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What’s the Diagnosis – Case 137

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Findings The radiographs show a fragmented bone about the calcaneocuboid joint with proximal migration of the majority of this bone. The bone is situated within the peroneus longus tendon. This is therefore an os peroneum which has fractured. There is marked thickening and T2 hyperintensity/edema of the peroneus longus indicating severe tendinosis and surrounding fluid in the tendon sheath indicating a tenosynovitis. A longitudinal split is present of the tendon with additional intrasbustance tearing of the limbs of the split tendon.

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Diagnosis: Painful Os Peroneum Syndrome Somewhat of a wastebasket term for lateral sided pain related to either an os peroneum ( a sesamoid bone situated in the peroneus longus tendon at the level of the calcaneocuboid joint) and/or tendinosis and tearing of the peroneus longus tendon. The os peroneum is a common finding said to be present in anywhere from 5-30% of the population. It may be present as a single bone, bipartite structure, or multipartite and can be unilateral or involve both feet. Both an acute injury or chronic inversion stress of the foot can lead to pathology of the os peroneum and the peroneus longus tendon. As the peroneus longus contracts the os peroneum can become compressed against the cuboid and cause stress injuries of the os peroneum, fracture, or diastasis across the components of a bipartite or multipartite os peroneum. Similar forces can lead to tendinosis or tearing of the peroneus longus.

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Continued‌ Depending on the location of the tear of the peroneus longus different findings can be found of the os peroneum. If the tear of the longus is directly at the site of the os peroneum the bone can fracture and a portion of the bone can become proximally retracted. If the tear of the longus is distal to the os peroneum then the entire os peroneum can be proximally displaced. The degree of proximal displacement of the os peroneum is also in part related to the integrity of the peroneal retinacula. If the inferior and then superior peroneal retinacula additionally become disrupted marked proximal displacement of the bone can ensue. It is stated with lower grade tears of the longus there is less proximal retraction of the os peroneum or diastasis of a bipartite bone. With complete longus disruption a greater degree of retraction (more than 1cm proximal to the calcaneocuboid joint) of the os peroneum is present. The crux of the matter is that isolated injuries can occur to an os peroneum but given their frequent association with peroneus longus injuries if there is an injury to an os peroneum investigation for peroneus longus injury is warranted.

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References Os peroneum imaging: normal appearance and pathological findings. Stefano Bianchi, Chandra Bortolotto, Ferdinando Draghi. Insights into Imaging. February 2017, Volume 8, Issue 1, pp 59–68. Painful Os Peroneum Syndrome (POPS). Jesse Chen MD, Shirley Hanna MD, Marlena Jbara MD, Cheryl Lin MD, and Raf Ratinam, MBBS. Global Radiology CME. April 29, 2017 Progressive retraction of a fractured os peroneum suggesting repetitive injury to the peroneus longus tendon. Jennifer L.Favinger MD, Michael L.RichardsonMD, Felix S.Chew MD. Radiology Case Reports. Volume 13, Issue 1, February 2018, Pages 216-219. Painful Os Peroneum Syndrome: Underdiagnosed Condition in the Lateral Midfoot Pain. Francisco Abaete Chagas-Neto, Barbara Nogueira Caracas de Souza, Marcello Henrique Nogueira-Barbosa. Case Rep Radiol. 2016; 2016: 8739362. Published online 2016 Jul 5. doi: 10.1155/2016/8739362.

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Profile for Hospital for Special Surgery

HSS What's the Diagnosis Case #137  

55-year-old man with 3 months of lateral foot pain.

HSS What's the Diagnosis Case #137  

55-year-old man with 3 months of lateral foot pain.