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Saturday, 28 July 2007

Peroneal Tendon Subluxation















Nadia (not her real name) was sub-elite gymnast when she came with sudden pain and snapping sensation in her right ankle after twisting her ankle during training 3 years ago. She was seen by another physician who diagnosed her condition and was treated conservatively with bracing for 1 month's duration followed by rehabilitation exercises for 8 weeks.

She had the snapping sensation when she stands on her toes ("On toes") and pointing her toes. I asked her to dorsiflex her ankle and evert the foot and her peroneal tendon would slip in front of the bony prominence (see photo). She only had mild pain everting her foot against resistance. As expected, there was a tendency for the opposite peroneal tendon to slip forward too due to increased laxity. Ultrasonography may be useful if we suspect a tendon tear.*

According to Ferran et al, the diagnosis and management plan are based on clinical evidence. Conservative management may be attempted in acute dislocations, and can be successful in up to 50% of patients, although there is a trend for operative management in athletes. Recurrent dislocations should be managed surgically.**

*J Ultrasound Med.2007; 26: 243-246
**Sports Med. 2006;36(10):839-46.

13 comments:

Yu Jin said...

Hi Dr Aston,

Interesting blog. Very good information for those who play a lot of sports but know nothing about injuries. Will surely recommend to my fellow sportsmen.

draston said...

Thanks, Yu Jin. Everyone is welcome to read and get some real life scenario on sports injury and how to manage them.

Anonymous said...

So serious athletes tend to be treated with a surgical remedy?

draston said...

It is not true that serious athletes will always be treated surgically. It depends on the requirements of the sport. We would need to evaluate individually depending on the response to rehabilitation exercises. I would tend to give at least 12 weeks of monitored rehabilitation before deciding on surgery. Usually I would also refer the athlete to the Foot and ankle surgeon for his opinion.

Anonymous said...

Wow! I have had this exact injury. That could be my ankle in the picture. I picked it up jumping and rolling during a Ninjutsu class. At the moment I'm still walking around & going to work (I teach drums) in an "Air Boot" My tendon hasn't subluxed for about 3-4 weeks. Did Nadia return to her gymnastics after this conservative, no operative, treatment? How come this injury isn't more common?

MJ said...

Hi. So I had a surgery to repair my retinaculum because of a subluxing peroneal tendon. The pain had increased over the years to an unmanageable level (my parents thought I was being a baby at the time). The surgery was done at the end of May '07 and I was out of PT and back to playing soccer by the middle of August. Over the past year and a half, there has been mild pain that had been decreasing, even throughout a highschool varsity season (though the post-sugery ankle was taped). Now a year and a half later, I am playing at the D3 college level and experiencing a lot of pain. I've been to the training room and they are trying to rehab it again with me but are still just relying mainly on managing the pain. This leaves me in a lot of pain after playing still. Knowing that you haven't got the hands on knowledge of my case specifically, do you have any suggestions on other steps that I could take? Even to just not be in as much pain?

draston said...

MJ, your best bet would be to discuss with your surgeon and physiotherapist about the nature of your pain, what movement elicits the pain, what time of the day it is worse, what relieves the pain. There are various options available besides popping painkillers. Local injections with Prolotherapy, Hyaluronic acid or corticosteroids could be an option. Before you do anything you need to know what's causing the pain! So talk it out with your doctor.

Anonymous said...

I had this problem, it developed though my twelve years of dancing. I had surgery on the 13 of April and today is the 29, how much longer will I have to use crutches?

Dr Aston Ngai Seng Huey said...

Dear Anonymous,
You'd need to check with your surgeon and physiotherapist. It depends on how you have been progressing in your rehab program.

mazinger234 said...

Hi there, how long did you use crutshes? I had the same operation. Thanks

Dr Aston Ngai Seng Huey said...

She was using a functional walking boot after 6 weeks.

mazinger234 said...

Dr Aston, thanks for your response. I understand tha each individual is different. I had a fhl complete rupture 2 inches away from sesamoids. My surgeon performed surgery reataching both ends of the torn tendon by adding a portion of another tendon taken from the top of my foot. It is going to be 3 weeks since operation. In average, how long would it take to walk with no boot or any other device ? (I understand that in the end it is up to my surgeon). I got a 4 inches cut at the bottom of my foot, and according to my dictor both tips were separated aprox. 1 inche. Right now I am wearing a light cast. Many thanks

Brett said...

I'm 17 and I've noticed I have this problem. I don't really have much pain though. I had an x-ray this week and in the next couple of days I'm going to go to my follow-up. I run track, and our first track meet is at the very last day in march. Will I be ready to run by then(if I don't need surgery that is)? Because I really, really, really have been looking forward to this track season....it's depressing......