Tendon Subluxation Research Articles

Arthroscopic Evaluation of Subluxation of the Long Head of the Biceps Tendon and Its Relationship with Subscapularis Tears.

BackgroundThe purpose of this study was to evaluate the angle between the long head of the biceps tendon (LHBT) and the glenoid during arthroscopic surgery and its correlation with biceps subluxation on magnetic resonance imaging (MRI). Furthermore, we evaluated the relationship of this angle with subscapularis tears and biceps pathologies.MethodsMRI and arthroscopic images of 270 consecutive patients who had undergone arthroscopic surgery were retrospectively evaluated. On MRI, 60 shoulders with biceps subluxation and 210 shoulders without subluxation were identified. On the arthroscopic view from the posterior portal, the angle between the LHBT and the glenoid (biceps-glenoid angle) was measured. The biceps-glenoid angle, tears of the LHBT, degenerative superior labrum anterior to posterior (SLAP) lesions, and presence of a subscapularis tear were compared according to the presence of biceps subluxation on MRI.ResultsIn the subluxation group, 51 (85%) had a subscapularis tendon tear and all shoulders showed biceps tendon pathologies. In the non-subluxation group, 116 (55.2%) had a subscapularis tendon tear, 125 (60%) had tears in the biceps tendon, and 191 (91%) had degenerative SLAP lesions. The incidences of subscapularis tears (p < 0.001) and biceps pathologies (p < 0.001) showed significant differences. The mean biceps-glenoid angle was 87.0° (standard deviation [SD], 11.4°) in the subluxation group and 90.0° (SD, 9.6°) in the non-subluxation group, showing a statistically significant difference (p = 0.037).ConclusionsShoulders with subluxation of the biceps tendon on the preoperative MRI revealed more pathologies in the subscapularis tendon and biceps tendon during arthroscopy. However, the arthroscopically measured biceps-glenoid angle did not have clinical relevance to the determination of subluxation of the LHBT from the bicipital groove.

A Repair of Sagittal Band for Subluxation of the Extensor Tendons at the Metacarpophalangeal Joint

A Repair of Sagittal Band for Subluxation of the Extensor Tendons at the Metacarpophalangeal Joint

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.

Prevention of Tendon Subluxation in Dequervain’s Tenosynovitis Release Using Retinacular Repair

This study compared the incidence of tendon subluxation in patients of a single surgeon undergoing Dequervain’s release with and without retinacular repair. The study reviewed 31 patients that underwent standard Dequervain’s release without retinacular repair and 49 that underwent Dequervain’s release with retinacular repair. Each subject’s functional status was assessed using the Patient-Rated Wrist/Hand Evaluation. Subjects were compared against age, gender, handedness, tendon subluxation, return to work duration, and surgical laterality. Tendon subluxation is an infrequent complication affecting patients undergoing Dequervain’s release. This complication has a higher incidence in younger females and demonstrates no predilection for hand dominance. The efficacy of retinacular repair is suggested by good Patient-Rated Wrist/Hand Evaluation outcome scores and should be considered as an adjunct to prevent tendon subluxation. This is a level 4 study.

Wrist Pain due to Abnormal Extensor Carpi Ulnaris Tendon.

Pain arising from lesions in the extensor carpi ulnaris (ECU) is known to occur mainly due to tenosynovitis, tendon rupture, and subluxation or dislocation of the ECU tendon [1,2]. However, anomalies of the ECU tendon itself and the surrounding extensor retinaculum are also possible factors contributing to the impairment of function at the dorso-ulnar aspect of the wrist and little finger [2,3]. We report a case in which an abnormal ECU tendon slip was revealed during exploration of the wrist. A 28-year-old right-handed female neurosurgeon visited our clinic due to dorso-ulnar wrist pain in her dominant hand for six months. The pain was exacerbated during wrist motion, especially during forearm supination for handling the needle holders in the operating field. A physical examination revealed no sensory changes and no specific signs, including the Phalen and Finkelstein tests. Radiographic studies also showed no problems such as joint subluxation. The hand showed a slight tender swelling of the ECU tendon around the wrist. With the suspicion of tenosynovitis, steroid injection into the sixth compartment was performed. However, the pain did not respond to medical treatment. Electrodiagnostic studies revealed no abnormalities. On exploration, we found the abnormal insertion of an additional ECU tendon slip into the radial inner side of the sixth compartment (Fig. 1). After simple excision of the entire abnormal ECU tendon slip, her symptoms improved. Fig. 1 The abnormal insertion of an additional extensor carpi ulnaris (ECU) tendon slip into the radial inner side of the sixth compartment. The ECU tendon is enclosed in the sixth compartment of the extensor retinaculum and various anomalies of the ECU tendon have been reported [2,3]. The prevalence of an accessory tendinous slip arising from the ECU tendon has been reported to be 10% to 34% [2,4], and Barfred and Adamsen [3] noted that the accessory tendinous slip of the ECU was sometimes connected with the extensor digiti minimi. Nakashima classified accessory slips into three types according to the insertion point of the main tendon to the fifth metacarpal bone: type A, on the base along with the main tendon; type B, on the midsection; and type C, on the head [2]. The case presented here belonged to type A. The average width of the slips has been reported to range from 1–1.53 mm [2,3], while the presented case showed a slip 1.5 mm in width and 2 cm in length. Taleisnik et al. [5] observed that the transverse fibers of the medial wall of the sixth compartment extend proximally to become confluent with the epimysium of the ECU, and are reinforced by the linea jugata, which normally prevents ECU tendon subluxation during full supination. Since the ECU tendon is exposed to maximal traction when the forearm is supinated, we believe that her wrist pain was induced by repetitive and excessive supination-pronation activity, which might otherwise remain non-symptomatic given usual movement patterns. Anatomical variations of the ECU may affect diagnostic and surgical procedures involving the dorso-ulnar aspect of the wrist. During surgery performed on the ECU, the surgeon must be aware of the possible existence of an accessory tendinous slip that may cause ECU lesions to persist.

A comprehensive approach including a new enlargement technique to prevent complications after De Quervain tendinopathy surgery

The goal of this study was to evaluate the outcome of our surgical approach aimed at preventing complications following surgery for De Quervain tendinopathy. Our stepwise surgical procedure is described in detail. We reviewed 56 cases operated by a senior surgeon over 5years, and re-evaluated them with a minimum 15months’ follow-up. Complications mentioned in the literature (poor wound healing, adhesions, nerve injury, incomplete decompression, tendon subluxation) were not present in any of the cases; the satisfaction rate was very high. Slight residual discomfort was noted in 16 cases. Among them, 13 had an associated pathology. In summary, the outcome after the comprehensive approach presented here is highly predictable. Properly applied, good to excellent results can be expected in most patients. Potential postoperative complications are effectively prevented. Some caution is needed in cases of associated pathologies.

Leg Pain in Swimmer

HISTORY: 20 year old NCAA Div. 3 female swimmer who was recently diagnosed with Hashimoto’s thyroiditis and placed on Levothyroxine 50mcg, about one month prior to presentation with no other significant PMH. She was running on the treadmill when she developed pain over the lateral right ankle. This was her only third time training on a treadmill, she typically does not run. She denied any trauma or falling while on the treadmill. She immediately stopped running, thinking the pain would subside, however it did not. She reported to the athletic trainer at her college. Her monthly menses that had not changed in frequency or intensity. PHYSICAL EXAMINATION: Well developed, well nourished, in NAD, slight limp. Thyroid: slight enlarged, no nodules. Skin: not dry Hair: not falling out CV: RRR, no murmurs, rubs. MSK: demonstrated normal strength, intact gross sensation of the foot and ankle, with TTP over the distal fibula, no deformity, minimal swelling of distal fibular. Her fibular rock test was negative. Her ATFL, CFL, and PTFL were all intact. Distal sensation was intact. Single leg heel raise was painful but could perform. DIFFERENTIAL DIAGNOSIS: 1) Lateral Ankle Sprain 2) Distal Tibia or Fibula occult or pathologic fracture 3) Tarsal Tunnel syndrome 4) Gout/ Pseudogout 5) Peroneal Tendon subluxations vs. tear 6) Degenerative Joint Disease 7) Osteochondral Lesion of Talus 8) Distal Fibular Stress Fracture 9) Popliteal Artery Entrapment 10) Exertional Compartment Syndrome TEST AND RESULTS: X-rays demonstrated a non-displaced transverse fracture of the distal fibula just proximal to level of the mortise. CBC: WNL, Chem 7: WNL. Following labs were ordered: PTH, TSH, estrogen, CBC and vitamin D levels. FINAL WORKING DIAGNOSIS: Non-traumatic Distal Fibular fracture in a swimmer TREATMENT AND OUTCOMES: She was placed in Short leg cast and made non-weight-bearing for 6 weeks. She progressed and did well. Lab work that was ordered was never acquired. She ended up transferring to a college in Colorado. Phone follow up was done. She has returned to swimming without issue. She no longer runs.

Recurrent Anterior Shoulder Pain With Repetitive Work Activity

HISTORY: A 35 year old right hand dominant male presented with a 12 year history of intermittent anterior right shoulder pain with associated popping. He thought his pain started after he tried to catch a door from falling in a forced adduction injury at the age of 23. He stated he felt a shifting in his shoulder multiple times per day while working at a Goodyear Tire Warehouse. He had been seen by a physician 6 years later in which he had a MRI and was told he had tendinitis. At that time, the patient was given anti-inflammatories, steroid injections, and physical therapy. He had difficulty sleeping on his right shoulder and had worsening pain with shoulder extension. He was seen in the emergency department 3 days prior to evaluation for worsening pain after he felt a pop while pulling overhead. He denied numbness, tingling, or neck pain. PHYSICAL EXAMINATION: Physical exam revealed tenderness over the bicipital groove and pain elicited with extension and flexion of the right shoulder. Speed’s and yergason’s test were positive. Hawkin’s and cross arm test were negative. He had normal range of motion. Muscle strength was 5/5 bilaterally. He was neurovascularly intact. No obvious deformity was visualized or palpated. No atrophy or swelling was appreciated. No instability or apprehension noted. DIFFERENTIAL DIAGNOSIS: 1. Rotator cuff injury 2. Labrum tear 3. Bicipital tendon subluxation 4. Mass lesion 5. Impingement syndrome 6. Bursitis 7. Cervical Radiculopathy TEST AND RESULTS: Right shoulder x-ray: 5 x 10 mm osteochondroma emanating from the bicipital groove at the level of the pectoralis major tendon. Right shoulder MRI: Mild subacromial/subdeltoid bursitis FINAL WORKING DIAGNOSIS: Osteochondroma of the bicipital groove TREATMENT AND OUTCOMES: 1. Excision of osteochondroma 2. Physical therapy

Predictive MRI correlates of lesser metatarsophalangeal joint plantar plate tear.

To identify correlated signs on non-enhanced MRI that might improve diagnostic detection of plantar plate (PP) tear. We performed an IRB-approved, HIPAA-compliant retrospective analysis of 100 non-contrast MRI (50 PP tear, 50 controls). All were anonymized, randomized, and reviewed; 20 were duplicated to assess consistency. One musculoskeletal radiologist evaluated qualitative variables. A trained non-physician performed measurements. Consistency and concordance were assessed. Pearson's Chi-square test was used to test the correlation between qualitative findings and PP tear status. Correlation between measurements and PP status was assessed using ttests and Wilcoxon's rank-sum test (p values < 0.05 considered significant). Classification and regression trees were utilized to identify attributes that, taken together, would consistently distinguish PP tear from controls. Quantitative measurements were highly reproducible (concordance 0.88-0.99). Elevated 2nd MT protrusion, lesser MT supination and rotational divergence of >45° between the 1st-2nd MT axis correlated with PP tear. Pericapsular soft tissue thickening correlated most strongly with PP tear, correctly classifying 95% of cases and controls. Excluding pericapsular soft tissue thickening, sequential assessment of 2nd toe enthesitis, 2nd flexor tendon subluxation, and splaying of the second and third toes accurately classified PP status in 92%. Pericapsular soft tissue thickening most strongly correlated with PP tear. For cases in which it might be difficult to distinguish pericapsular fibrosis from neuroma, sequential assessment of 2nd toe enthesitis, flexor tendon subluxation and splaying of the 2nd and 3rd toe is most helpful for optimizing accurate diagnosis of PP tear.

Posteromedial peroneal tendon groove deepening treatment of the chronic subluxation of the peroneal tendons

Objective To investigate the clinical curative result of the new method of postermedial deepen of the fibular groove in the treatment of chronic peroneal tendon subluxation. Methods From March 2006 to October 2012, 21 patients (15 male, 6 female) with chronic peroneal tendon subluxation via a novel method of postermedial deepen of the fibular groove. In this group: I grade 5 cases; II grade 9 cases; III grade 5 cases; IV grade 2 cases. All patients were followed up for at least 24 months. The American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scale score and visual analogue score (VAS) were used to evaluate the clinical outcomes. Operation time, time to heal and complications were also recorded. Results The average operation time was 50 minutes (30-70 minutes). The blood loss was 30-60 ml, average 40 ml. All incisions healed after operation, no case of incision infection, skin necrosis and sural nerve,vascular injuryed. Mean AOFAS score was significantly increased from (55.2±7.1) preoperative to (93.6±5.6) postoperative. 15 patients with excellent, good for 1 cases. The excellent and good rate was 100% (16/16). VAS score by an average of (5.3±2.1) points down to (1.2±1.1) points postperative. All the patients can wear normal shoes postoperative, waking with normal gait. No patients had peroneal tendon tenosynovitis, tendon adhesion, fracture of lateral malleolus and other serious complications, no dislocation recurrent, strength of the peroneal muscle returns to normal. Conclusion The novel method of postermedial deepen of the fibular groove in the treatment of chronic peroneal tendon subluxation was safe and effective for ankle instability with a relatively short time. Key words: Tendinopathy; Clinical protocols; Comparative effectiveness research

Clinico-Radiological Correlation of Subcoracoid Impingement with Reduced Coracohumeral Interval and its Relation to Subscapularis Tears in Indian Patients.

Clinically, subcoracoid impingement is characterized by pain at the anterior aspect of the shoulder that is induced by adduction, internal rotation and forward flexion. This position leads to narrowing of the Coraco-Humeral Interval (CHI)-that is, the space between the coracoid process and the lesser tuberosity of the humerus. Structures in the rotator interval are at greatest risk for impingement which includes the Subscorapularis tendon, tendon of the long head of the biceps, and the middle gleno-humeral ligament. This may result in Rotator interval pathologies such as subscapularis tear and long head of biceps tendon subluxation or fraying. To study the prevalence of radiological evidence of reduced Coraco-Humeral Interval (CHI) in patients with clinically evident Subcoracoid impingement and to examine the presence of Subscapularis tears in these patients. Twenty four patients (6 males, 18 females, average age 52.83 years) were included in this prospective study who were diagnosed to have rotator cuff tears clinically. Nine of these patients were clinically found to have concomitant subcracoid impingement. All patients were subjected to MRI of shoulder. Measurement of the CHI was done in images with humerus in maximal internal rotation. Presence of subscapularis tear was examined intraoperatively. Statistical evaluation of the data was performed using Student's t-test and Fisher's exact test and the results were applied to two cohorts of patients. One cohort consisted of patients who had a CHI value of less than 5.5mm and the other cohort had a CHI value greater than 5.5mm. Average CHI values in patients with and without a subscapularis tear were determined. Nine patients who had clinical subcoracoid impingement were found to have an average CHI of 5.33mm. All nine of them had an associated tear of subscapularis with long head of Biceps tendon subluxation and/or fraying. Remaining 15 patients had an average CHI of 10.48 and they did not have either signs of Subcracoid impingement or subscapularis tear but had a tear elsewhere (Supraspinatus or Infraspinatus). Difference between these two groups was found highly significant (p-value<0.001). All patients with a CHI value of equal to, or less than 5.5mm had a subscapularis tear, whereas only 11% of patients with a CHI value more than 5.5mm had a tear (p-value<0.001, highly significant). Reduction in the CHI has a significant association with rotator interval pathologies such as subscapularis tears and subluxation or fraying of long head of biceps tendon. Treatment of such patients should include modalities such as coracoplasty or anterior shoulder stabilisation. We recommend that clinical evidence of subcoracoid impingement should lead to further Investigation in the form of MRI and estimation of CHI. A CHI of less than 5.5 mm may indicate subscapulais tear in Indian patients.

Relative Contribution of the Subsheath to Extensor Carpi Ulnaris Tendon Stability: Implications for Surgical Reconstruction and Rehabilitation

To identify the varying contributions of the proximal and distal portions of the subsheath of the extensor carpi ulnaris (ECU) to its stability, evaluate the correlation of ulnar groove depth and ECU subluxation, and observe the effect of forearm and wrist positions on ECU stability. Extensor carpi ulnaris tendon position relative to the ulnar groove was measured in 10 human cadaveric specimens with the subsheath intact, partially sectioned (randomized to distal or proximal half), and fully sectioned. Measurements were obtained in 9 positions: forearm supinated, neutral, and pronated and wrist extended, neutral, and flexed. Ulnar groove depth was measured on all specimens. In 7 of 10 specimens with an intact subsheath, the ECU tendon subluxated out of the groove in at least 1 forearm-wrist position. We noted the subluxation of the ECU tendon in all wrist-forearm positions with the exception of pronation-extension in at least 1 specimen. For partial subsheath sectioning, tendon displacement markedly increased after distal subsheath sectioning but not after proximal sectioning. For full subsheath sectioning, wrist flexion produced subluxation in all forearm positions, and forearm supination produced subluxation in all wrist positions. Maximum displacement occurred in supination-flexion. There was no correlation between ulnar groove depth and ECU subluxation. Mild tendon subluxation occurred in the intact specimens in most tested positions. Two positions were remarkable for their consistency in maintaining the tendon within the groove: pronation-neutral and pronation-extension. In fully sectioned specimens, the greatest subluxation occurred in supination-flexion, with supination and flexion independently producing subluxation. Partial sectioning demonstrated that the distal portion of the subsheath played a more important role than the proximal portion in stabilizing the ECU. Subsheath repair or reconstruction should target the distal portion of the subsheath. During postinjury rehabilitation or following surgical reconstruction, combined forearm supination and wrist flexion should be avoided.

Subluxation of the peroneus long tendon in the cuboid tunnel: is it normal or pathologic? An ultrasound and magnetic resonance imaging study.

To evaluate the position of the peroneus longus (PL) tendon relative to the cuboid tuberosity and cuboid tunnel during ankle dorsiflexion and plantarflexion using ultrasound and MRI. The study population included two groups: 20feet of 10 asymptomatic volunteers who underwent prospective dynamic ultrasound and 55 ankles found through retrospective review of routine ankle MRI examinations. The location of the PL tendon at the cuboid tuberosity and cuboid tunnel was designated as completely within the tunnel, indeterminate, or subluxed with respect to ankle dorsiflexion and plantarflexion. On dynamic ultrasound, the PL tendon was perched plantar to the cuboid tuberosity in dorsiflexion, and glided to enter the cuboid tunnel distal to the tuberosity in plantarflexion in all 20feet. On the MRI evaluation, there was a statistically significant difference (p = 0.0006) in the location of the PL tendon between the ankles scanned in dorsiflexion and plantarflexion. Based on our findings on ultrasound and MRI, the PL tendon can glide in and out of the cuboid tunnel along the cuboid tuberosity depending on ankle position. Thus, "subluxation" of the tendon as it curves to enter the cuboid tunnel, which to the best of our knowledge has not yet been described, should be recognized as a normal, position-dependent phenomenon and not be reported as pathology.

Tendinopathies of the Extensor Carpi Ulnaris.

To improve its mechanical advantage, the extensor carpi ulnaris (ECU) muscle uses, as if it was a pulley, the 6(th) extensor compartment, a dorsal fibro-osseous tunnel formed by the ulnar sulcus and the ECU tendon sub-sheath. Rupture or insufficiency of that sheath may allow anteromedial ECU tendon subluxation and subsequent destabilization of the distal radioulnar and ulnocarpal joints. Sometimes, it is not sheath problem, but excessive friction between the sheath and the tendon what causes a painful degeneration of the tendon (tendinosis) with or without tendon entrapment. The term "ECU tendinopathy" has been chosen to designate all painful ECU anomalies resulting from a dysfunctional 6(th) extensor compartment. ECU tendinopathies are frequent among sportsmen using bats, sticks or clubs. There are 2 major types of tendinopathy: 1) constrained tendinopathies, where there is entrapment of a thickened overused tendon, and 2) unconstrained tendinopathies, where a ruptured ECU sub-sheath allows the ECU to sublux in a volar direction, a position precluding all its stabilizing potential. In the first type, the goal of the treatment is to avoid further degeneration and subsequent rupture of the diseased tendon; in the second, to re-establish the normal connections between the ulna and the ECU tendon. This article reviews the management of the most frequent ECU tendinopathies.

Pulley Reconstruction As Part of the Surgical Treatment for de Quervain Disease: Surgical Technique with Medium-Term Results.

Background Simple decompression of the first extensor compartment is commonly used for treating de Quervain disease, with the possible complication of subluxation of the tendons of the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) over the radial styloid. To prevent this painful subluxation of the tendons, several methods of reconstructing the pulley have been proposed. Questions/Purposes The purpose of our study was to evaluate a new technique for reconstructing the first extensor compartment following a release for de Quervain disease. Patients and Methods A retrospective study (mean length 40.4 months) was performed in 45 patients. The outcome assessment involved two different questionnaires and ultrasound evaluation of any tendon subluxation. Results None of the patients required reoperation for tendon instability or incomplete decompression of the first extensor compartment. Two patients experienced clicking around the radial styloid after surgery. This was not related to the amount of volar migration of the tendons. Conclusions We believe the reconstruction proposed here is an effective method of preventing painful subluxation of the APL and EPB following a release of the first extensor compartment.

Closed Sagittal Band Injury of the Metacarpophalangeal Joint.

Although it is an uncommon injury, traumatic rupture of the sagittal band often results in subluxation or dislocation of the extensor digitorum communis tendon. The radial sagittal band prevents ulnar subluxation of the extensor tendon at the metacarpophalangeal joint. Injury may result from a direct blow to the hand or from relatively low-energy mechanisms. Symptoms range from metacarpophalangeal joint pain and edema to dislocation of the extensor tendon. Associated injuries include collateral ligament sprains, capsular injury, and osteochondral fractures. Many acute injuries can be managed nonsurgically with extension splints. Optimal management of subacute or chronic injuries remains undefined. Surgical management consists of repair or reconstruction of the radial sagittal band. Numerous adjunctive surgical techniques have been described to prevent subluxation of the extensor tendon.

Wrist &amp; Hand

The June 2015 Wrist &amp; Hand Roundup360 looks at: Collagenase and Dupuytren’s disease – a genuine alternative to surgery?; iPad PROMise?; Should we learn how to do endoscopic carpal tunnel release?; Two-week radiographs a relic of the past?; Bible? Aspirate or excise?; Patient expectations and trapeziometacarpal osteoarthritis; Splintage in the treatment of sagittal band incompetence and extensor tendon subluxation

Prevalence and Role of a Low-Lying Peroneus Brevis Muscle Belly in Patients With Peroneal Tendon Pathologic Features: A Potential Source of Tendon Subluxation

A peroneus brevis low-lying muscle belly (LLMB) is a rare anomaly. A few published studies have supported the presence of this anomaly as an etiology for a peroneal tendon tear. However, the association between a peroneus brevis LLMB and tendon subluxation has not been well explored. In the present retrospective study, the magnetic resonance imaging (MRI) and intraoperative findings of 50 consecutive patients undergoing primary peroneal tendon surgery during a 5-year period were assessed. The sensitivity and specificity of MRI compared with the intraoperative findings for identifying peroneal tendon disease were investigated. The presence of associated peroneal tendon pathologic features in patients with and without a peroneus brevis LLMB was also compared. The sensitivity of MRI was high for identifying peroneal tenosynovitis (81.58%) and tear (85.71%). Although the sensitivity of MRI for detecting a peroneus brevis LLMB (3.23%) and tendon subluxation (10.00%) was low, MRI had high specificity at 94.74% and 100%, respectively. Intraoperatively, a peroneus brevis LLMB was seen in 62.00% of the patients with chronic lateral ankle pain and was associated with 64.52% of the patients with tenosynovitis, 29.03% of those with tendon subluxation, and 80.65% of those with a peroneus brevis tendon tear. Although the presence of a peroneus brevis LLMB did not show any statistically significant association with peroneus brevis tendon subluxation, of the 10 patients with intraoperatively observed tendon subluxation, 9 had a concomitant peroneus brevis LLMB. More studies with larger patient populations are needed to better investigate the role of a peroneus brevis LLMB as a mass-occupying lesion resulting in peroneal tendon subluxation.

Wrist Pain in a Tennis Player

HISTORY: A 19 year-old male Division I tennis player developed atraumatic left wrist pain, worsening over 2.5 weeks. His pain was located at the ulnar aspect of his wrist and radiated proximally along his forearm. The pain was exacerbated by ulnar deviation during his backhand swing. He initially denied mechanical symptoms, including clicking and snapping, as well denying any numbness and tingling. His pain did not improve with physical therapy over one month, at which time he presented with new onset of clicking at the ulnar aspect of his wrist during ulnar deviation. PHYSICAL EXAMINATION: Initial examination revealed no swelling or deformities. He had no tenderness to palpation. He exhibited full range of motion and strength, equal to the opposite side. Ulnar deviation reproduced pain at the ulnar aspect of the wrist. At his follow up visit, the patient exhibited focal tenderness along the extensor carpi ulnaris tendon and subluxation of the tendon was visualized and palpated during active supination of the forearm. DIFFERENTIAL DIAGNOSIS: 1. Extensor carpi ulnaris tendon subluxation 2. Extensor carpi ulnaris tendinopathy and/or tenosynovitis 3. Extensor carpi ulnaris tendon partial tear 4. Triangular fibrocartilage complex tear TEST AND RESULTS: Left wrist radiographs: - No evidence of fracture or dislocation Left wrist ultrasound (performed prior to development snapping): - Extensor carpi ulnaris tendon intact with normal morphologic appearance, overall normal wrist ultrasound Left wrist MRI (performed prior to development snapping): - Mild extensor carpi ulnaris tendinopathy and peritendonitis, no subluxation FINAL WORKING DIAGNOSIS: Extensor carpi ulnaris subluxation TREATMENT AND OUTCOMES: 1. Due to the development of new subluxation and failed improvement with conservative treatment, the patient elected for surgical intervention of the tendon subluxation following development of mechanical symptoms and considering that he was an in-season athlete. 2. The patient underwent successful surgical reconstruction of the extensor compartment. A sample of soft tissue confirmed chronic tenosynovitis. 3. The patient was casted for three weeks, followed by rehabilitation and return to play 3 months later.

Trends in Ankle Arthroscopy and Its Use in the Management of Pathologic Conditions of the Lateral Ankle in the United States: A National Database Study

This study aimed to investigate current trends in ankle arthroscopy across time, sex, age, and region of the United States as well as the use of ankle arthroscopy in the management of lateral ankle instability. Patients who underwent ankle arthroscopy and those who underwent ankle arthroscopy and lateral ankle ligament repair or peroneal retinacular repair from 2007 through 2011 were identified using the PearlDiver national database. These searches yielded volumes of unique patients, sex and age distribution, and regional volumes of patients. Χ-square linear-by-linear association analysis was used for comparisons, with P < .05 considered significant. We identified 15,366 ankle arthroscopy procedures in the database from 2007 to 2011. Over the 5-year study period, there was a significant increase in the overall number of ankle arthroscopies being performed, from 2,814 in 2007 to 3,314 in 2011 (P< .0001). Female patients had ankle arthroscopy more frequently than did male patients (P= .027). The majority of patients who had ankle arthroscopy were between the ages of 30 and 49 years. The use of ankle arthroscopy during lateral ligament repair procedures increased from 37.2% in 2007 to 43.7% in 2011 (P < .0001). The incidence of combined ankle arthroscopy and peroneal tendon retinacular repair increased 50%, from 2.8/100 ankle arthroscopies in 2007 to 4.2/100 ankle arthroscopies in 2011 (P < .0001). The incidence of ankle arthroscopy increased significantly from 2007 to 2011, outpacing shoulder, knee, and elbow arthroscopy. Ankle arthroscopy was performed more frequently in female patients and most commonly in patients younger than 50 years. The use of ankle arthroscopy in the surgical management of lateral ankle instability also increased significantly. The incidence of concomitant ankle arthroscopy and lateral ligament repair increased significantly, as did the incidence of concomitant ankle arthroscopy and repair of peroneal tendon subluxation. Level IV, therapeutic case series.