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Training Collections
Library Memberships
On-demand course library with video lectures, expert case reviews, and more
Fellowship Certificate™ Programs
Practice-focused training programs designed to help you gain experience in a specific subspecialty area.
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Unlock access to our full Course Library and all self-paced Fellowships.
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Get access to free live lectures, every week, from top radiologists.
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Musculoskeletal Imaging
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Supplement your training program with case-based learning for residents, registrars, fellows, and more.
For Private Practices
Upskill in high growth, advanced imaging areas.
Emergency Call Prep
Prepare trainees to be on call for the emergency department with this specialized training series.
Practice Cases
Worklist 1
10 topics, 11 min.
Practice Cases
Worklist 2
10 topics, 18 min.
Practice Cases
Worklist 3
10 topics, 37 min.
Practice Cases
Worklist 4
10 topics, 7 min.
Practice Cases
Worklist 5
10 topics, 46 min.
0:00
This is a 63-year-old man with lateral
0:03
ankle pain assessing the peroneal tendons.
0:07
We soon realized that the peroneus longus
0:11
tendon is abnormal in talus as compared to the
0:14
adjacent peroneus brevis in this patient.
0:17
The location of the peroneus brevis
0:19
is medial to the peroneus longus.
0:22
This is an anatomic variant, also termed
0:25
pseudo-subluxation of the peroneus brevis.
0:28
Completely normal arrangement of
0:30
the peroneal tendons at this level
0:32
in the retromalleolar groove.
0:35
As we come down into the inframalleolar region,
0:38
the peroneus longus tendon demonstrates marked
0:43
longitudinal split tearing that is centered at the
0:48
level of the lateral calcaneal wall, where a large
0:52
hypertrophic peroneal trochlea is identified.
0:57
This is one of the most important
0:59
etiological factors for peroneus brevis.
1:03
This peroneus longus dysfunction is
1:06
the presence of a hypertrophic peroneal
1:08
trochlea where the tendon is going to have
1:12
attritional change against the osseous surface
1:16
and undergo longitudinal split tearing.
1:20
As we keep on going down into the region
1:23
of the talonavicular-cuboid articulation,
1:27
it becomes apparent that there is an
1:29
intra-tendinous T1 bright focus of signal
1:33
intensity corresponding to an os peroneum.
1:36
The tear stops at the level of the
1:39
ossicle, and then we see some tendinosis
1:42
of the peroneus longus as it travels.
1:46
under the cuboid and the midfoot region to
1:50
insert at the base of the first metatarsal.
1:53
On side detail images, we can see that the,
1:57
dysfunction of this peroneus longus tendon is
2:01
centered at the level of the lateral calcaneal
2:03
wall where there is marrow edema in the
2:07
presence of a hypertrophic peroneal trochlea.
2:10
site of tearing of the peroneus longus
2:14
tendon standing proximal and distal
2:17
to the area of attritional change.
Wk 2, Case 2 - Review
HIDEInteractive Transcript
0:00
This is a 63-year-old man with lateral
0:03
ankle pain assessing the peroneal tendons.
0:07
We soon realized that the peroneus longus
0:11
tendon is abnormal in talus as compared to the
0:14
adjacent peroneus brevis in this patient.
0:17
The location of the peroneus brevis
0:19
is medial to the peroneus longus.
0:22
This is an anatomic variant, also termed
0:25
pseudo-subluxation of the peroneus brevis.
0:28
Completely normal arrangement of
0:30
the peroneal tendons at this level
0:32
in the retromalleolar groove.
0:35
As we come down into the inframalleolar region,
0:38
the peroneus longus tendon demonstrates marked
0:43
longitudinal split tearing that is centered at the
0:48
level of the lateral calcaneal wall, where a large
0:52
hypertrophic peroneal trochlea is identified.
0:57
This is one of the most important
0:59
etiological factors for peroneus brevis.
1:03
This peroneus longus dysfunction is
1:06
the presence of a hypertrophic peroneal
1:08
trochlea where the tendon is going to have
1:12
attritional change against the osseous surface
1:16
and undergo longitudinal split tearing.
1:20
As we keep on going down into the region
1:23
of the talonavicular-cuboid articulation,
1:27
it becomes apparent that there is an
1:29
intra-tendinous T1 bright focus of signal
1:33
intensity corresponding to an os peroneum.
1:36
The tear stops at the level of the
1:39
ossicle, and then we see some tendinosis
1:42
of the peroneus longus as it travels.
1:46
under the cuboid and the midfoot region to
1:50
insert at the base of the first metatarsal.
1:53
On side detail images, we can see that the,
1:57
dysfunction of this peroneus longus tendon is
2:01
centered at the level of the lateral calcaneal
2:03
wall where there is marrow edema in the
2:07
presence of a hypertrophic peroneal trochlea.
2:10
site of tearing of the peroneus longus
2:14
tendon standing proximal and distal
2:17
to the area of attritional change.
Report
Patient History
63-year-old man complaining of pain and swelling of the right lateral ankle for 6 months.
Findings
SKELETAL/BONES:
Giant hypertrophic elongated lateral calcaneal peroneal tubercle, with associated reactive/stress related osteoedema.
No further stress related osteoedema. No micro- or macro-trabecular fracture. No stress fracture. No aggressive osseous abnormality.
Incidental note is made of a 6 mm os peroneus (embedded within the cuboid tunnel segment of the peroneus longus). No osteoedema of the os peroneus.
ARTICULATIONS:
Tibiotalar joint/talar dome: No osteochondral defect of the talar dome or tibial plafond.
Ankle mortise/syndesmosis: The ankle mortise is in anatomic alignment. No syndesmosis widening.
Chopart joint: Unremarkable.
Midfoot/hindfoot: Marked degenerative arthrosis of the 2nd tarsometatarsal joint and mild degenerate arthrosis of the 3rd tarsometatarsal joint. No fracture or injury of the anterior calcaneal process.
LIGAMENTS:
High ankle: Intact.
Low ankle: Intact.
Subtalar/Chopart: Intact.
TENDONS:
Diffuse moderately to markedly hypertrophic tendinosis with tenosynovitis involving the supramalleolar, juxtamalleolar and inframalleolar peroneus longus tendon, with a complex tear measuring 5.0 cm in length. Tear extends from the juxtamalleolar segment into the inframalleolar segment, to just proximal to the small os peroneus. Peroneus longus hypertrophic tendinosis without tearing through the cuboid tunnel and distal plantar aspect. Peroneal retinaculum swollen but intact. Peroneus brevis unremarkable.
Extensor tendons intact and unremarkable in appearance. Flexor tendons intact and unremarkable.
Achilles tendon intact. Small enthesophyte without active osteoedema/inflammation at the distal Achilles insertion/dorsal calcaneus.
GENERAL:
Sinus tarsi: Unremarkable.
Muscles: No traumatic muscle injury. No volumetric muscle atrophy.
Soft tissue: Unremarkable.
Plantar fascia: Intact.
Neurovascular complex/tarsal tunnel: Unremarkable. No evidence of entrapment neuropathy.
Intra-articular/loose bodies: None.
Impressions
1. Diffuse moderate to marked hypertrophic tendinosis/tenosynovitis involving the supramalleolar, juxtamalleolar and inframalleolar peroneus longus tendon with an associated complex (predominantly longitudinal interstitial) tear measuring 5 cm in length.
2. Giant hypertrophic elongated lateral calcaneal peroneal tubercle (likely predisposing to the adjacent peroneus longus tendinopathy/tearing). Reactive osteoedema.
3. Incidental small juxta-cuboid os peroneus. Plantar and juxta-cuboid peroneus longus tendinosis. No tendon tearing around the ossicle.
4. Incidental 2nd and 3rd tarsometatarsal arthrosis as described.
Case Discussion
Faculty
Stephen J Pomeranz, MD
Chief Medical Officer, ProScan Imaging. Founder, MRI Online
ProScan Imaging
Jenny T Bencardino, MD
Vice-Chair, Academic Affairs Department of Radiology
Montefiore Radiology
Edward Smitaman, MD
Clinical Associate Professor
University of California San Diego
Tags
Musculoskeletal (MSK)
MRI
Foot & Ankle
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