0:00

That brings us to the perineal tendons

0:02

where a lot can go wrong.

0:04

Okay? We can see injuries, stress related problems, tears,

0:08

partial or complete,

0:10

and abnormalities related to the sperum.

0:14

I wanted to show you again the course of

0:17

that Peroneous longest tendon that extends in the region of

0:21

that OID groove all the way over

0:23

to the medial aspect of the foot.

0:27

And in fact, that tendon reinforces the lis frank joint.

0:30

It's one of the tendons that does that.

0:33

At that groove, you can get friction.

0:36

So partial tearing enlargement of the groove

0:39

and on the under surface

0:41

of the OID extensive marrow edema may be seen.

0:45

And in this case, teno synovitis as well

0:49

as the tendency extended along the plantar

0:52

aspect of the foot.

0:54

Please remember to look at this plantar region

0:58

of the peroneous longest tendon

1:01

because pathology can occur there.

1:05

Now one of the important syndromes

1:07

that is well known is the Peroneous brevis

1:10

tendon split syndrome.

1:12

So I wanted to show you these photographs showing you here

1:17

a split peroneous brevis tendon

1:19

with a peroneous longest tendon located behind it here,

1:24

the longest has been drawn away.

1:26

To show you that split. Let's make it more obvious.

1:29

That is a split tear.

1:31

A split tear is a full thickness, generally

1:36

collagen sparing tear of attendant.

1:39

And this is the classic location, not the only location,

1:44

but the classic location of a split tear.

1:48

So I wanted to show you

1:49

what these can look like here on a transverse image at the

1:53

level of the fibula.

1:55

Two portions of the brevis split into two pieces.

1:59

No tendon in the middle. This is what it would look like.

2:02

Diagrammatically. Here's an example.

2:04

In a cadaver, there's one part of the brevis.

2:07

Here's the other, no tendon connection.

2:11

This sometimes can be difficult

2:13

because as I already mentioned,

2:15

the brevis tendon normally is flattened in this region,

2:20

but there should be tendon continuity between the medial

2:24

and lateral aspect of the normal tendon.

2:27

You need good resolution images, okay?

2:31

Could sometimes sort out what is normal

2:34

and what represents a partial

2:36

or even split tear in this region.

2:39

Another example shown here as we move from a more proximal

2:44

location, transverse images

2:46

as we move down the arrows showing you the split tear

2:50

of the peroneous brevis with the longest making its way

2:54

and truly between the two pieces of the brevis tendon.

2:59

We can also of course get complete tears

3:02

of the peroneous brevis tendon.

3:05

I show you an example here in three planes.

3:08

This the coronal plane showing you the torn

3:12

and retracted tendon fibers.

3:14

Here the tendon is gap.

3:16

We look at the higher level, we can see the abnormal

3:20

retracted fibers.

3:21

At the level of the gap, we can only see the longest tendon.

3:28

Now the normal position

3:30

of an ossified os perineum is at the level of the calcan

3:35

cuboid joint or slightly distal to it.

3:39

When we have problems with the peroneous longest tendon,

3:42

particularly complete tears that perineum may migrate.

3:48

Here's an example showing you the position of it.

3:51

In February, 2018 here,

3:54

March, 2018,

3:56

and here in June, a fragmented approximately displaced

4:01

or dislocated peroneum.

4:04

There are reports in the literature

4:06

of partial pairs involving the peroneous longest tendon

4:11

where the OS can migrate at least for a shorter distance.

4:16

But when it migrates this far, okay,

4:19

typically you're dealing with a complete tear.

4:22

Here's another example.

4:24

A complete tear of the peroneous longest tendon,

4:28

the case from Eddie Smitherman.

4:29

Now the OS located at the level of the ankle.

4:32

Here was what it looks like in the torn, retracted head.

4:39

I already mentioned once the painful perineum syndrome,

4:43

often called pop syndrome.

4:45

It relates to abnormalities in the region of the O perineum

4:49

between it and the cuboid or it and the calcaneus

4:53

or with both bones.

4:56

A number of things can lead to pops painful

4:59

peroneum syndrome, including fractures as shown here,

5:04

including enlarged, uh, peroneum, uh,

5:08

including nearby tendon pathology.

5:11

And what we look for often is edema within

5:16

the OS shown in this example,

5:20

peroneous longest tendon tears typically occur

5:23

in three locations.

5:24

I've listed them for you here,

5:27

although variations certainly may be seen.

5:29

These tears may be partial or complete.

5:33

The complete ones dominate in the region

5:35

of the cuboid groove.

5:37

Okay, I want to show you this nice example.

5:40

It's an old case, but it was kinda nice one.

5:44

We're looking at transverse images at the level

5:46

of the hind foot here, the peroneous brevis,

5:50

which looks pretty good.

5:52

Here is a full thickness split tear of the peroneus

5:56

Long tendon, maybe even the three pieces as shown here.

6:01

And here's a peroneus cordes accessory muscle

6:04

and tendon attaching to the calcaneus.

6:09

And then I wanted to show you this case.

6:11

Uh, Wilber Wang, uh, one of our previous, uh, fellows, uh,

6:15

show this and others, and an exhibit at the RSNA in 2017.

6:20

Here's that plantar aspect of the Peroneous longest tendon.

6:25

It is thickened, it is partially torn.

6:27

This is a high grade partial tear,

6:30

but a common site for a complete tear is at the level

6:33

of the oid.

6:35

Here you can see that here is the retracted torn

6:40

tendon at this level.

6:41

Here's what it looked like at surgery.

6:45

A complete tear of the peroneous longest tendon at the level

6:49

of the cuboid groove emphasizing,

6:51

you've gotta look at this portion

6:54

of the perineal longest tendon.

6:57

I'm not gonna talk very much about subluxations of tendons.

7:01

I would just show you I think a couple of cases.

7:05

There is a classification system,

7:07

odin's classification system for subluxations

7:10

and dislocations of the perineal tendons, often associated

7:16

with calcaneal fractures, as was the occurrence here.

7:20

This is a small avulsion fracture

7:22

where the superior perineal Retin AUM attaches to the fibula

7:27

with the split tear of the brevis associated with that.

7:32

This sublux slightly in the longest located behind

7:36

this would be a type three reac UL ulcer.

7:40

And as I mentioned earlier in this lecture,

7:43

you can get subluxation involving the tibialis

7:47

posterior tendon.

7:48

It's not a common finding.

7:50

Here's an example of what it would look like.

7:53

It's an abnormal tendon.

7:55

It is displaced medially, and with it, it's stripped

8:00

or torn, the adjacent flexor ret macular.

8:05

And then finally, in this particular slide, I wanted

8:08

to show you one particular tumor

8:11

or tumor like lesion that favors the region of the ankle

8:16

and uh, foot.

8:18

And that is the condition

8:20

of Xan dermatosis typically seen in persons

8:23

with hypocholesterolemia.

8:25

And in those with diabetes, it leads to enlargement

8:29

of a tendon with a regular,

8:31

but mainly low signal intensity,

8:34

simulating tendonosis.

8:37

So in some cases you may read the,

8:40

the findings as tendonosis.

8:42

In this particular example, multiple tendons are involved,

8:46

which will certainly help you.

8:48

Here's what it looked like in the sagittal plane.

8:51

Again, a case from Eddie Mann.