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MRI Features of Chronic Injuries of the Superior Peroneal Retinaculum

¹ Radiology Department, Hospital for Joint Diseases, 301 E 17th St., New York, NY 10003.
² Huntington Hospital, North Shore Long Island Jewish Health Center, New Hyde Park, NY.
³ Orthopedic Department, St. Luke's-Roosevelt Hospital, New York, NY 10003.

View larger version (40K): [in a new window]   Fig. 1. —Drawing of normal superior peroneal retinaculum. Retinaculum originates from distal fibula. Most common insertion sites include lateral wall of calcaneus and aponeurosis of Achilles tendon. AT = Achilles tendon, PL = peroneus longus, SPR = superior peroneal retinaculum, IPR = inferior peroneal retinaculum, PB = peroneus brevis.

View larger version (138K): [in a new window]   Fig. 2. —MRI of normal superior peroneal retinaculum in 30-year-old man. Axial T1-weighted image (TR/TE, 700/22) depicts superior peroneal retinaculum (thick white arrows) blending with fibrous ridge (thin white arrow) at fibular malleolar attachment site and traversing posteriorly toward aponeurosis of Achilles tendon. Flat fibular groove (straight black arrows) accommodates peroneal tendons (curved arrow).

View larger version (47K): [in a new window]   Fig. 3. —Schematic representation of Oden's surgical classification of superior peroneal retinacular injuries [4]. Normal indicates that superior peroneal retinaculum originates from distal fibula. Small fibrous ridge is noted. Type I indicates that superior peroneal retinaculum is stripped off distal fibula, forming pouch lateral to bone. Peroneal tendons can sublux or dislocate into this pouch. Type II indicates that superior peroneal retinaculum is avulsed of its distal fibular insertion. Type III indicates that superior peroneal retinaculum, along with small avulsion fragment, is avulsed off distal fibula. Type IV indicates superior peroneal retinaculum is torn off at its posterior attachment. PB = peroneus brevis tendon, PL = peroneus longus tendon, SPR = superior peroneal retinaculum.

View larger version (154K): [in a new window]   Fig. 4. —Type I superior peroneal retinacular injury in 44-year-old man after ankle sprain. Axial spin-echo proton density image (TR/TE, 1,183/30) shows pouch formed by stripped-off periosteum and superior peroneal retinaculum (thin solid arrows). Peroneus brevis and longus tendons (thick arrow) are dislocated into pouch. Fibular groove (open arrow) is flat.

View larger version (165K): [in a new window]   Fig. 5. —Type I superior peroneal retinacular injury in 49-year-old woman with chronic dislocation of peroneus brevis tendon. Axial T1-weighted image (TR/TE, 900/22) depicts dislocation of peroneus brevis tendon (curved arrow) into pouch formed by elevated superior peroneal retinaculum (straight long arrow). Fibular groove (straight short arrows) is irregular and flat. Small fragment of peroneus brevis tendon remained in groove (open arrow).

View larger version (152K): [in a new window]   Fig. 6. —Type I superior peroneal retinacular injury with collapsed pouch in 48-year-old man with posttraumatic clinically dislocatable peroneal tendons. Axial T1-weighted image (TR/TE, 900/22) depicts linear low signal lateral to distal fibular groove (white arrow) consistent with collapsed pouch. Peroneal tendons (black arrow) are in normal position.

View larger version (157K): [in a new window]   Fig. 7. —False-positive finding of type II superior peroneal retinacular injury in 28-year-old woman with pain along lateral malleolus suspected clinically to have superior retinacular injury. Thickening and indistinctness of superior peroneal retinaculum are noted on axial T1-weighted image (TR/TE, 900/22) and were believed to be avulsion injury. At surgery, superior peroneal retinaculum was edematous but intact.

View larger version (140K): [in a new window]   Fig. 8A. —Type III superior peroneal retinacular injury in 48-year-old woman with history of chronic peroneal tendon instability. Axial T1-weighted image (TR/TE, 800/20) depicts focal defect in distal fibula (straight long arrow) consistent with avulsion fracture. Avulsed cortical fragment is not visualized. Superior peroneal retinaculum (open arrow) is thickened and disrupted. Peroneus brevis and peroneus longus tendons (curved arrows) are in normal position. Tear of peroneus brevis was suspected.

View larger version (131K): [in a new window]   Fig. 8B. —Type III superior peroneal retinacular injury in 48-year-old woman with history of chronic peroneal tendon instability. Fast spin-echo T2-weighted image (4,500/96) depicts increased signal in distal fibula (asterisk) consistent with marrow edema. Fluid is also present in peroneal tendons' sheath. Defect in distal fibula (long arrow) and thickened superior peroneal retinaculum (short arrow) are again seen.

View larger version (143K): [in a new window]   Fig. 9. —MRI of type I superior peroneal retinacular injury in 37-year-old woman. Axial fat-suppressed proton density image (TR/TE, 3,280/32) depicts dislocation of fragmented peroneus brevis tendon (solid arrows) into pouch formed by stripped superior peroneal retinaculum. Peroneus longus tendon has migrated proximally (open arrow). Peroneus quartus tendon (arrowhead) is medial to peroneus longus tendon.

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