MRI Shows Brevis Split Tear, but that's not where it hurts

Triathlon Forum
1

Hi folks -

So about 6 weeks ago, I woke up one morning with pain on the side of my foot towards the heel (lateral posterior calcaneus), sort in in the center of the flat part there. Here’s the overview:

Pain worse in morning directly out of bedPain mostly at heel-lift, just as heel lifts, or on inversion under loadNo swelling or discolorationNo pain on impact, percussionCalf stretching helps a lot with symptomsRiding and swimming seem fine.
I initially ran short on this a few times, and it got significantly worse. Felt like a sprain with pain epicenter about 2cm below the malleolus, but sore all over the side of the calcaneus back towards the heel - but generally hard to localize the pain. Took several weeks off running, pretty much to pain free. Two mile run, no dice. After more time off, it’ll feel much better but even too much walking will result in soreness the next AM.

So I bit the bullet and got an MRI last week (checking peroneals and sfx). Result? 4.5cm split longitudinal tear. Seems to have progressed since another MRI in the area (totally different issue on medial side) in 2010.

Moderately large peroneal tendon sheath effusion is present, and the effusion extends into the plantar midfoot. The PBT forms a longitudinal split at the retroareolar groove. The 2 components rejoin distale to the peroneal tubercle…There is prominent tenosynovitis

I’ve rolled that ankle many times (not recently), and my peroneals subluxate a bit on dorsiflexion. But, my PBT doesn’t hurt. At all. Not on palpation, not on resistance. The pain I get running is distal/posterior to that area by a cm or more (hard to hold the ruler there when running ;)).

Upon talking with the doc about this (sports med), she suggested that the pain is coming from my lower back, given the lack of symptoms. I’ve got a messy L5/S1 bulge on that side, many years old, but it been behaving lately. I’m skeptical of this because the pain I have acts like a real injury with the morning being worse and it getting better if I lay off it, but not really better.

How likely is this? Could that effusion be causing symptoms away from the injury site? How is it I’m asymptomatic with that big of a tear?

I’m a little stumped as to how to tackle this at this point. The MRI doesn’t show any thing else.

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I’m confused because you say it doesn’t “hurt” there, but your symptoms are consistent with your MRI findings and you are describing pain there? Many people walk/run around on split peroneal tendon tears for quite some time, but generally always do have some symptoms - often vague like you are describing. MRIs can be misread if not a good musculoskeletal radiologist (i.e. peroneal longus and brevis split low behind the malleolus and misread as a tear), but I think your reading is good. A 4.5cm tear if pretty large and that will definitely not heal on its own, immobilization or not. Your subluxing peroneals isn’t helping of course. I’ll assume you have a high arched, somewhat rigid foot as well.

3

Thanks for the reply. Yes, high arches.

I do not have any pain along the trajectory of the PBT itself. I get pain on the side of my calcaneus, 1-2cm beyond the malleolus (e.g… towards the the bottom of the foot), often all the way back to the heel. When its sore, the sorest point to palpation is along the forward ridge of the lateral process, but typically if I point to where it hurts, I’ll point to the broad part of the lateral calcaneus.

I guess I’m expecting to have some sort of pain along the tendon trajectory itself and/or some way to reproduce symptoms that are local to it.

But maybe you’re answering my question, you’re saying this sort of non-localized pain is consistent with the MRI findings even w/o direct PBT symptoms?

4

That midpoint calcaneal point you are describing is likely the peroneal tubercle and about where most tears end (or begin, depending on one’s perspective) and is commonly a source of pain. Yes, most people do have some tenderness proximally along the peroneal sheath with your MRI (made worse with weigtbearing inversion), but no all. Hard to ignore that MRI, but a live ultrasound exam with moving the ankle/tendons might be useful as well.

5

I can’t really answer your question but I had the same tear late in 2010. I woke up a few days after my last race of the year with ankle pain, like I rolled it to the outside. I took 3 months off from running and biking and it didn’t go away. I didn’t notice it in daily activities, but any heavy lifting or uneven terrain would remind me something wasn’t right. MRI showed 5cm longitudinal tear in peroneus brevis tendon. My pain was just behind and above the malleolus. I now have a 10cm scar which follows the PBT and is pretty well centered on the bottom of the malleolus.

Jeff

6

Thanks!

Yeah, mine hurts in a different place but the input makes me think I need another local opinion.

So you had surgery? How did that go?

7

I too had a PBT back in fall of 10’ I took three month off no running , ate well and slowly came back and all was well. Since then I have had two flare-ups one that I just got over where I get tendonitis type symptoms so I dial down the running take some proteolytic enzymes and it fades away.

8

I have high arches as well. Yes, right into surgery a few days later to try and save IMLP that summer. Surgery kind of sucked, but I had never had surgery before so it could have been not that bad compared to others. 2 months in crutches and another month in a boot. 3mos PT starting 8wks after surgery. 1/26 surgery, 5/18 first jog (10min), 7/24 IMLP (6:36 bike & 4:20 run). Now a days it is always tight in the morning but loosens up in a few minutes. I’m still really careful with it, am always worried about rolling it, or hurting it when I feel it on a ride or run, etc… I hope that some day that fear might go away.

Jeff