Review| Volume 57, ISSUE 3, P572-578, May 2018

Prevalence of Peroneal Tendon Instability in Calcaneus Fractures: A Systematic Review and Meta-Analysis

Published:March 14, 2018DOI:


      Peroneal tendon instability associated with an intraarticular calcaneal fracture is a common injury that still often passes undiscovered by both radiologists and orthopedic surgeons. Timely identification of this injury will guide the choice of surgical technique used and treatment of patients. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, several databases were searched through June 2017 for any observational or experimental studies that reported the prevalence/incidence of peroneal tendon subluxation/dislocation with a calcaneus fracture with regard to fracture classifications and the significance of the fleck sign. Nine studies were included, with 1027 patients and 1050 calcaneus fractures. The overall prevalence of peroneal instability (PI) in association with a calcaneus fracture was 29.3%. An increasing prevalence of PI increased the severity of the calcaneus fractures, 5.4% in Sanders I, 19% in Sanders II, 39.4% in Sanders III, and 49.5% in Sanders IV. The presence of a fleck sign is a strong indicator of PI, with a prevalence of 54.7%. The computed tomography findings can overestimate the presence of PI compared with the intraoperative findings. The global reported prevalence of peroneal tendon instability associated with intraarticular calcaneal fractures is high and increases with increasing severity of the calcaneus fracture.

      Level of Clinical Evidence


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The Journal of Foot and Ankle Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Daftary A.
        • Haims A.H.
        • Baumgaertner M.R.
        Fractures of the calcaneus: a review with emphasis on CT.
        Radiographics. 2005; 25: 1215-1226
        • Sanders R.
        Displaced intra-articular fractures of the calcaneus.
        J Bone Joint Surg Am. 2000; 82: 225-250
        • Rosenberg Z.S.
        • Feldman F.
        • Singson R.D.
        • Price G.J.
        Peroneal tendon injury associated with calcaneal fractures: CT findings.
        AJR Am J Roentgenol. 1987; 149: 125-129
        • Toussaint R.J.
        • Lin D.
        • Ehrlichman L.K.
        • Ellington J.K.
        • Strasser N.
        • Kwon J.Y.
        Peroneal tendon displacement accompanying intra-articular calcaneal fractures.
        J Bone Joint Surg Am. 2014; 96: 310-315
        • Panic N.
        • Leoncini E.
        • de Belvis G.
        • Ricciardi W.
        • Boccia S.
        Evaluation of the endorsement of the preferred reporting items for systematic reviews and meta-analysis (PRISMA) statement on the quality of published systematic review and meta-analyses.
        PLoS One. 2013; 8: e83138
        • The Joanna Briggs Institute
        Critical appraisal tools.
        (Available at:)
        • Crim J.
        • Enslow M.
        • Smith J.
        CT assessment of the prevalence of retinacular injuries associated with hindfoot fractures.
        Skeletal Radiol. 2013; 42: 487-492
        • Ebraheim N.A.
        • Zeiss J.
        • Skie M.C.
        • Jackson W.T.
        Radiological evaluation of peroneal tendon pathology associated with calcaneal fractures.
        J Orthop Trauma. 1991; 5: 365-369
        • Ketz J.P.
        • Maceroli M.
        • Shields E.
        • Sanders R.W.
        Peroneal tendon instability in intra-articular calcaneus fractures: a retrospective comparative study and a new surgical technique.
        J Orthop Trauma. 2016; 30: e82-e87
        • Kwaadu K.Y.
        • Fleming J.J.
        • Florek D.
        Superior peroneal retinacular injuries in calcaneal fractures.
        J Foot Ankle Surg. 2015; 54: 458-463
        • Ohashi K.
        • Sanghvi T.
        • El-Khoury G.Y.
        • Ahn J.M.
        • Bennett D.L.
        • Geijer M.
        • Inaoka T.
        • Berbaum K.
        Diagnostic accuracy of 3D color volume-rendered CT images for peroneal tendon dislocation in patients with acute calcaneal fractures.
        Acta Radiol. 2015; 56: 190-195
        • Tresley J.
        • Subhawong T.K.
        • Singer A.D.
        • Clifford P.D.
        Incidence of tendon entrapment and dislocation with calcaneus and pilon fractures on CT examination.
        Skeletal Radiol. 2016; 45: 977-988
        • Wong-Chung J.
        • Marley W.D.
        • Tucker A.
        • O'Longain D.S.
        Incidence and recognition of peroneal tendon dislocation associated with calcaneal fractures.
        Foot Ankle Surg. 2015; 21: 254-259
        • Ho R.T.
        • Smith D.
        • Escobedo E.
        Peroneal tendon dislocation: CT diagnosis and clinical importance.
        AJR Am J Roentgenol. 2001; 177: 1193
        • Meena S.
        • Gangary S.K.
        • Sharma P.
        Review article: operative versus nonoperative treatment for displaced intraarticular calcaneal fracture: a meta-analysis of randomised controlled trials.
        J Orthop Surg (Hong Kong). 2016; 24: 411-416
        • Eckert W.R.
        • Davis E.A.
        Acute rupture of the peroneal retinaculum.
        J Bone Joint Surg Am. 1976; 58: 670-672
        • Heckman D.S.
        • Reddy S.
        • Pedowitz D.
        • Wapner K.L.
        • Parekh S.G.
        Operative treatment for peroneal tendon disorders.
        J Bone Joint Surg Am. 2008; 90: 404-418
        • Selmani E.
        • Gjata V.
        • Gjika E.
        Current concepts review: peroneal tendon disorders.
        Foot Ankle Int. 2006; 27: 221-228
        • Church C.C.
        Radiographic diagnosis of acute peroneal tendon dislocation.
        AJR Am J Roentgenol. 1977; 129: 1065-1068
        • Earle A.S.
        • Moritz J.R.
        • Tapper E.M.
        Dislocation of the peroneal tendons at the ankle: an analysis of 25 ski injuries.
        Northwest Med. 1972; 71: 108-110
        • Essex-Lopresti P.
        The mechanism, reduction technique, and results in fractures of the os calcis, 1951-52.
        Clin Orthop. 1993; 290: 3-16
        • Sanders R.
        • Fortin P.
        • DiPasquale T.
        • Walling A.
        Operative treatment in 120 displaced intraarticular calcaneal fractures: results using a prognostic computed tomography scan classification.
        Clin Orthop. 1993; 290: 87-95
        • Chen W.
        • Li X.
        • Su Y.
        • Zhang Q.
        • Smith W.R.
        • Zhang X.
        • Zhang Y.
        Peroneal tenography to evaluate lateral hindfoot pain after calcaneal fracture.
        Foot Ankle Int. 2011; 32: 789-795
        • Borrelli J.
        • Lashgari C.
        Vascularity of the lateral calcaneal flap: a cadaveric injection study.
        J Orthop Trauma. 1999; 13: 73-77
        • Ehrlichman L.K.
        • Toussaint R.J.
        • Kwon J.Y.
        Surgical relocation of peroneal tendon dislocation with calcaneal open reduction and internal fixation: technique tip.
        Foot Ankle Int. 2014; 35: 938-942
        • Mak M.F.
        • Tay G.T.
        • Stern R.
        • Assal M.
        Dual-incision approach for repair of peroneal tendon dislocation associated with fractures of the calcaneus.
        Orthopedics. 2014; 37: 96-100