0:01

The history we have on this one is a 62 year old with pain and swelling

0:06

at the peroneals for about a year. What we can see here,

0:11

okay, at the, uh, lateral aspect of the ankle, okay?

0:15

We have, uh, some, uh, robust, uh,

0:19

tens synovial fluid and, um,

0:23

debris or teno synovial debris within the perineal tendon sheets,

0:27

and obviously abnormal, uh, peroneal tendons. Okay? Um,

0:32

they're, they are large, okay? They're tendon and thus tendon,

0:36

and we can also appreciate that they're also both, uh, uh,

0:41

likely partially torrance, uh, more so probably the brevis,

0:45

as we can appreciate that. That's more, uh,

0:47

the signal change is closer to fluid signal. Okay? Now,

0:51

this is just a run of the mill, uh, run of the mill, uh,

0:54

peroneal tendinopathy and with some tearing, okay? And, but, uh,

0:59

what I wanna highlight with this case is when you read peroneal tendon tears,

1:04

uh, you want to try to mention, uh, the length of the tear and, uh,

1:08

where it begins, okay? So in this case, I would, I,

1:12

I would likely read this case as, uh, pros,

1:14

brevis tendinosis with a longitudinal split tear beginning at the level

1:19

of the lateral retro ular groove and extending for, um,

1:25

such and such, uh, you know, a few centimeters, uh, segment length,

1:30

okay.

1:30

With reconstitution at approximately the level of the tarsal sinus or canal

1:35

here. Okay? And obviously I would do the same thing with the, uh, the, uh,

1:39

pros longus, um, as in this case, um, here. Also,

1:44

we can appreciate that, uh,

1:45

there's some reactive marrow edema along the lateral aspect of the calcaneus,

1:50

okay? Some other pertinent, uh,

1:53

findings to look for when you're dealing with perineal tendon pathology,

1:56

and particularly the revis, okay? You wanna look for, um, uh,

2:01

a Perus Cortes muscle, okay? Which happens, or, uh,

2:06

depending on who you read, okay? But,

2:08

but you should be calling a Peroneus Cortes in about a quarter,

2:11

about 25% of your ankle MRIs, okay?

2:15

Because what can happen there is that crowds the other perineal tendons

2:21

and is thought to, uh, with this crowding, predisposed to, uh,

2:25

perineal tendon pathology. Okay? Another thing that I also like to look for,

2:30

okay? Is a potentially prominent perineal tubercle.

2:33

And the next question I usually get is, well, what's prominent? Um, so the,

2:38

A group out of Mass General, okay? Uh,

2:41

put out a nice article in the skeletal radiology, and typically, um,

2:45

the perineal tubercle, which is this thing, this little bump right here, okay?

2:51

Okay. Is basically a, uh,

2:53

focal osseous prominence at the lateral aspect of the dec calcaneus, which,

2:59

Um, uh,

3:01

allows for gliding of the brevis superiorly and the longest

3:07

inferiorly, okay? But when this tubercle is, is prominent, and,

3:11

and the article states that about six or seven millimeters, okay,

3:16

in the transverse dimension, that can predispose to perineal tendon pathology,

3:21

okay? So I will at least eyeball this region, and if there's a,

3:25

a large perineal tubercle,

3:26

and sometimes you can even see it on radiographs on a, on an AP of a radiograph.

3:32

Um, and I will, I will mention that and, and, uh, you know, ask, uh,

3:37

for correlation for possible peroneal tendon pathology. Um,

3:41

so those are some things to that I, uh, uh,

3:44

try to mention or think about at least when I'm, and when I'm reading, um,

3:48

perineal tendon pathology. And obviously, um, this is, uh,

3:52

on the differential for diagnosis for lateral ankle pain.

3:56

So once you've cleared, uh, the lateral ankle tendons, uh,

4:01

or sorry, ligaments, sorry, misspoken, uh, the low lateral, uh,

4:05

ankle ligaments particularly, uh, the next thing you wanna look at, uh,

4:08

laterally is obviously the perineal tendons. Um, and, um, this can,

4:13

uh, these perineal tendon tears can happen acutely or, um, with,

4:18

uh, over time with a sort of degener sort of phenomenon, right?

4:22

The other thing you wanna also look for is, uh,

4:25

an intact superior perineal retin aum, okay? If it's torn or,

4:30

um, too lax or what have you, prior injury,

4:33

sometimes there's a fleck of bone at its attachment. And there's also, uh,

4:37

for those that are interested in Odin classification for superior, uh,

4:41

peroneal reac injuries, um, that is, uh, spelled ODIN, um,

4:47

uh, that, uh, you know, if you have a deficient, uh, uh,

4:52

superior peroneal retin aum,

4:53

that can predispose also to peroneal tendon pathology.

4:56

But the one I'd probably wanna highlight,

4:58

especially for those that read ankle radiographs or cover, uh, traumas or eds,

5:04

you want to, uh,

5:05

pay specific attention for on your radiographs for an odin type three,

5:09

which is basically what you'll see is a,

5:11

about a one centimeter longitudinally oriented fleck of bone, typically, uh,

5:16

along the lateral malleolus. And that can be a sign of, uh, the,

5:21

an avulsion of the SPR at its attachment, at the, uh, uh,

5:26

lateral malloc or lateral aspect of the distal fibula. And as you can imagine,

5:30

that can predispose to, uh, ankle instability, that is subluxation, uh,

5:35

perineal tendon subluxation or dislocation,

5:37

which can be confirmed with mr or better yet,

5:41

dynamic ultrasound if you're doing, 'cause, um, you know, as, as we know,

5:46

uh, MRI, if, if you're not doing dynamic imaging with MRI, the, you know,

5:51

you're just getting static images, but you may not,

5:54

the peroneal tendons may be normally located on your static images on an MRI.

5:59

So just some things to think about, and I think that's all I got. Uh,

6:03

regarding peroneal tendon pathology.