Congenital Variations of the Peroneal Tendons

  • Jay M. Sobel
  • Mark Sobel


Stenosing tenosynovitis, subluxation of the peroneal tendons, and peroneus brevis split tears can occur in association with an encroachment of an anomalous peroneus quartus tendon or low-lying peroneus brevis muscle belly. The presence of extra tissue within the fibular groove can contribute to stenosis or subluxation of the peroneus brevis tendon causing laxity of the superior peroneal retinaculum and eventually subluxation or dislocation of the peroneus brevis over the sharp posterior ridge of the distal fibula. This dynamic mechanism can eventually result in splitting or tearing of the peroneus brevis tendon. A convex or shallow fibular groove can further contribute to this dynamic phenomenon in Zone A. Also, an irregular retromalleolar groove predisposes to peroneal tendon disease. Hypertrophy of the peroneal tubercle along the lateral wall of the calcaneus can also contribute to stenosing tenosynovitis and impingement of the peroneal tendons in Zone B. The presence of an enlarged os peroneum can contribute to stenosing tenosynovitis or rupture of the peroneus longus tendon in the cuboid tunnel Zone C. Fracture of an enlarged or bipartite os peroneum with proximal migration of the proximal pole of the os peroneum can lead to peroneus longus tendon rupture.


Peroneus quartus tendon Low-lying peroneus brevis muscle belly Superior peroneal retinaculum Convex Shallow fibular groove Enlarged peroneal tubercle Cuboid tunnel Enlarged fractured painful os peroneum Stenosing tenosynovitis Impingement subluxation split tear peroneus brevis tendon Rupture peroneus longus tendon Rupture peroneus brevis tendon Tenodesis Ankle injuries Dorsiflexion injury Dislocation peroneal tendons Anterior talofibular ligament 

Supplementary material

Video 3.1

The Dynamics of Peroneus Brevis Splits/Tears


  1. 1.
    Hecker P. Study on the peroneus of the tarsus. Anat Rec. 1923;26:79–82.Google Scholar
  2. 2.
    Sobel M, Levy ME, Bohne WHO. Congenital variations of the peroneus quartus muscle: an anatomic study. Foot Ankle. 1990;11:81–9.PubMedPubMedCentralGoogle Scholar
  3. 3.
    Sobel M, Geppert MJ, Olson EJ, Bohne WHO, Arnoczky SP. The dynamics of peroneus brevis tendon splits: a proposed mechanism, technique of diagnosis, and classification of injury. Foot Ankle. 1992;13:413–22.PubMedPubMedCentralGoogle Scholar
  4. 4.
    Donley BG, Leyes M. Peroneus quartus muscle. Am J Sports Med. 2001;29:373–5.PubMedGoogle Scholar
  5. 5.
    Zammit J, Singh D. The peroneus quartus muscle. Anatomy and clinical relevance. J Bone Joint Surg Br. 2003;85-B:1134–7.Google Scholar
  6. 6.
    Bilgili MG, Kaynak G, Botanlıoğlu H, Basaran SH, Ercin E, Baca E, Uzun I. Peroneus quartus: prevalence and clinical importance. Arch Orthop Trauma Surg. 2014;134:481–7.PubMedGoogle Scholar
  7. 7.
    Yammine K. The accessory peroneal (fibular) muscles: peroneus quartus and peroneus digitiquinti. A systematic review and meta-analysis. Surg Radiol Anat. 2015;37:617–27.PubMedGoogle Scholar
  8. 8.
    Athavale SA, Vangara SV. Anatomy of the superior peroneal tunnel. J Bone Joint Surg. 2011;93(6):564–71.PubMedGoogle Scholar
  9. 9.
    Athavale SA, Gupta V, Kotgirwar S, Singh V. The peroneus quartus muscle: clinical correlation with evolutionary importance. Anat Sci Int. 2012;87:106–10.PubMedGoogle Scholar
  10. 10.
    Habashy A, Cook B, Sumarriva G, Treuting R. Peroneus quartus muscle. Am J Orthop. 2017;46:E419–22.PubMedGoogle Scholar
  11. 11.
    Chinzei N, Kanzaki N, Takakura Y, Takakura Y, Toda A, Fujishiro T, Hayashi S, Hashimoto S, Kuroda R, Kurosaka M. Surgical management of the peroneus quartus muscle for bilateral ankle pain. J Am Podiatr Med Assoc. 2015;105:85–91.PubMedGoogle Scholar
  12. 12.
    Sönmez M, Kosar ÇM. The supernumerary peroneal muscles: case report and review of the literature. Foot Ankle Surg. 2000;6:125–9.Google Scholar
  13. 13.
    Moroney P, Borton D. Multiple accessory peroneal muscles: a cause of chronic lateral ankle pain. Foot Ankle Int. 2004;25:322–4.PubMedGoogle Scholar
  14. 14.
    Prakash NC, Singh DK, Rajini T, Venkatiah J, Singh G. Anatomical variations of peroneal muscles. J Am Podiatr Med Assoc. 2011;101:505–8.PubMedGoogle Scholar
  15. 15.
    Saupe N, Mengiardi B, Pfirrmann CWA, 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.Google Scholar
  16. 16.
    Chepuri NB, Jacobson JA, Fessell DP, Hayes CW. Sonographic appearance of the peroneus quartus muscle: correlation with MR imaging appearance in seven patients. Radiology. 2001;218:415–9.PubMedGoogle Scholar
  17. 17.
    Cheung YY, Rosenberg ZS, Ramsinghani R, Beltran J, Jahss MH. Peroneus quartus muscle: MR imaging features. Radiology. 1997;202:745–50.PubMedGoogle Scholar
  18. 18.
    Sammarco GJ, Brainard BJ. A symptomatic anomalous peroneus brevis in a high-jumper. A case report. J Bone Joint Surg Am. 1991;73:131–3.PubMedGoogle Scholar
  19. 19.
    Martinelli B, Bernobi S. Peroneus quartus muscle and ankle pain. Foot Ankle Surg. 2002;8:223–5.Google Scholar
  20. 20.
    Nascimento SRR, Costa RW, Ruiz CR, Wafae N. Analysis on the incidence of the fibularis quartus muscle using magnetic resonance imaging. Anat Res Int. 2012;2012:1–6.Google Scholar
  21. 21.
    Kulshreshtha R, Kadri S, Rajan DT. A case of unusual combination of injuries around the lateral malleolus. Foot. 2006;16:51–3.Google Scholar
  22. 22.
    Davis WH, Sobel M, Deland J, Bohne WH, Patel MB. The superior peroneal retinaculum: an anatomic study. Foot Ankle Int. 1994;15:271–5.PubMedGoogle Scholar
  23. 23.
    Geppert MJ, Sobel M, Bohne WH. Lateral ankle instability as a cause of superior peroneal retinacular laxity: an anatomic and biomechanical study of cadaveric feet. Foot Ankle. 1993;14:330–4.PubMedGoogle Scholar
  24. 24.
    Gumusalan Y, Ozbag D. A variation of fibularis quartus muscles: musculus fibulocalcaneusexternum. Clin Anat. 2007;20:998–9.PubMedGoogle Scholar
  25. 25.
    Regan TP, Hughston JC. Chronic ankle “sprain” secondary to anomalous peroneal tendon. Clin Orthop Relat Res. 1977;123:52–4. Scholar
  26. 26.
    Mick CA, Lynch F. Reconstruction of the peroneal retinaculum using the peroneus quartus. A case report. J Bone Joint Surg. 1987;69:296–7.PubMedGoogle Scholar
  27. 27.
    White AA, Johnson D, Griswold DM. Chronic ankle pain associated with the peroneus accessorius. Clin Orthop Relat Res. 1974;103:53–5.Google Scholar
  28. 28.
    Taljanovic MS, Alcala JN, Gimber LH, Rieke JD, Chilvers MM, Latt LD. High-resolution US and MR imaging of peroneal tendon injuries. Radiographics. 2015;35(1):179–99.Google Scholar
  29. 29.
    Öznur A, Arik A, Alanay A. Peroneus quartus muscle as a rare cause of the chronic lateral ankle pain. Foot Ankle Surg. 2002;8(3):227–30.Google Scholar
  30. 30.
    Sobel M, Mizel MS. Peroneal tendon injury. In: Pfeffer GB, Frey CC, editors. Current practice in foot and ankle surgery. New York: McGraw-Hill, Health Professions Division; 1993. p. 33.Google Scholar
  31. 31.
    Sobel M, Bohne WHO, Obrien SJ. Peroneal tendon subluxation in a case of anomalous peroneus brevis muscle. Acta Orthop Scand. 1992;63:682–4.PubMedGoogle Scholar
  32. 32.
    Sobel M, Mizel MS. Peroneal tendon injury. In: Pfeffer GB, Frey CC, editors. Current practice in foot and ankle surgery. New York: McGraw-Hill, Health Professions Division; 1993. p. 34.Google Scholar
  33. 33.
    Sobel M, Mizel MS. Peroneal tendon injury. In: Pfeffer GB, Frey CC, editors. Current practice in foot and ankle surgery. New York: McGraw-Hill, Health Professions Division; 1993. p. 35.Google Scholar
  34. 34.
    Amini B. Low-lying peroneus brevis muscle belly [Internet Blog]. Roentgen ray reader 2011. Accessed 5 Nov 2018. Available from:
  35. 35.
    Dombek MF, Lamm BM, Saltrick K, Mendicino RW, Catanzariti AR. Peroneal tendon tears: a retrospective review. J Foot Ankle Surg. 2003;42:250–8.PubMedPubMedCentralGoogle Scholar
  36. 36.
    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
  37. 37.
    Mirmiran R, Squire C, Wassell D. The prevalence and role of a low-lying peroneus brevis muscle belly in patients with peroneal tendon pathologic features: a potential source of tendon subluxation. J Foot Ankle Surg. 2015;54:872–5.PubMedPubMedCentralGoogle Scholar
  38. 38.
    Highlander P, Pearson KT, Burns P. Magnetic resonance imaging analysis of peroneal tendon pathology associated with low-lying peroneus brevis muscle belly. Foot Ankle Spec. 2015;8:347–53.PubMedGoogle Scholar
  39. 39.
    Freccero DM, Berkowitz MJ. The relationship between tears of the peroneus brevis tendon and the distal extent of its muscle belly: an MRI study. Foot Ankle Int. 2006;27:236–9.PubMedPubMedCentralGoogle Scholar
  40. 40.
    Unlu MC, Bilgili M, Akgun I, Kaynak G, Ogut T, Uzun I. Abnormal proximal musculotendinous junction of the peroneus brevis muscle as a cause of peroneus brevis tendon tears: a cadaveric study. J Foot Ankle Surg. 2010;49:537–40.PubMedPubMedCentralGoogle Scholar
  41. 41.
    Housley SN, Lewis JE, Thompson DL, Warren G. A proximal fibularis brevis muscle is associated with longitudinal split tendons: a cadaveric study. J Foot Ankle Surg. 2017;56:34–6.PubMedGoogle Scholar
  42. 42.
    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.PubMedGoogle Scholar
  43. 43.
    Sobel M, Mizel MS. Peroneal tendon injury. In: Pfeffer GB, Frey CC, editors. Current practice in foot and ankle surgery. New York: McGraw-Hill, Health Professions Division; 1993. p. 32.Google Scholar
  44. 44.
    Sobel M, Mizel MS. Peroneal tendon injury. In: Pfeffer GB, Frey CC, editors. Current practice in foot and ankle surgery. New York: McGraw-Hill, Health Professions Division; 1993. p. 30–3.Google Scholar
  45. 45.
    Rosenberg ZS, Bencardino J, Astion D, Schweitzer ME, Rokito A, Sheskier S. MRI features of chronic injuries of the superior peroneal retinaculum. Am J Roentgenol. 2003;181:1551–7.Google Scholar
  46. 46.
    Wang X-T, 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.PubMedPubMedCentralGoogle Scholar
  47. 47.
    Edwards ME. The relations of the peroneal tendons to the fibula, calcaneus, and cuboideum. Am J Anat. 1928;42:213–53.Google Scholar
  48. 48.
    Kumai T, Benjamin M. The histological structure of the malleolar groove of the fibula in man: its direct bearing on the displacement of peroneal tendons and their surgical repair. J Anat. 2003;203:257–62.PubMedPubMedCentralGoogle Scholar
  49. 49.
    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;15:112–24.PubMedPubMedCentralGoogle Scholar
  50. 50.
    Davda K, Malhotra K, O’Donnell P, Singh D, Cullen N. Peroneal tendon disorders. EFORT Open Rev. 2017;2:281–92.PubMedPubMedCentralGoogle Scholar
  51. 51.
    Sugimoto K, Takakura Y, Okahashi K, Tanaka Y, Ohshima M, Kasanami R. Enlarged peroneal tubercle with peroneus longus tenosynovitis. J Orthop Sci. 2009;14:330–5.PubMedGoogle Scholar
  52. 52.
    Hyer CF, Dawson JM, Philbin TM, Berlet GC, Lee TH. The peroneal tubercle: description, classification, and relevance to peroneus longus tendon pathology. Foot Ankle Int. 2005;26:947–50.PubMedPubMedCentralGoogle Scholar
  53. 53.
    Hofmeister E, Juliano P, Lippert F. The anatomical configuration and clinical implications of the peroneal tubercle. Foot. 1996;6:138–42.Google Scholar
  54. 54.
    Palmanovich E, Laver L, Brin YS, Kotz E, Hetsroni I, Mann G, Nyska M. Peroneus longus tear and its relation to the peroneal tubercle: a review of the literature. Muscles Ligaments Tendons J. 2011;4:153–60.Google Scholar
  55. 55.
    Dr-P A Peroneal Tendon Complex Injury And Rehabilitation. In: 986 Dr Pributs Blog. Accessed 24 Oct 2018.
  56. 56.
    Pierson JL, Inglis AE. Stenosing tenosynovitis of the peroneus longus tendon associated with hypertrophy of the peroneal tubercle and an os peroneum. A case report. J Bone Joint Surg Am. 1992;74:440–2.PubMedPubMedCentralGoogle Scholar
  57. 57.
    Bruce WD, Christofersen MR, Phillips DL. Stenosing tenosynovitis and impingement of the peroneal tendons associated with hypertrophy of the peroneal tubercle. Foot Ankle Int. 1999;20:464–7.PubMedPubMedCentralGoogle Scholar
  58. 58.
    Lui TH. Endoscopic resection of the peroneal tubercle. J Foot Ankle Surg. 2012;51:813–5.PubMedGoogle Scholar
  59. 59.
    Chen YJ, Hsu RW, Huang TJ. Hypertrophic peroneal tubercle with stenosing tenosynovitis: the results of surgical treatment. Changgeng Yi Xue Za Zhi. 1998;21:442–6.PubMedGoogle Scholar
  60. 60.
    Burman M. Stenosing tendovaginitis of the foot and ankle: studies with special reference to the stenosing tendovaginitis of the peroneal tendons at the peroneal tubercle. AMA Arch Surg. 1953;67:686.PubMedPubMedCentralGoogle Scholar
  61. 61.
    Brandes CB, Smith RW. Characterization of patients with primary peroneus longus tendinopathy: a review of twenty-two cases. Foot Ankle Int. 2000;21:462–8.Google Scholar
  62. 62.
    Dutton P, Edmonds EW, Lark RK, Mubarak SJ. Prevalence of painful peroneal tubercles in the pediatric population. J Foot Ankle Surg. 2012;51:599–603.PubMedGoogle Scholar
  63. 63.
    Taki K, Yamazaki S, Majima T, Ohura H, Minami A. Bilateral stenosing tenosynovitis of the peroneus longus tendon associated with hypertrophied peroneal tubercle in a junior soccer player: a case report. Foot Ankle Int. 2007;28:129–32.PubMedGoogle Scholar
  64. 64.
    Watson GI, Karnovsky SC, Levine DS, Drakos MC. Surgical treatment for stenosing peroneal tenosynovitis. Foot Ankle Int. 2018;40:282–6.PubMedGoogle Scholar
  65. 65.
    Sarrafian SK. Anatomy of the foot and ankle: descriptive, topographic, functional. Philadelphia: J.B. Lippincott; 2011.Google Scholar
  66. 66.
    Mook WR, Parekh SG, Nunley JA. Allograft reconstruction of peroneal tendons. Foot Ankle Int. 2013;34:1212–20.PubMedPubMedCentralGoogle Scholar
  67. 67.
    Wapner KL, Taras JS, Lin SS, Chao W. Staged reconstruction for chronic rupture of both peroneal tendons using hunter rod and flexor hallucis longus tendon transfer: a long-term follow up study. Foot Ankle Int. 2006;27:591–7.Google Scholar
  68. 68.
    Jockel JR, Brodsky KW. Single-stage flexor tendon transfer for the treatment of severe concomitant peroneus longus and brevis tendon tears. Foot Ankle Int. 2013;34:666–72.Google Scholar
  69. 69.
    Seybold JD, Campbell JT, Jeng CL, Short KW, Myerson MS. Outcome of lateral transfer of the FHL or FDL for concomitant peroneal tendon tears. Foot Ankle Int. 2016;37:576–81.PubMedPubMedCentralGoogle Scholar
  70. 70.
    Barton DC, Lucas P, Jomha NM, Cross MJ, Slater K. Operative reconstruction after transverse rupture of the tendons of both peroneus longus and brevis: surgical reconstruction by transfer of the flexor digitorum longus tendon. J Bone Joint Surg Br. 1998;80:781–4.Google Scholar
  71. 71.
    Blitz NM, Nemes KK. Bilateral peroneus longus tendon rupture through a bipartite os peroneum. J Foot Ankle Surg. 2007;46(4):270–7.PubMedGoogle Scholar
  72. 72.
    Stockton KG, Brodsky JW. Peroneus longus tears associated with pathology of the os peroneum. Foot Ankle Int. 2014;35:346–52.PubMedPubMedCentralGoogle Scholar
  73. 73.
    Smith JT, Johnson AH, Heckman JD. Nonoperative treatment of an osperoneum fracture in a high-level athlete: a case report. Clin Orthop Relat Res. 2011;469:1498–501.PubMedPubMedCentralGoogle Scholar
  74. 74.
    Hamilton P, Robinson AHN. Peroneal tendon disorders. In: Bentley G. (eds) Eur Surg Orthop Traumatol. Springer, Berlin, Heidelberg. 2014:3637–57.Google Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Jay M. Sobel
    • 1
  • Mark Sobel
    • 2
  1. 1.Icahn School of Medicine at Mount Sinai, Biomedical SciencesNew YorkUSA
  2. 2.Lenox Hill Hospital – Northwell Health, Orthopaedic SurgeryNew YorkUSA

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