peroneus quartus tendon

This confluence of fibrous structures may make the peroneal tubercle a suitable alternate insertion site for the peroneus brevis tendon. Several hypotheses were emitted by these different authors to try and explain the onset of such symptoms. the display of certain parts of an article in other eReaders. In regards to these different publications and our patients symptoms, it seems difficult to render PQ the sole responsible for bilateral FAI (inadequate ratio between its relatively high incidence: up to 21.7% according to the series, and the very few symptomatic cases reported), however it seems that it partially contributes to this instability. Anat Sci Int 87:106110, Nascimento SRR, Costa RW, Ruiz CR, Wafae N (2012) Analysis on the incidence of the fibularis quartus muscle using magnetic resonance imaging. White et al. Ankle radiographs were normal (figure 5). We describe a 51-year-old woman with a longitudinal split tear of the peroneus brevis tendon confirmed by magnetic resonance imaging. If this does not provide any improvement steroid injection around the peroneal tendon sheath can help with pain as well as assist with diagnosis. Generating an ePub file may take a long time, please be patient. it is the retrotrochlear eminence of the calcaneum (50% of the dissections and 83% of MRI exams) just like for Cheung et al. Les amplitudes articulaires de la cheville et du pied sont normales et symtriques. CPT 28200 is for repair of tendon. 20 year old male with variant peroneus brevis tendon insertion on the calcaneus. PMC Clin Ter 163(4):307309, CAS FINDINGS: Contiguous coronal proton density MRI images of the right ankle demonstrate the peroneus brevis tendon (short arrow) descending to its attachment on the calcaneal, 24 year old male with variant peroneus brevis tendon insertion on the calcaneus. bifid peroneus brevis and peroneus quartus tendons), which may also appear as "extra" tendinous bands within the peroneal tendon sheath. Anatomical variations of peroneal muscles: a cadaver study in an Indian population and a review of the literature. Murlimanju BV, D'Souza PS, Prabhu LV, Saralaya VV, David SJ. Les paramtres quantitatifs de marche mesurs sur le GAITRite sont normaux. Le plus souvent, ce muscle surnumraire est de dcouverte fortuite et nest responsable daucune symptomatologie. Il sagit de la complication volutive la plus frquente des entorses de cheville dont lincidence est estime jusqu 40 % selon les sries. It is related to many pathologic conditions in the lateral ankle compartment but also it can be used as a tendon graft for reconstructive procedures. When we look at the literature, and you look about peroneal tendon disorder, you are going to see this group of foot and ankle people who seem to be the most published on things that go on with the peroneal tendons. The site of insertion was variable and included the calcaneus, peroneus longus tendon, peroneus brevis tendon; and cuboid bone. It most commonly arose from the peroneus brevis muscle and inserted into the retrotrochlear eminence of the calcaneus. Radiologist and surgeons should recognize this variant to prevent the incorrect pre-operative assumption of peroneus brevis tendon tear and performing unnecessary surgery in affected individuals. Since a quartus tendon can insert on the peroneal tubercle, a variant peroneus brevis tendon insertion on the peroneal tubercle without a quartus muscle present may represent a spectrum of these variants. The peroneus quartus muscle fibers often arise from the peroneus brevis [8, 10]. Med J Malaysia 61(Suppl B):4547, Lepow GM, Korfin DH (1985) Calcification of an accessory peroneal tendon in an athlete: a case presentation. Epub 2019 Feb 6. This site needs JavaScript to work properly. Surg Radiol Anat. In fact, we observed in our patient, a lingering strength deficit on the peroneal muscles (clinical testing and isokinetic evaluation), in spite of a well-conducted rehabilitation training program. Its incidence varied according to the various studies: after dissection, Sobel et al. If conservative treatment has failed, operative management options of each type of disorder are as follows: Treatment depends on the cause of the subluxation or dislocation. [2], The primary imaging modality with any suspected peroneal tendon disorder is X-rays of the ankle. Associated pathologies are longitudinal degeneration and tear in the tendon of peroneus brevis. Surgical resection was also effective in that case. FINDINGS: Contiguous coronal proton density MRI images of the right ankle demonstrate the peroneus brevis tendon (short arrow) descending to its attachment on the calcaneal peroneal tubercle (asterisk). Associated pathologies are longitudinal degeneration and tear in the tendon of peroneus brevis. Associated pathology included a longitudinal tear in the tendon of peroneus brevis, possible peroneal tendon subluxation or dislocation, and a prominent retrotrochlear eminence. Cest un symptme fonctionnel subjectif diffrencier de la laxit qui est un signe dexamen clinique objectif. It was associated to a thickening of the superior peroneal retinaculum. Cependant, dautres pathologies varies peuvent tre cause ou consquence de linstabilit chronique de cheville: les lsions ostochondrales (notamment du dme du talus), les lsions des tendons des fibulaires, certains troubles statodynamiques de la cheville et du pied ou encore certaines atteintes neurologiques (nerf fibulaire commun). Patients must undergo screening for prior steroid injections and history of recent antibiotic use; Fluoroquinolones and steroids have associations with tendon disease. The peroneus brevis is more often torn isolated peroneus longus tears occur less frequently. and seven out of 32 (22%) for Chepuri et al. For irreparable tears of the tendon, a salvage procedure is indicated with segmental resection followed by reconstruction with tenodesis, tendon transfer, or bridging the defect using allograft or autograft. FINDINGS: Contiguous axial proton density MRI images of the right ankle demonstrate the peroneus brevis tendon (short arrow) descending to its attachment on the calcaneal, 20 year old male with variant peroneus brevis tendon insertion on the calcaneus. Ultrasound diagnosis of peroneal tendon tears. Brandes CB, Smith RW. The tendons rubbing over the posterolateral fibula can also lead to longitudinal tears of the tendons. Quartus Prime maintains the look and feel of Quartus II, but it has a whole new infrastructure under the hood - specifically designed to handle the monster designs that will be thrown at the company's "Generation 10" FPGAs. These tests did not highlight any sensitive disorders. Beobachtungen aus der Menschlichen und Vergleichenden Anatomie H VII:3580, Chaney DM, Lee, Khan MA, KruegerWA, Mandracchia VJ, Yoho RM (1996) Study of ten anatomical variants of the foot and ankle. An ultrasound of the ankles ( Fig. Saxena A, Cassidy A. Peroneal tendon injuries: an evaluation of 49 tears in 41 patients. Lobjectif de ce cas clinique est de discuter limputabilit de la prsence dun quatrime fibulaire bilatral, chez un patient souffrant dinstabilit chronique. 1 article features images from this case Repair end to end of acute complete tears, Side-to-side anastomosis or Pulvertaft weave with chronic tears, Peroneal tendon disorders can cause lateral ankle pain. At the clinical examination we found a genu varum (varus knee) and bilateral pes valgus planus. This may occur due to overuse, or the peroneal tendon may be pinched beneath the bone that is courses under. A case series, Contribution of isokinetic in the treatment of meniscal lesions: Report of 26 cases, Assessment of pain during the injection of the botulinum toxin: Physical medicine and rehabilitation experience. No imaging follow-up of the patient was obtained. J Am Podiatr Med Assoc 86:532537, Rosenberg ZS, Beltran J, Cheung YY, Colon E, Herraiz F (1997) MR features of longitudinal tears of the peroneus brevis tendon. Most patients will require some type of rehabilitation to regain muscle function and strength. [10], Peroneal tendonitis presents with gradual onset of pain and swelling. An accessory peroneal tendon (peroneus quartus) with an abnormal calcaneal insertion was discovered during the procedure and excised. A 24 year old male presented for medical care following a two week history of non-traumatic right ankle pain. 1997 Mar;202(3):745-50. doi: 10.1148/radiology.202.3.9051029. Nurses will often be the point of initial contact at each visit, and their input on whether therapy is progressing should merit consideration. Saxena showed 87% return to the sport in a case series of operatively treated tears. One additional case was identified. Epub 2021 Jun 23. In the same manner, Hammerschlag and Goldner described some instability consecutive to the presence of a peroneus digiti minimi muscle and Regan and Hughston reported a clinical picture of FAI with the discovery during surgery of a trifurcation of the peroneus brevis, probably a remnant of a supernumerary muscle. We dissected 102 cadaver legs and reviewed the magnetic resonance images of 80 patients with symptoms from the ankle. No treatment or prognosis has been described for variant peroneus brevis tendon insertion. With pain improvement and return to activity. The authors could find only one previous case report for alternate peroneus brevis tendon insertion on the calcaneus which was discovered during surgical exploration. 2011 Nov-Dec;101(6):505-8. doi: 10.7547/1010505. For the vast majority of the population, the peroneus brevis tendon inserts on the lateral aspect of the fifth metatarsal base at the styloid process. Summary table for variant peroneus brevis tendon insertion on the calcaneal peroneal tubercle. No surgical management was indicated. Epub 2018 Nov 8. 4 , 17 It is rarely involved in pathologic processes of the . Peroneus Brevis Tendon Variant Insertion on the Calcaneus. Correspondence to It plays an important role in the development of pain, swelling and functional impairment of the ankle joint. No: 11, Zuhuratbaba, 34147, Istanbul, Turkey, Mustafa Gkhan Bilgili,Ersin Ercin&Emre Baca, Department of Orthopaedics and Traumatology, Istanbul University Cerrahpasa Medical Faculty, Istanbul, Turkey, Department of Orthopaedics and Traumatology, Karabuk University, Karabuk, Turkey, Medical Faculty Forensic Medicine Division, Akdeniz University, Antalya, Turkey, You can also search for this author in , a PQ within the peroneal sheath brings a real conflict between a normal sheath and its unusual voluminous content due to PQ preventing tendons from gliding properly. Its presence will be quickly validated by imaging exams (ultrasound or MRI). This patient also showed some bilateral strength deficit of the peroneal muscles, seen at the clinical examination and validated during isokinetic testing. Furthermore by trying to strengthen the peroneus brevis and longus, we also probably strengthen the PQ thus increasing the conflict within the sheath by increasing the volume of this supernumerary muscle. Peroneal tendon disorders are common causes of lateral and retromalleolar ankle pain. FAI is the most common complication of ankle sprains with an incidence that can go up to 40% according to the series. [15] Post-op repair of peroneal tendon tears in a retrospective review by Dombek showed that 98% of patients returned to full activities at an average follow up of 13 months. Foot Ankle 11:8189, Prakash, Narayanswamy C, Singh DK, Rajini T, Venkatiah J, Singh G (2011) Anatomical variations of peroneal muscles: a cadaver study in an Indian population and a review of the literature. [12], CT scanning does expose the patient to radiation but provides better bony detail to evaluate possible bony deformity causing possible tendon dysfunction. This injury is more common in athletes than non-athletes. Il nous semble intressant de discuter chez ce patient la responsabilit de ce muscle dans linstabilit devant la persistance dun dficit de force des muscles fibulaires malgr un travail de renforcement adapt, en labsence de lsion neurologique. Variationally, there may be various accessory tendons, the incidence of which changes from one population to another, such as peroneus tertius muscle )PT(, and peroneus digiti quinti muscle )PDQ(, and particularly peroneus quartus muscle )PQ(. Proc R Soc Lon 16:229244, Wood J (1868) Variations in human myology observed during the winter session of 18671868 at Kings College London. The peroneus quartus (PQ) is an accessory muscle of the peroneal/lateral compartment of the leg. However a few cases of chronic ankle pain, peroneal tendon sprains or ankle instability were reported in the literature . Zammit J, Singh D. The peroneus quartus muscle. MeSH Il ny a pas de tiroir antrieur. This concurs with the results described by Coudert, of a real conflict within the peroneal sheath due to the inadequate relationship between content/container volumes. A surgical correlation. Magnetic resonance imaging (MRI) of the ankle was then obtained. in the lateral ankle compartment but it may be used to reconstruct some pathologic conditions. Peroneal tendonitis occurs when the long tendon of the peroneus muscle becomes inflamed and irritated. Peroneus brevis split tears should not be confused with anatomic variants (i.e. 24 year old male with variant peroneus brevis tendon insertion on the calcaneus. Lexamen clinique retrouve une hyperlaxit en varus bilatrale, modre, prdominant droite et un dficit bilatral de force musculaire des fibulaires. FINDINGS: Contiguous axial proton density MRI images of the right ankle demonstrate the peroneus brevis tendon (short arrow) descending to its attachment on the calcaneal, 24 year old male with variant peroneus brevis tendon insertion on the calcaneus. TECHNIQUE: Digital radiography. 30 It has a prevalence of 1%. FINDINGS: AP and lateral radiographs of the right ankle show no osseous or soft tissue abnormalities. The peroneus quartus muscle, with a number of different attachments, was present in 5.2 % (6/115) of the legs. - M. Peroneus Brevis. [6] Ankle drawer test should be done to asses ankle ligamentous stability. Bone block procedures that involve performing osteotomy of the fibula lateralizing it to create a bony block for the tendons. Le peroneus quartus est l'une des plus frquentes. There is a third myotendinous structure within the peroneus tendon sheath postero-medial to the longus and brevis tendons, that can be followed down to the retrotrochlear eminence of the calcaneus. Nonsteroidal anti-inflammatory drugs, ice, rest or immobilization, and physical therapy. Would you like email updates of new search results? The peroneus quartus muscle, with a number of different attachments, was present in 5.2 % (6/115) of the legs. He then appears to extensively debride the peroneus longus and brevis tendons for moderate tendinosis, moderate synovitis, scar tissue, no tearing to either tendon. A normal peroneus longus tendon with magic angle artifact (long arrow) is also annotated. Pain on the outer portion of your foot and ankle may result making it difficult to walk or run normally. Thus, when walking or worse when running, during the initial stance phase the back of his foot is responsible for impact between the tip of the lateral malleolus and the orifice of the tarsal sinus. We report here the clinical case of a young patient presenting a debilitating bilateral FAI (stopped all athletic activities) in spite of a well-conducted medical treatment. Before [11], MRI is the next step in evaluation with a high-quality view of the tendons with no exposure to radiation. [6], The most common patient population with tears of the peroneal tendons are active young patients. Following the surgery, the patients could partially weight-bear after 3- 4 . Faced with pain or chronic instability after trauma, or lingering instability or strength deficit of the peroneal muscles in spite of well-conducted rehabilitation sessions, the possibility of a supernumerary PQ should be looked at. Accessibility It is attached to the fibula head proximally with its belly running down the majority of the bone. If x-rays indicate the possibility of fracture, peroneal tubercle, or retro trochlear eminence CT scan would be useful and determine possible management. Radiology 218:415419, Borne J, Fantino O, Besse JL, Clouet P, Tran Minh V (2002) Aspect IRM des variantes anatomiques des muscles, tendons et ligaments de la cheville. 1Department of Radiology, Mike OCallaghan Federal Medical Center, Nellis AFB, NV, USA, 2Department of Radiology, Landstuhl Regional Medical Center, Landstuhl, Germany. It's a tendon that crosses two articulations that begins at the superolateral condylar bridge of the knee and extends distally to the middle aspect of the calcaneus. Accessory peroneal muscles are a group of accessory muscles that can occur in the foot region as a normal variant in some individuals. Sobel M, Levy ME, Bohne WH. Not established (The authors discovered 2 cases in 200 examined ankle MRI exams), Avulsion of the peroneus brevis tendon from the lateral base of 5. It most commonly arose from the peroneus brevis muscle and inserted into the retrotrochlear eminence of the calcaneus. Discussion The lateral compartment of the leg includes: The peroneus longus muscle which arises from the proximal fibula and the peroneus brevis muscle which arises from the lower two-thirds of the fibula [1]. They commonly occur at the level of the retromalleolar groove. Chronic neuropathic pain in spinal cord injured patients: What is the effectiveness of surgical treatments excluding central neurostimulations? Anomalous peroneal tendon insertion masquerading as a retracted tendon tear: case report. A surgical consultation was scheduled to look at a possible resection of this supernumerary muscle. Eklem Hastalik Cerrahisi 21(3):153158, PubMed [9], History is essential in differentiating the pathology of peroneal tendons. Furthermore, most authors reported a male predominance (2.5/1 for Saupe et al. Zammit J, Singh D. The peroneus quartus muscle. The peroneus quartus muscle was present in 27 legs (21.7% of specimens). The functionality is limited to basic scrolling. Peroneus quartus, a common variant muscle of the foot and ankle with many variations of origin and insertions, can lead to many pathologies such as peroneal tendinopathy, stenosis, tenosynovitis, tendon attrition and tears. Note: the thickened upper peroneal retinaculum (arrow); b: distal insertion of the PQ muscle on the tendon of the peroneus longus muscle (PL) on the longitudinal view. In both the acute and chronic setting, partial tear is usually demonstrated by a bisected or C shape morphology of the peroneus brevis tendon, most apparent on axial imaging, and often with interposition of the peroneus longus tendon [3]. Peroneus quartus: prevalance and clinical importance. The objective of this clinical study is to discuss the implication of the bilateral peroneus quartus muscle in functional ankle instability. Peroneal Tendon Tears and Instability represent a spectrum of traumatic injuries to the lateral ankle that include tenosynovitis, tendinopathy, tendon tears and/or tendon instability. The opinions expressed in this document are solely those of the authors and do not represent an endorsement by or the views of the United States Air Force, the Department of Defense, or the United States Government. It has been shown to be effective in identifying tears as well with a sensitivity of 100 % and specificity of 85%. It is unknown if variant peroneus brevis insertion on the calcaneus can be identified by history or clinical exam. However no neurological impairment was detected during the electroneuromyogram. The dynamics of peroneus brevis tendon splits: a proposed mechanism, technique of diagnosis, and classification of injury. The Quartus II software includes solutions for all phases of FPGA and CPLD design (Figure 1). Finally, the presence of this PQ muscle can explain the lateral retromalleolar pain in our patient. This view highlights the muscle body of the peroneus quartus (PQ) stemming from the body of the peroneus brevis (PB) and the distal insertion on the tendon of the peroneus longus (PL). Lucas DE, Hyer CF, Berlet GC, Shockley JA. Access free multiple choice questions on this topic. This activity also highlights the importance of the interprofessional team in the management of peroneal tendon syndromes. The tendon inserts on the peroneal tubercle of the calcaneus. Arthrosc Tech. Treatment depends on the degree of tendon torn and whether the tear is acute or chronic, Must rule out ankle sprain, rheumatoid arthritis, calcaneus fractures, or fractured os peroneum. Cheung YY, Rosenberg ZS, Ramsinghani R, Beltran J, Jahss MH. Llectroneuromyogramme des muscles fibulaires est normal. Clipboard, Search History, and several other advanced features are temporarily unavailable. If there is any hindfoot varus alignment, this should also be corrected to decrease stress on the peroneus longus with hindfoot osteotomy. Anyone you share the following link with will be able to read this content: Sorry, a shareable link is not currently available for this article. Imaging techniques included sagittal inversion recovery (TI 150 ms; TE 17 ms; TR 5000 ms; slice 3.5 mm; gap 0 mm; 256 x 192); sagittal proton density (TE 34 ms; TR 4000 ms; slice 3.5 mm; gap 0 mm; 512 x 320; NEX 2); sagittal T1 (TE 10 ms; TR 600 ms; slice 3.5 mm; gap 0 mm; 256 x 192); coronal proton density (as above with slice 4 mm; gap 0 mm); coronal fat suppressed T2 (TE 65 ms; TR 4000 ms; slice 4 mm; gap 0 mm; 256 x 192; frequency selective fat suppression); axial proton density (as above with slice 4 mm; gap 0 mm). The PQ is the most common supernumerary muscle of the distal lateral portion of the fibula (up to 21.7% according to the series). Dynamic X-rays did not show any anterior drawer laxity. Peroneal tendon tears: a retrospective review. In the literature the incidence of a supernumerary peroneus quartus muscle varies from 0 to 21.7%. Bilgili MG, Kaynak G, Botanliolu H, Basaran SH, Ercin E, Baca E, Uzun I. Arch Orthop Trauma Surg. At the end of this thorough check up, our patient did 15 new rehabilitation sessions focused on strength training of the peroneal muscles mainly in eccentric mode associated to proprioceptive work (protocol identical to the recommendations published by the HAS in January 2000 [French National Health Agency] ). Skelet Radiol 40:13991413, Sarrafian SK (2011) In: AS Kelikian (ed) Sarrafians anatomy of the foot and ankle: descriptive, topographic, functional, 3rd edn. And in this example, we can see on the right the Achilles being completely raptured with the plantaris . The tendons occupy a common synovial sheath that runs posterior to the distal fibula, once past the fibula they each have their own synovial sheath. Finally, the term lateral ankle stenosis syndrome was first used by Donley and Leyes then again by Moroney and Borton , they described a prominent body of the PQ within the peroneal sheath reducing the available space for proper functioning of the peroneal tendons or even compressing them. Selmani E, Gjata V, Gjika E. Current concepts review: peroneal tendon disorders. Another physical exam technique is to have the patient lay prone with a knee to 90 degrees flexion and examine for peroneal tendon subluxation. However, the presence of hyperlaxity increases the risk of instability . PURPOSE To determine the prevalence of the peroneus quartus (PQ) muscle, to demonstrate the morphology of this accessory muscle on magnetic resonance (MR) images, and to reassess the reported association of the PQ . Le reste de lexamen neurologique est sans anomalies. Figure 3 Axial PD MRI at four different levels. Case Discussion Typical position of the peroneus quartus accessory muscle. The peroneal tubercle was hypertrophied at the insertion in most cases. Overlying the peroneal tubercle are the fibers of the inferior peroneal retinaculum which blend with the common peroneal tendon sheath [5]. Le bilan radiographique standard est sans anomalies. Patients with mild injury may present to the nurse practitioner or primary care provider. Endoscopic Resection of Peroneus Quartus. However, we found a bilateral hyperlaxity in forced varus at 15 on the left side and 20.5 on the right side for a positive threshold set at 10 ( Fig. The characteristic image finding for this variant is a peroneus brevis tendon which inserts on the lateral calcaneus on or near the peroneal tubercle. The peroneus quartus is the most common supernumerary muscle of the foot and ankle. After all conservative treatments failed, the surgical explorations validated the presence of supernumerary PQ muscles and after surgical resections all symptoms disappeared. The peroneal tubercle is not present in every individual, with sources reporting its presence in 40%55% of individuals [3, 4]. [2] Sometimes anomalous anatomy can lead to a peroneal disorder such as low lying brevis muscle belly or the presence of peroneus quartus muscle. Insertion on the peroneal tubercle has also been reported [7]. The rest of the neurological examination was eventless. Lincidence de ce muscle varie selon les sries de 0 21,7 %. Several anatomical muscle-tendon variations have been described in the literature as being sometimes responsible for this instability, the peroneus quartus muscle being the most frequent. Regarding the various therapeutic options, the authors seem to agree on the fact that in case of failure of the various medical therapeutic options (e.g. In fact, faced with the persistent instability symptoms and the strength deficit of the peroneal muscles still seen during clinical testing, we wanted to evaluate the responsibility of this PQ muscle in this lingering strength deficit and thus chronic bilateral FAI symptoms of this patient. Acute symptoms There are several variations of this accessory muscle, and its terminology is very confusing. He stopped all athletic activities and sports the year before. Patients can get back to sports or athletic activities after a few months. It shows the muscle body of the peroneus quartus (arrow) within the tendon sheath of the peroneus brevis and longus muscles; b: MRI T2-weighted axial view. Sobel et al. It is important for the radiologist to be aware of this variant. That particular case report describes a tendon insertion just distal to the peroneal tubercle [2]. Avulsion fracture of the fifth metatarsal or fibular groove should entail fixation or repair. 4,17 It is rarely involved in pathologic processes of the foot . PubMed Epub 2019 Feb 15. On this page: Article: Epidemiology Clinical presentation Pathology Radiographic features Treatment and prognosis Differential diagnosis See also Figure 3 24 year old male with variant peroneus brevis tendon insertion on the calcaneus. strengthening of the peroneus muscles, proprioceptive work), yet no symptom improvements were noted. In eccentric mode these values were 29.8% on the left side and 21.4% on the right side for normal values set between 43 and 45%. Variant insertion of the peroneus brevis tendon on the calcaneus is congenital (table 1). The peroneus longus is a superficial muscle located in the lateral part of the leg. Observation Il s'agit d'un patient de 26 ans venant consulter pour des pisodes d'entorses latrales rptition. Several anatomical tendon abnormalities were described in the literature as being responsible for clinical symptoms such as instability . Additionally, a pharmacist may be necessary to verify medication reconciliation if the decision is made to institute NSAID or other pain management pharmacotherapy. Department of Orthopaedics and Traumatology, Dr Sadi Konuk Research and Training Hospital, Tevfik Saglam Cad. Peroneal tendon disorders are a cause of hindfoot and lateral foot pain. X-rays should be weight-bearing and include standard AP, mortise, and lateral ankle views. They act as active stabilizers of the talocrural joint, but also of the subtalar and midfoot joints. What is Quartus used for? Not recognizing or treating these conditions may lead to continued pain or lateral ankle instability. PRP injections with ultrasound guidance have shown improved functional outcomes with tendinopathy in the study by Dallaudiere. There was no deficit of the tibialis posterior muscle. Peroneal tendon subluxation in athletes: new exam technique, case reports, and review. MRI findings for complete tear would include absence of a tendon inserting on the base of the fifth metatarsal. After tendon tear repair surgery, complications are re-tear and continued symptoms, shown to occur in about 10% of patients by Dombek.[7]. In the setting of absent peroneal brevis tendon insertion on the fifth metatarsal base, the radiologist should assess the MRI for variant attachment at the peroneal tubercle. It can be symptomatic and associated with splits or tears in the peroneus brevis, subluxation or dislocation of the peroneal tendon, tendinous calcification, chronic peroneal compartment syndrome, and painful hypertrophy of the retrotrochlear eminence. The peroneus quartus is estimated to have a prevalence of approximately 6.6 to 13% and has been . True split tears typically manifest with a "boomerang" appearance of the brevis tendon enveloping the longus tendon, and there is . eccentric peroneal muscle strengthening, proprioceptive work) did not improve the symptoms. Chronic ankle instability as a cause of peroneal tendon injury. Part of Springer Nature. official website and that any information you provide is encrypted Finally, in an anatomical and imaging study (dissection of 102 legs and review of 80 ankle MRI exams) Zammit and Singh reported an overall incidence of 6.6% (12/182). Archives of Orthopaedic and Trauma Surgery MR imaging of the accessory muscles around the ankle. Subluxation may be apparent with voluntary eversion. Authors have been arguing about the most common insertion site: for Zammit et al. The peroneus quartus, with a number of different attachments, was present in 6.6% of the legs. Diagnosis is made clinically with subfibular ankle pain with the sensation of apprehension or subluxation with active dorsiflexion and eversion against resistance. Saupe N, Mengiardi B, Pfirrmann CW, et al. Accessory peroneus quartus muscle and edema Kager's fat pad. Il sagit dun patient de 26 ans venant consulter pour des pisodes dentorses latrales rptition des chevilles. TECHNIQUE: Siemens Verio 3T, coronal proton density sequence without injected contrast (TR 3850, TE 36, 3mm slice thickness/spacing). Sammarco and Brainard described the case of a 22-year-old woman, high-jump athlete, with ankle and feet pain that appeared spontaneously. 2 ) showed the presence of a supernumerary bilateral muscle: the PQ muscle, stemming from the peroneus brevis and inserted distally on the tendon of the peroneus longus muscles at the level of the peroneal tubercle of the calcaneus. MRI using the imaging parameters described above revealed a peroneus brevis tendon inserting on the calcaneal peroneal tubercle (figure 668). Imaging demonstrated insertion of the peroneus brevis tendon on the calcaneal peroneal tubercle with absence of the tendon distal to the calcaneus. Furthermore this patient did not have any personal or family history and was not under any treatment. The peroneus quartus is a supernumerary muscle that has been well described in anatomical studies. In the acute setting, one would expect a significant amount of surrounding edema on MRI. However several other pathologies can be the cause or consequence of this chronic ankle instability: osteochondral lesions, especially of the talus (OLT), lesions of the peroneal tendons, some postural disorders of the ankle of feet or some neurological impairments (common fibular or common peroneal nerve). It most commonly arose from the peroneus brevis muscle and inserted into the retrotrochlear eminence of the calcaneus. On observe ensuite lors de la phase dappui un passage en valgus bilatral. Some thickening of the peroneal tendon sheath was excised. Cependant quelques cas de douleurs chroniques de cheville ou dinstabilit ont t rapports dans la littrature. [9], Non-operative treatment should be for 4 to 6 months to allow resolution of inflammation. You may switch to Article in classic view. [7], The primary function of the peroneal tendons is to evert and plantarflex at the ankle. It is a comprehensive environment for system-on-a-programmable-chip (SOPC) design. 8600 Rockville Pike Peroneal tendon disorders are a cause of hindfoot and lateral foot pain. Proc R Soc Lond 16:483525, Pozzi S (1872) Sur une vari_et_e fr_equente du muscle court p_eronier lateral chez lhomme (anomalie reversive). (b) The peroneus quartus muscle running along the peroneus longus tendon was excised. Cheung et al. Google Scholar, Choudhary S, McNally E (2011) Review of common and unusual causes of lateral ankle pain. Ce sont des stabilisateurs actifs de larticulation talo-crurale, mais galement des articulations sous-talienne et du mdio-pied. It works to plantar and evert flex the ankle. Surgical exploration determined good health of the peroneal tendons. Radiographics 25(3):587602, Brandes CB, Smith RW (2000) Characterisation of patients with primary peroneus longus tendinopathy: review of twenty two cases. VHDL and Verilog are considered general-purpose digital design languages, while SystemVerilog represents an enhanced version of Verilog . If it seems obvious that the symptoms presented are probably due to several factors (postural dynamic disorders due to pes valgus planus, hyperlaxity due to ligament insufficiency, peroneal muscle strength deficit), it seems that the presence of a bilateral PQ muscle is involved in this FAI. The tests highlighted a bilateral muscle strength deficit for the peroneus brevis and longus evaluated at 4-/5. Additional X-ray views are the axillary/Harris heel view and AP, lateral and oblique views of the foot to look for other fractures and foot alignment. Cheung YY, Rosenberg ZS, Ramsinghani R, et al. FINDINGS: Contiguous sagittal proton density MRI images of the right ankle demonstrate the peroneus brevis tendon (short arrow) descending to its attachment on the calcaneal. Reports exist of peroneal compartment syndrome after acute rupture of the peroneus longus tendon. Orthopaedics, anatomists and radiologists should be aware of this accessory tendon structure because of its clinical importance. Modification of shoe wear can also help unload the peroneal tendons with the use of a lateral heel wedge. Dynamic X-rays in forced varus (tibiotalar angle measure at 20.5 on the right side and 15 on the left side). The peroneal tendons are in the lateral compartment of the leg and include the peroneus longus and peroneus brevis muscles. Tendon tears often have constant swelling, pain, or patient feeling of ankle instability or weakness. It is possible that its presence may be more common in individuals who have variant insertion of the peroneus brevis tendon, or another known variant, such as a peroneal tubercle insertion of a peroneus quartus tendon. Radiology 202:745750, Wood J (1866) Variations in human myology observed during the winter session of 18651866 at Kings College London. After each sprain he benefited from specific therapeutic care, he wore a specific ankle orthotic and attended a well-conducted rehabilitation training program (e.g. Fibular groove morphology and measurements on MRI: correlation with fibularis tendon abnormalities. He was also prescribed some custom-made orthopedic shoes, to compensate his bilateral pes valgus planus disorder. 1,31 The PCI muscle originates along the inner part of the lower third of the fibula. Saupe et al also found peroneus quartus in 17% of normals commonly associated with lateral ligament injuries of the ankle - about 50% also have ankle instability; peroneal tenosynovitis, tears and instability may be present in up to 70% of patients with ankle instability usually longitudinal, partial tears - only about 10% are complete tears Finally, Donley and Leyes reported the case of a 15-year-old football player complaining about painful popping of the peroneal tendons after severe lateral ankle sprains. Lippincott, Williams & Wilkins, Philadelphia, p 240245, Zammit J, Singh D (2003) The peroneus quartus muscle anatomy and clinical relevance. Characterization of patients with primary peroneus longus tendinopathy: a review of twenty-two cases. As a reminder, our patient has a bilateral PQ muscle stemming from the muscle tissue of the peroneus brevis with a distal insertion on the tendon of the peroneus longus muscle. government site. Often a split tear with bisected or C shape appearance of the tendon with interposition of the peroneus longus tendon. [2] The peroneus quartus muscle most commonly runs form the peroneus brevis to the retrotrochlear eminence of the calcaneus and is associated with peroneus brevis tears, and subluxation. pain, swelling, instability). PDF | On Dec 1, 2018, Rahul Jha and others published Peroneus Quartus Muscle: Revisited | Find, read and cite all the research you need on ResearchGate A certain diagnosis can be established by magnetic resonance imaging (MRI) or surgery. On ne note, par ailleurs, pas de signe dhyperlaxit constitutionnelle lexamen. A normal peroneus longus tendon with magic angle artifact (long arrow) is also annotated. and transmitted securely. All unhealthy portions of tendon sharply debrided with a 15-blade. They named this the retromalleolar attrition syndrome. There are three primary disorders of the tendons; peroneal tendonitis, peroneal subluxation, and peroneal tendon tears; these conditions are a cause of lateral ankle pain and may lead to ankle instability. However its symptomatic clinical presentation seems quite rare and harder to demonstrate. However some cases of chronic ankle pain or instability have been reported in the literature. Generally, these muscles arise from peroneus brevis but their insertions exhibit variabilities. We are experimenting with display styles that make it easier to read articles in PMC. Sympathetic blocks, nerve blocks and intrathecal drugs, Clinical practice guidelines for chronic neuropathic pain in the spinal cord injury patient: Introduction and methodology, Interest of rehabilitation in healing and preventing recurrence of ankle sprains, The winged scapula; a muscle rupture or a nerve paralysis? An official website of the United States government. already built in. There was no positive sign at the anterior drawer test. Learn more about Institutional subscriptions, Hecker P (1923) Study of the peroneus of the tarsus. Classiquement, suite aux travaux de Freeman , on distingue deux grands types dinstabilit: linstabilit mcanique imputable des lsions ligamentaires responsable dune laxit clinique objective et linstabilit dite fonctionnelle corrle un dficit proprioceptif et de commande neuromusculaire. Findings include fluid surrounding the tendons, discontinuity, edema of the bone, and any bony deformity. Failure to recognize this variant may result in the incorrect diagnosis of a peroneus brevis tendon rupture and an unnecessary attempt at reparative surgery. Finally, some examples of chronic dislocation of the peroneal tendons were mentioned . All of the three patients received open peroneal tendon repair with groove tubular deepening for the 1 st patient. These symptoms can spontaneously appear but usually they are triggered by acute trauma such as lateral ankle sprain. Peroneal Tendonitis General Characterized by gradual onset of pain, swelling, warmth of the posterolateral ankle Lateral ankle instability can lead to laxity Increased motion of the tendons around the fibula with stretched superior peroneal retinaculum Low lying peroneus brevis muscle belly having to go through the narrow tendon sheath 24 related questions found. TECHNIQUE: Siemens Verio 3T, axial proton density sequence without injected contrast (TR 4830, TE 35, 4mm slice thickness/spacing). Unable to load your collection due to an error, Unable to load your delegates due to an error. Both receive innervation from the superficial peroneal nerve and blood supply from the peroneal artery. 24 year old male with variant peroneus brevis tendon insertion on the calcaneus. This muscle is important for walking, running, and standing on your toes, among other activities. The peroneus quartus tendon (white arrow) is markedly thickened and oedematous compared with the previous study (Fig. Radiology. The peroneus quartus muscle, with a number of different attachments, was present in 5.2% (6/115) of the legs. Most times, this supernumerary muscle is completely asymptomatic and is fortuitously discovered during imaging exams. The symptoms disappeared after surgical resection of the PQ muscle followed by short immobilization time and rehabilitation training. reported the progressive onset of pain and swelling behind or under the lateral malleolus in women over the age of 50. Distal peroneus brevis tendon indistinctness with local fluid collection/edema. For Coudert et al. But there is strong relationship between peroneus brevis degeneration and peroneus quartus existence (p: 0.03). FAI, common complication of lateral ankle sprain, has several etiologies going from lesion of the ligaments to a deficit in muscle strength not forgetting tendon, osteochondral or neurological lesions. Arch Orthop Trauma Surg 134, 481487 (2014). Findings on the x-ray that indicate peroneal pathology are avulsion from the base of the fifth metatarsal, avulsion fracture of the distal fibular groove, os peroneum, and retromalleolar groove flattening. Furthermore, single support stance could not be kept for 30 seconds without help. 1 ). In these cases, peroneal sheath tenosynovitis is usually present on MRI. Patients with varus heel may have associated Charcot-Marie-Tooth. Chronic subluxation is associated with fibular groove flattening laxity of the superior retinacular ligament, Musculotendinous junction during forceful contraction or in the cuboid tunnel, Most tears are longitudinal and result from chronic subluxation over the distal fibula. J Bone Joint Surg Am 73-A:131133, Trono M, Tueche S, Quintart C, Libotte M, Baillon JM (1999) Peroneus quartus muscle: a case report and review of the literature. Le peroneus quartus est lune des plus frquentes. We dissected 102 cadaver legs and reviewed the magnetic resonance images of 80 patients with symptoms from the ankle. Son origine est le plus souvent commune avec celle du muscle court fibulaire et sa terminaison trs variable: minence rtrotrochlaire du calcanum, tendon du long fibulaire, tubrosit du cubode pour ne citer que les plus frquentes. (c) An end-to-side transfer of the peroneus longus tendon to the peroneus brevis tendon was performed. sharing sensitive information, make sure youre on a federal The main alternate consideration is a complete tear of the peroneus brevis tendon with tendinous retraction (table 2). The degenerated part of the peroneus tendon was excised. 2022 May 29. During surgical exploration, a supernumerary muscle fascia that could have been a remnant of a PQ was found, without any obvious abnormality of the peroneal groove, retinaculum or tendons. Notre examen ne permet pas de mettre en vidence de trouble sensitif. it was the peroneal tubercle of the calcaneus (63%). Wang XT, Rosenberg ZS, Mechlin MB, Schweitzer ME. PubMed In: StatPearls [Internet]. Trono et al. Foot Ankle 13:413422, Article Matcuk GR Jr, Patel DB, Cen S, Heidari KS, Tan EW. Peroneal tendonitis presents as a sharp or aching sensation along the length of the tendons or on the outside of your foot. , in their anatomical study, reported the presence of tendon lesions of the peroneus brevis muscle in 18% of the patients with PQ. And again, by the inferior peroneal retinaculum where the fibers of the peroneus longus will dive lower than the peroneus brevis to avoid different friction syndromes. They run in a tunnel bordered by the superior peroneal retinaculum, the posterior fibula that has a retromalleolar groove, and the calcaneofibular ligament. As for the ligaments, some scarring was noted on the left anterior talofibular ligament. This is a preview of subscription content, access via your institution. The presence of a supernumerary peroneus quartus (PQ) muscle was reported as one of the most common. (5) Biomechanics and Injury Peroneal tendon injures are a direct result of their anatomy and biomechanics. 2022 Springer Nature Switzerland AG. The pain was characterized as radiating from the ankle to the base of the fifth metatarsal. J Radiol Case Rep. 2015 May; 9(5): 2228. [1][9], For patients with Peroneal tendon tears, postoperative outcomes are good. This pain led the patient to decrease her athletic training and she even ended up stopping all her athletic activities. The electroneuromyogram of the peroneus muscles was normal. Lateral ankle instability can cause laxity, leading to the increased motion of the tendons around the fibula with stretched superior peroneal retinaculum, Low lying peroneus brevis muscle belly having to go through the narrow tendon sheath, Instability can be acute from the rupture of the superior retinaculum or fibular groove avulsion or chronic. If the tendons chronically subluxate, this can lead to inflammation and irritation causing tendonitis. Grant TH, Kelikian AS, Jereb SE, McCarthy RJ. L'objectif de ce cas clinique est de discuter l'imputabilit de la prsence d'un quatrime fibulaire bilatral, chez un patient souffrant d'instabilit chronique. Cheung Y, Rosenberg ZS. If the superior peroneal retinaculum is torn then open or endoscopic repair or reconstruction is necessary. It would be interesting to study these individuals further to discover if they are subject to higher rates of ankle instability or acute/chronic injuries of the peroneal tendons. Summarize the treatment and management options available for peroneal tendon syndromes. [6], Physical exam should begin with an inspection of the ankle and foot for erythema or swelling, muscle strength testing of eversion and plantar flexion. We then observed, during the stance phase, a passage in bilateral valgus. Identify the epidemiology of peroneal tendon syndromes. The primary location of tenderness is along the peroneal tendons as they pass posterior and inferior to the fibular head. then Oznur et al. Immobilization can include cast or controlled ankle motion boot. TECHNIQUE: Siemens Verio 3T, coronal proton density sequence without injected contrast (TR 4030, TE 39, 4mm slice thickness/spacing). JBJS Br 8:11341137, Clarkson MJ, Fox JN, Atsas S, Daney BT, Dodson SC, Lambert HW (2013) Clinical implications of novel variants of the fibularis (peroneus) quartus muscle inserting onto the cuboid bone: peroneocuboideus and peroneocalcaneocuboideus. The peroneal tendons are in the lateral compartment of the leg and include the peroneus longus and peroneus brevis muscles. Figure 4 Sagittal PD MRI. The peroneus longus originates at the proximal fibula and lateral tibia and inserts at the base of the first metatarsal and the medial cuneiform. [5] Anatomical variants of the fibular retromalleolar groove, hindfoot alignment or cavus foot can lead to abnormal movement of the tendon leading to a predisposition towards subluxation or dislocation. AJR Am J Roentgenol 168:141147, Chepuri NB, Jacobson JA, Fessell DP, Hayes CW (2001) Sonographic appearance of the peroneus quartus muscle: correlation with MR imaging appearance in seven patients. These conditions are a cause of lateral ankle pain and may lead to ankle instability. Google Scholar, Murlimanju BV, DSouza PS, Prabhu LV, Saralaya VV, David SJ (2012) Peroneus quartus, an accessory muscle in human: case report and its clinical importance. Au terme de cette premire consultation, nous lui avons propos de raliser un bilan plus complet afin de prciser le diagnostic tiologique de cette instabilit chronique. Image courtesy Dr Chaigasame, Peroneal tendon syndrome- Longitudinal split tear of the peroneus brevis tendon. No plantar flexion or eversion strength deficits were documented on physical examination. In one review of 82 patients with chronic lateral ankle instability, MRI sensitivity and specificity of peroneal tendinopathy were reported as 83.9% and 74.5%, respectively [11]. Epub 2014 Feb 14. Absence of lateral ankle edema and peroneal tenosynovitis should raise suspicion for variant tendon insertion. contraction of the peroneal tendons. One of the hypotheses, previously described in the literature, would be the overcrowding effect resulting in a true conflict by reducing the available space for the peroneal muscles in the peroneal sheath. On the MR scans its presence was associated with pain and weakness of the ankle. Enfin, une douleur est dclenche la palpation du sinus du tarse et des gouttires rtromallolaires latrales, droite comme gauche. These conditions are a cause of lateral ankle pain and may lead to ankle instability. FINDINGS: Contiguous axial proton density MRI images of the right ankle demonstrate the peroneus brevis tendon (short arrow) descending to its attachment on the calcaneal peroneal tubercle (asterisk). [16] [Level 2], Peroneal tendon syndromes. It most commonly arose from the peroneus brevis muscle and inserted into the retrotrochlear eminence of the calcaneum. It seems also relevant to establish a diagnosis as early as possible to avoid lesions of the ligaments resulting from recurrent ankle sprains that will then foster this chronic instability. Le bilan dimagerie a mis en vidence la prsence dun muscle peroneus quartus bilatral. If the fibular groove is shallow endoscopic or open fibular groove deepening can be performed to provide a better structure for the peroneal tendons. The more distally positioned and variably present peroneal tubercle separates the peroneus longus tendon from the peroneus brevis tendon. Philbin TM, Landis GS, Smith B. Peroneal tendon injuries. What is the efficacy of regional interventions? FINDINGS: Contiguous sagittal T1 MRI images of the right ankle demonstrate the peroneus brevis tendon (short arrow) descending to its attachment on the calcaneal peroneal tubercle (asterisk). The patients symptoms resolved with conservative therapy. The peroneus quartus is found with a frequency varying from 10 to 21.7% of observed individuals. A retrospective review of peroneal tendon tears showed brevis tears in 88% of patients, longus tears in 13% of patients and combined peroneus longus and brevis tears in 37%. In our series, this anatomic variant was present in 2/200 (1%) cases. Peroneal tendon injuries vary in their severity and are managed by an interprofessional team to achieve the best outcomes. Finally the adapted therapeutic solution seems to be surgical resection, leading to good results with complete disappearance of the symptoms for all reported cases. Intratendinous injection of platelet-rich plasma under US guidance to treat tendinopathy: a long-term pilot study. Tears are more likely to be longitudinal due to subluxation over the fibula, but can also be transverse. Researchers have categorized AFM on the basis of origin and insertion as peroneus quartus [2,6, [8] [9] [10], peroneus accessorius [10], peroneus digiti minimi (quinti brevis) [2,8,10],. TECHNIQUE: Siemens Verio 3T, coronal proton density sequence without injected contrast (TR 4030, TE 39, 4mm slice thickness/spacing). Google Scholar, Tubbs RS, May WR, Shoja MM, Loukas M, Salter EG, Oakes WJ (2008) Peroneotalocalcaneus muscle. [Updated 2022 May 29]. Besides these acute episodes, the patient reported a sensation of bilateral instability, with no predominant side, when walking on uneven ground and jogging. In this patient, it seems that the bilateral ankle instability is caused by several factors. The calcaneus was the insertion site in 11 cases. 20 year old male with variant peroneus brevis tendon insertion on the calcaneus. Its origins, insertions, and size varied. Davda K, Malhotra K, O'Donnell P, Singh D, Cullen N. Peroneal tendon disorders. Il dcrit galement des douleurs bilatrales, prmallolaire infrieure dclenches survenant lors daccidents dinstabilit. These episodes started at the age of 17 following minor trauma or even no trauma at all. We dissected 115 cadaver legs and investigated prevalence of peroneus quartus. The frequent occurrence of this muscle in humans is suggestive of a progressive evolutionary change to evert the foot in order to assume a bipedal gait. In our patient, given the associated ligament insufficiency, an associated arthroscopic surgical reconstruction of the injured ligaments could be proposed and eventually take place at the same time as the resection. Associated pathologies are longitudinal degeneration and tear in the tendon of peroneus brevis. The prevalence of the PQ muscle was 10% (14 of 136 cases). Incidence of this supernumerary muscle has been reported between 6.6 22 % on MRI and cadaveric studies [4, 69]. The PQ is a supernumerary muscle of the distal lateral portion of the fibula. We report a case of 24-year old male presenting with non-traumatic ankle pain who underwent ankle magnetic resonance imaging. a: MRI T1-weighted axial view. There are three basic types of peroneal tendon disorders, tendonitis, subluxation, and tears. Along the outside edge of your fifth . Il ny a pas de signe clinique de luxation tendineuse des fibulaires ou du tibial postrieur. Soft tissue edema in region of peroneus brevis partial tear. Tendon subluxation patients will have painful clicking and popping at the lateral malleolus. eCollection 2020 Jan. Hallinan JTPD, Wang W, Pathria MN, Smitaman E, Huang BK. Foot Ankle 10:4547, Mick CA, Lynch F (1987) Reconstruction of the peroneal retinaculum using peroneus quartus: a case report. This muscle is the longest of all three fibularis muscles. The many cadaveric studies that have been conducted indicate a general population prevalence ranging from 6.6% to 23%. Four hundred eight patients showed 23 patients with peroneal tendon disorders. What is Quartus II used for? The peroneus brevis provides a small portion of the foots plantar flexion power and 28% of the hindfoot eversion power [1]. Normal anatomy of the lateral ankle is shown in Fig. The many cadaveric studies that have been conducted indicate a general population prevalence ranging from 6.6% to 23%. 1b), and bigger than the peroneus brevis tendon (B) and almost as big as the peroneus longus tendon (L). Dallaudire B, Pesquer L, Meyer P, Silvestre A, Perozziello A, Peuchant A, Durieux MH, Loriaut P, Hummel V, Boyer P, Schouman-Claeys E, Serfaty JM. The term medial refers to a point closer to the center of the body. A normal peroneus longus tendon (long arrow) and calcaneofibular ligament (open arrowhead) are also annotated. The increase in muscle volume during efforts would appear to be the triggering element for these symptoms (pain, instability). Il sagit dun patient de 26 ans venant consulter pour des pisodes dentorses latrales rptition. The peroneus brevis tendon was absent at the base of the fifth metatarsal. The clinical examination found a moderate hyperlaxity on the right side in bilateral ankle varus. It seems relevant to discuss, around the clinical case of this patient, the impact of this muscle on ankle instability especially when faced with lingering weakness of the peroneus brevis and longus muscles in spite of eccentric strength training and in the absence of any neurological impairment. StatPearls Publishing, Treasure Island (FL). Absence of peroneus brevis tendon insertion on 5. Anat Rec 26:7982, Article Rerouting the peroneal tendons underneath the calcaneofibular ligament. The Altera Quartus II design software provides a complete, multiplatform design environment that easily adapts to your specific design needs. The sensitivity is 83%, and specificity is 75% for peroneus brevis tears. (a) Heterotopic ossification existed inside the peroneus longus tendon. Tendonitis of the Foot and Ankle Peroneus quartus muscle: MR imaging features. 2014 Apr;134(4):481-7. doi: 10.1007/s00402-014-1937-4. TECHNIQUE: Siemens Verio 3T, axial proton density sequence without injected contrast (TR 4830, TE 35, 4mm slice thickness/spacing). The muscle has often been implicated as a cause of pain in the lateral ankle region, and subluxation or attrition of the peroneal tendons. We also present 2year result of a patient who had torn superior peroneal retinaculum reconstructed with peroneus quartus tendon. Saxena A, Ewen B. Peroneal subluxation: surgical results in 31 athletic patients. J Radiol 83:2738, Saupe N, Mengiardi B, Pfirrmann CW, Vienne P, Seifert B, Zanetti M (2007) Anatomicvariants associated with peroneal tendon disorders: MR imaging findings in volunteers with asymptomatic ankles. Please enable it to take advantage of the complete set of features! However, if the injury is severe, the patient should be referred to a specialist. peroneus quartus muscle or a low-lying muscle belly makes individuals also more susceptible for peroneal tendon dislo-cation [37, 42, 43]. FAI is a subjective functional symptom to be differentiated from laxity, which is an objective clinical symptom. 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