Case 1
A 58-year-old marathon runner presented with pain in the lateral aspect of the ankle during running. Pain was severe, with peak severity after 30 km of running and forcing him to stop training.
Localized tenderness over the lateral aspect of the foot was present on physical examination. It worsened with inversion of the ankle due to stretching of the peroneal tendons. Swelling over the lateral aspect of the calcaneous was noted, with no rubor.
Ultrasound (US) at the area of maximum tenderness revealed a hypertrophic peroneal tubercle and a thickened peroneus longus with synovitis around the tendon (Figure 1). Magnetic resonance imaging (MRI) showed a synovitic, thickened peroneus longus tendon (Figure 2).
Nonoperative management consisting of rest and physical therapy did not provide relief. The patient underwent excision of the hypertrophic peroneal tubercle and repair of the peroneus longus tendon that had a partial longitudinal tear (Figure 3).
Post-operative management included immediate walking with full weight bearing. Physiotherapy was initiated 3 weeks after surgery and he returned to running activity at 6 weeks. Four months after surgery, he finished the New York marathon.
Case 2
A sixty-year-old male jogger with no history of trauma developed gradual pain on the lateral aspect of the foot. He stopped jogging as a result.
Upon physical examination, localized tenderness was found over the lateral aspect of the foot. It worsened with inversion that generating peroneal stretching and with palpation over the groove of the peroneus longus tendon.
Computerized Tomography (CT) revealed a hypertrophic peroneal tubercle (Figure 4) and in sagital plane saw the enlarged peroneal tubercle and the thickened peroneus longus compared to the other healthy calcaneous (Figure 5).
Conservative treatment resulted in no improvement. Surgical exposure of the lateral ankle disclosed a partial longitudinal tear of the peroneus longus over the enlarged tubercle. Excision of the tubercle was performed followed by suture of the peroneus longus. We noted an anomaly of the peroneus brevis, which was inserted to the peroneal tubercle.
Postoperative management included immediate full weight bearing and initiation of physiotherapy 3 weeks after surgery. He returned to jogging only a few weeks later.