Description of patient (type of occupation, indication of age, intensity of sport):
24 year old recreational soccer player.
History and previous treatment:
Since one year she has complaints posterolateral left ankle after exercise. In the past she had e few ankle sprains. A cortisone injection in the ankle joint gave relieve for one week and al lot of systemic side effects. She had Physiotherapy by a good therapist with no decrease of pain.
Pain after activities and a long day work. No instability.
Recognizable tenderness on palpation behind the lateral malleoli in and a way also over the FHL. Resistance of the peroneal tendon is painful. Forced posterior impingement is not painful. FHL manipulation provokes little pain.
Additional investigation (MRI):
Low riding muscle belly of the FHL and the peroneal tendon without any signal on T2
24 year old lady with pain around her peroneal tendon with low ridding muscle but no signs of tendinitis or fusion of the tendon sheet. Also little pain over the FHL with the same signs on MRI.
Question(s) to this case:
Operative options are:
1) open reduction of the peronal muscle belly
2) in combination with hindfoot artroscopy en reduction/release of the FHL muscle
3) hindfoot artroscopy with reduction of the peroneal muscle and FHL
I'm affraid of option 2 that the weeks cast for the peroneal retinaculum gives adhesions of the hindfoot endoscopy which I normaly immediatly sent for mobilisation.
What would you do?
The muscle belly of FHL is indeed lowriding.
If there is recognisable tenderness over the FHL (which seems to be the case from your description) then endoscopic release could indeed be performed.
If there are also symptoms over the peroneal tendons then tendoscopy of the peroneals can be performed at the same time inorder to check for pathology and possibly resect the lowriding muscle belly. But first check again the MRI for the excistence of a peroneus quartus muscle.