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Imaging-based prevalence of the peroneus quartus muscle and its association with peroneal tendon pathology: a
Luiza Borba de Almeida Madruga1, Pandora Eloa Oliveira Fonseca2, Giovanna Macanhã Scremin3
1Department of Radiology, Beth Israel Deaconess Medical Center (BIDMC), 330 Brookline Avenue, Boston, MA, 02215, USA. lmadruga@bidmc.harvard.edu.
Objective:
To determine the imaging-based prevalence of the peroneus quartus muscle and to quantify concurrent peroneal tendon pathology among individuals with this anatomical variant.
Materials And Methods:
A systematic review and meta-analysis were conducted following PRISMA 2020 guidelines. PubMed, EMBASE and Cochrane were searched from inception to 2025 for imaging-based studies reporting peroneus quartus prevalence. Overall prevalence was estimated using generalized linear mixed models with random effects. Heterogeneity was assessed using the I² statistic. Risk of bias was evaluated using design-specific Joanna Briggs Institute critical appraisal checklists. Subgroup analyses examined sex and laterality distribution among positive cases.
Results:
Seventeen studies comprising 3,725 ankle imaging examinations were included. The overall prevalence of the peroneus quartus was 11% (95% CI: 8-15%), with substantial heterogeneity (I² = 80.5%). Among six studies (315 positive ankles), peroneal tendon pathology was present in 51.4% (95% CI: 41.9-60.8%). In three studies reporting tears in ankles with and without the peroneus quartus, its presence was associated with higher odds of peroneal tendon tears (pooled odds ratio 3.40, 95% CI: 2.03-5.68; I² = 0%; p < 0.001). The majority of studies (58.8%) were classified as low risk of bias.
Conclusion:
The peroneus quartus muscle is identified in approximately one of nine ankle imaging examinations, and in studies with a comparison group its presence was associated with higher odds of peroneal tendon tears. This supports the proposed crowding-effect hypothesis, although a causal relationship remains to be established.
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