Overview of Peroneal Tendon Issues

Many patients that we treat at our office have chronic ankle instability in the form of lateral tendon dislcocations, or chronic ankle sprains. Many times these patients are unclear as to how important these tendons are to the overal stability and function of the ankle joint. With abnormal tendon gliding and ligamentous attenuations and ruptures, these tendons may also become painful with patients who have chronic ankle sprains. This is a comprehensive overview of this pathology and treatment options to help out with the understanding of these clinical scenarios.

History of the Procedure
Disorders of the peroneal tendons have been reported infrequently. Monteggia described peroneal tendon subluxation in 1803, and this entity seems to be more commonly encountered than are disruptions of the peroneus longus or brevis alone. Nonetheless, peroneus brevis disorders have been described more often in the literature, with peroneus longus problems gaining more recent attention. However, much of the literature regarding both tendons is in the form of case reports.

Problem
The peroneal muscles make up the lateral compartment of the leg and receive innervation from the superficial peroneal nerve. The peroneus longus muscle originates from the lateral condyle of the tibia and the head of the fibula. The tendon of peroneus longus courses behind the peroneus brevis tendon at the level of the ankle joint, travels inferior to the peroneal tubercle, and turns sharply in a medial direction at the cuboid bone. The tendon inserts into the lateral aspect of the plantar first metatarsal and medial cuneiform.
A sesamoid bone called the os peroneum may be present within the peroneus longus tendon at about the level of the calcaneocuboid joint. The frequency with which an os peroneum occurs is controversial, with many supporting the idea that one is always present. However, the os peroneum may be ossified in only 20% of the population. The peroneus longus serves to plantar flex the first ray, evert the foot, and plantar flex the ankle.

The peroneus brevis originates from the fibula in the middle third of the leg. Its tendon courses anterior to the peroneus longus tendon at the ankle. It courses over the peroneal tubercle and inserts onto the base of the fifth metatarsal. The peroneus brevis everts and plantar flexes the foot.

Problems may arise in either of the tendons alone, or both may be involved with subluxation. The hallmark of disorders of the peroneal tendons is laterally based ankle or foot pain. Whether the problem is tendinous degeneration or subluxation, the clinical manifestation is pain. With time, loss of eversion strength may occur.

Problems arising with the peroneus longus include tenosynovitis and tendinous disruption (acute or chronic). The os peroneum may be involved with the degenerative process or as a singular disorder and can be fractured or fragmented. Longitudinal tears of the peroneus longus are uncommon but have been reported.
Longitudinal tears of the tendon are the most common problem seen with the peroneus brevis tendon. These may be single or multiple. Tendinitis and tenosynovitis also may occur.

Subluxation of both peroneal tendons may occur following an acute traumatic episode or may be of a more chronic nature.

Frequency
Disorders of the peroneal tendons are less common than other tendon problems involving the Achilles or posterior tibial tendons. However, it is impossible to estimate their true frequency in the United States or abroad.

Etiology
The precise etiology of peroneal tendon disorders depends somewhat on the specific problem being addressed. All disorders may result following a traumatic episode, direct or indirect, with a lateral ankle sprain being the most common trauma. Brandes and Smith have reported that 82% of patients with primary peroneus longus tendinopathy had a cavo-varus hindfoot.3 The presence of an os peroneum also has been postulated to predispose to peroneus longus rupture. Ruptures likewise have been reported to occur secondary to rheumatoid arthritis and psoriasis, as well as diabetic neuropathy, hyperparathyroidism, and local steroid injection.4,5,6
Longitudinal splits in the peroneus brevis tendon appear to result from mechanical factors. Repetitive or acute trauma causes the attritional ruptures. These ruptures may result from an incompetent superior peroneal retinaculum that allows the peroneus brevis to rub abnormally against the fibula.

Overcrowding from a peroneus quartus muscle also has been reported. The blood supply to the tendon has been shown to be adequate.

Subluxation of the peroneal tendons results from disruption of the superior peroneal retinaculum and usually involves avulsion of the retinaculum from its fibular insertion. The mechanism of injury typically involves an inversion injury to the dorsiflexed ankle with concomitant forceful contraction of the peroneals. Some patients have a more chronic presentation and cannot recall a traumatic episode. Congenital dislocations also have been reported. An inadequate groove for the peroneals in the posterolateral fibula may be a cause of subluxation as well.

Pathology of the longus and brevis tendons almost always occurs concurrently. Brandes and Smith noted a 33% incidence of concomitant problems.

Presentation
The patient with peroneal tendon pathology typically complains of laterally based ankle or hindfoot pain. The pain usually worsens with activity. However, presentation and diagnosis often are delayed. Patients may or may not recall a specific episode of trauma. Brandes and Smith reported that only 9 of 22 patients with primary peroneus longus tendinopathy recalled an inciting event and that the event was an average of 4.3 months prior to presentation.

Peroneal tendon subluxation or dislocation may present acutely following a traumatic injury to the ankle. However, it is not uncommon for these to present later with an uncertain history of trauma. Patients also may complain of snapping or popping in the ankle.

On physical examination, there usually is tenderness to palpation along the course of the peroneal tendons. Edema also may be present. These disorders require a high level of suspicion. Even frank dislocations may be missed if not specifically evaluated.

A provocative test for peroneal pathology has been described. The patient's foot is examined hanging in a relaxed position with the knee flexed 90º. Slight pressure is applied to the peroneal tendons posterior to the fibula. The patient is then asked to forcibly dorsiflex and evert the foot. Pain may be elicited, or the tendons may be felt to sublux.

Indications
The primary indication for treating these disorders is pain. Nonsurgical treatment usually is attempted first. Failure of conservative measures is an indication for operative intervention.

Operative Considerations

With physical therapy, MRI, and need for primary or secondary repair will be determined based on overal health of the patient, as well as how effective nonsurgical measures have been. If the pain and resolution is not fully noted through physical therapy and bracing one should consider the possiblity of repair. If there are tendon tears associated with the pathology, repair is recommended. If an associated low muscle (peroneus quartius) or ruptured retinaculum is identified, repair is also likely required. We are experts in this pathology, and treat this regularly, and I feel a proper evaluation for this condition will be beneficial to anyone with recurrent ankle sprains, as well as pain in the lateral ankle.

Hammer Toes

Hammertoes occur when the smaller toes of the foot become bent and prominent. The four smaller toes of the foot are much like the same fingers in the hand. Each has three bones (phalanges) which have joints between them (interphalangeal joints). The toes form a joint with the long bones of the foot (metatarsals) and it is this area that is often referred to as the ball of the foot.
Normally, these bones and joints are straight. A hammertoe occurs when the toes become bent at the first interphalangeal joint, making the toe prominent. This can affect any number of the lesser toes. In some cases, a bursa (rather like a deep blister) is formed over the joint and this can become inflamed (bursitis). With time, hard skin (callous) or corns (condensed areas of callous) can form over the joints or at the tip of the toe.




What causes hammertoes?
There are many different causes but commonly it is due to shoes or the way in which the foot works (functions) during walking. If the foot is too mobile and / or the tendons that control toe movement are over active, this causes increased pull on the toes which may result in deformity.
In some instances trauma (either direct injury or overuse from walking or sport) can predispose to hammertoes. Patients who have other conditions such as diabetes, rheumatoid arthritis and neuromuscular conditions are more likely to develop hammertoes.

Are women more likely to get the problem?
It is more common in women as they tend to wear tighter, narrower shoes with increased heel height. These shoes place a lot of pressure onto the joint and predispose to deformity. It is common for patients to wear shoes that are too small and this can predispose to the problem. In a study we have performed, 95% of patients were in the wrong size shoes.

Will it get worse?
At the start of the deformity, it is generally mobile which means that the toe can be straightened. However, with time, the joint become fixed or rigid. This can then affect the joint at the ball of the foot and, in severe cases, the joint capsule ruptures (tears) so that the joint becomes dislocated and the toe sits up in the air.

What are the common symptoms?
Deformity / prominence of toe
Pain
Redness around the joints
Swelling around the joints
Corn / Callous
Difficulty in shoes with deformity of the shoe upper
Difficulty in walking
Stiffness in the joints of the toe

How is it identified?

Clinical examination and a detailed history allow diagnosis. X-rays are often not required but can help to evaluate the extent of the deformity and the degree of arthritis within the joint.

What can I do to reduce the pain?
There are several things that you can do to try and relieve your symptoms:
Wear good fitting shoes with a deep toe box
Avoid high heels
Use a toe prop to straighten the toe if it is still mobile
Wear a protective pad over the toe
See a doctor at the Family Foot and Leg Center.

What can we as a specialist do to correct or reduce your symptoms?
If simple measures do not reduce your symptoms, there are other options:
Advise appropriate shoes
Advise exercises if the toes are still mobile
Show you how to strap the toe in a corrected position
Provide a splint or protection
Consider orthotics

Advise on surgery
The way in which your foot loads during walking can place increased stress on the ball of the foot and cause increased toe activity. Special shoe inserts (orthoses) can help to control foot movement. Whilst these are unlikely to resolve established deformity they may help reduce discomfort in the ball of the foot.

Will this cure the problem?
If the deformity is mobile, then this may help prevent progression although there have been no scientific studies to analyse the benefit. If the deformity is fixed, then orthotics will not cure the problem but may reduce the associated symptoms.

What will happen if I leave this alone?
Generally, the deformity becomes worse with time and slowly becomes fixed (stiff). This can cause discomfort in shoes. The position of the toe places increased stress on the ball of the foot and this can become painful. Corn and callous formation on the ball of the foot is not uncommon. In some cases, the metatarsophalangeal joint capsule ruptures, causing the toe to sit up in the air.

Can the deformity be reversed or cured?
The only effective way of correcting the deformity is to have an operation.

How does the operation correct the deformity?
There are a number of different operations. However, the most common operations are:
Tendon transfer
Digital arthroplasty
Digital arthrodesis


Hopefully this is an effective run down of various questions commonly asked by my patients here, and if you come up with more please comment and the questions will be answered.

Baby and Toddler Shoes



Before babies starts walking, they don't need shoes. In fact, supportive shoes like hard-soled Mary Janes may actually get in the way of your child's developing mobility. Socks, booties, and soft-soled baby shoes are useful for warmth, but bare feet are fine, too. In actuality their feet are very adaptable to the ground, whether it is carpeted or wood and tile. And early on it allows their proprioceptive feedback to allow them to balance easier and develop more readily in the very early stages without shoes. 

Once your child takes those first steps, it's time for a pair of real shoes. Unlike "baby shoes," which are more like slippers, first shoes will have a flexible, nonskid sole (probably rubber) and a more substantial upper. Shoes protect kids' feet outdoors and anywhere else that could be hazardous – a splintery surface, for example.

Note: Your child's foot is still developing, so it won't look (or act) like an adult foot. If your child still has a padding of baby fat under the arches, for example, she might appear a bit flat-footed. Or she may have a tendency to turn her toes in when she walks, called in-toeing or toeing in.Indoors (and outdoors on safe surfaces, such as sand), it's still a good idea to let new walkers wear soft baby shoes or socks. Your child can even go barefoot, if it's warm enough. Toddling around with feet bare or lightly covered actually helps little ones build strength and coordination in their legs and feet.
Mention any concerns to your child's doctor. It's easier to correct foot problems when your child is younger.


What to look for when buying
Choose a breathable, lightweight material. Soft leather or cloth is best. Avoid stiff leather shoes, which can hinder foot development, and synthetics, which don't breathe. Bend the soles. They should be flexible and gripping, not smooth and stiff. A nonskid rubber sole with ridges will offer good traction.

Check the fit. Have your child try on the shoes and stand up. There should be just enough room to squeeze your pinky between your child's heel and the heel of the shoe, and a full thumb-width between the end of your child's longest toe and the front of the shoe. The shoe should provide just enough wiggle room without being too big. Because baby feet grow quickly, it's a good idea to check every month to make sure the shoes still fit.
Give it a squeeze. If the shoe is made of soft fabric, try to grab some of the material on the top of the foot when your child is wearing them. If you can't, the shoes might be too tight.
Shop later in the day. Babies' feet swell and are often bigger at the end of the day. Shoes purchased in the morning might feel tight in the evening so usually try shoes on before dinner before you buy.
Look for problem spots. Your baby's shoes shouldn't need any breaking in. Let your child toddle around indoors wearing the shoes, then take them off and look for any irritated areas on your child's foot which could be red areas or blisters, and in more rare cases even a callus formation can occur but this is not common.
Make the choice: laces versus Velcro. Velcro fasteners make it easier to get shoes on and off, and you won't have to worry about retying laces all day. But a child may figure out how to remove his shoes and take them off when you wish he wouldn't! If you choose shoes with laces, make sure they're long enough to tie into double knots, so they won't come undone as often.

Achilles Tendonitis

The Achilles tendon is the thickest and strongest tendon in the human body. This tendon, which runs along the back of the leg and inserts onto the heel, can endure forces of up to 6 to 8 times the body weight during repetitive activities such as running.  Because of the high load of stress it must endure, the Achilles tendon is prone to injury and inflammation. This condition is known as Achilles tendinitis and is a common cause of leg and heel pain in the active individual. 

There are many factors which may contribute to the development of Achilles tendinitis, but it is commonly an overuse injury which results from a sudden change in activity level without proper training or conditioning. Other factors include tight leg muscles, improper shoes, and biomechanical faults within the foot and leg. 

Signs of Achilles tendinitis often begin with swelling and a dull ache or stiffness in the back of the leg and heel that typically occurs at the end of activities. If left untreated, the pain can worsen and become present at the start of activities or even during normal walking. In severe cases, the tendon may even partially or completely rupture. 

Early cases of Achilles tendinitis can be treated conservatively with rest, ice, and gentle stretching. Orthotics and heel lifts may help relieve tension on the tendon. Physical therapy can be initiated to provide additional reduction of inflammation and pain. In some cases, the Achilles tendon may require temporary immobilized within a walking boot. 

Surgery may be necessary for individuals with pain that persists or worsens despite conservative treatments. However, it may be possible to avoid surgery through the use of advanced therapies such as extracorporeal shock wave therapy or platelet gel injections. Once the pain resolves, it is important to have a gradual return to activities to avoid re-aggravating the Achilles tendon. 

Participation in a regular physical activity is an important part of maintaining a healthy lifestyle. Proper shoes, stretching, and strengthening exercises can help prevent injuries. For any foot or ankle pain, a podiatrist should be seen for a full assessment and treatment.

Treatment and Prevention of Blisters



A common complaint athletes have is the formation of blisters on their feet. They arise in areas that are subjected to excessive and repetitive friction. In addition, heat and moisture contribute to blister formation by softening the outer layer of skin. These factors are all present during activities such as running. While blisters typically are a painful nuisance, they may develop into an infection if not properly cared for.

Some blisters will resolve if left alone, but if the blister is painful, it may be drained. Using rubbing alcohol, sterilize a needle and the skin over the blister. Carefully lance the thin, outer layer of the blister and drain the fluid. Apply an antiseptic (iodine or antibiotic ointment) and cover with a bandage. Continue to watch for any signs of infection over the next few days as the blister heals.

If you develop recurrent blisters, you may treat them after they form; however, a better solution is to prevent their formation.

There are numerous products available that can decrease the coefficient of friction. These products (Body Glide, Bag Balm, or petroleum jelly) act as a lubricant when applied to the skin.

If your feet sweat a lot, your skin will soften over time increasing the likelihood of a blister. Foot powders can help absorb excess moisture keeping your skin dry and intact. Spraying your feet with an antiperspirant is another easy option.

The next step in prevention is wearing proper socks which should be made from a synthetic, moisture-wicking fabric. Consider wearing a double-layered sock (WrightSock) as it reduces friction against your skin. If you tend to develop blisters between your toes, a toesock (Injinji) provide extra protection.

And finally, the most common cause of blister formation is improperly fitting shoes. Make sure your shoes fit properly around your heel and that there is plenty of room in the toebox. Shoes that are too long or wide can cause your heel to slide and lead to a heel blister. Shoes that are too short or narrow increase the frictional forces upon your toes.

The best treatment of blisters is pro-active prevention. By following these suggestions, blisters do not have to be a part of your sport or exercise routine.

Time for New Shoes?

You’ve finally found the perfect pair of running shoes. They fit and feel wonderful. You feel as if you can run forever in them, but they are now starting to show some wear. Is it time toss your favorite shoes and get a new pair?


There are several things to consider when deciding if your athletic shoes need to be replaced. First, how much has the shoe been used? For high-impact activities such as basketball or tennis, shoes should be replaced after roughly 60 hours of use. A simple guideline for running shoes is to change them every 300-500 miles, but there are many factors than can shorten or extend the life of a shoe. For example, a petite runner will have less wear than a heavy runner. The type of running surface can also make a difference as a soft trail will result in less wear than a concrete sidewalk.


Next, check for signs of wear on the outsole. Place your shoes on a flat surface and examine them from behind. Excessive wear may cause the shoe to tilt to one side. If the heels are not perpendicular to the ground, the shoes need to be replaced. For most heel-striking runners, a normal wear pattern is on the outside corner of the heel. If one typically runs on a road or track with a cant (cross slope), an asymmetric wear pattern may develop. A significant asymmetry should be evaluated by a podiatrist as it may be caused by an issue that may be improved through the use of a custom orthotic. 

Finally, it is important to know that the cushioning and support of a shoe will eventually wear down, even if the visible exterior remains in good condition. Athletic shoe midsoles are typically made of EVA which is a compressible material that loses its shock absorptive capabilities with prolonged use. Other factors can speed the degradation of EVA such as high heat or UV light. Loss of cushioning can lead to injuries such as stress fractures or shin splints. Another part of the shoe that can wear out is the upper which holds the shoe onto the foot. This supportive portion of the shoe can become over-stretched with use. When this occurs, the foot has more room to move inside the shoe which can lead to injuries and sprains. 

Good shoes are important in all activities as they provide support, stability, and shock absorption. With continued use, the loss of these protective functions can potentially lead to overuse injuries of the foot and leg such as plantar fasciitis, stress fractures, ankle sprains, and shin splints. The decision to replace your shoes depends on several factors, but if your shoes appear worn, it is time for new shoes.

Runner's Knee

Runner's Knee

A new course record was set at the Chicago Marathon last year.  With a time of 2:04:38, Tsegaye Kebede became the first Ethiopian man to win on Chicago’s flat course.  Thousands of first-timers and other runners followed the elite runners this morning.  For these endurance athletes, training is essential to reach the finish line, but overtraining or overpacing can easily lead to injury.  One common running injury is known as runner’s knee (patellofemoral pain syndrome) which is associated with pain behind the kneecap.  It is an overuse injury often seen in runners and cyclists, but it can also be seen in sports which require repetitive jumping or cutting.  While this pain can be cause by a direct impact injury, it is typically caused by repetitive bending of the knee.

 

The major symptom is pain which usually begins as a dull ache or stiffness behind the kneecap (patella).  The patella is attached to the thigh by the quadriceps muscle and tendon and to the leg by the patellar tendon.  Injuries or weakness of these supporting structures can lead to improper alignment and tracking of the patella as the knee  bends and straightens.  This results in irritation and pain.

 

Conservative treatments for patellofemoral pain syndrome begin with reduced training, ice, and anti-inflammatory medication.  Incorporate stretching and strength training of the quadriceps and hamstrings to improve stability around the knee.  In addition to these therapies, custom arch supports (orthotics) may be considered.

 

Recent studies have provided evidence that orthotics reduce patellofemoral pain by improving the tracking of the patella during the bending motion of the knee.  Although orthotics have been generally thought to benefit individuals with excessive collapsing of the arch (over pronation), these studies have shown that people of all foot types have reduction in knee pain with orthotics when compared to flat inserts.

 

Patellofemoral pain syndrome is a degenerative condition that can progressively get worse over time.  Proper training and conditioning can help prevent this and other lower extremity injuries.  Following any injury, the goal of returning to activity as quickly and safely as possible can be achieved with proper evaluation and treatment.  Custom orthotics casted by a podiatrist can be an important addition to the standard treatments for runner's knee.