Anatomical variations related to pathological conditions of the peroneal tendon: evaluation of ankle MRI with a 3D SPACE sequence in symptomatic patients

  • Elif ErsozEmail author
  • Nil Tokgoz
  • Ahmet Y. Kaptan
  • Akif M. Ozturk
  • Murat Ucar
Scientific Article



To evaluate anatomical variations in the lateral ankle and their relationships with pathological conditions of the peroneal tendon on magnetic resonance imaging (MRI) in symptomatic patients.

Materials and methods

Sixty-nine ankles MRIs of 60 adult patients with symptomatic ankles were included. The presence and sizes of peroneal tubercle and retrotrochlear eminence (RTE), the prevalence of peroneus quartus (PQ), os peroneum, and boomerang-shaped peroneus brevis (PB) tendon, the shape of the retromalleolar fibular groove (RMFG), and the location of the PB muscle–tendon junction were evaluated. The relationships of these variations with peroneal tendinopathies were assessed. The correlations between pathological peroneal conditions on MRI and clinical findings were evaluated.


Peroneal tubercle (mean size, 3.2 mm) and RTE (mean size, 4.5 mm) were identified in 58 (84%) and 69 (100%) ankles respectively. PQ muscle, os peroneum, and boomerang-shaped PB tendon were found in 9 (13%), 7 (10%), and 24 (34.8%) ankles respectively. The RMFG was concave, flat, convex, and irregular in 14 (20.3%), 40 (58%), 13 (18.8%), and 2 (2.9%) ankles respectively. Sixteen (23.2%) patients had low-lying PB muscle belly. Only boomerang-shaped PB tendons showed a significant relationship with peroneal tendinopathies. MRI and clinical findings had a poor correlation in pathological peroneal conditions and both had low sensitivity in diagnosis.


Lateral ankle anatomical variations are common and cannot be attributed to pathological conditions of the peroneal tendon, except for boomerang-shaped PB tendons. Both clinical and MRI findings have low sensitivity in the diagnosis of peroneal tendinopathies, which are often incidental findings on MRI.


Magnetic resonance imaging Ankle Foot Pathological conditions of the peroneal tendon Anatomical variations 


Compliance with ethical standards

Conflicts of interest

The authors declare that they have no conflicts of interest.


  1. 1.
    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.CrossRefGoogle Scholar
  2. 2.
    Galli MM, Protzman NM, Mandelker EM, Malhotra AD, Schwartz E, Brigido SA. An examination of anatomic variants and incidental peroneal tendon pathologic features: a comprehensive MRI review of asymptomatic lateral ankles. J Foot Ankle Surg. 2015;54:164–72.CrossRefGoogle Scholar
  3. 3.
    Hammerschlag WA, Goldner JL. Chronic peroneal tendon subluxation produced by an anomalous peroneus brevis: case report and literature review. Foot Ankle. 1989;10:45–7.CrossRefGoogle Scholar
  4. 4.
    Geller J, Lin S, Cordas D, Vieira P. Relationship of a low-lying muscle belly to tears of the peroneus brevis tendon. Am J Orthop (Belle Mead NJ). 2003;32:541–4.Google Scholar
  5. 5.
    Buschmann WR, Cheung Y, Jahss MH. Magnetic resonance imaging of anomalous leg muscles: accessory soleus, peroneus quartus and the flexor digitorum longus accessorius. Foot Ankle. 1991;12:109–16.CrossRefGoogle Scholar
  6. 6.
    Boles MA, Lomasney LM, Demos TC, Sage RA. Enlarged peroneal process with peroneus longus tendon entrapment. Skeletal Radiol. 1997;26:313–5.CrossRefGoogle Scholar
  7. 7.
    Zammit J, Singh D. The peroneus quartus muscle: anatomy and clinical relevance. J Bone Joint Surg Br. 2003;85:1134–7.CrossRefGoogle Scholar
  8. 8.
    Rosenberg ZS, Bencardino J, Astion D, Schweitzer ME, Rokito A, Sheskier S. MRI features of chronic injuries of the superior peroneal retinaculum. AJR Am J Roentgenol. 2003;181:1551–7.CrossRefGoogle Scholar
  9. 9.
    Sobel M, Levy ME, Bohne WH. Congenital variations of the peroneus quartus muscle: an anatomic study. Foot Ankle. 1990;11:81–9.CrossRefGoogle Scholar
  10. 10.
    Saupe N, Mengiardi B, Pfirrmann CW, Vienne P, Seifert B, Zanetti M. Anatomic variants associated with peroneal tendon disorders: MR imaging findings in volunteers with asymptomatic ankles. Radiology. 2007;242:509–17.CrossRefGoogle Scholar
  11. 11.
    Saxena A, Luhadiya A, Ewen B, Goumas C. Magnetic resonance imaging and incidental findings of lateral ankle pathologic features with asymptomatic ankles. J Foot Ankle Surg. 2011;50:413–5.CrossRefGoogle Scholar
  12. 12.
    O’Neil JT, Pedowitz D, Kerbel YE, Codding JL, Zoga AC, Raikin SM. Peroneal tendon abnormalities on routine magnetic resonance imaging of the foot and ankle. Foot Ankle Int. 2016;37(7):743–7.CrossRefGoogle Scholar
  13. 13.
    Rademaker J, Rosenberg ZS, Beltran J, Colon E. Alterations in the distal extension of the musculus peroneus brevis with foot movement. AJR Am J Roentgenol. 1997;168:787–9.CrossRefGoogle Scholar
  14. 14.
    Agarwal AK, Jeyasingh P, Gupta SC, Gupta CD, Sahai A. Peroneal tubercle and its variations in the Indian calcanei. Anat Anz. 1984;156:241–4.PubMedGoogle Scholar
  15. 15.
    Hyer CF, Dawson JM, Philbin TM, et al. The peroneal tubercle: description, classification, and relevance to peroneus longus tendon pathology. Foot Ankle Int. 2005;26:947–50.CrossRefGoogle Scholar
  16. 16.
    Mirmiran R, Squire C, Wassell D. The prevalence and role of low lying peroneus brevis muscle belly in patients with peroneal tendon pathologies: a potential source for tendon subluxation. J Foot Ankle Surg. 2015;54(5):872–5.CrossRefGoogle Scholar
  17. 17.
    Muehleman C, Williams J, Bareither ML. A radiologic and histologic study of the os peroneum: prevalence, morphology, and relationship to degenerative joint disease of the foot and ankle in a cadaveric sample. Clin Anat. 2009;22(6):747–54.CrossRefGoogle Scholar
  18. 18.
    Sobel M, Pavlov H, Geppert MJ, Thompson FM, DiCarlo EF, Davis WH. Painful os peroneum syndrome: a spectrum of conditions responsible for plantar lateral foot pain. Foot Ankle Int. 1994;15(3):112–24.CrossRefGoogle Scholar
  19. 19.
    Cheung Y, Rosenberg ZS. MR imaging of the accessory muscles around the ankle. Magn Reson Imaging Clin N Am. 2001;9:465–73.PubMedGoogle Scholar
  20. 20.
    Cheung YY, Rosenberg ZS, Ramsinghani R, Beltran J, Jahss MH. Peroneus quartus muscle: MR imaging features. Radiology. 1997;202:745–50.CrossRefGoogle Scholar
  21. 21.
    Cecava ND, Campbell SE. Peroneus brevis tendon variant insertion on the calcaneus. J Radiol Case Rep. 2015;9(5):22–9.PubMedPubMedCentralGoogle Scholar
  22. 22.
    Diaz GC, van Holsbeeck M, Jacobson JA. Longitudinal split of the peroneus longus and peroneus brevis tendons with disruption of the superior peroneal retinaculum. J Ultrasound Med. 1998;17(8):525–9.CrossRefGoogle Scholar
  23. 23.
    Giza E, Mak W, Wong SE, Roper G. A clinical and radiological study of peroneal tendon pathology. Foot Ankle Spec. 2013;6(6):417–21.CrossRefGoogle Scholar
  24. 24.
    Kuwada GT. Surgical correlation of preoperative MRI findings of trauma to tendons and ligaments of the foot and ankle. J Am Podiatr Med Assoc. 2008;98:370–3.CrossRefGoogle Scholar
  25. 25.
    Park HJ, Lee SY, Park NH, et al. Accuracy of MR findings in characterizing peroneal tendon disorders in comparison with surgery. Acta Radiol. 2012;53:795–801.CrossRefGoogle Scholar

Copyright information

© ISS 2019

Authors and Affiliations

  1. 1.Department of RadiologyGazi University Faculty of MedicineAnkaraTurkey
  2. 2.Department of Orthopedics and TraumatologyGazi University Faculty of MedicineAnkaraTurkey

Personalised recommendations