Peroneal Tendon Syndromes Clinical Presentation

The histories for each type of peroneal tendon injury have subtle differences. The key is to have a clinical suspicion and to listen carefully to the patient.

• Peroneal tendinitis

  • Symptoms of pain behind and distal to the lateral malleolus usually occur when the patient returns to activity after a period of time off.
  • Swelling and tenderness may also be present.
• Peroneal tendon subluxation

  • Snapping along the lateral ankle is present, with a sense of weakness or pain. A painful snapping sensation over the lateral ankle is the classic indication of peroneal tendon subluxation.
  • Pain with toe walking or cutting laterally while playing on a field are also observed.
  • With acute injury, pain and swelling are noted over the posterolateral aspect of the ankle.
  • Chronic injuries can lead to subluxation, including recurrent inversion injuries, leading to lateral ankle instability and painful snapping across the ankle.
• Peroneal tendon tears

  • With acute injury, pain and swelling are inferior and posterior to lateral malleolus. The patient may have had pain before the injury, but now the pain is debilitating and strength is decreased.
  • Chronic injury results in the subtle, insidious onset of pain posterior to lateral malleolus that progressively worsens in terms of both function and the level of pain.
• Anomalous peroneus brevis muscle injury

  • This injury can be acute or chronic.
  • The patient may have debilitating pain with the push-off portion of the stance, without a history of ankle injury.

The examination should concentrate on ankle function and stability.

• Inspection: Observe the amount and location of any swelling. Note ecchymosis and any ankle or foot deformity (the foot is in varus for acute brevis tears). Note the position of the peroneal tendons, which may be visibly subluxed without manipulative testing. Observe the patient's gait for abnormal rotation, heel strike, or weight transfer.
• Palpation: Palpate the lateral ankle ligaments and along the peroneal tendons down to their insertion sites. Palpate along the bony structures to identify possible fractures. Palpate the pulses, and check the neurovascular status.
• Specific tests: After testing passive and active plantarflexion, dorsiflexion, inversion, and eversion, a few specific tests for stability should be performed.

  • Anterior drawer test: Have the patient sit on the edge of the table with his or her legs dangling. Hold the distal tibia stable with your nondominant hand as the dominant hand pulls the posterior aspect of the calcaneus forward. Laxity indicates an injury to the anterior talofibular ligament. (See image below.) Anterior drawer test, which assesses anterior talofibular ligament stability. The top hand stabilizes, while the lower hand translates the calcaneus and talus directly toward the operator. From Karageanes SJ. Principles of Manual Sports Medicine, Lippincott Williams & Wilkins, 2005.
  • Tilt test: With the patient seated on the edge of the table with his or her legs dangling, hold the distal tibia stable with your nondominant hand. With the dominant hand holding the calcaneus, attempt to open the lateral ankle compartment. Opening indicates an injury to the calcaneofibular ligament. (See image below.) Tilt test. The operator tilts the talus and calcaneus, not the forefoot. This assesses the integrity of the calcaneofibular ligament. From Karageanes SJ. Principles of Manual Sports Medicine, Lippincott Williams & Wilkins, 2005.
  • Peroneal tendon stability test: The operator hold the athlete’s foot with one hand, while the opposite hand gently palpates the peroneal tendons just posterior to the lateral malleolus. The operator moves the foot into end-range inversion, and then asks the athlete to evert against resistance. The other hand is monitoring the peroneal tendon, feeling for a palpable snap or translation. (See image below.) Peroneal stability test. The patient pushes the foot laterally against resistance, while the operator monitors the tendon. From Karageanes SJ. Principles of Manual Sports Medicine, Lippincott Williams & Wilkins, 2005.

Most peroneal tendon injuries are caused by the typical acute or recurrent lateral ankle sprain. As stated above, isolated injury to the peroneal tendons is rare.

• Acute injury involves forceful dorsiflexion with contraction of the peroneal muscles or an inversion injury with a high load. Most acute injuries have subacute and chronic tendinopathy.
• Chronic injury involves repeated inversion injuries, damage to the posterior talofibular and lateral malleolar retinaculum, and/or recurrent dislocation of the peroneal tendons, leading to chronic tears and lateral ankle instability. (See the image below.) Dislocated peroneal tendons. Left, Note the course of the tendons anterior to the lateral malleolus. Right, Image demonstrates manual relocation of the displaced tendons.

Biomechanical factors can set up the peroneal tendons for injury.

• Gait abnormalities must be fully evaluated and treated. Excessive eversion can pinch and put pressure on the peroneal tendons as they travel between the lateral malleolus and the peroneal trochlea.
• Severe pes planus or hindfoot deviation (valgus or varus) can be a factor.
• Equinus or restricted ankle dorsiflexion can lead to injury of the peroneal tendons.
• Anterolateral ankle impingement, particularly soon after an ankle sprain, can lead to peroneal overcompensation.
• Poor fitting equipment, such as ice skates or basketball high-top shoes, can be factors in peroneal tendon injuries.