calcaneal wall. Debris, fluid, and scar (black arrows) surround the tendons. The hypertrophied peroneal tubercle is not well depicted in b.

 


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  		Figure 5b. Traumatic partial tears of the peroneus longus and brevis tendons, associated with hypertrophied peroneal tubercle in a 37-year-old woman. (a) Oblique coronal T1-weighted spin-echo MR image (600/16) of the foot depicts hypertrophied peroneal tubercle (*) and marrow edema (arrowheads). The peroneus longus tendon (open arrow) is barely visible and has heterogeneous signal intensity. The peroneus brevis tendon is not well depicted. Scar and debris (solid arrows) surround both tendons. (b) Axial intermediate-weighted MR image (2,500/20) of the ankle depicts splits of the peroneus longus (open arrow) and peroneus brevis (solid white arrow) tendons. Marrow edema (arrowheads) is visible along the lateral calcaneal wall. Debris, fluid, and scar (black arrows) surround the tendons. The hypertrophied peroneal tubercle is not well depicted in b.

 
Surgical findings confirmed the MR imaging findings of tear of the peroneus longus tendon in all three patients who underwent surgery. No false-positive results were seen. The surgical findings included intrasubstance degeneration and tear of the tendon in one patient in whom an MR imaging diagnosis of partial tear was established and complete tendon discontinuity in two other patients in whom an MR imaging diagnosis of complete tear was established. The remaining six patients were treated nonsurgically with immobilization, nonsteroidal antiinflammatory drugs, and a rehabilitation program.


   DISCUSSION
TOP
 Abstract
 Introduction
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
References
 
Tear of the peroneus longus tendon at the level of the lateral malleolus (2) and in association with fractures of the calcaneus (7,8) are well-known entities, with imaging features that have been described in the literature (2,7,8). Tear of the peroneus longus tendon at the midfoot, however, is reported (9–11) to be an uncommon entity, and little attention has been paid to methods of diagnostic evaluation (4,12).

Tear of the peroneus longus tendon at the midfoot presents a diagnostic dilemma to the clinician and may be clinically underdiagnosed. Many of the patients in our series had nonspecific symptoms, as did similar patients described in the literature (9,13). The authors of several case reports (4,14,15) have focused on an abnormal position of an os peroneum on conventional radiographs as a clue for possible tear of the peroneus longus tendon. Peacock et al (15) suggested that the presence of an os peroneum is a predisposing factor for attritional tear just distal to the os peroneum, where the tendon slides into the groove of the cuboid bone. Our results support Sammarco's (13) observation that tear of the peroneus longus tendon at the midfoot also is prevalent in the absence of this accessory bone. Whereas Sammarco noticed an os peroneum in 50% of patients, none of the patients in our series had such a bone within the tendon. We did not have conventional radiographs; thus, we relied on the less sensitive MR images to detect an os peroneum. Nevertheless, our findings suggest that the role the os peroneum plays with regard to tear of the peroneus longus tendon should not be overestimated.

We speculate that the persistent gliding motion of the peroneus longus tendon under the cuboid bone may lead to increased stress on the tendon, which could predispose it to tear. In our series, the tears at the midfoot occurred in older patients, presumably because of underlying chronic attrition and mechanical wear and tear of the tendon. Major trauma was not a prevalent factor in at least four of nine patients. Acute tear of the peroneus longus tendon at the midfoot also can develop as a result of a sports-related injury or trauma (12,13,16). Such injuries usually are found in young, athletic individuals.

Hypertrophy of the peroneal tubercle has been implicated as a cause for tear of the peroneus longus tendon at the midfoot (5,17). Three patients in our series had a marked increase in the size of the peroneal tubercle, which suggests that this causative factor may play an important role in the formation of a tear of the peroneus longus tendon. In two of the three patients with marrow edema along the lateral calcaneal wall, the peroneal tubercle was enlarged. This further supports the idea that friction at the tubercle can predispose the peroneus longus tendon to tear.

Treatment in patients with a tear of the middle portion of the peroneus longus tendon is dependent on the clinical situation. A rehabilitation program with exercise is recommended if the patient is minimally symptomatic and has little loss of function. If pain and weakness are severe, however, direct repair of the tendon is required. The surgical procedure is tailored according to the extent of the tear and the degeneration of the tendon and may include suturing of longitudinal splits, débridement of the tendon, tenodesis of the tendon to the cuboid bone, excision of the hypertrophied tubercle, excision of the os peroneum, and/or tendon grafts (13,16). Preoperative MR imaging assessment of the site and extent of a damaged peroneus longus tendon may, therefore, be useful for treatment guidance and preoperative surgical planning.

There are several limitations to our study. Both the total number of patients and the number of patients in whom surgical proof was available were small. Nevertheless, to our knowledge, the present study included the largest number of patients described in the radiology literature with a partial or complete tear of the peroneus longus tendon at the midfoot (13). In three of the patients with MR imaging evidence of a distal tear, surgical results confirmed the MR imaging findings. Reasons for the lack of surgical intervention were the relatively older age of most of the patients and the presence of mild symptoms in many of them. Most of the patients who did not undergo surgery responded to treatment with nonsteroidal antiinflammatory drugs and a rehabilitation program.

In summary, MR imaging assessment of the peroneus longus tendon for a tear at the midfoot should be performed whenever persistent lateral ankle and plantar foot pain are present. Acquisition of additional oblique coronal MR images of the midfoot may be added to the imaging protocol when a tear of the middle segment of the peroneus longus tendon is noted. MR imaging findings suggestive of the presence of these tears include heterogeneity and/or discontinuity of the peroneus longus tendon; an empty, fluid-filled tendon sheath; marrow edema along the lateral calcaneal wall; and hypertrophied peroneal tubercle.


   Footnotes
 
2 Current address: Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass. Back

Author contributions: Guarantor of integrity of entire study, Z.S.R.; study concepts and design Z.S.R., J.R.; definition of intellectual content, J.R., Z.S.R.; literature research, J.R.; clinical studies, all authors; data acquisition, Z.S.R., Y.Y.C., E.M.D., M.E.S.; data analysis, Z.S.R., J.R.; manuscript preparation, Z.S.R., J.R.; manuscript editing, J.R., Z.S.R.; manuscript review, Z.S.R.


   References
TOP
 Abstract
 Introduction
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 

  1. Schweitzer ME, Eid ME, Deely D, Wapner K, Hecht P. Using MR imaging to differentiate peroneal splits from other peroneal disorders. AJR Am J Roentgenol 1997; 168:129-133.[Abstract/Free Full Text]
  2. Khoury NJ, El-Khoury GY, Saltzman CL, Kathol MH. Peroneus longus and brevis tendon tears: MR imaging evaluation. Radiology 1996; 200:833-841.[Abstract/Free Full Text]
  3. Tjin A, Ton ER, Schweitzer ME, Karasick D. MR imaging of peroneal tendon disorders. AJR Am J Roentgenol 1997; 168:135-140.[Free Full Text]
  4. Truong DT, Dussault RG, Kaplan PA. Fracture of the os peroneum and rupture of the peroneus longus tendon as a complication of diabetic neuropathy. Skeletal Radiol 1995; 24:626-628.[Medline]
  5. Boles MA, Lomasney LM, Demos TC, Sage RA. Enlarged peroneal process with peroneus longus tendon entrapment. Skeletal Radiol 1997; 26:313-315.[Medline]
  6. Edwards ME. The relations of the peroneal tendons to the fibula, calcaneus, and cuboideum. Am J Anat 1928; 42:213-253.
  7. Goodwin MI, O'Brien PJ, Connell DG. Intra-articular fracture of the calcaneus associated with rupture of the peroneus longus tendon. Injury 1993; 24:269-271.[Medline]
  8. Rosenberg ZS, Feldman F, Singson RD, Price G. Peroneal tendon injury associated with calcaneal fractures: CT findings. AJR Am J Roentgenol 1987; 149:125-129.[Abstract/Free Full Text]
  9. Thompson FM, Patterson AH. Rupture of the peroneus longus tendon: report of three cases. J Bone Joint Surg Am 1989; 71:293-295.[Free Full Text]
  10. Thompson FM, Patterson AH. Rupture of the peroneus longus tendon (letter). J Bone Joint Surg Am 1990; 72:306-307.[Free Full Text]
  11. Evans JD. Subcutaneous rupture of the tendon of the peroneus longus: report of a case. J Bone Joint Surg Br 1966; 48:507-509.
  12. Tehranzadeh J, Stoll DA, Gabriele OM. Posterior migration of the os peroneum of the left foot indicating a tear of the peroneum tendon. Skeletal Radiol 1984; 12:44-47.[Medline]
  13. Sammarco GJ. Peroneus longus tendon tears: acute and chronic. Foot Ankle Int 1995; 16:245-253.[Medline]
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  16. Sammarco GJ. Peroneal tendon injuries. Orthop Clin North Am 1994; 25:135-145.[Medline]
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