Abstract
Intersection syndrome is a rare condition often treated by conservative measures. First described in 1841 within orthopedic wrist literature, it is known to have a very low prevalence. The most common area of foot intersection syndrome is at the fibrous knot of henry. A less common area is also along the lateral column at the intersection of the 5th metatarsal base, peroneal tendons, and plantar fascia. The purpose of this case series is to add to the limited literature on this condition as well as explain its etiologies, diagnostic pearls, and options for surgical treatment and postoperative protocol. Clinical procedural code search was performed to identify patients who underwent peroneal tendon evaluation in conjunction with a lateral plantar fascial release. Over a three year time span, we describe eight cases requiring surgical management. Seven of the eight were able to return to normal activity without postoperative complication. We do document one case of recurrent pain within a year of a patient who underwent plantar fascial release and had developed peroneal tendon pathology at a later date. Lateral intersection syndrome is a rare condition which can present itself subtly to the provider. This pathology requires a close watchful eye of recurrent symptoms around the 5th metatarsal intersection. In resistant cases, we describe a successful management with lateral plantar fascial release and peroneal tenolysis.
Introduction
Intersection syndrome is a condition of repetitive friction at the junction of tendons in close proximity, creating persistent tenosynovitis. ,,,, As an overuse type injury, it was initially described in wrist literature in 1841 by Alfred Armand Louis Marie Velpeau and later coined by James H. Dobyns in 1978. Prevalence is typically underreported as it often responds well to conservative treatment. ,,,, Cases of foot intersection syndrome have been described at the “master knot” of Henry.” ,,, The purpose of this paper is to also describe the evaluation and management of a different type of foot intersection syndrome along the lateral column.
Lateral intersection syndrome requires a careful clinical diagnosis. Accurate identification can be difficult due to the many pathological conditions that affect the peroneal tendons, including: tenosynovitis, tendon tear, tendinopathy, tendon dislocation or subluxation, and the presence of painful ossicles. , This type of “fibularis intersection syndrome” or lateral intersection syndrome exists in present literature as an overuse condition occurring at the intersection of the peroneus longus and brevis. For challenging cases resistant to conservative treatment we describe a small cohort of patients who were managed surgically. We describe a small case series of patients who were successfully managed with lateral plantar fascial release and peroneal tenolysis.
Methods
We retrospectively selected patients following electronic medical record search based on clinical procedural terminology (CPT) code search within our practice group comprising tenolysis of flexor tendon (CPT28060) and plantar fascia release (CPT28060). Operative reports, postoperative notes, and perioperative clinical notes were reviewed by the primary author (CM) throughout the patient’s diagnosis and postoperative course. Preoperative history and physicals were reviewed to assess medical comorbidities and social history. Patients were included if they were treated within the last three years, were 18 years or older and had operative intervention based on the above listed CPT codes. Patients were excluded if they did not have a diagnosis of lateral intersection syndrome, were lost to follow up, did not have both given CPT codes, and or did not have available operative reports and postoperative notes with a minimum of 1 year follow up.
Lateral intersection syndrome was diagnosed ultimately out of exclusion. Clinically, each patient presented with persistent pain greater than three months along the plantar lateral column of their foot with diffuse pain along 5th metatarsal base, peroneal tendon sheath and plantar lateral arch. While exhausting all conservative treatment option protocols at our institution, standard weightbearing imaging scans were obtained each revealing no signs of fracture, dislocation, or osseous abnormality.. Further imaging in the form of MRI revealed broad but non-focal signal changes to the peroneal tendons, 5th metatarsal base and irregularities along the plantar fascia. Measurements were recorded for the plantar fascia and peroneal brevis. Musculoskeletal diagnostic ultrasound, while helpful, was also nonspecific in each patient and inconsistently ordered for each case due to provider preference.
Our surgical protocol consisted of the patient positioned in either a lateral decubitus or supine position. A thigh tourniquet is placed and utilized for hemostasis. A curvilinear incision is drawn beginning from the posterior aspect of the lateral malleolus and extending distal toward the base of the fifth metatarsal. The distal and anterior lateral malleolus is identified and a small incision is made with a 15 blade into the combined peroneal tendon sheath just distal and posterior to the apex of the lateral malleolus. The peroneal tendon sheath is then released from its most proximal margin extending into the 5th metatarsal base. Visualization and meticulous dissection at the level of the styloid process and medial under the cuboid groove is performed to release any additional soft tissue adhesions or scar. Following this the surgeon may release the lateral band of the plantar fascia distal to the peroneal insertion. Synovitis is debrided as necessary within the operative field. The patient is then placed in a well padded posterior splint and instructed to remain non-weight bearing.
Results
Following review, we identified eight total cases of lateral intersection syndrome managed with peroneal tenolysis and a release of the lateral plantar fascial band. The average age of the patient was 46.5 years (range 30-62). 62.5 % (n 6) of cases were on the right foot. Each patient went on to return to documented normal weightbearing activities and improved post recovery return to normal function. An average plantar fascial width of 5 mm and a peroneal brevis width measurement of 6 mm was recorded among each MRI study. Two cases of sural neuritis were identified during the postoperative period, one of which required reoperation. Seven cases went on to satisfactory postoperative courses not requiring revision ( Table 1 ).
Table 1
Patient demographic and operative data.
| Patient | Age | Laterality | Complications | Reoperations | Comorbidities | Smoker |
|---|---|---|---|---|---|---|
| 1 | 30 | Left | None | No | None | No |
| 2 | 62 | Left | None | No | Hypothyroid | No |
| 3 | 54 | Right | None | No | None | No |
| 4 | 51 | Right | None | No | IBS, GERD, COPD, OSA, Depression, PTSD | Former |
| 5 | 54 | Right | None | No | HTN, Skin cancer | No |
| 6 | 50 | Right | None | No | HLD | No |
| 7 | 30 | Left | Sural Neuritis | Yes | HLD | No |
| 8 | 41 | Right | Sural Neuritis | No | None | Current |
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