Peroneus quartus muscle: a case report and review of the literature

Rupture of the peroneus quartus tendon in a professional rugby player

The peroneus quartus is one of a variety of described accessory peroneal muscles, most commonly an incidental finding on MRI or ultrasound of the ankle. We present the only described case in the literature of a peroneus quartus tendon rupture in a professional rugby player as well as the MRI findings.

Endoscopic Resection of Peroneus Quartus

The peroneus quartus is the most common supernumerary muscle of the foot and ankle. It can be symptomatic and associated with splits or tears in the peroneus brevis, subluxation or dislocation of the peroneal tendon, tendinous calcification, chronic peroneal compartment syndrome, and painful hypertrophy of the retrotrochlear eminence. The purpose of this Technical Note was to describe the details of endoscopic resection of the peroneus quartus. This technique has the advantages of better cosmetic results, less pain, less surgical trauma, and the possibility of dealing with associated pathologies endoscopically.

Heterotopic Ossification of the Peroneus Longus Tendon in the Retromalleolar Portion with the Peroneus Quartus Muscle: A Case Report

Heterotopic ossification (HO) is an ectopic formation of the lamellar bone in the soft tissues. Some authors have previously reported HO or calcific tendinitis of the peroneus longus tendon at the level of the cuboid bone, while the HO of the peroneus longus tendon in the retromalleolar portion has not been reported. The purpose of this report is to describe clinical, radiological, and histological features of this rare ossification and its treatment. To the best of our knowledge, this is the first report presenting a case of HO of the peroneus longus tendon, which developed in the retromalleolar portion.

Clinical results of peroneal tendon repair in a retrospective series of 30 patients

INTRODUCTION

Peroneal tendinopathy is an under-diagnosed pathology, mainly triggered by ankle sprain. Failure of medical treatment often leads to surgery, with modalities adapted to the lesion type. The present study aimed to assess clinical and functional results of tendon repair and to analyze the influence of hindfoot alignment on quality of outcome. The study hypothesis was that hindfoot varus impairs medium-term results.

MATERIALS AND METHODS

A retrospective series of 30 patients undergoing peroneal tendon repair or tenodesis was analyzed at a mean 20 months' follow-up. All patients had preoperative ultrasound scan or NMRI. Clinical assessment was based on AOFAS and FAAM scores. Hindfoot alignment was assessed on Méary view; 2 groups were distinguished: valgus (n=11) and varus (n=17).

RESULTS

Mean AOFAS score improved, from 74.5±11.2 preoperatively to 86.7±9.4 at follow-up. There was a significant intergroup difference (p=0.0003) in AOFAS at follow-up: valgus, 93/100; varus, 82/100. There was no significant intergroup difference in FAAM score. Time to surgery, lesion type and surgical technique did not influence clinical results.

DISCUSSION/CONCLUSION

Clinical results for surgical repair of peroneal tendons were satisfactory and in line with literature reports. However, hindfoot varus was associated with poorer results, raising the possibility of correction by opening wedge calcaneal osteotomy.

LEVEL OF EVIDENCE

IV, retrospective case series.

Surgical management of the peroneus quartus muscle for bilateral ankle pain: a case report

The peroneus quartus muscle is an accessory muscle seen in the lateral compartment of the lower leg. Although the peroneus quartus muscle is asymptomatic in general, it sometimes becomes pathologic. We present the rare case of bilateral ankle pain with crepitation caused by the peroneus quartus muscle. Magnetic resonance imaging should be considered to assist with diagnosing this condition. Foot and ankle surgeons should consider it in the preoperative differential diagnosis when patients present with posterior ankle pain.

MRI appearances of the anterior fibulocalcaneus muscle: a rare anterior compartment muscle

MRI of a 62-year-old female presenting with ankle pain demonstrated an accessory muscle within the anterior compartment of the lower leg. The muscle originated from the fibula and anterior crural septum. The tendon passed anterior to the lateral malleolus and inserted at the critical angle of Gissane on the calcaneus. This muscle was initially described in the anatomic literature by Lambert and Atsas in 2010. To our knowledge, this is the first time the MRI appearances of this muscle has been described in the radiological literature. Awareness of the fibulocalcaneal muscle is important as it may represent a cause of ankle pain. In addition, the tendon could potentially be harvested for use in reconstructive procedures.

A new morphological classification for the fibularis quartus muscle

PURPOSE

The fibularis quartus muscle (FQ) is an accessory fibular muscle that can be found in humans, reportedly in up to 22%. The aim of this study was to classify morphological patterns of the FQ and its anatomical variations.

METHODS

Eighty lower limbs of 40 formalin-fixed adult Korean cadavers were used in this study.

RESULTS

The FQ was present in 13 of 80 specimens (16.3%). In two specimens, each specimen had two FQs with different origins and insertion sites. Thus, 15 cases of FQ were found in 13 specimens. The FQ originated from the fibularis brevis muscle (FB) in 12 cases (15%). In these cases, the FQ arose either as a muscle or as a tendon. The muscle fibers of the FQ merged into a tendon (8 of 12 cases) that inserted variously into (1) the tendon of the FB (three cases, 3.8%), (2) the lateral surface of calcaneus (two cases, 2.5%), (3) the inferior peroneal retinaculum (two cases, 2.5%), or (4) the dorsal surface of the base of fifth metatarsal bone (one case, 1.3%). The FQ arose as a tendon from the FB in 4 of 12 cases. In three of the four cases, the FQ inserted into the lateral surface of calcaneus. The FQ arose from structures other than the FB (three cases, 3.8%).

CONCLUSION

The present study has demonstrated a new classification for the FQ and its anatomical variations, and provided detailed data for its accurate identification of a muscle and relevant surgical procedures.

Peroneus quartus: prevalance and clinical importance

INTRODUCTION

The most common variant muscle of the ankle, peroneus quartus muscle, is located in the lateral leg compartment. In literature there is ambiguous nomenclature of this muscle because of its different origin and insertion sides. It is related to many pathologic conditions in the lateral ankle compartment but also it can be used as a tendon graft for reconstructive procedures.

MATERIAL AND METHOD

We dissected 115 cadaver legs and investigated prevalence of peroneus quartus. We also present 2 year result of a patient who had torn superior peroneal retinaculum reconstructed with peroneus quartus tendon.

RESULTS

The peroneus quartus muscle, with a number of different attachments, was present in 5.2 % (6/115) of the legs. It most commonly arose from the peroneus brevis muscle and inserted into the retrotrochlear eminence of the calcaneus. Associated pathologies are longitudinal degeneration and tear in the tendon of peroneus brevis. There is no any association between the prevalence of peroneus quartus and the height of retrotrochlear eminence or presence of peroneal tubercule (p > 0.05). But there is strong relationship between peroneus brevis degeneration and peroneus quartus existence (p: 0.03). We also defined a new type of peroneus quartus with a bifurcated insertion around the peroneus brevis. In literature our case report is unique because we present a patient who has torn superior peroneal retinaculum which is reconstructed with peroneus quartus tendon with 2 year follow up.

CONCLUSION

Peroneus quartus may lead to some pathologic conditions (pain, snapping, tear, synovitis, etc.) in the lateral ankle compartment but it may be used to reconstruct some pathologic conditions. Orthopaedics, anatomists and radiologists should be aware of this accessory tendon structure because of its clinical importance.

Clinical implications of novel variants of the fibularis (peroneus) quartus muscle inserting onto the cuboid bone: peroneocuboideus and peroneocalcaneocuboideus

Two variants of the fibularis (peroneus) quartus muscle were identified and photographed in the legs of a 70-year-old white male cadaver. A rare peroneocuboideus (fibulocuboideus) muscle (as described by Chudzinski) and a novel peroneocalcaneocuboideus (fibulocalcaneocuboideus) muscle was found in the right and left leg, respectively. The latter muscle has not been previously reported and was termed "peroneocalcaneocuboideus" on the basis of its origin and insertions. Also, the distal attachment of both muscles inserted onto the distal lip of the peroneal sulcus of the cuboid bone, which differs from the historical data. The insertion of the peroneocuboideus muscle was previously described as being at the tuberosity of the cuboid bone or, simply, the lateral surface of the cuboid. Therefore, the present case study provides the first gross anatomic photographs of these variant leg muscles along their entire length, identifies a novel fibularis quartus variant, and describes a new insertion site for the peroneocuboideus muscle. Throughout our report, the historical data are reviewed to list the prevalence and describe the clinical implications of the fibularis quartus muscle and its variants. The presence of variant fibularis quartus muscles has been known to cause lateral ankle pain and stenosis, ankle instability, fibular tenosynovitis, subluxation of the fibular (peroneal) tendons, and longitudinal splitting of the fibularis brevis tendon in radiologic and case studies. Therefore, surgeons, radiologists, and clinicians should be aware of these variant muscles when considering various diagnoses, interpreting radiographs, and pursuing surgical intervention to relieve lateral ankle pathologic features.

Anatomical variations of peroneal muscles: a cadaver study in an Indian population and a review of the literature

BACKGROUND

Persistent lateral ankle pain is a common presentation in clinics. Various studies on anatomical variations of the peroneal compartment muscles, including the peroneus quartus muscle, have been reported in different populations. However, such studies are rarely from India. Hence, the present study was undertaken on cadavers in an Indian population.

METHODS

The lateral compartments of the legs were dissected in 70 specimens to study the presence, origin, and insertion of accessory muscles. Different peroneal tendons were observed for tears and splits.

RESULTS

Three of 70 specimens (4.3%) showed prevalence of the peroneus quartus muscle. Twenty specimens (28.6%) had split or tear lesions of the peroneus brevis muscle. Presence of the peroneus quartus muscle in this Indian population was relatively low compared with that in previous reports in English and American populations (6.6%-21.9%).

CONCLUSIONS

Racial differences, cultural variations, and postural habits, along with different stages of evolution, may be factors contributing to different observations. Split lesions of the peroneus brevis tendon were six to seven times more prevalent than was presence of the peroneus quartus muscle, which implies that split or tear lesions of the peroneus brevis tendon are more frequently involved in the manifestation of persistent retromalleolar pain compared with complications arising out of presence of the peroneus quartus muscle. Hence, accurate knowledge of presence of the peroneus quartus muscle in different populations is important because it can also be used in grafting and reconstruction in foot and ankle surgery.

Peroneus quartus and functional ankle instability

INTRODUCTION

Physical and rehabilitation medicine physicians commonly see patients with chronic functional ankle instability. The main anatomical structures involved in ankle stability are the peroneus (fibularis) brevis and peroneus longus muscles. Several anatomical muscle-tendon variations have been described in the literature as being sometimes responsible for this instability, the peroneus quartus muscle being the most frequent. The objective of this clinical study is to discuss the implication of the bilateral peroneus quartus muscle in functional ankle instability.

CLINICAL CASE

This 26-year-old patient was seen in PM&R consultation for recurrent episodes of lateral ankle sprains. The clinical examination found a moderate hyperlaxity on the right side in bilateral ankle varus. We also noted a bilateral weakness of the peroneus muscles. Additional imaging examinations showed a supernumerary bilateral peroneus quartus. The electroneuromyogram of the peroneus muscles was normal.

DISCUSSION

In the literature the incidence of a supernumerary peroneus quartus muscle varies from 0 to 21.7%. Most times this muscle is asymptomatic and is only fortuitously discovered. However some cases of chronic ankle pain or instability have been reported in the literature. It seems relevant to discuss, around the clinical case of this patient, the impact of this muscle on ankle instability especially when faced with lingering weakness of the peroneus brevis and longus muscles in spite of eccentric strength training and in the absence of any neurological impairment. One of the hypotheses, previously described in the literature, would be the overcrowding effect resulting in a true conflict by reducing the available space for the peroneal muscles in the peroneal sheath.

First report of an accessory popliteal muscle: detection with MRI

During an MRI examination of the knee in a 48-year-old patient suffering from degenerative changes of a partly resected medial meniscus and concomitant osteoarthritis of the knee joint, an unusual variant of an accessory muscle in the popliteal fossa was found. To our best knowledge this muscle has never been described before. Because of the close relationship to the popliteal muscle with regard to course and localisation in the deep popliteal fossa ventral to the popliteal artery, the term "accessory popliteal muscle" is proposed.

Peroneal tendon tears: a retrospective review

Tears of the peroneal tendons are not uncommon but remain an underappreciated source of chronic lateral ankle pain. The purpose of this study was to identify the typical patient profile and nature of the injury, to analyze the course of treatment, and to determine the prevalence of complications seen with surgical repair. Forty patients with chronic pain over the peroneal tendons from the Foot and Ankle Institute at the Western Pennsylvania Hospital underwent peroneal tendon repair. During a 3-year period, a retrospective review was performed by evaluating medical records, surgical reports, and radiographs. The average patient age was 42 years (range, 13 to 64 years). The most common cause was an ankle sprain or other traumatic injury (58%). Peroneus brevis tears (35 patients; 88%), peroneus longus tears (5 patients; 13%), combined peroneus brevis and longus tears (15 patients; 37%), low-lying peroneus muscle belly (13 patients; 33%), lateral ankle ligamentous disruptions (13 patients; 33%), and peroneal subluxation (8 patients; 20%) were identified during surgery. The average follow-up was 13 months (range, 9 to 40 months). Ninety-eight percent of the patients were able to return to full activities without pain at final follow-up. The minor complication rate (transient symptoms) was 20%. Clinically significant (major) complications (continued symptoms or revisionary surgery) occurred in 10% of patients. This study indicates that lateral ankle ligamentous incompetence, combined peroneal brevis and longus tears, and low-lying peroneus muscle belly commonly coexist in patients with peroneal tendon injuries. Appropriate surgical intervention of peroneal tendon tears and their coexisting pathology yields successful and predictable results with few clinically significant complications.