peroneal longus rupture/p. brevis tear

by annielou
(Colorado)

53 year-old female, obese, with osteo-arthritis, severe scoliosis. 2009 surgery to remove large bone spur under Achilles tendon left foot. Asthma treated by inhaled cortisteroids last 4 years.

" " items are direct quotations from op report/MRI interp.
I am 5 weeks postop left foot for repair of peroneus longus rupture and peroneus brevis longitudinal split tear. Due to pending surgery right knee, I was non-weight bearing in wheelchair for 4 weeks postop. (My rt knee/hip were very happy about that!) Weight bearing in knee-hi Aircast since last week (4 weeks postop). Other than swelling, no problems or excessive pain - much easier than Achilles tendon surgery.
Right foot is now having symptoms similar to onset of left foot injury in 2012. I want to avoid further progression in right foot, trying to figure out need for second opinion on treatment or whether I need to be more persistent with my podiatrist regarding my concerns.
Am I being paranoid about the same problem happening in my right foot? I will start physical therapy next week (6 weeks postop), and I know what is good for left foot will be also be helpful to strengthen the right foot. Still, I feel like there is an ever-increasing speed and cycle of injury and damage here. I don't want to get have the same thing happen on the right foot.

Detailed history below (You did say 'be as specific as possible', sorry for the length.)
Recent history, reverse chronological order:
June 5, 2013 Surgical Procedure: "Peroneal anastomosis, peronus longus to brevis in a functioning physiological tension position, left ankle."
Post-op diagnosis "Essentially ruptured peroneus longus tendon in the midsubstance with secondary healing, with loss of any physiological tension of the peroneus long tendon, left ankle. Longitudinal split tear, peroneus brevis tendon."
Pathology: "Noted ruptured peroneus longus tendon in the midfoot arch which had adhesed or re-scarred back in attenuated and elongated position thus making it nonfunctional."
(detail from the op report) Peroneus brevis tear was "identified, debrided and repaired." When p.longus was found to have "re-scarred back", "the peroneus longus tendon was pulled distally to increase its physiological tension. Once this was accomplished it was anastomosed to the brevis...in running technique." "The tendon was noted to function in conjunction with the peroneus brevis postoperatively."
May 24, 2013 MRI report "high-grade and suspected full thickness tear of the distal aspect of the peroneus longus, approx 10 mm from the distal insertion. Minimal and poorly defined tendon retraction. Surrounding tendon fibers are highly thickened, irregular and edemateous." This area looked like a badly frayed rope (my words). Decision for surgery peroneal anastomosis. Pre-op diagnosis: 1. Ruptured peroneus longus tendon, 2. Peroneus brevis longitudinal split tear
May 17, 2013 I was walking (in Aircast) when I felt/heard a 'THUNK' bottom-middle of left foot, severe pain, swelling. No break found by xray at ER. Started using crutches, and Aircast 24/7. RICE, NSAIDs and waited for approval of MRI by insurance...
April 2013 Returned to podiatrist, went back to using Aircast, RICE, NSAIDs. No improvement after 4 weeks. Saw podiatrist again, MRI ordered May 16, 2013. Due to insurance issues, MRI did not happen until May 24 2013 (after ER visit).
March 2013 - Severely twisted right knee, full thickness meniscal tear, torn cartilage on femur and tibia, bone on bone in two compartments of the right knee joint. Surgical options were being discussed, including possible knee replacement. Left foot became primary weight-bearing. Left foot pain increased to point of non-weight bearing by the time I saw podiatrist in April.
July 2012 Saw podiatrist, no fracture or bone-related problem found by xray. Presumed diagnosis was stress fracture with possible concurrent peroneus longus tendonitis. Treated with immobilization (boot) for eight weeks, switched to surgical shoe for 4 weeks then back to regular shoes. Pain was less but still present. Did not get follow up MRI due to insurance/financial issues. Treated pain with NSAIDs, ice, elevation.
June 2012 Left foot burning/very painful, outside and bottom of foot in cuboib region.
April 2012 Started having significant arthritis pain in *right* hip and knee, left foot/leg bore most weight.

Ancient history, chronological order:
- Longterm Achilles tendonitis left foot, 10+ years (onset in late 1990s, flared up and subsided many times). Treated with physical therapy, RICE. Consistently painful from 2002-2009.
- Arch pain in both feet (very high arches) treated by custom made orthotics which helped a LOT
2002-2004 extensive physical therapy for back paid associated with scoliosis, right knee and shoulder pain, left foot pain and Achilles tendonitis.
2007 Began exercise and weight loss program. Recumbent bike, free weights, phys therapy exercises for back, knee, shoulder.
2008 xray showed large bone spur under Achilles tendon. Tendonitis treated by NSAIDs, ice, immobilization for about 16 months, before seeing podiatrist for second opinion.
April 2009 Surgery left foot to remove large bone spur under Achilles tendon. Favorable results but long term swelling without pain on outer side of foot in peroneal tendon area. MRI 6 months postop showed fluid in the peroneal tendon sheath but no tear. Overall foot response after surgery was good, NO Achilles pain for first time in a decade!!!
August 2009 Surgery right knee to remove 3 large loose bodies, repair torn meniscus and trim torn cartilage. Previously problem, was exacerbated when right leg was primary weight-bearing after left foot surgery.

RESPONSE

Hi Annielou,

Thank you for your life story regarding your feet, ankles and knees. The only word I really needed to see was "obese" and I could almost predict your history of lower extremity problems.
I am probably not telling you any thing you do not already know, as you strike me as being fairly intelligent based on the narrative you supplied me with.
Your "scenario" presents to most podiatrists on a regular basis. Due to your excess weight, your feet, ankles and knees are essentially collapsing under the strain of carrying so much weight. It will be more progressive in some rather than others, but will happen to everyone who carries too much weight.
So what is happening here is that your doctors and surgeons are trying to repair damage that has already occurred, when in reality you are the only one who can prevent the problems from happening in the first place.
It is important to note that every time one of your surgeons "fixes" one of your problem, even with the best technique and result, the final product is never as good as the original product. This is because once mankind starts messing with what mother nature put together there is going to be inherent issues like scarring, loss of function, etc.
Based on the way you have been addressing your problems, in my opinion, you are fighting a losing battle as you will continue to have lower leg issues going forward.
The only way you are going to avoid further problems is to either spend the rest of your life in a wheelchair or lose weight.
Your are way too young to be in a wheelchair.
What I am about to say is the same thing I say to similar patients in my office, you need to take charge of your life.
I am not saying it will be easy, in fact it will be difficult. You need to make "getting healthy" the number one priority in your life.
This means finding a doctor who specializes in nutrition, working with a trainer who specializes in your situation and making life style changes.
This may not have been the answer you were hoping for but in my way of thinking it is the only thing that may prevent similar problems with your right foot.
For the short term in order to prevent further progression of the right foot, one area you might want to discuss with your podiatrist is what is known as an ankle-foot orthosis (AFO). This device is an orthotic which not only supports your foot, but also stabilizes the ankle joint and tries to create proper alignment of the foot, ankle and lower leg. If you have proper alignment, then you reduce the stress of the tendons coming into the foot (peroneal tendons,etc.) and reduce the chance of tendon problems.
The reason I think an ankle foot orthosis might be a better idea than a walking cast is that the AFO will allow you to walk more normal, while a walking cast may put too much strain on your other leg which may then aggravate that leg.
Good luck.

Marc Mitnick DPM
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