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Saturday, April 18, 2015

Peroneal Tendon Injury: Email Advice

Dear Dr. Blake,
I am in my late 50s and fractured my os peroneum bone into several pieces along with tearing my peroneus brevis and longus tendons making a sharp turn, walking in my office.  I did not twist my ankle...I was just walking.  I would greatly appreciate any advice you have for me.
I stupidly delayed treatment for 5 months, but have now completed 10 weeks in a short CAM walker including a) 10 weeks of wrapping sponge and Elastikon tape around my foot, in front of the ankle (yet covering the os peroneum) and b) 7 weeks of using the Exogen bone stimulator twice daily.  The new Xray shows slight new bone being deposited in the area.  I am just starting the process of gentle stretching and weaning out of the boot.  Your website has really helped me (and others I am sure) now understand good pain versus bad pain, and how to wean into a shoe.
Dr Blake's comment: Your injury does not make sense. How could you fracture a bone and tear two tendons without a significant fall/sprain? "Something is rotten in Denmark" borrowing from Shakespeare. But you did injure something, and did not get it treated for 5 months, so you placed yourself into the Immobilization Phase. I would only be convinced of a os peroneum injury with a positive bone scan, or bone edema on MRI. Please email me with other info you have. 
Thank goodness I no longer have the os peroneum syndrome sensation of stepping on sharp rocks.  If you have time, I would appreciate your answers and any treatment suggestions that you have for me:
1.      Have you successfully treated os peroneum fractures?
Dr Blake's comment: Our surgeons have had to remove several, and several just stopped hurting with orthotics, etc. I have seen so few that I do not have a great understanding. Several I thought were not injured, it was just the inflammation from the tendon injury that made the bone look inflamed. You did the right thing getting the bone stim.
2.      Do you think that I should continue to tape my foot?  If so, what tape brand and where would you recommend that I apply it?  The recommended Elastikon tape around my foot in front of my ankle in the shoe is bulky, even with the new extra wide sneaker with a wide base.
Dr Blake's comment: I love this tape you get at Get the small size. 
3.      I have a naturally wide foot.  I feel pressure from the tied sneaker being pulled over the os peroneum area.  Should I cut a hole in the sneaker so that it doesn’t rub that area?
Dr Blake's comment: I am afraid that that would lead to some instability. Get some 1/4" adhesive felt from and place on your foot in areas that take the pressure off the sore area. 
4.      My podiatrist wants to firmly press along the tendon and broken bone every time I see him.  I am worried about aggravating or slowing down the healing process.  Should I be?
Dr Blake's comment: No, that does not come close to weight bearing stress. However, soreness from this problem will remain for up to 1 year longer than the injury, as the healing continues. So, palpable soreness is a poor way of judging healing. Gradual improvement in function, or lack of improvement, is a better way. 
5.      Does the bone stimulator help?  Can it hurt if I use it too long?
Dr Blake's comment: Unsure if it helps, since I am not sure what you have, but if will do no harm. 
6.      When will it be OK for me to wear 1” wedge shoes again?  Before I went into the CAM walker, I found that a slight wedge shoe was actually more comfortable because it shifted the weight off of that area of my foot.
Dr Blake's comment: You are gradually moving from the Immobilization Phase, through the ReStrengthening Phase, and into the Recovery to Activity Phase. You said that you tore some tendons, are you doing something to get them strong? MRIs typically show peroneal tendon problems when they do not exist. I would need more info on those tendons. You should be doing peroneal tendon strengthening exercises, and gradually introducing various shoes to see what works (start with one hour at a time). You really do not know how healed you are right now. Go easy. 
7.      Other suggestions?
Dr Blake's comment: I love orthotics for this, but the doc/therapist/pedorthist has to know about stabilizing that half of your foot (lateral one half). See my blog posts on supination correction with orthotics to give you some idea. Definitely, continue icing and contrast bathing daily to control inflammation and increase healing with swelling control. Good luck!!
Dr. Blake, thank you for taking the time to get back to me.

And the patient's response:

Dear Dr. Blake,

Thank you for all of your good advice and especially for the reminder to go easy. I needed that.

By way of background, I should have mentioned that an MRI confirmed the X-ray finding of a fractured  os peroneum which is now in many fragments.  For comparative purposes, an X-ray of my good foot showed an intact os peroneum.  It was a freak injury where I was walking quickly and took a quick turn.  It felt like someone hit me in the foot with a bat.  Two radiologists independently confirmed the fragmented os peroneum, severe partial tears of the perroneal brevis and longus tendons and that the distal peroneum tendon appears thinned. Besides intense pain flexing my foot away from my body, I had the sensation of stepping on sharp stones with every step and weakness/the inability to lift my heel and go up on my toes on the one bad foot.

You have me thinking now that there is something rotten in Denmark.  It has been about 8 years since my last bone scan, and maybe it is time for another.  I have been practicing yoga barefoot for about 10 years.  Would flexing my foot at 45 degrees in certain yoga lunges  or downward dog poses put added strain on the tendons simply because I have an os peroneum bone?  What causes a tendon to thin?  I sure welcome any insight you have to help prevent this from happening again.

Still grateful,

Dr Blake's comment: 
     Thank you for the response and confirmation that we are dealing with an Os Peroneum Fracture. The bone is so buried in your foot, I have a hard time understanding how it breaks in the first place without a history of a fall. A bone density screen is great. Again, the peroneals get thinned and look bad on most MRIs even when they do not hurt (more mystery). How is the tendon function? Are you strengthening the peroneus longus and brevis? Rich

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.