Professional Soccer Athlete With A Tender Ankle Nodule - Page #4

Working Diagnosis:
Ankle sprain.

The athlete was initially treated with a lace-up ankle brace, non-steroidal anti-inflammatory medications, RICE protocol, and physical therapy for two weeks.

After the above treatment, pain was significantly improved, eversion strength returned to 5/5 on the right ankle, and he was able to return to play in two weeks.

At three weeks follow-up, he was complaining of persistent lateral ankle pain. On this exam, a tender nodule was palpated at the inferior aspect of the right lateral malleolus, which was not palpated on initial exam. The rest of the exam was unremarkable. At this point, magnetic resonance imaging of the right lower extremity was done, which showed a full-thickness tear of the peroneus longus tendon with retraction to the level of the calcaneus. Case Photo #1 Coronal view posterior to anterior showing complete tear of the peroneus longus tendon. Case Photo #2 Axial view superior to inferior showing intact insertion of the peroneus longus tendon. Case Photo #3 Sagittal view lateral to medial showing complete tear of the peroneus longus tendon. Despite the athlete’s significant tendon injury, it was not impairing his ability to compete at the professional level, and a plan was made to consider surgical correction once the season was over. The athlete continued with the above conservative management. After the season ended, the patient underwent a peroneus longus to brevis tendon transfer, and is now playing again professionally.

Author's Comments:
Patients presenting with ankle pain rarely have involvement of the peroneus longus as the etiology. Peroneus longus tendon injuries can present as incomplete longitudinal, partial, or as a complete transverse tear (Clarke et al. 1998). Acute injury to this tendon usually occurs after significant ankle inversion, tendon subluxation, or fracture of the os peroneum (Bassett et al., 1993, Truong et al., 1995). Quick diagnosis and treatment is key for good patient outcomes and satisfaction (Arbab et al. 2014). Surgical management is the standard of treatment, and has shown to be successful with predictable outcomes. A delay in diagnosis and treatment of a peroneal tendon rupture can be complicated by recurrent ankle sprains and instability (Wind et al., 2001). Our case highlights the importance of a good physical exam, which subsequently lead to appropriate imaging, diagnosis, and treatment of a peroneus longus tendon rupture.

Editor's Comments:
Peroneal brevis is more common than Peroneal longus.

The peroneus longus functions as the primary evertor of the foot, first metatarsal plantarflexor, and secondary ankle plantarflexor.

A common causes of tears of the longus tendon is associated with a varus deformity of the heel or a cavovarus foot deformity

terrific review article:
Cerrato R, Myerson M. Peroneal Tendon Tears, Surgical Management and Its Complications. Foot and Ankle Clinics, 2009-06-01, Volume 14, Issue 2, Pages 299-312

Arbab, D., Tingart, M., Frank, D., Abbara-Czardybon, M., Waizy, H., & Wingenfeld, C. (2014). Treatment of Isolated Peroneus Longus Tears and a Review of Literature. Foot and Ankle Specialist, 7, 113-118.

Bassett, F.H. 3rd, & Speer, K.P. (1993). Longitudinal rupture of the peroneal tendons. American Journal of Sports Medicine, 21, 354-357.

Clarke, H., Kitaoka, H., & Ehman, R. (1998). Peroneal tendon injuries. Foot & Ankle International, 19, 280-288.

Truong, D.T., Dussault, R.G., & Kaplan, P.A. (1995). Fracture of the osperoneum and rupture of the os peroneus longus tendon as a complication of diabetic neuropathy. Skeletal Radiology, 24, 626-628.

Wind, W.M., & Rohrbacher, B.J. (2001). Peroneus Longus and Brevis Rupture in a Collegiate Athlete. Foot & Ankle International, 22, 140-143.

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