P eroneal tendon dislocations are well-known pero-neal tendon injuries in athletes. Recurrent pero-

neal tendon dislocations lead to chronic inflammation and mechanical irritation, which ultimately can result in longitudinal tears of the tendon. Furthermore, per-oneus longus or peroneal brevis tendon tears caused by anomalies in the tendon or in the peroneus have been reported. However, complete peroneus longus and bre-vis tendon ruptures have rarely been reported. This case report describes a patient with a complete peroneus longus and brevis tendon rupture due to a sports injury, for whom a semitendinosus and gracilis tendon graft provided good results.

Case Report

The patient, a 38-year-old woman, suffered a left ankle sprain while dancing and was treated conserva-tively. She subsequently had pain along the left pero-neal tendon during sports activity. Peroneal tendonitis

was diagnosed and treated conservatively using low reactive level laser therapy.

Two years after the injury (40-years-old), the patient twisted and re-injured her left ankle while dancing. The pain in the left foot soon improved, but she had diffi-culty standing with the left foot in equinus.

Tenderness and swelling along the peroneal tendon were observed. Range of motion was normal, with no obvious anterior instability. However, the muscle strength of the peroneus was decreased, and the patient was unable to stand with a single leg in the equinus position with stability. Relief of the peroneal tendon could not be seen on the affected side.

Plain radiography showed no abnormalities (Fig. 1). On MRI axial imaging, the peroneus longus and brevis tendons on the affected side were less distinct than those on the normal side (Fig. 2). A complete peroneal tendon tear was diagnosed. Surgery was performed 2 years and 2 months after the initial injury.

A skin incision was made along the peroneal tendon posterior to the lateral malleolus. Both the peroneus

Acta Med. Okayama, 2019Vol. 73, No. 6, pp. 533-536CopyrightⒸ 2019 by Okayama University Medical School.

http ://escholarship.lib.okayama-u.ac.jp/amo/Case Report

Reconstruction of Complete Peroneus Longus and Brevis Tendon Ruptures Using a Semitendinosus and Gracilis Tendon Graft

Yusuke Morimoto＊, and Yasuaki Tokuhashi

Department of Orthopedic Surgery, Nihon University School of Medicine, Itabashi-ku, Tokyo 173-8610, Japan

The patient was a 40-year-old female who had been treated at our hospital for left peroneal tendonitis due to an ankle sprain 2 years earlier. She re-injured that ankle while dancing. The pain in the lateral left foot soon improved, but she had difficulty standing with the left foot in equinus. Complete peroneus longus and brevis tendon ruptures were diagnosed. The ipsilateral semitendinosus and gracilis tendons were harvested and used to reconstruct the tendons. Three months after surgery, the patient was able to stand in equinus, and at 5 months after surgery she resumed her original level of sports activities.

Key words: peroneus longus and brevis, complete rupture, reconstruction, hamstring tendon, tendon grafting

Received February 25, 2019 ; accepted July 11, 2019.＊Corresponding author. Phone : +81-3-3972-8111; Fax : +81-3-3972-4824E-mail : morimoto.yusuke@nihon-u.ac.jp (Y. Morimoto)

Conflict of Interest Disclosures: No potential conflict of interest relevant to this article was reported.

longus and brevis tendons were found to be completely ruptured, and exposure along the tendon sheath showed that, in addition to these ruptures, the superior pero-neal retinaculum was also ruptured and shortened. The proximal stump was thickened, and the distal stump was adherent to the surrounding soft tissue. When the scarred and damaged area was debrided, an 8-cm defect in the peroneal brevis tendon and a 10-cm defect in the peroneus longus tendon were observed (Fig. 3).

The ipsilateral semitendinosus and gracilis tendons were harvested and used to reconstruct the tendons with

interlacing sutures to the torn tendon/muscle stump and distal stump (Fig.4). Moderate graft tension was applied to the peroneal muscle with the ankle joint plantar flexed at 10 degrees.

The ankle was then immobilized in a plaster cast for 2 weeks. Passive range of motion training was started on day 15 postoperatively, active motion was started on day 21, and partial weight bearing was started on day 35. The

534 Morimoto et al. Acta Med. Okayama　Vol. 73, No. 6

A BFig. 1　 Plain radiography (A, A-P view; B, lateral view). There were no abnormalities.

AA BFig. 2　 MRI cross-sectional imaging. The peroneus longus and brevis tendons on the affected side (B) were less distinct than those on the normal side (A).

Fig. 3　 The peroneus longus and brevis tendons were completely ruptured. The proximal stump was thickened, and the distal stump was adherent to the surrounding soft tissue. When the scarring and damaged area were debrided, an approximately 8-cm defect in the peroneus brevis tendon and a 10-cm defect in the peroneus longus tendon were revealed. PB, peroneal brevis tendon; PL, peroneus longus tendon; LM, lateral malleolus.

Fig.  4　 The ipsilateral semitendinosus tendon and gracilis tendon were harvested and used to reconstruct the tendons with interlacing sutures to the torn tendon/muscle stump and the distal stump.

patient was able to stand on a single leg in equinus 3 months after surgery (Fig. 5). She was allowed to par-ticipate in limited sports activity 4 months after surgery, and she resumed her original level of sports activity 5 months after surgery.

Discussion

Peroneal tendon injuries include peroneal tendonitis, peroneal tendon instability, peroneal tendon dislocations, and peroneal tendon tears. [1] Tears can be longitudinal or complete. Bonnin [2] reported in 1997 that, among 77 patients who underwent surgery for ankle joint insta-bility, 23% had longitudinal tears. This suggests that peroneal tendon injuries are not rare. Longitudinal tears associated with peroneal tendon dislocations and longi-tudinal tears due to muscle variants [3 , 4] and abnor-malities of the peroneal trochlea [5] have also been reported. Overall, several cases of peroneal tendon longitudinal tear have been reported. [2-8] However, based on our search of the literature, complete tears are relatively rare. [9] Furthermore, complete tears of both the peroneus longus and the peroneal brevis tendons are an extremely rare occurrence.

As a mechanism underlying peroneal tendon injury,

Sobel et al. [10] described an injury of the peroneus brevis tendon in which there were peroneus brevis tendon dislocations and encroachment between the peroneus longus tendon. With regard to injury of the peroneus longus tendon, Bassett et al. [11] reported repetitive excessive plantar flexion and inversion of the ankle as a mechanism by which injury occurs. In addition, frac-tures, anatomical variants, degeneration, and inflam-mation have been reported as causes of complete tears of the peroneal tendon. In the present patient, chronic peroneal tendinitis and repetitive mechanical irritation probably resulted in the complete tearing of the pero-neus longus and brevis tendons.

Complete tears of the peroneal tendon can occur beneath the superior peroneal retinaculum, at the distal end, and in the cubital tunnel. The present patient had a tear near the superior peroneal retinaculum.

Surgical treatment is usually performed if there is a tear of the peroneal brevis muscle or peroneus longus muscle. The torn tendon is excised, or tenodesis is per-formed by suturing the torn side to the healthy side. However, either excision or tenodesis sacrifices tendon function and leads to unsatisfactory outcomes in patients who wish to resume high-level functions such as sports activities. End-to-end anastomosis is sometimes per-formed for fresh tears, but since there is tendon degen-eration in most chronic cases, end-to-end anastomosis is problematic. The flexor hallucis longus muscle tendon is often used for tendon grafting. However, the present patient had ruptures of both the peroneus longus and brevis tendons with a large defect. Moreover, the patient wanted to be able to continue athletic activities. Therefore, to avoid foot and ankle joint dysfunction, reconstruction using semitendinosus and gracilis tendons were deter-mined to be the most effective options.

The present patient had a history of a left ankle sprain followed by peroneal tendonitis and subluxation. In addi-tion, the patient’s continuation of sports activities may have prolonged the tendinitis and allowed the tendons to degenerate. The pain laterally in the left foot may also have developed due to a tear in the peroneus brevis ten-don occurring at this time, resulting in an increased load on the peroneus longus tendon. The subsequent recur-rent twist injury of the left ankle may also have led to rupture of the peroneus longus tendon.

Complete rupture of the peroneal tendon is very rare. In this case, semitendinosus and gracilis tendons were used for the reconstruction of the peroneus longus and

December 2019 Peroneus Tendon Complete Rupture 535

Fig. 5　 The patient was able to stand on a single leg in equinus 3 months after surgery.

brevis. It is easy to harvest these tendons and recon-struction is relatively complication-free. Following the reconstruction, the patient exhibited no dysfunction in her foot and ankle and was able to return to her previous sports activities. Reconstruction using the semitendi-nosus and gracilis tendons produced a good outcome.

References

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 3. Pellegrini MJ, Adams SB and Parekh SG. Allograft reconstruction of peroneus longus and brevis tendons tears arising from a single muscular belly. Case report and surgical technique. Foot Ankle Surg (2015) 21: e12-15.

 4. Unlu MC, Bilgili M, Akgun I, Kaynak G, Ogut T and Uzun I: Abnormal proximal musculotendinous junction of the peroneus brevis muscle

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 5. Palmanovich E, Laver L, Brin YS, Hetsroni I and Nyska M: Tear of peroneus longus in long distance runners due to enlarged pero-neal tubercle. BMC Sports Sci Medicine Rehabil (2014) 6: 1.

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 8. Radice F, Monckeberg JE and Carcuro G: Longitudinal tears of peroneus longus and brevis tendons: a gouty infiltration. J Foot Ankle Surg (2011) 50: 751-753.

 9. Redfern D and Myerson M: The management of concomitant tears of the peroneus longus and brevis tendons. Foot Ankle Int (2004) 25: 695-707.

10. Sobel M, Bohne WH and OʼBrien SJ: Peroneal tendon subluxation in a case of anomalous peroneus brevis muscle. Acta orthop Scand (1992) 63: 682-684.

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