Longitudinal Split Tear Research Articles

Comparison of Preoperative MRI With Intraoperative Findings for Peroneal Tendon Pathologies

Magnetic resonance imaging (MRI) is commonly used to evaluate soft tissue pathology of the foot and ankle. Prior investigations have reported limitations of this modality, however, in evaluation of pathologies related to the peroneal tendons. This article investigates the correlation of pre-operative MRI studies with intraoperative findings. Five board-certified radiologists interpreted MRIs of 80 ankles that subsequently underwent surgical procedures performed by one board-certified foot and ankle surgeon, after which comparison was made between their findings. Statistically significant disagreement was found between radiologist and surgeon findings of a normal peroneus brevis (PB), PB and peroneus longus (PL) tendinosis, PB and PL hypertrophy, PB and PL partial linear tears, PB and PL flattening, PB longitudinal split tears, and the PB attritional spectrum (combined analysis of flattening, partial linear tearing, and longitudinal split tears). These results suggest that given the disconcordance between MRI and intraoperative findings, surgeons should remain cautious in their reliance upon this imaging modality when evaluating this anatomic region.

Successful reconstruction of distal peroneus longus tendon dislocation associated with a split lesion \u2013 a case report

BackgroundPeroneal tendon injuries are one of the differential diagnoses in lateral ankle and rearfoot pain. While partial tears are not uncommon, peroneal tendon dislocation at the peroneal tubercle is very rare. Until now, only three papers have been published, presenting five cases of peroneus longus tendon dislocation over the peroneal tubercle. This report adds a previously undescribed case of a peroneus longus tendon split tear that was partially dislocated and entrapped over the peroneal tubercle. The respective operative approach and the outcome are described.Case presentationA 25-year-old international top-level speed skater developed a painful mass over the lateral calcaneal wall. There was no specific inducing injury in his medical history. In contrast to previous reports, according to the patient’s history, a snapping phenomenon was not present. Conservative treatment was not effective. By inspection and palpation an enlarged peroneal tubercle was assumed. During operative exploration, we found an incomplete longitudinal split tear of the peroneus longus tendon, which was partially dislocated and entrapped over the peroneal tubercle. This mimicked an enlarged peroneal tubercle. A portion of the split tendon was resected. A deepening procedure of the flat groove of the peroneus longus tendon below the peroneal tubercle and a transosseous reconstruction of the avulsed inferior peroneal retinaculum were performed. After six months, the patient had completely reintegrated into his elite sport and has been free of symptoms since then.ConclusionsFrom the presented case it can be speculated that the inferior peroneal retinaculum was overused, worn out, detached, or ruptured due to overpronation and friction the lateral edge of the low-cut speed skating shoe. Then the peroneus longus tendon experienced substantial friction with the peroneal tubercle with possible dislocation during ankle motion. This frictional contact may have finally led to further degeneration and a longitudinal tear of the tendon. Obviously, dislocations can develop insidiously resulting in lesions of the peroneus longus tendon at the peroneal tubercle, ultimately leading to a tendon entrapment. This mimics an enlarged tubercle. The pathology is very rare and can be successfully addressed surgically.

Impact of the T2-weighted axial oblique MRI sequence in the assessment of peroneal tendons

To define the role of the T2-weighted axial oblique sequence for the magnetic resonance imaging (MRI) assessment of peroneal tendon pathologies. Two radiologists interpreted 180 ankle MRI examinations using standard sequences alone and then in combination with an axial oblique sequence. The readers indicated how likely a peroneal pathology was present using a five-level confidence scale. Diagnostic confidence, interobserver agreement, and clinical correlation were compared. Changes in diagnosis were recorded. For both readers, the diagnostic confidence was significantly higher using the axial oblique sequence for tendinosis and inframalleolar tenosynovitis for both tendons and for peroneus brevis partial and longitudinal split tears (p<0.001). For reader 1, the diagnostic confidence was also higher using the axial oblique sequence for peroneus longus partial tears (p=0.007). Changes in diagnosis were seen for tendinosis and tenosynovitis of both tendons and for peroneus brevis partial and longitudinal split tears in 0.6-10.8% of cases. Inter-rater reliability was significantly higher with the axial oblique sequence for the diagnosis of tendinosis, inframalleolar tenosynovitis, and partial tear for both tendons, and for peroneus brevis longitudinal split tear. Amongst 105 examinations with clinical information, peroneal pathologies were most frequently diagnosed as present in cases with lateral symptoms (17% versus 14%) and absent in cases without lateral symptoms (92% versus 86%) on the axial oblique sequence. The axial oblique sequence for the assessment of peroneal tendons allows for higher diagnostic confidence, inter-rater reliability, and clinical correlation and can lead to changes in diagnosis.

Intrasheath Instability of the Peroneal Tendons: Dynamic Ultrasound Imaging.

Peroneal intrasheath instability is a painful snapping condition of the lateral ankle. It consists of a transient retromalleolar subluxation of the peroneal tendons without disruption of the superior peroneal retinaculum or evidence of a previous definite trauma. In type A intrasheath instability, the peroneus longus and brevis tendons are intact, and there is an intertendinous intrasheath switch. In type B intrasheath instability, the peroneus brevis tendon has a longitudinal split tear through which the peroneus longus subluxates. Both types can be missed on a physical examination because there is no displacement of the peroneal tendons over the lateral malleolus. Dynamic ultrasound is the imaging modality of choice for evaluating retromalleolar subluxation of the peroneal tendons. This review article aims to provide an overview of the anatomic basis for peroneal intrasheath instability and provide physicians with guidelines for its ultrasound assessment.

A Proximal Fibularis Brevis Muscle Is Associated with Longitudinal Split Tendons: A Cadaveric Study

The anomalous distal musculotendinous junction of the fibularis brevis muscle has been hypothesized to contribute to the development of longitudinal fibularis brevis tendon tears. Specifically, the mass effect of the low-lying fibularis brevis muscle belly was thought to increase the pressure on the superior peroneal retinaculum and increase the probability of fibularis brevis tendon subluxation. A more recent examination of the fibularis brevis tendon junction found, contrary to this hypothesis, a statistically significant association between an anomalous proximal musculotendinous junction and the prevalence of longitudinal split tears. However, no rationale was offered. The present study examined the relationship between the musculotendinous junction and the prevalence of longitudinal fibularis brevis tendon tears. A total of 24 fibularis brevis tendon lengths were measured bilaterally in 12 human cadaveric specimens. The tendon lengths were assessed as the vertical distance from the most inferior aspect of the lateral malleolus to the most distal fibularis brevis musculotendinous extension. Only full-thickness tears were identified and included. The lengths of tendons with and without longitudinal tears were compared. Of the 24 tendons examined, 7 (29%) presented with full-thickness longitudinal tears from 4 cadavers (33%). The mean length for the tendons with tears was significantly longer (p < .001) than the mean length of those without tears (28.86 ± 3.02 mm versus 16.29 ± 7.30 mm). Our research concurs with the most recent findings, identifying a statistically significant association between an anomalous proximal muscle belly extension and longitudinal fibularis brevis tendon tears. Furthermore, we propose the hypothesis that a more proximal musculotendinous junction might predispose individuals to a lesser stabilizing effect of the muscle against the posterior lateral surface of the fibula, increasing the probability of anterolateral subluxation, attrition, and longitudinal tear development.

Longitudinal Split Tears of the Ulnotriquetral Ligament

A tear of the ulnotriquetral (UT) ligament can be a troubling source of pain for the athlete, especially those participating in racquet and batting sports. The UT ligament originates from the TFCC and ulnar styloid and is typically injured when an axial load is applied to an extended wrist with forearm supination. The diagnosis is based on physical exam, specifically the ulnar fovea sign. The stability of the distal radioulnar joint (DRUJ) differentiates a longitudinal split tear of the UT ligament from a TFCC foveal tear. The utility of radiographic imaging is primarily to rule out other causes of ulnar-sided wrist pain. Once a UT ligament tear has been suspected by history and examination, the diagnosis can be confirmed arthroscopically, and one or two sutures are typically sufficient for repair. Arthroscopic repair leads to excellent results with return to full athletic participation.

Treatment of rotator cuff intrasubstance tears with autologous blood injections; a novel treatment using ultrasound guidance

Purpose Assessment of sonographic guided autologous blood injections (ABI) as an effective minimally invasive treatment for rotator cuff interstitial delamination tears which are problematic to treat and difficult to diagnose by arthroscopy. Methods and materials Forty-two patients with clinical suspicion of rotator cuff tear underwent magnetic resonance imaging (MRI). Confirmed cases of supraspinatus longitudinal split tear were prospectively enrolled in the study and had ultrasound (US) assessment to characterise echotexture, interstitial tearing and neovascularity. Individuals randomised into two groups; first group (21 patients, age 18–45) received standard treatment with 3 millilitres (ml) Bupivacaine and 40 milligrams (mg) triamcinolone into the subacromial-subdeltoid (SASD) bursa. The second group (21 patients, age 19–50) received standard therapy and ABI into the site of fibrillar discontinuity. We performed two injections and sonographically monitored any tendon changes. Pain scores and functional improvement assessed with Oxford Shoulder Score (OSS). Results Pre-procedural, ten days, six weeks, three, 12 and 18 month post-procedure OSS were compared. Changes in echogenicity, neovascularity and interstitial tear size noted. Patients in the ABI group showed statistical and clinical long-term pain relief and functional improvement as assessed by the overall OSS. Conclusion ABI appears to be a viable alternative and more clinically effective when compared to standard steroid injection therapy for rotator cuff delamination tearing. Assessment of sonographic guided autologous blood injections (ABI) as an effective minimally invasive treatment for rotator cuff interstitial delamination tears which are problematic to treat and difficult to diagnose by arthroscopy. Forty-two patients with clinical suspicion of rotator cuff tear underwent magnetic resonance imaging (MRI). Confirmed cases of supraspinatus longitudinal split tear were prospectively enrolled in the study and had ultrasound (US) assessment to characterise echotexture, interstitial tearing and neovascularity. Individuals randomised into two groups; first group (21 patients, age 18–45) received standard treatment with 3 millilitres (ml) Bupivacaine and 40 milligrams (mg) triamcinolone into the subacromial-subdeltoid (SASD) bursa. The second group (21 patients, age 19–50) received standard therapy and ABI into the site of fibrillar discontinuity. We performed two injections and sonographically monitored any tendon changes. Pain scores and functional improvement assessed with Oxford Shoulder Score (OSS). Pre-procedural, ten days, six weeks, three, 12 and 18 month post-procedure OSS were compared. Changes in echogenicity, neovascularity and interstitial tear size noted. Patients in the ABI group showed statistical and clinical long-term pain relief and functional improvement as assessed by the overall OSS. ABI appears to be a viable alternative and more clinically effective when compared to standard steroid injection therapy for rotator cuff delamination tearing.

Sonography of the accessory head of the biceps brachii.

Anatomic variations in the anterior aspect of the shoulder, such as an accessory head of the biceps brachii muscle, are not uncommon. The magnetic resonance imaging and arthroscopic appearance of the accessory head of the biceps brachii has been recently described. This series demonstrates the sonographic appearance of the accessory head of the biceps brachii in the bicipital groove. It is an asymptomatic, flat, echogenic structure with average measurements of 7.7 × 1.2 mm in cross section. Knowledge of this anatomic variant can avoid the misdiagnosis of a longitudinal split tear and improve the accuracy of sonography.

Utility of Magnetic Resonance Imaging for Detection of Longitudinal Split Tear of the Ulnotriquetral Ligament

Wrist magnetic resonance imaging (MRI) has established utility in the diagnosis of wrist ligament tears, including complete tears of the ulnotriquetral ligament (UTL) and other components of the triangular fibrocartilage complex. A new type of longitudinal split tear of the UTL has recently been described with no imaging correlate. Our aims were to describe putative MRI findings associated with longitudinal UTL split tears and to assess diagnostic accuracy. We randomly selected 40 patients with arthroscopically proven longitudinal UTL split tears and 20 patients with intact UTLs, all of whom had preoperative 3 T MRI of the same wrist performed, from a list of operative notes spanning from January 1997 through October 2011, filtered with the terms "ulnotriquetral ligament" and "ulnar triquetral ligament." Two musculoskeletal radiologists who were blinded to surgical results and clinical information independently reviewed the exams. They recorded the degree of certainty of whether a longitudinal UTL split tear was present and whether several other hypothesized associated abnormalities were present. Overall sensitivity for definitive longitudinal UTL split tear detection on MRI was 58% for reader 1 and 30% for reader 2. Specificity was 60% for both. There were no statistically significant discriminatory findings. Among a selected group of patients who all had wrist arthroscopy, preoperative noncontrast 3 T wrist MRI had poor sensitivity and specificity for detection of the longitudinal split type of UTL tear. To date, MRI may be more helpful to exclude potential alternative diagnoses in the patient with ulnar wrist pain.

Postsurgical Imaging of the Peroneal Tendons

Peroneal tendon problems are most often related to two pathologies: dislocation or subluxation at the superior peroneal retinaculum and longitudinal split tears of the tendons themselves. The interpretation of postsurgical imaging is enhanced by understanding the surgical procedures performed to treat these. Imaging of the peroneal tendons is best done with combined anatomical and fluid-sensitive sequences, and it is especially improved by images done in a para-axial plane to accommodate the sharp curve in the tendons at the lateral malleolus. Use of a reduced field of view enhances spatial resolution.

Operative Management of Distal Tibialis Anterior Tendinopathy

The results of operative management for distal tibialis anterior tendinopathy (DTAT) without rupture have not previously been described in the literature. We present the results of 12 operative procedures. Of 40 patients diagnosed clinically and radiographically with DTAT, we reviewed 11 patients who underwent surgery for failure of nonoperative management. Assessment included pre and postoperative AOFAS midfoot scores, clinical examination and postoperative VAS pain scoring, at a mean followup of 29 months. Ten women (ten feet) and one man (2 feet) underwent surgery. The mean age at surgery was 59 years. The mean duration of symptoms prior to surgery was 1 year. The mean preoperative AOFAS score was 52. Preoperative MRI showed tendinosis in two tendons and tendinosis with longitudinal split tears in ten tendons. Six of the twelve cases showed some associated degenerative changes of the midfoot. Six tendons were simply debrided and the insertion reinforced with a suture anchor. Six tendons were augmented with an extensor hallucis longus (EHL) transfer into the medial cuneiform. All patients improved postoperatively, with a mean improvement in AOFAS score of 33 and the mean postoperative pain VAS of 0.9 out of 10. Two patients underwent concomitant procedures on the same foot. Three of the six treated with EHL transfer have some symptomatic hallux interphalangeal joint extensor lag. In six cases the patient was completely satisfied. Three were satisfied with minor reservations. Of the three that were dissatisfied, two underwent subsequent surgery improving their symptoms. The third, though pain-free, was troubled by her toe-catching when walking barefoot. No patient regretted having had the surgery. Debridement and repair of DTAT, with EHL augmentation for greater than 50% tendon involvement, provided a high level of patient satisfaction after nonoperative management failed in this series.

Distal Tendinosis of the Tibialis Anterior Tendon

Disorders of the tibialis anterior (TA) tendon have infrequently been reported but spontaneous rupture of this tendon is well recognized. The clinical presentation of tendinosis without rupture of the distal TA has not previously been reported and is the basis of this paper. A study of 29 patients diagnosed with distal TA tendinosis was undertaken. Data collected included, patient demographics, weight, height, pain profile and examination findings. All patients underwent MRI of the symptomatic foot. Operative findings of those patients undergoing surgery for this condition were collected. Twenty-nine patients (32 feet) were included in the study group. Their mean age was 62 years and 27 patients were female. Twenty-one patients were overweight. The usual presenting symptom was burning medial midfoot pain that was often reported to be worst at night. Swelling over the TA tendon was frequently observed. On MRI the TA was thickened in all patients. Longitudinal split tears were observed in 19 feet. Chondral thinning and/or osteophyte formation at the first tarsometatarsal or medial naviculocuneiform joints was observed in 11 feet. Eleven feet underwent surgery. Universally the TA tendon was macroscopically thickened and had lost its normal fibrillary appearance. Longitudinal split tears were observed in eight tendons. Pathology was typical of a degenerative tendinosis. Distal TA tendinosis is a condition that seems to predominantly affect overweight elderly women. It often presents with nocturnal burning medial midfoot pain.

Partial Rupture of the Flexor Hallucis Longus Tendon in a Tennis Player: A Case Report

A 39-year-old woman sustained a forced dorsiflexion injury to the left great toe while pivoting to the right during tennis activity. Posteromedial ankle pain was reproduced with active plantarflexion and passive dorsiflexion of the great toe and, to a smaller extent, the lesser toes. Symptoms persisted for 9 months despite nonoperative treatment. Magnetic resonance imaging 5 months after injury revealed evidence of fluid surrounding the flexor hallucis longus (FHL) tendon. Operative findings 9 months after injury included scar tissue and tenosynovitis of the FHL and flexor digitorum longus tendon sheaths, with impingement of distal FHL muscle fibers and a longitudinal split tear (partial rupture) of the FHL tendon. Tenolysis, tenosynovectomy, excision of the distal muscle fibers, and repair of the partial tendon rupture were performed, resulting in resolution of symptoms. Partial rupture of the FHL tendon as a single-impact injury, or in activity other than ballet, has not been documented previously.