Is There A Role For Tendoscopy In Treating Peroneal Pathology?

First described in 1998, peroneal tendoscopy has a number of indications including retrofibular pain, tenosynovitis, subluxation or dislocation, intrasheath subluxation, partial tears, impingement of a peroneus quartus tendon or a low lying muscle belly.^1,2 Tendoscopy of the peroneal tendons allows for less soft tissue dissection of the peroneal tendon. This could lead to less adhesions and scar tissue, possibly resulting in faster recovery and return to activity.

In regard to the technique for peroneal tendoscopy, a lateral position is preferable in order to gain appropriate access to the peroneal tendons as well as to limit operating table obstacles with the arthroscopic equipment. The two main portals one would utilize are two cm distal to the lateral malleolus and about five to six cm proximal to the tip of the lateral malleolus. Subcutaneous tissue dissection is paramount in order to expose the tendon sheath. I recommend performing a “nick and spread” technique in order to gain access to the tendon sheath while being careful to avoid making the portal too large as this can influence fluid management.  

The surgeon must incise the peroneal sheath in order to gain intra-sheath visualization. One can use a blunt tocar to free up any adhesions or fibrous attachments while creating a space for the scope. Typically, one employs a small dilator to open the sheath and allow for easier access with the arthroscope. A 2.7 or 4.0mm, 30-degree scope is reasonable, however I find it much easier to manipulate through the tendon sheath with a 2.7 short arthroscope.  

If necessary, one can perform debridement with the insertion of a 3.5 mm shaver into the proximal portal. I will start distally for a known peroneus brevis tear and then proximally in a retrofibular manner to assess any known peroneus longus tear. This is an opportunity to document in detail any longitudinal tears and the degree of synovitis. Be careful to avoid the sural nerve throughout the procedure.^2,3

Practical Applications Of Peroneal Tendoscopy 

Very often, we see peroneal tendinitis that has failed conservative treatment with a less than impressive MRI. Tendoscopy and debridement can be beneficial in these cases. Due to the “magic angle” on MRI, some peroneal pathology may be underdiagnosed.⁴ The arthroscope allows an alternate pathway for visualization of the tendon prior to an open procedure. When I suspect there may be greater pathology, I usually utilize tendoscopy as a first line option.  

Through a scope, I am able to better visualize and determine whether the patient is experiencing pain from tenosynovitis or if there is a greater tear that I need to address. If there does not appear to be a tear, I use a shaver in order to debride the tenosynovitis, making the procedure completely arthroscopic. If I see a tear, I often open the surgical site and perform an open repair where it is necessary. 

It is important to note that we must also keep in mind the pathology that may have caused the tendinitis. Tendoscopy allows us to perform adjunctive procedures (i.e. Dwyer osteotomy, subtalar joint fusion) during the same surgical session and limit the degree of soft tissue trauma and dissection. 

Keep in mind that much like arthroscopy of the ankle or hindfoot, tendoscopy does have a learning curve that one must master in order to maximize patient outcomes.

Dr. Pirozzi is a Fellow of the American College of Foot and Ankle Surgeons (ACFAS), and serves as Vice President for ACFAS Region 2. She is in private practice in Phoenix. 

References

1. van Dijk CN, Kort N. Tendoscopy of the peroneal tendons. Arthroscopy. 1998;14:471-478.
2. Monteagudo M, Maceira E, Martinez de Albornoz P. Foot and ankle tendoscopies: current concepts review. EFORT Open Rev. 2017;1(12):440-447.
3. Wang XT, Rosenberg ZS, Mechlin MB, Schweitzer ME. Normal variants and diseases of the peroneal tendons and superior peroneal retinaculum: MR imaging features. Radiographics. 2005;25:587–602 
4. Sammarco VJ. Peroneal tendoscopy indications and techniques. Sports Med Arthrosc Rev. 2009;2:94-99