Weekly Case

Title : Case 687

Age / Sex : 71 / F


Chief complaint : left foot pain (onset: 2mo ago), dystonia of left foot, on medication for parkinson disease

What is your diagnosis?

Two weeks later, you can see the final diagonosis with a brief discussion of this case (Please submit only one answer).


Courtesy : 
정혜원 Hye Won Chung, 서울아산병원 Asan Medical Center


 


Diagnosis:

Cuboid Pulley Lesion



Discussion


Findings:


Bone marrow edema is noted at the lateral and plantar ridge of the cuboid (arrow head), which is wrapped by the peroneus longus tendon (arrow).


Peroneus longus tendon shows swelling and subtle enhancement at the lateral aspect of plantar foot near the cuboid bone. Tendon sheath is thickened and diffusely enhanced.


These findings suggest tendinosis and tenosynovitis of peroneus longus tendon.


 


 


Differential Diagnosis:


Acute traumatic tendon injury


Neuropathic arthropathy


Osteomyelitis and infectious tenosynovitis


Inflammatory tenosynovitis


Painful os peroneum syndrome


 


Discussion:


The cuboid acts as a bony pulley for the peroneus longus tendon. Peroneus longus tendon changes its direction as it wraps around the cuboid ridge. Thus muscle contraction from the midstance through the late propulsive phase exerts an eversion torque on the cuboid through the peroneus longus tendon. In a wraparound region against the bony surface, the tendon experiences mechanical stress. When compressive stress is added perpendicularly to the direction of the tendon fiber in the wraparound region, tendon experiences local pressure near the contact surface. So the cuboid pulley also endures local stress on the contact surface against the tendon.


Significant associations exist between cuboid pulley lesions and peroneal tenosynovitis, Achilles enthesitis, and inflammatory arthritis


 


There are four peroneus longus pulleys: lateral malleolus, peroneal notch of calcaneus, peroneal groove of cuboid, and base of 1st MT bone and medial cuneiform. Tendon changes its direction at these points.


 


 


 References:


MRI of cuboid pulley lesion.  AJR 2018; 211:867–871


Normal variants and diseased of the peroneal tendons and superior peroneal retinaculum: MR 

imaging features. Radiographics 2005:25;587-602


https://epos.myesr.org/posterimage/esr/ecr2015/129247/media/612751



Correct Answer
Total applicants 21 Correct answers 5
Name Institution
윤유성 순천향대 부천병원, 전문의
김기욱 전문의
김동언 서울아산병원, 전문의
박진희 서울아산병원, 전문의
권기언 서울아산병원, 전문의
Semi-Correct Answer
Total applicants 21 Semi-Correct answers 2
김형민 연세의대 강남세브란스병원, 전문의
김성진 365병원, 전문의


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