Knee Surg Sports Traumatol Arthrosc DOI 10.1007/s00167-015-3562-3
ANKLE
Peroneal tendinosis as a predisposing factor for the acute lateral ankle sprain in runners Pejman Ziai · Emir Benca · Florian Wenzel · Reinhard Schuh · Christoph Krall · Alexander Auffahrt · Martin Hofstetter · Reinhard Windhager · Tomas Buchhorn
Received: 6 October 2014 / Accepted: 27 February 2015 © European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2015
Abstract Purpose A painful episode in the region of the peroneal tendons, within the retromalleolar groove, is a common precipitating event of an acute lateral ankle sprain. A forefoot striking pattern is suspected to cause peroneal tendinosis. The aim of this study is to analyse the role of peroneal tendinosis as a predisposing factor for ankle sprain trauma in runners. Methods Fifty-eight runners who had experienced acute ankle sprain trauma, with pre-existing pain episodes for up to 4 weeks in the region of the peroneal tendons, were assessed clinically. Fractures were excluded by conventional radiography. An magnetic resonance imaging (MRI) scan had been P. Ziai (*) · E. Benca · R. Schuh · R. Windhager Department of Orthopaedics, Medical University of Vienna, Waehringer Guertel 18‑20, 1090 Vienna, Austria e-mail: [email protected] F. Wenzel Department of Trauma Surgery, Medical University of Vienna, Waehringer Guertel 18‑20, 1090 Vienna, Austria C. Krall Section for Medical Statistics, Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria A. Auffahrt Department of Traumatology and Sports Injuries of the Paracelsus Medical University, Muellber Hauptstraße 48, 5020 Salzburg, Austria M. Hofstetter Department of Biomedical Imaging and Image‑Guided Therapy, Medical University of Vienna, Waehringer Guertel 18‑20, 1090 Vienna, Austria T. Buchhorn Sporthopaedicum Straubing, Bahnhofplatz 27, 94315 Straubing, Germany
performed within 14 days after the traumatic event and was subsequently evaluated by two experienced radiologists. Results MRI revealed peroneal tendinosis in 55 patients (95 % of the total study population). Peroneus brevis (PB) tendinosis was found in 48 patients (87 % of all patients with peroneal tendinosis), and peroneus longus (PL) tendinosis was observed in 42 cases (76 %). Thirty-five patients (64 %) had combined PB and PL tendinosis. A lesion of the anterior talofibular ligament was found to be the most common ligament injury associated with peroneal tendinosis (29 cases; 53 %), followed by a lesion of the calcaneofibular ligament (16 cases; 29 %) and a lesion of the posterior tibiofibular ligament (13 cases; 24 %). Conclusion The results of this study reflect the correlation between peroneal tendinosis and ankle sprain trauma. Injuries of one or more ligaments are associated with further complications. A period of rest or forbearance of sports as well as adequate treatment of the peroneal tendinosis is essential to prevent subsequent ankle injuries, especially in runners. Modification of the running technique would also be beneficial. Level of evidence IV. Keywords Peroneal tendinosis · Ankle sprain trauma · Running injury · Lateral ankle stabilisation
Introduction Peroneal tendinosis is suspected to cause ankle sprain trauma in runners. Peroneal tendinosis as a consequence of excessive strain in conjunction with lateral chronic ankle instability (CAI) has been extensively described in the published literature and is often associated with a foot deformity, such as a pes cavovarus [3, 6, 7]. The peroneal tendons
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are known as active stabilisers of the ankle [14, 20]. The passive stabilising role of the peroneal tendons due to their anatomical location and their viscoelastic properties has been discussed in recent studies [15, 36]. The above-mentioned phenomena may result in greater peroneal tendon activity to compensate passive ankle instability at the functional level. Besides, excessive strain on the peroneal tendons as a result of viscoelastic degradation might be a potential cause of acute as well as chronic peroneal tendinosis [5]. Recent publications have addressed the forefoot running technique, especially in mid-distance races [16]. Increased tension in the foot arch of the plantar flexed foot due to the foot strike pattern might result in greater tensile loads on the passive stabilising ligaments and tendons surrounding the ankle during the stance phase [26]. In fact, the classic forefoot strike pattern and flat positioning of the foot during the stance phase while running are associated with greater plantar flexion of the ankle joint and a higher knee flexion angle. This is believed to ensure better proportional distribution of energy loads and cushioning impact forces during initial ground contact [11]. Ankle overload as a result of increasing torque in plantar flexion might be one of the reasons for a higher incidence of tendinopathy [1, 29, 34]. The prevalence of the forefoot, midfoot and rearfoot strike pattern has been discussed in peer-reviewed reports, but no consensus has been achieved in this regard. The choice of the strike pattern might depend on several cofactors, such as mileage, speed or footwear [22, 28, 34]. Large running distances accompanied by high impact forces, resulting in muscle weakening and loss of stabilising muscle function, cause high strain on passive stabilising structures and a predisposition for overloading ligaments as well as tendons. Christina et al. [8] noted weakening of the anterior tibial muscle and subsequent loss of eccentric control during dorsiflexion of the ankle. Reduced absorption of impact forces during initial ground contact, followed by a high workload during loading response in the stance phase and higher strain on the peroneal muscles, might create a predisposition for tendinopathy [19, 21, 25]. Reduction in active lateral ankle stabilisation may lead to more frequent ankle sprain trauma in supination-inversion [5, 37]. The purpose of this study is to analyse peroneal tendinosis as a predisposing factor for ankle sprain trauma in runners.
Materials and methods Fifty-eight runners with a painful episode in the region of the peroneal tendons during 2–4 weeks prior to their ankle
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sprain trauma were included in the study. The painful episode was recorded retrospectively in the patient’s medical history. The patients’ mean age was 35.6 ± 11.0 years. Further inclusion criteria were a weekly running mileage of at least 20 km, a clinical grade III lesion according to the established classifications for the evaluation of ligament and accompanying injuries in the ankle, and exclusion of a fracture on conventional radiographs in two planes. No obvious correlation was found between rearfoot alignment and peroneal tendon overload. An MRI scan had been performed within 14 days after the traumatic event. Immobilisation in a walker brace (DJO Global, Inc., Carlsbad, CA, USA) in neutral position was prescribed until the MRI findings were available. The study was approved by the ethics committee of the Medical University of Vienna, and informed consent was obtained from all patients prior to enrolment in the study. Magnetic resonance imaging was performed on a 3.0 Tesla MR scanner (Magnetom Trio; Siemens Medical Solutions, Erlangen, Germany). All images were obtained with an eight-channel high-resolution, small field of view (FoV) foot and ankle imaging coil (Invivo, Gainesville, FL, USA). This dedicated phased array coil is designed to utilise the advantages of the eight-channel system, including parallel imaging. Due to its boot design, it easily slides down over the foot and ankle, and can be fixed, which results in less motion artefacts. Patients were scanned with the ankle fixed in neutral position. The total scanning time including localisation was 42 min per patient. The anterior and posterior talofibular ligaments were evaluated in the axial plane (T2- and T1-weighted), and the calcaneofibular ligament in the oblique axial plane (T2-weighted), with the foot in neutral position. The peroneal tendons were visualised on sagittal and axial T1- and T2-weighted images. Increased signal intensity in the peroneal tendon on T1-weighted images, but no fluid signal on T2-weighted images, was interpreted as peroneal tendinosis. Two senior radiologists with experience in musculoskeletal imaging evaluated the images. The distinction between post-traumatic tendonitis as a result of ankle sprain and overuse tendinosis was taken into account.
Results The MRI scans revealed peroneal tendinosis in 55 of 58 patients (95 %). Peroneus brevis (PB) tendinosis was found in 48 patients (87 %) (Fig. 1), and peroneus longus (PL) tendinosis in 42 (76 %). Thirty-five patients (64 %) had combined tendinosis of the PB and PL tendons. No peroneal tendinosis was found in three patients (5 %). A lesion of the anterior talofibular ligament (ATFL) was the most common ligament injury associated with peroneal
Knee Surg Sports Traumatol Arthrosc Fig. 1 Tendinosis of the peroneus brevis tendon on the axial T2-weighted sequence in magnetic resonance imaging performed on a 3.0 Tesla MRI scanner
tendinosis (29 cases; 53 %), followed by a lesion of the calcaneofibular ligament (CFL) (16 cases; 29 %), and that of the posterior tibiofibular ligament (PTFL) (13 cases; 24 %). Various combinations of ligament lesions and peroneal tendinosis are shown in Fig. 2. Mild tendinosis of the Achilles tendon was found in two patients. Lesions in other tendons like the FHL (flexor hallucis longus), the FDL (flexor digitorum longus) or the TP (tibialis posterior) were not found.
Discussion The most important finding of the present study reflects the correlation between peroneal tendinosis and acute ankle sprain trauma in runners. The peroneus brevis (PB) tendon was most commonly affected, followed by the peroneus longus (PL) tendon and combined tendinosis of the PL and PB tendon. Thus, both tendons might have been exposed to similar strain rates in the examined runners. Our data concerning a lateral ligament lesion confirm the outcomes of previous research: the ATFL was most commonly affected, followed by combined ATFL and CFL lesions [18, 35]. An unexpectedly high rate of isolated as well as combined posterior talofibular ligament (PTFL) lesions was found to be associated with peroneal tendinosis. Injury of the PTFL is uncommon; it is usually observed in combination with an ATFL and/or a CFL lesion [33]. Impaired active and passive stabilising abilities of the peroneal tendons due to tendinosis, with greater rotational workloads on the talus in cases of ankle supination-inversion trauma,
Fig. 2 Absolute frequencies of various combinations of ligament lesions in patients with PL tendinosis (peroneus longus), those with PB tendinosis (peroneus brevis) and those with PB and PL tendinosis. The red part at the bottom of each bar represents patients with peroneal tendinosis alone compared to those with PL (PB) tendinosis alone, and those with both conditions. Note the total length of the PL (PB) bar and the total length of the PB–PL bar
could be responsible for this phenomenon [36]. In the present study, a combined lateral ligament lesion (ATFL, CFL and PTFL) in conjunction with peroneal tendinosis
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was observed less frequently than a single lateral ligament lesion, but the results in general are similar to those of other studies [3, 4, 12, 33]. The role of the peroneal tendons in active lateral ankle stabilisation against internal rotation is a proven fact [2, 31]. All patients in the present investigation experienced subjective lateral ankle instability while running ever since the onset of pain in their peroneal tendons. The peroneal tendons are involved in the pronationeversion movement, stabilise the ankle during the stance phase, and support hindfoot alignment and an appropriate positioning of the foot prior to and at initial contact in gait [13, 17]. Due to their viscoelastic properties, the peroneal tendons may also play a role in passive stabilisation of the ankle joint [36]. Consequently, peroneal tendinosis could be responsible for the loss of stabilisation during the stance phase of gait. Chronic peroneal tendinosis and subsequent degradation of intact tendon tissue might deteriorate the tendon’s viscoelastic properties and thus impair passive stabilisation as well. Evaluation of peroneal tendon activity consists of an EMG examination in addition to a clinical investigation [10, 13, 23]. Despite normal EMG results, a loss of function in the peroneal tendons may be suspected on clinical investigation. During clinical evaluation of passive stabilisation in supination-inversion, chronic lateral ankle instability with partial dislocation of the talus is commonly associated with an elongation of the peroneal tendons, regardless of their functional activity [36]. Peroneal tendon injuries related to ankle sprains have been described in several studies [3, 12, 26]. Lesions of the peroneus brevis, due to its anatomical location in the retromalleolar groove, are reported to occur more frequently than lesions of the peroneus longus tendon [3, 25]. Concomitant injury of the superior extensor retinaculum and a chronic partial dislocation of the peroneal tendons from the retromalleolar groove have been reported by various authors [17, 37]. Chronic peroneal tendinopathy due to chronic ankle instability has also been discussed extensively [4, 6, 24, 25, 37]. To our knowledge, the incidence of peroneal tendinosis and its correlation with lateral ankle instability has only been investigated in ballet dancers [27]. Peroneal tendinosis as a predisposing factor for ankle sprain trauma in runners has not been addressed so far. The relevance of the striking pattern as a cofactor for the genesis of peroneal tendinosis, followed by ankle sprain trauma, should be given attention in future investigations. The prevalence of forefoot, midfoot and rearfoot striking patterns should be analysed and taken into account in the treatment of running-related pathologies in the ankle joint. One limitation of the present study is the lack of correlation between hindfoot alignment and peroneal tendinosis.
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As shown in a biomechanical study by Mann RA et al., physiological hindfoot alignment is important to ensure proper distribution of impact forces [9, 32]. Hindfoot pathologies, such as a pes cavovarus, may result in greater strain on lateral ankle-stabilising structures during the stance phase [9]. Constant malpositioning of the foot and increased forces on the peroneal tendons are believed to significantly influence the emergence of peroneal tendinosis. The striking patterns of active athletes are considered to influence their running performance [22]. The majority of persons in the present study had undergone running analysis in the past and had a forefoot striking pattern during the clinical evaluation. However, running analysis data were not available for all patients and were not taken into account in the analysis. High strains on single tendons and tendon groups, depending on their function and the technique of running, have been discussed in the published literature but require further investigation [22, 30, 34]. Upcoming retrospective studies comparing patients with and without peroneal tendinosis before ankle sprain trauma will be necessary. Based on the results of this study, early detection and treatment of peroneal tendinosis should be integrated into clinical routine for the purpose of preventing subsequent ankle sprain-associated injuries.
Conclusion Peroneal tendinosis in runners is a frequent cause of ankle sprains. This and other previously described predisposing factors, such as chronic ankle instability and hindfoot malalignment (pes cavovarus), should be considered in clinical practice and treated by proprioceptive training under the guidance of a physiotherapist as well as orthotic insoles. Acute or chronic peroneal tendinosis should be addressed by anti-inflammatory medication and ankle braces. A period of rest should be considered until the final resolution of symptoms. Conflict of interest The authors declare that they have no conflict of interest.
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Knee Surg Sports Traumatol Arthrosc 3. Bare A, Ferkel RD (2009) Peroneal tendon tears: associated arthroscopic findings and results after repair. Arthroscopy 25(11):1288–1297 4. DiGiovanni BF, Fraga CJ, Cohen BE, Shereff MJ (2000) Associated injuries found in chronic lateral ankle instability. Foot Ankle Int 21(10):809–815 5. Bonnel F, Toullec E, Mabit C, Tourne Y (2010) Chronic ankle instability: biomechanics and pathomechanics of ligaments injury and associated lesions. Orthop Traumatol Surg Res 96(4):424–432 6. Bonnin M, Tavernier T, Bouysset M (1997) Split lesions of the peroneus brevis tendon in chronic ankle laxity. Am J Sports Med 25(5):699–703 7. Brandes CB, Smith RW (2000) Characterization of patients with primary peroneus longus tendinopathy: a review of twenty-two cases. Foot Ankle Int 21(6):462–468 8. Christina KA, White SC, Gilchrist LA (2001) Effect of localized muscle fatigue on vertical ground reaction forces and ankle joint motion during running. Hum Mov Sci 20(3):257–276 9. Deben SE, Pomeroy GC (2014) Subtle cavus foot: diagnosis and management. J Am Acad Orthop Surg 22(8):512–520 10. Denyer JR, Hewitt NL, Mitchell AC (2013) Foot structure and muscle reaction time to a simulated ankle sprain. J Athl Train 48(3):326–330 11. Divert C, Mornieux G, Baur H, Mayer F, Belli A (2005) Mechanical comparison of barefoot and shod running. Int J Sports Med 26(7):593–598 12. Dombek MF, Lamm BM, Saltrick K, Mendicino RW, Catanzariti AR (2003) Peroneal tendon tears: a retrospective review. J Foot Ankle Surg 42(5):250–258 13. Fong DT, Chu VW, Chan KM (2012) Myoelectric stimulation on peroneal muscles resists simulated ankle sprain motion. J Biomech 45(11):2055–2057 14. Fujii T, Kitaoka HB, Luo ZP, Kura H, An KN (2005) Analysis of ankle-hindfoot stability in multiple planes: an in vitro study. Foot Ankle Int 26(8):633–637 15. Hatch GF, Labib SA, Rolf RH, Hutton WC (2007) Role of the peroneal tendons and superior peroneal retinaculum as static stabilizers of the ankle. J Surg Orthop Adv 16(4):187–191 16. Hayes P, Caplan N (2012) Foot strike patterns and ground contact times during high-calibre middle-distance races. J Sports Sci 30(12):1275–1283 17. Heckman DS, Gluck GS, Parekh SG (2009) Tendon disorders of the foot and ankle, part 1: peroneal tendon disorders. Am J Sports Med 37(3):614–625 18. Hintermann B (1999) Biomechanics of the unstable ankle joint and clinical implications. Med Sci Sports Exerc 31(7 Suppl):S459–S469 19. Hsu AR, Gross CE, Lee S, Carreira DS (2014) Extended indications for foot and ankle arthroscopy. J Am Acad Orthop Surg 22(1):10–19 20. Konradsen L (2002) Sensori-motor control of the uninjured and injured human ankle. J Electromyogr Kinesiol 12(3):199–203 21. Nigg BM (2001) The role of impact forces and foot pronation: a new paradigm. Clin J Sport Med 11(1):2–9
22. Ogueta-Alday A, Rodriguez-Marroyo JA, Garcia-Lopez J (2014) Rearfoot striking runners are more economical than midfoot strikers. Med Sci Sports Exerc 46(3):580–585 23. Palmieri-Smith RM, Hopkins JT, Brown TN (2009) Peroneal activation deficits in persons with functional ankle instability. Am J Sports Med 37(5):982–988 24. Park HJ, Cha SD, Kim HS, Chung ST, Park NH, Yoo JH, Park JH, Kim JH, Lee TW, Lee CH, Oh SM (2010) Reliability of MRI findings of peroneal tendinopathy in patients with lateral chronic ankle instability. Clin Orthop Surg 2(4):237–243 25. Park HJ, Lee SY, Park NH, Rho MH, Chung EC, Kwag HJ (2012) Accuracy of MR findings in characterizing peroneal tendons disorders in comparison with surgery. Acta Radiol 53(7):795–801 26. Philbin TM, Landis GS, Smith B (2009) Peroneal tendon injuries. J Am Acad Orthop Surg 17(5):306–317 27. Ritter S, Moore M (2008) The relationship between lateral ankle sprain and ankle tendinitis in ballet dancers. J Dance Med Sci 12(1):23–31 28. Rothschild CE (2012) Primitive running: a survey analysis of runners’ interest, participation, and implementation. J Strength Cond Res 26(8):2021–2026 29. Salzler MJ, Bluman EM, Noonan S, Chiodo CP, de Asla RJ (2012) Injuries observed in minimalist runners. Foot Ankle Int 33(4):262–266 30. Shih Y, Lin KL, Shiang TY (2013) Is the foot striking pattern more important than barefoot or shod conditions in running? Gait Posture 38(3):490–494 31. Sinkjaer T, Toft E, Andreassen S, Hornemann BC (1988) Muscle stiffness in human ankle dorsiflexors: intrinsic and reflex components. J Neurophysiol 60(3):1110–1121 32. Svoboda Z, Honzikova L, Janura M, Vidal T, Martinaskova E (2014) Kinematic gait analysis in children with valgus deformity of the hindfoot. Acta Bioeng Biomech 16(3):89–93 33. Swenson DM, Collins CL, Fields SK, Comstock RD (2013) Epidemiology of U.S. high school sports-related ligamentous ankle injuries, 2005/06–2010/11. Clin J Sport Med 23(3):190–196 34. Tam N, Astephen Wilson JL, Noakes TD, Tucker R (2014) Barefoot running: an evaluation of current hypothesis, future research and clinical applications. Br J Sports Med 48(5):349–355 35. Watanabe K, Kitaoka HB, Berglund LJ, Zhao KD, Kaufman KR, An KN (2012) The role of ankle ligaments and articular geometry in stabilizing the ankle. Clin Biomech (Bristol, Avon) 27(2):189–195 36. Ziai P, Benca E, von Skrbensky G, Graf A, Wenzel F, Basad E, Windhager R, Buchhorn T (2013) The role of the peroneal tendons in passive stabilisation of the ankle joint: an in vitro study. Knee Surg Sports Traumatol Arthrosc 21(6):1404–1408 37. Ziai P, Sabeti-Aschraf M, Fehske K, Dlaska CE, Funovics P, Wenzel F, Graf A, Buchhorn T (2011) Treatment of peroneal tendon dislocation and coexisting medial and lateral ligamentous laxity in the ankle joint. Knee Surg Sports Traumatol Arthrosc 19(6):1004–1008
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Peroneal tendinosis as a predisposing factor for the acute lateral ankle sprain in runners Pejman Ziai · Emir Benca · Florian Wenzel · Reinhard Schuh · Christoph Krall · Alexander Auffahrt · Martin Hofstetter · Reinhard Windhager · Tomas Buchhorn
Received: 6 October 2014 / Accepted: 27 February 2015 © European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2015
Abstract Purpose A painful episode in the region of the peroneal tendons, within the retromalleolar groove, is a common precipitating event of an acute lateral ankle sprain. A forefoot striking pattern is suspected to cause peroneal tendinosis. The aim of this study is to analyse the role of peroneal tendinosis as a predisposing factor for ankle sprain trauma in runners. Methods Fifty-eight runners who had experienced acute ankle sprain trauma, with pre-existing pain episodes for up to 4 weeks in the region of the peroneal tendons, were assessed clinically. Fractures were excluded by conventional radiography. An magnetic resonance imaging (MRI) scan had been P. Ziai (*) · E. Benca · R. Schuh · R. Windhager Department of Orthopaedics, Medical University of Vienna, Waehringer Guertel 18‑20, 1090 Vienna, Austria e-mail: [email protected] F. Wenzel Department of Trauma Surgery, Medical University of Vienna, Waehringer Guertel 18‑20, 1090 Vienna, Austria C. Krall Section for Medical Statistics, Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria A. Auffahrt Department of Traumatology and Sports Injuries of the Paracelsus Medical University, Muellber Hauptstraße 48, 5020 Salzburg, Austria M. Hofstetter Department of Biomedical Imaging and Image‑Guided Therapy, Medical University of Vienna, Waehringer Guertel 18‑20, 1090 Vienna, Austria T. Buchhorn Sporthopaedicum Straubing, Bahnhofplatz 27, 94315 Straubing, Germany
performed within 14 days after the traumatic event and was subsequently evaluated by two experienced radiologists. Results MRI revealed peroneal tendinosis in 55 patients (95 % of the total study population). Peroneus brevis (PB) tendinosis was found in 48 patients (87 % of all patients with peroneal tendinosis), and peroneus longus (PL) tendinosis was observed in 42 cases (76 %). Thirty-five patients (64 %) had combined PB and PL tendinosis. A lesion of the anterior talofibular ligament was found to be the most common ligament injury associated with peroneal tendinosis (29 cases; 53 %), followed by a lesion of the calcaneofibular ligament (16 cases; 29 %) and a lesion of the posterior tibiofibular ligament (13 cases; 24 %). Conclusion The results of this study reflect the correlation between peroneal tendinosis and ankle sprain trauma. Injuries of one or more ligaments are associated with further complications. A period of rest or forbearance of sports as well as adequate treatment of the peroneal tendinosis is essential to prevent subsequent ankle injuries, especially in runners. Modification of the running technique would also be beneficial. Level of evidence IV. Keywords Peroneal tendinosis · Ankle sprain trauma · Running injury · Lateral ankle stabilisation
Introduction Peroneal tendinosis is suspected to cause ankle sprain trauma in runners. Peroneal tendinosis as a consequence of excessive strain in conjunction with lateral chronic ankle instability (CAI) has been extensively described in the published literature and is often associated with a foot deformity, such as a pes cavovarus [3, 6, 7]. The peroneal tendons
13
are known as active stabilisers of the ankle [14, 20]. The passive stabilising role of the peroneal tendons due to their anatomical location and their viscoelastic properties has been discussed in recent studies [15, 36]. The above-mentioned phenomena may result in greater peroneal tendon activity to compensate passive ankle instability at the functional level. Besides, excessive strain on the peroneal tendons as a result of viscoelastic degradation might be a potential cause of acute as well as chronic peroneal tendinosis [5]. Recent publications have addressed the forefoot running technique, especially in mid-distance races [16]. Increased tension in the foot arch of the plantar flexed foot due to the foot strike pattern might result in greater tensile loads on the passive stabilising ligaments and tendons surrounding the ankle during the stance phase [26]. In fact, the classic forefoot strike pattern and flat positioning of the foot during the stance phase while running are associated with greater plantar flexion of the ankle joint and a higher knee flexion angle. This is believed to ensure better proportional distribution of energy loads and cushioning impact forces during initial ground contact [11]. Ankle overload as a result of increasing torque in plantar flexion might be one of the reasons for a higher incidence of tendinopathy [1, 29, 34]. The prevalence of the forefoot, midfoot and rearfoot strike pattern has been discussed in peer-reviewed reports, but no consensus has been achieved in this regard. The choice of the strike pattern might depend on several cofactors, such as mileage, speed or footwear [22, 28, 34]. Large running distances accompanied by high impact forces, resulting in muscle weakening and loss of stabilising muscle function, cause high strain on passive stabilising structures and a predisposition for overloading ligaments as well as tendons. Christina et al. [8] noted weakening of the anterior tibial muscle and subsequent loss of eccentric control during dorsiflexion of the ankle. Reduced absorption of impact forces during initial ground contact, followed by a high workload during loading response in the stance phase and higher strain on the peroneal muscles, might create a predisposition for tendinopathy [19, 21, 25]. Reduction in active lateral ankle stabilisation may lead to more frequent ankle sprain trauma in supination-inversion [5, 37]. The purpose of this study is to analyse peroneal tendinosis as a predisposing factor for ankle sprain trauma in runners.
Materials and methods Fifty-eight runners with a painful episode in the region of the peroneal tendons during 2–4 weeks prior to their ankle
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Knee Surg Sports Traumatol Arthrosc
sprain trauma were included in the study. The painful episode was recorded retrospectively in the patient’s medical history. The patients’ mean age was 35.6 ± 11.0 years. Further inclusion criteria were a weekly running mileage of at least 20 km, a clinical grade III lesion according to the established classifications for the evaluation of ligament and accompanying injuries in the ankle, and exclusion of a fracture on conventional radiographs in two planes. No obvious correlation was found between rearfoot alignment and peroneal tendon overload. An MRI scan had been performed within 14 days after the traumatic event. Immobilisation in a walker brace (DJO Global, Inc., Carlsbad, CA, USA) in neutral position was prescribed until the MRI findings were available. The study was approved by the ethics committee of the Medical University of Vienna, and informed consent was obtained from all patients prior to enrolment in the study. Magnetic resonance imaging was performed on a 3.0 Tesla MR scanner (Magnetom Trio; Siemens Medical Solutions, Erlangen, Germany). All images were obtained with an eight-channel high-resolution, small field of view (FoV) foot and ankle imaging coil (Invivo, Gainesville, FL, USA). This dedicated phased array coil is designed to utilise the advantages of the eight-channel system, including parallel imaging. Due to its boot design, it easily slides down over the foot and ankle, and can be fixed, which results in less motion artefacts. Patients were scanned with the ankle fixed in neutral position. The total scanning time including localisation was 42 min per patient. The anterior and posterior talofibular ligaments were evaluated in the axial plane (T2- and T1-weighted), and the calcaneofibular ligament in the oblique axial plane (T2-weighted), with the foot in neutral position. The peroneal tendons were visualised on sagittal and axial T1- and T2-weighted images. Increased signal intensity in the peroneal tendon on T1-weighted images, but no fluid signal on T2-weighted images, was interpreted as peroneal tendinosis. Two senior radiologists with experience in musculoskeletal imaging evaluated the images. The distinction between post-traumatic tendonitis as a result of ankle sprain and overuse tendinosis was taken into account.
Results The MRI scans revealed peroneal tendinosis in 55 of 58 patients (95 %). Peroneus brevis (PB) tendinosis was found in 48 patients (87 %) (Fig. 1), and peroneus longus (PL) tendinosis in 42 (76 %). Thirty-five patients (64 %) had combined tendinosis of the PB and PL tendons. No peroneal tendinosis was found in three patients (5 %). A lesion of the anterior talofibular ligament (ATFL) was the most common ligament injury associated with peroneal
Knee Surg Sports Traumatol Arthrosc Fig. 1 Tendinosis of the peroneus brevis tendon on the axial T2-weighted sequence in magnetic resonance imaging performed on a 3.0 Tesla MRI scanner
tendinosis (29 cases; 53 %), followed by a lesion of the calcaneofibular ligament (CFL) (16 cases; 29 %), and that of the posterior tibiofibular ligament (PTFL) (13 cases; 24 %). Various combinations of ligament lesions and peroneal tendinosis are shown in Fig. 2. Mild tendinosis of the Achilles tendon was found in two patients. Lesions in other tendons like the FHL (flexor hallucis longus), the FDL (flexor digitorum longus) or the TP (tibialis posterior) were not found.
Discussion The most important finding of the present study reflects the correlation between peroneal tendinosis and acute ankle sprain trauma in runners. The peroneus brevis (PB) tendon was most commonly affected, followed by the peroneus longus (PL) tendon and combined tendinosis of the PL and PB tendon. Thus, both tendons might have been exposed to similar strain rates in the examined runners. Our data concerning a lateral ligament lesion confirm the outcomes of previous research: the ATFL was most commonly affected, followed by combined ATFL and CFL lesions [18, 35]. An unexpectedly high rate of isolated as well as combined posterior talofibular ligament (PTFL) lesions was found to be associated with peroneal tendinosis. Injury of the PTFL is uncommon; it is usually observed in combination with an ATFL and/or a CFL lesion [33]. Impaired active and passive stabilising abilities of the peroneal tendons due to tendinosis, with greater rotational workloads on the talus in cases of ankle supination-inversion trauma,
Fig. 2 Absolute frequencies of various combinations of ligament lesions in patients with PL tendinosis (peroneus longus), those with PB tendinosis (peroneus brevis) and those with PB and PL tendinosis. The red part at the bottom of each bar represents patients with peroneal tendinosis alone compared to those with PL (PB) tendinosis alone, and those with both conditions. Note the total length of the PL (PB) bar and the total length of the PB–PL bar
could be responsible for this phenomenon [36]. In the present study, a combined lateral ligament lesion (ATFL, CFL and PTFL) in conjunction with peroneal tendinosis
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was observed less frequently than a single lateral ligament lesion, but the results in general are similar to those of other studies [3, 4, 12, 33]. The role of the peroneal tendons in active lateral ankle stabilisation against internal rotation is a proven fact [2, 31]. All patients in the present investigation experienced subjective lateral ankle instability while running ever since the onset of pain in their peroneal tendons. The peroneal tendons are involved in the pronationeversion movement, stabilise the ankle during the stance phase, and support hindfoot alignment and an appropriate positioning of the foot prior to and at initial contact in gait [13, 17]. Due to their viscoelastic properties, the peroneal tendons may also play a role in passive stabilisation of the ankle joint [36]. Consequently, peroneal tendinosis could be responsible for the loss of stabilisation during the stance phase of gait. Chronic peroneal tendinosis and subsequent degradation of intact tendon tissue might deteriorate the tendon’s viscoelastic properties and thus impair passive stabilisation as well. Evaluation of peroneal tendon activity consists of an EMG examination in addition to a clinical investigation [10, 13, 23]. Despite normal EMG results, a loss of function in the peroneal tendons may be suspected on clinical investigation. During clinical evaluation of passive stabilisation in supination-inversion, chronic lateral ankle instability with partial dislocation of the talus is commonly associated with an elongation of the peroneal tendons, regardless of their functional activity [36]. Peroneal tendon injuries related to ankle sprains have been described in several studies [3, 12, 26]. Lesions of the peroneus brevis, due to its anatomical location in the retromalleolar groove, are reported to occur more frequently than lesions of the peroneus longus tendon [3, 25]. Concomitant injury of the superior extensor retinaculum and a chronic partial dislocation of the peroneal tendons from the retromalleolar groove have been reported by various authors [17, 37]. Chronic peroneal tendinopathy due to chronic ankle instability has also been discussed extensively [4, 6, 24, 25, 37]. To our knowledge, the incidence of peroneal tendinosis and its correlation with lateral ankle instability has only been investigated in ballet dancers [27]. Peroneal tendinosis as a predisposing factor for ankle sprain trauma in runners has not been addressed so far. The relevance of the striking pattern as a cofactor for the genesis of peroneal tendinosis, followed by ankle sprain trauma, should be given attention in future investigations. The prevalence of forefoot, midfoot and rearfoot striking patterns should be analysed and taken into account in the treatment of running-related pathologies in the ankle joint. One limitation of the present study is the lack of correlation between hindfoot alignment and peroneal tendinosis.
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Knee Surg Sports Traumatol Arthrosc
As shown in a biomechanical study by Mann RA et al., physiological hindfoot alignment is important to ensure proper distribution of impact forces [9, 32]. Hindfoot pathologies, such as a pes cavovarus, may result in greater strain on lateral ankle-stabilising structures during the stance phase [9]. Constant malpositioning of the foot and increased forces on the peroneal tendons are believed to significantly influence the emergence of peroneal tendinosis. The striking patterns of active athletes are considered to influence their running performance [22]. The majority of persons in the present study had undergone running analysis in the past and had a forefoot striking pattern during the clinical evaluation. However, running analysis data were not available for all patients and were not taken into account in the analysis. High strains on single tendons and tendon groups, depending on their function and the technique of running, have been discussed in the published literature but require further investigation [22, 30, 34]. Upcoming retrospective studies comparing patients with and without peroneal tendinosis before ankle sprain trauma will be necessary. Based on the results of this study, early detection and treatment of peroneal tendinosis should be integrated into clinical routine for the purpose of preventing subsequent ankle sprain-associated injuries.
Conclusion Peroneal tendinosis in runners is a frequent cause of ankle sprains. This and other previously described predisposing factors, such as chronic ankle instability and hindfoot malalignment (pes cavovarus), should be considered in clinical practice and treated by proprioceptive training under the guidance of a physiotherapist as well as orthotic insoles. Acute or chronic peroneal tendinosis should be addressed by anti-inflammatory medication and ankle braces. A period of rest should be considered until the final resolution of symptoms. Conflict of interest The authors declare that they have no conflict of interest.
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