Variability in peroneus brevis tendon localisation on magnetic resonance at the lateral malleolus: an observational cohort study

PurposeThis study aimed to classify anatomical variants in peroneus brevis position and assess associations with tendon shape, size, and the presence of the peroneus quartus muscle and low-lying peroneus brevis muscle. MethodsThis observational cohort study included 230 ankle magnetic resonance examinations (3T) with normal peroneal tendons. Peroneus brevis position relative to peroneus longus was categorized into four types: medial, overlapping with medial protrusion, overlapping with lateral protrusion, and overlapping with both. Tendon shape was classified as general flat, flattened convex medially, flattened convex laterally, or oval. Associations between position and shape were tested using chi-square. Differences in cross-sectional area (mm{superscript 2}) and width (mm) across groups were assessed with analysis of variance and Tukeys post hoc test. A regression model identified predictors of tendon overlap. ResultsThe most common position was overlap with medial protrusion (72.0%), followed by medial, lateral, and combined protrusions. Position was significantly associated with shape (p < 0.001); oval tendons were typically medial, while flattened tendons overlapped. Width and cross-sectional area differed significantly across positions (p = 0.0088), with the largest area in tendons protruding medially and laterally (16.9 mm{superscript 2}). Width correlated strongly with overlap (r = 0.79, p <0.001) and was the strongest predictor in regression ({beta} = 0.51, p <0.001). Peroneus quartus was independently associated with increased overlap ({beta} = 0.22, p = 0.03), while low-lying peroneus brevis muscle showed no significant effect. ConclusionPeroneus brevis position is highly variable and depends on its shape, width, and the presence of peroneus quartus.