Peroneus Tertius Research Articles

Discovery of the anterior fibulocalcaneus muscle: an anomalous leg muscle

A novel muscle, the anterior fibulocalcaneus, has been discovered bilaterally in the anterior compartment of the leg in three separate cadaveric dissections. This muscle originates from the fibula, anterior crural septum, and the investing fascia of the fibularis tertius. Its tendon passes anterior to the lateral malleolus to insert onto the calcaneus, anterosuperior to the fibular trochlea. Anomalous fibulocalcaneal muscles associated with the lateral malleolus have been noted to cause a variety of ankle pathologies, and supernumerary muscles within the talocrural joint have been utilized for surgical reconstructive procedures. Radiologists and clinicians should be aware of this muscle when embarking in diagnosis and imaging interpretation, especially when chronic ankle pain is localized anterior to the lateral malleolus (Lambert and Atsas, 2010).

An anterior fibulocalcaneus muscle: An anomalous muscle discovered in the anterior compartment of the leg

Anomalous fibulocalcaneus muscles were discovered bilaterally in the anterior compartment of the leg during a routine dissection of a 76-year-old Caucasian male in the medical gross anatomy laboratory. These muscles originated from the fibula, anterior crural septum, and the investing fascia of the fibularis tertius, and they passed anterior to the lateral malleolus and inserted on the calcaneus, anterosuperior to the fibular trochlea. To our knowledge, these anterior fibulocalcaneus muscles have not been described previously.

Early Observations of the Effects of Lateral Wedge Orthoses on Lower Limb Muscle Length and Potential for Exacerbating Spasticity

Lateral wedge orthoses are often prescribed to correct varus deformity after stroke. Spasticity is implicated in varus deformity and is caused by velocity-related muscle length changes, so a lateral wedge may affect spasticity by manipulating foot and ankle kinematics which, in turn, may alter the length of these muscles. We sought to test this theory in healthy participants. Eight volunteers walked with no wedge and with lateral wedges of 5 and 8.5 degrees in both shoes. Qualysis motion capture system collected kinematic data and SIMM musculoskeletal modeling software calculated muscle tendon length of plantarflexor and peroneal muscle groups using 3-D ankle and knee joint angle data. The wedges increased ankle eversion (p < 0.0001) and total excursion of tibialis posterior, peroneus longus and brevis by 13-29% (p < 0.05). Muscle length of peroneus longus and brevis increased by <1% (p < 0.005). Potentially clinical meaningful effects were found for tibialis posterior (15%), peroneus brevis (23%) and peroneus tertius (13%). Further research is required to be conclusive and to explore the effects of lateral wedge orthoses in patients with stroke. If such changes are seen in people with stroke, a change in orthotic prescription practice could be indicated as lateral wedge orthoses may exacerbate spasticity.

Accessory muscle belly of peroneus tertius in the leg – a rare anatomical variation with clinical relevance – utility in reconstructions

We report here a rare muscular anomaly of the lower leg in an adult male cadaver observed during routine cadaveric dissection. Peroneus tertius (PT) is peculiar to man, being a hallmark of bipedal locomotion and erect posture. During the course of gross anatomy dissection, a rare finding of accessory belly of PT muscle was discovered. A meticulous dissection was performed and the observations were noted. The PT displayed two distinct bellies of origin. Both the bellies were substantial in size and were eventually fused close to their insertion at the base of the fifth meta-tarsal bone. Innervation of both the bellies was derived from the deep peroneal nerve. Soft tissue defects of the leg may be effectively covered by local muscles in the vicinity of the wounds. PT has been reliably used in the past for local transposition flaps in the lower extremities. The relations of the superficial nerve and the PT during placement of the anterolateral portal in ankle arthroscopy are vital to avoid inadvertent neuromuscular injuries. The presence of two bellies of the PT muscle has been discussed in the comparative perspective. A precise and detailed knowledge of the anatomical details of the crural muscles is important for performing reconstructive surgeries.

The ‘missing piece’ sign: distant migration of a patellar tendon cerclage wire

A 37-year-old man presented with a tender palpable lump medial to his left patella. Two years previously he underwent surgical repair of a patellar tendon rupture including a protecting cerclage wire. He was informed that the wire did not require removal. There was no further history of trauma subsequent to the surgery. He had no other musculoskeletal problems and no past history of relevance. Clinical examination revealed a midline scar over the left knee with a tender palpable wire on the medial side of the patella. There were no other significant clinical findings in the knee. Plain radiographs revealed three wire fragments around the knee (Figure 1). These three fragments did not appear to account for the full circumference of the patellar tendon, raising the concern of a missing piece of wire. A further radiographic survey revealed that the missing wire fragment lay at the anterolateral aspect of the ankle joint (Figures 2 and 3). On surgical exploration, the wire was located between the peroneus tertius and extensor digitorum longus tendons with the tip just proximal to the superior retinaculum. It was assumed to have found its way from the subcutaneous space anterior to the knee into the anterior compartment of the leg and migrated distally to abut the talus.

Electromyographic sensitivity of peroneus tertius relative to abductor hallucis in assessment of peripheral neuropathy

The objective of this study was to compare the sensitivity of needle electromyography of the abductor hallucis and peroneus tertius muscles in the diagnosis of mild length-dependent peripheral neuropathy (PN). Nerve conduction studies and needle examination were performed on 50 patients with clinical evidence of mild PN. Results demonstrated that the peroneus tertius is as sensitive and is more specific than the abductor hallucis. It is particularly useful when more proximal muscles, such as the tibialis anterior and medial gastrocnemius, are not yet involved.

Muscle response to leg lengthening during distraction osteogenesis

Continuous lengthening of intact muscles during distraction osteogenesis leads to an increase of sarcomeres and enhances the regeneration of tendons and blood vessels. A high distraction rate leads to an excessive leg and muscle lengthening and might cause damages of muscle fibers with fibrosis, necrosis, and muscle weakness. Complications like muscle contractures or atrophy after postoperative immobilization emphazize the importance of muscles and their function in the clinical outcome. In an animal model of distraction osteogenesis, 18 sheep were operated with an external fixator followed by 4 days latency, 21 days distraction (1.25 mm per day) and 51 days consolidation. The anatomical location (gastrocnemius, peroneus tertius, and first flexor digitorum longus muscle), dimension and occurrence of muscular defects were characterized histologically. The callus formation and leg axis was monitored by weekly X-rays. Additionally, serum creatine kinase was analyzed during a distraction and consolidation period. Significant signs of muscle lesions in all three observed muscles can be found postoperatively, whereas normal callus formation and regular leg axis was observed radiologically. The peroneus tertius and first flexor digitorum longus muscles were found to have significantly more signs of fibrosis, inflammatory, and necrosis. Creatine kinase showed two peaks: 4 and 39 days postoperative as an indication of muscle damage and regeneration. The study implicates that muscle damages should be considered when a long-distance distraction osteogenesis is planned. The surgeon should consider these muscle responses and individually discuss a two-stage treatment or additional muscle tendon releases to minimize the risk of muscle damages.

Tibialis posterior transfer by interosseous route for the correction of foot drop in leprosy

This article summarises a prospective study to evaluate the long-term results produced by interosseous transfer of the tibialis posterior tendon for the correction of foot drop due to leprosy neuritis. The study was carried out in 120 feet in 69 patients. All patients had closed elongation of the tendo Achillis (ETA) before transfer of the bifurcated tibialis posterior tendon through the interosseous route to the tendons of tibialis anterior and peroneous tertius or brevis over the dorsum of feet. At final follow-up of average 24 months, all the patients with ETA had a significantly greater range of active dorsiflexion of more than 10 degrees above 90 degrees, which was not merely from the tenodesing effect. The results, in terms of improvement in gait and prevention of trophic changes, remained satisfactory. An interosseous route is preferred with split attachment to the tibialis anterior and to the peroneus brevis or tertius tendons.

Tibialis Posterior Tendon Transfer for Persistent Drop Foot after Peroneal Nerve Repair

Despite advances in the surgical treatment of peroneal nerve injuries, a significant fraction of patients do not recover adequately. Among 35 patients who had previous repair of the peroneal nerve, 19 had permanent drop foot, and 16 of these patients underwent tibialis posterior (TP) tendon transfer. Mean duration of paralysis was 26.7 (range, 7 to 192) months. TP tendon was carried to the anterior compartment via the circumtibial route, and then attached to the tibialis anterior, extensor hallucis longus, extensor digitorum communis, and peroneus tertius tendons using tendon-tendon anastomosis. All patients except for one achieved active dorsiflexion to or beyond neutral. Mean preoperative drop foot angle increased from -33.8 degrees to + 9.7 degrees. According to the Stanmore system, the results were excellent in 10 patients (62.5%), good in 4 (25.0%), fair in 1 (6.2%), and poor in 1 (6.2%). The average Stanmore score was 85, which corresponded to an excellent result. We believe that the TP tendon transfer is a straightforward and reliable solution in the treatment of drop foot.

Extramembranous transfer of the tibialis posterior tendon for the correction of drop foot deformity

We evaluated the effectiveness of extramembranous transfer of the tibialis posterior (TP) tendon for the treatment of drop foot deformity. The study included 13 patients (6 females, 7 males; mean age 30 years; range 10 to 46 years) who underwent 15 tendon transfers for drop foot deformity. Ten patients (76.9%) had deformity due to unrepairable nerve injuries, which were associated with surgical procedures in six patients and trauma in the remaining four. In four feet (26.7%), the TP tendon was turned from the intero-anterior aspect of the tibia and fixed by tenodesis to the lateral cuneiform bone, while in 11 feet (73.4%), it was transferred to the extensor hallucis longus, extensor digitorum communis, and peroneus tertius tendons. The patients were assessed according to the Stanmore system questionnaire. The mean follow-up was 25.3 months (range 12 to 80 months). According to the Stanmore system, the results were poor in two feet (13.3%), moderate in three feet (20%), good in three feet, and very good in seven feet (46.7%). All the patients were satisfied with the final outcome. The mean foot dorsiflexion was 5 degrees (range, -5 degrees to 10 degrees ), which was 10 degrees in four feet (26.7%), and 5 degrees to 10 degrees in six feet (40%). Apart from complaints of bulging in four patients (30.8%) in the dorsum of the foot due to tendon and suture material, no complications were seen during the early postoperative period. Extramembranous transfer of the TP tendon for the treatment of drop foot deformity enables the patients to walk without the aid of orthosis and increases their quality of life.

Fibularis tertius: Some true facts

Clinical AnatomyVolume 21, Issue 1 p. 87-87 Letter to the EditorFree Access Fibularis tertius: Some true facts Srijit Das, Corresponding Author Srijit Das [email protected] Lecturer, Department of Anatomy, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, 50300 Kuala Lumpur, MalaysiaDepartment of Anatomy, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, 50300 Kuala Lumpur, MalaysiaSearch for more papers by this author Srijit Das, Corresponding Author Srijit Das [email protected] Lecturer, Department of Anatomy, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, 50300 Kuala Lumpur, MalaysiaDepartment of Anatomy, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, 50300 Kuala Lumpur, MalaysiaSearch for more papers by this author First published: 18 December 2007 https://doi.org/10.1002/ca.20573AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article. REFERENCES Basmajian JH,Slonecker CE. 1989. Grant's Method of Anatomy. A Clinical Problem Solving Approach. 11th Ed. Baltimore: Williams & Wilkins. p 306. Joshi SD,Joshi SS,Athavale SA. 2006. Morphology of peroneus tertius muscle. Clin Anat 19: 611– 614. Rourke K,Dafydd H,Parkin IG. 2007. Fibularis tertius: Revisiting the anatomy. Clin Anat 20: 946– 949. Wood Jones F. 1949. Structure and function as seen in the foot. 2nd Ed. London: Baillire, Tindall and Cox. p 158– 159. Volume21, Issue1January 2008Pages 87-87 ReferencesRelatedInformation

Fibularis tertius: Revisiting the anatomy

Fibularis tertius (FT) may be used during reconstructive surgery and muscle transposition with retention of function. The muscle was examined in both lower limbs of 41 cadavers. Measurements were made of muscle belly length and width, tendon length and width, and the size of the origin on the fibula. Tendon insertion, nerve and blood supplies were also examined. FT was absent in five (6.1%) lower limbs of three (7.3%) subjects. The size of its origin demonstrated inter- and intra-individual variation. FT arose from the distal fibula and on average occupied (28.4 +/- 9.1)% (mean +/- S. D.) of the total shaft length. In all cases the tendon inserted into the dorsal surface of the shafts of both the fourth and fifth metatarsals. A small nerve branch consistently arose from the deep fibular nerve near the origin of extensor digitorum longus. The nerve ran parallel to the length of this muscle, between it and extensor hallucis longus, before piercing FT. Anatomy textbooks describe FT as inserting into the fifth metatarsal only. This study, supported by data from previous reports, suggests that the "textbook" accounts of FT should be updated to record that most commonly its tendon reaches both the fourth and fifth metatarsals.

Changes Induced in Limb Muscles by Distraction Osteogenesis: Histopathology and Histomorphometry of Gastrocnemius and Peroneus Tertius Muscles in Sheep

Distraction osteogenesis induces morphological tissue damage in the muscle envelope of bone. This damage is revesible as long as the frame stiffness, expressed by the transfixing wire stiffness, does not exceed 1000 N.

Peroneus Tertius Muscle as a Cause of Snapping and Ankle Pain

Peroneus Tertius Muscle as a Cause of Snapping and Ankle Pain

Extensor retinaculum syndrome after distal tibial fractures: anatomical basis

Fractures of the distal extremity of the tibia include physeal injuries among teenagers and more complex fractures among adults. Displacement causes the compression of the muscles located between the distal tibia and the superior extensor retinaculum (SER). Among the muscles of anterior compartment of the leg, the extensor hallucis longus (EHL) is particularly vulnerable due to the amount of muscle fibers extending under the SER. Consequently, a partial anterior compartment syndrome could result, affecting only the distal portion located under the SER. In clinical practice, Mubarak measured the intramuscular pressure isolated under the SER and suggested the physio-pathological hypothesis of a compression of distal muscle fibers. The aim of this study is to compare the ratios of anterior compartment muscle fibers extending under the SER. Twenty legs were dissected in order to study how much of these muscles extend under the SER, their passages possibly dividing into two of the SER, as well as their vascularization and their innervation. On the last seven legs, the engagement of the muscles were measured in the spontaneous position and with a dorsal flexion of 0 degrees . The posterior muscle fibers of this compartment always descend lower than the anterior fibers. EHL muscle fibers and those of the inconsistent fibularis tertius always extend under the retinaculum, unlike those of the tibialis anterior and of the extensor digitorum longus. The EHL muscle extends under the SER more than the other muscles. Its posterior fibers are longer when this muscle goes through a dividing into two of the retinaculum. Its vascularization seems lesser, which could explain why this muscle tends to suffer more. The deep fibular nerve innervates the anterior compartment of the leg, yet no nerve branches can be found under the upper edge of the retinaculum. In all cases, the muscle fibers do not extend as much under the SER in a 0 degrees of dorsal flexion. This anatomical study allows us to explain why the EHL is more likely to suffer from this partial compartment syndrome and confirms that when the latter occurs it is necessary, in all cases, to do emergency surgery opening the distal crural fascia and necessarily including the SER.

Foot Pain- Recreational Tennis Player

HISTROTY: 77-year-old female with HTN, OA comes to our clinic for R foot pain, R foot drop and a newly formed lump over the R dorsomedial ankle. Pain began over the dorsomedial ankle 11 months ago while playing tennis, with progressive worsening over the next 6 months. She saw an orthopedic foot specialist who gave her a corticosteroid injection to the area with marked improvement. Four months after the injection, the pain returned, worse than previously. A podiatrist diagnosed her with Anterior Tibialis (AT) tendonitis, administered a steroid injection to the same area previously injected and sent her to PT with no improvement. Soon after, the patient sustained a fall when she tripped on a rug. She then noticed a large soft lump over the dorsomedial ankle and visited our clinic a few days later. PHYSICAL EXAMINATION: No atrophy in both feet. A 3cm x 1 cm soft, mildly tender mass is seen at the R dorsomedial ankle. Full PROM in bilateral feet. Active ADFat R ankle is 10 degrees less than PROM. Motor testing revealed 4/5 R ADF and inversion w/ pain and poor contraction of AT. Otherwise, 5/5 strength for bilateral feet and ankles. Sensation and reflexes intact. DIFFERENTIAL DIAGNOSIS: AT tendon rupture AT strain, tendonitis, tendinosis, tenosynovitis Deltoid ligament injury Ganglion cyst Peroneal neuropathy, plexopathy, L4-5 radiculopathy RA Stress fracture of tarsal or ankle bones Soft tissue tumor TEST AND RESULTS: X-rays of R ankle- unremarkable. MRI of R foot and ankle- severe tendinosis and chronic tenosynovitis of the TA tendon at the ankle and inferior lower leg with no evidence of tendon tear. FINAL WORKING DIAGNOSIS: TA tendon rupture partial vs. complete TA tendonosis / tenosynovitis TREATMENT AND OUTCOMES: Second read by a dedicated musculoskeletal radiologist confirmed TA tendon partial tear. Patient was evaluated by an orthopedic foot surgeon and underwent exploration/ repair. TA tendon rupture at its insertion was found and repaired, with Peroneus Tertius tendon transfer. Patient made NWB for 8 weeks, with crutch ambulation leading to L patellofemoral pain. At 8 months post-op, L knee pain is 0/10. The R ankle is occasionally stiff. She notes numbness over the dorsum of the ankle and decreased ankle AROM. She is able to ambulate long distances with minimal pain and has started to play tennis again.

Bilateral tibial hemimelia I

Congenital absence of tibia is a rare anomaly. We report a case of bilateral tibial hemimelia born to phenotypically normal parents. The two amputated legs with tibial dysplasia obtained from a 3-year-old boy were studied by radiography and anatomical dissection. The radiological evaluation revealed a normal hip joint. The lower end of femur was normal without any bifurcation, shortening or bowing. Fibula was present on both legs and there was no sign of bowing or doubling. Both right and left tibiae were absent. In addition, on the right side, five tarsal bones, two metatarsals and the corresponding digital rays were absent. On the left side, three tarsal bones were absent. Dissection of the amputated segments showed the presence of extensor digitorum longus, peroneus tertius, peroneus longus and brevis, gastrocnemius, and soleus. Following bilateral knee disarticulation the patient was fitted with prosthesis and is doing well.

The Significance of Peroneus Tertius Muscle in Ankle Injuries

Background The peroneus tertius is absent in 5% to 17% of the human white population. The function of the peroneus tertius is eversion and dorsiflexion of the foot. These 2 strength parameters have been identified as important parameters in the development of ankle ligament injuries. Hypothesis Subjects without the peroneus tertius are at higher risk for ankle ligament injuries. Study Design Cohort study (Prevalence); Level of evidence, 1. Methods One hundred physical education students were palpated for the presence of peroneus tertius before the start of their education; they were also isokinetically measured for eversion and dorsiflexion strength. All ankle injuries were registered during 2 years, and exposure to sport was recorded. Results The peroneus tertius was absent in 37 of the 200 subjects (18.5%). In the group with peroneus tertius (n = 163), 21 ankle sprains (12.9%) were observed during the 2-year follow-up. In the group without peroneus tertius (n = 37), 7 ankle sprains (18.9%) were noted. Statistical analysis (Cox regression) showed no significant difference between both groups in the incidence of ankle sprains (P = .335). Comparisons between the group of subjects with peroneus tertius and the group without peroneus tertius concerning the concentric and eccentric isokinetic eversion and the concentric dorsiflexion strength did not attain significance at any tested velocity (P > .05). Conclusion This study shows that subjects without peroneus tertius are not at higher risk for an ankle ligament injury. In addition, subjects without peroneus tertius do not exhibit decreased eversion or dorsiflexion strength. Clinical Relevance This study is the first to clarify the exact contribution of the peroneus tertius within the muscular system around the ankle. As a result, the clinical importance of the peroneus tertius concerning prevention and treatment of ankle ligament injuries is low.

Intratendinous ganglion of peroneus tertius–A case report

Abstract We present a case report of a 48-year-old male with an intratendinous ganglion cyst of the peroneus tertius. He complained of occasional pins and needles on the dorsum of the foot. Surgical exploration revealed a ganglion, completely contained in the expanded peroneus tertius tendon, in front of the lateral malleolus. A few fibres of the tendon were sacrificed for complete excision. The cutaneous branch of the superficial peroneal nerve, which was lying over the ganglion, was preserved. At 6-month follow-up he was completely asymptomatic. Intratendinous ganglion of peroneus tertius can cause impingement on the cutaneous branch of superficial peroneal nerve and cause sensory symptoms. Careful preservation of the nerve with complete excision gives excellent results.

Morphology of peroneus tertius muscle

Peroneus tertius (PT) muscle is peculiar to man, and man is the only member among the primates in whom this muscle occurs. The muscle is variable in its development and attachment. Because of functional demands of bipedal gait and plantigrade foot, part of extensor digitorum brevis (EDB) has migrated upwards into the leg from the dorsum of foot. PT is a muscle that evolution is rendering more important. In a total of 110 cadavers, extensor compartment of leg and dorsum of foot were dissected in both the lower limbs and extensor digitorum longus (EDL), and PT muscles were dissected and displayed. PT was found to be absent in 10.5% limbs, the incidence being greater on the right side. The remaining limbs in which the PT muscle was present had a very extensive origin from lower 3/4th of extensor surface of fibula (20% on right and in 17% on left), and the EDL was very much reduced in size. In approximately 12%, the tendon of PT was thick or even thicker than the tendon of EDL. In 4%, the tendon extended beyond fifth metatarsal up to metatarsophalangeal joint of fifth toe, and in 1.5%, it extended up to the proximal phalanx of little toe. In two cases (both on the right side), where PT was absent, it was replaced by a slip from lateral margin of EDL. We conclude that PT, which is preeminently human, is extending its purchase both proximally and distally.