eMedicine Specialties > Sports Medicine > Lower Limb

Peroneal Tendon Syndromes

Steven Karageanes, DO, Director, Primary Care Sports Medicine Fellowship, Director, Sports Medicine Education, Center for Orthopedics and Neuroscience; Department of Medical Education, Oakwood Healthcare System
Kathleen Sharp, MD, Sports Medicine Fellow, Department of Family Practice, Henry Ford Hospital

Updated: Sep 2, 2008

Introduction

Background

Injuries to the peroneal tendons are common but not always clinically significant.¹ They are misdiagnosed as a lateral ankle sprain most of the time, because isolated injury to the peroneal tendons is rare.^2,3 Injury can occur in one or both peroneus longus and brevis tendons and is typically classified as acute or chronic. Function can be severely compromised by any tendon disruption; conversely, complete tendon rupture can be asymptomatic. Lesions have been seen in symptomatic patients, as well as in cadaver studies of patients who were presumably asymptomatic.⁴ The reason for this variation is not known.

Acute injuries of the peroneal tendons include tendinitis, tear/rupture, laceration, and dislocation/subluxation. Acute injuries typically have 1 of 2 mechanisms as the cause: (1) inversion ankle injury, which is often seen with associated anterior talofibular ligament and/or calcaneofibular ligament disruption, and (2) a powerful contraction of the peroneal muscles with a forcefully dorsiflexed foot.

Chronic injuries include longitudinal tears^5,6,7,8,9 and recurrent subluxation^10,11,12 of the peroneus brevis tendon.¹³ These chronic injuries are usually associated with ankle or subtalar arthritis and ankle instability. People with "bad" or "weak" ankles may have peroneal tendon pathology. Core and lower extremity biomechanics must be evaluated in any chronic atraumatic peroneal tendinopathy, as flaws in those mechanics are usually the culprit.

For excellent patient education resources, visit eMedicine's Foot, Ankle, Knee, and Hip Center and Sprains and Strains Center. Also, see eMedicine's patient education article Ankle Sprain.

Frequency

United States

The occurrence of injuries to the peroneal tendons is not actually known. DiGiovanni et al found that 25-77% of patients with chronic lateral ankle instability had some type of injury to the peroneal tendons.¹⁴ Over 33 months, Fallat et al noted that of 638 acute ankle "sprains" seen at the Oakwood Hospital Downriver Center Emergency Room and Occupational Medicine Clinic in Dearborn, Michigan, only 83 involved damage to the peroneal tendons, whereas more than 450 involved the anterior talofibular ligament.¹

Functional Anatomy

The peroneal tendons originate in the lateral compartment of the leg. The peroneus longus originates from the head and proximal two thirds of the fibula, whereas the peroneus brevis originates from the distal two thirds of the fibula. Both tendons have a musculotendinous portion that courses just below the lateral malleolus.

At the posterior aspect of the lateral malleolus, the peroneal tendons lie within the fibular groove, with the peroneus brevis medial and anterior to the peroneus longus. The fibular groove forms the anterior border of the fibro-osseous tunnel that the peroneal tendons course through. The inferior retinaculum and the calcaneofibular ligament form the posterior border.

The posterior talofibular and the calcaneofibular ligaments form the medial border. The superior retinaculum forms the lateral border. Just inferior to the lateral malleolus, the peroneus brevis courses anteriorly, crossing over the cuboid to insert on the fifth metatarsal styloid.

Inferior to the peroneus brevis, the peroneus longus turns beneath the cuboid in a tunnel formed by the long plantar ligament and the groove of the cuboid. It then courses to insert onto the first metatarsal and medial cuneiform. In 20% of the population, an os peroneum may be present within the peroneus longus tendon as it turns under the cuboid bone. In 0.1% of the population, a structure known as the os vesalianum—a sesamoid bone—is found at the insertion of the peroneus brevis tendon.

Sport-Specific Biomechanics

Most sports have elements of running and lateral movement. Sports such as soccer, basketball, and football can be highly demanding on the lower extremity.

The role of the peroneus muscles is to evert the ankle and stabilize its subtalar motion. In balancing the foot, they play off the posterior tibialis muscle on the opposite side of the tibia. Maximal exertion occurs with side-to-side movement and jumping.

The importance of the peroneus muscles is most obvious after lateral ankle sprains. Trauma to the lateral ankle distorts the proprioceptive sense and stretches the connective tissues. The peroneus muscles are often stretched and injured from traction when the foot inverts.

Ankle instability ensues and continues until the lateral retinaculum heals, the peroneal muscles recover, and proprioception returns. If the retinaculum does not heal properly and cannot retain its tension to stabilize the peroneal tendons, symptoms of instability may not resolve without further intervention.

An analysis of overall biomechanics is essential in finding out the factors involved with peroneal tendon damage, especially when there is no traumatic insult. Leg-length discrepancies, femoroacetabular impingement, core instability, and low back pain are some of the correlated factors involved with lower extremity repetitive injuries, but little research has cemented the relationship. However, the core is the powerhouse of the body, and if foot planting is not well controlled by the hip and thigh, then extraneous forces run through the lower leg, ankle, and foot. This can only be controlled by increasing the activity of the supporting muscles, of which the peroneal tendons belong.

Clinical

History

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.

Physical

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 2.)
  • 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 3.)
  • 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 5.)

Causes

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.

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.

Differential Diagnoses

Other Problems to Be Considered

Ankle arthritis
Calcaneus bone injuries
Distal fibula fracture
Fifth metatarsal styloid fracture
Os trigonum
Osteochondritis dissecans
Peroneal nerve palsy
Sinus tarsus syndrome

Workup

Imaging Studies

• Radiography is the first-line study for excluding fractures of the lateral malleolus or calcaneus, arthritis, or loose bodies. Radiography is also useful to observe a migration of the os peroneum in a peroneus longus tendon rupture. Most importantly, radiographs are used to identify a rim fracture, which is an avulsion of the superior peroneal retinaculum from the lateral malleolus. A talar stress view is helpful; if more than 15° of tilt is seen, talar instability that can lead to peroneal instability may be present.
• Magnetic resonance imaging (MRI) is the criterion standard for identifying peroneal tendon injuries, which are demonstrated by the high signal intensity within the affected tendon on T2-weighted axial views.^6,16,17  Kijowski et al found that the presence of uniform or predominantly intermediate signal intensity within the peroneal tendons on 3 consecutive axial proton density-weighted images is a highly sensitive and moderately specific indicator of symptomatic peroneal tendinopathy, as well as the presence of circumferential fluid greater than 3 mm in maximal width.¹⁶
• Ultrasonography is useful for detecting all types of peroneal lesions. In particular, real-time ultrasonography can be performed to assess dynamic stability.^7,11,18 This approach is institution dependent because not all facilities are proficient with musculoskeletal ultrasonography. However, Neustadter et al found the positive predictive value of dynamic ultrasonography for peroneal tendon subluxation was 100% in 13 patients.¹¹
• Computed tomography (CT) scanning is useful for evaluating bony irregularities and suspected fractures, particularly in the calcaneus.¹⁹  Heterotopic ossifications can also be identified more accurately with CT scans.
• Tenography is useful for assessing large lesions of the tendons but is rarely used in practical settings.

Related Medscape topic:
Specialty Site Radiology

Other Tests

• Electromyelography (EMG) may be useful in difficult cases with profound weakness and no significant damage to the peroneal tendons.
• EMG should be used in instances of drop foot.

Treatment

Acute Phase

Rehabilitation Program

Physical Therapy

In the acute phase, most ankle injuries are managed with rest, ice, compression, and elevation (RICE), with or without a short period of no weight bearing. Nonsteroidal anti-inflammatory drugs (NSAIDs) can also be prescribed to reduce inflammation and pain. Once the swelling and pain have decreased, a more extensive examination can be performed. If the symptoms are minimal and if no significant instability is present, a rehabilitation program can be started. This program should include an ankle strengthening, flexibility, and proprioception regimen.

In cases of peroneal tendinosis in which the tendon is degenerated but not ruptured, acute care may include 2-6 weeks of cast immobilization, particularly if the symptoms are recurrent.

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Medical Issues/Complications

Complications of conservative treatment are continued symptoms that worsen and instability of gait that leads to falls or further injury to the ankle.

Surgical complications vary depending on the procedure. They may include sural nerve injury, continuation of symptoms, chronic lateral ankle pain, and restricted range of motion.

Surgical Intervention

Surgery is indicated in the acute phase for peroneus brevis tendon rupture, acute dislocation, anomalous peroneal brevis muscle hypertrophy, and in peroneus longus tears that are associated with diminished function.²⁰ Tears can be horizontal or longitudinal. The repair for subluxation usually involves the peroneal retinaculum, the lateral ankle ligaments, and possibly the peroneal tendons. A procedure to deepen the fibular groove is also performed in many cases.¹²

Consultations

An orthopedic surgeon, or a foot and ankle surgeon, should be consulted for surgical repair or if an associated fracture is identified.

Other Treatment

Cast immobilization with a short leg non–weight-bearing cast for 4-6 weeks with the foot in plantarflexion and inversion is an alternative treatment for acute peroneal tendon dislocation.

Injection with corticosteroid is not recommended for the peroneal tendons. The peroneal tendons are very superficial and are in close approximation with the sural nerve. Injecting in this area can cause fat necrosis and a sural neuroma, making it painful for the patient to wear a shoe.

Recovery Phase

Rehabilitation Program

Physical Therapy

In the recovery phase, steps are taken to restore ankle strength and flexibility and to return the patient to their activity.

With respect to surgical/casting intervention, there is a period of cast immobilization from 2-6 weeks, depending on the procedure. Then, the patient wears a walking boot for another 2-3 weeks.

Once the cast is removed after either surgical or nonsurgical treatment, a physical therapy regimen is started with light range of motion progressing to stretching exercises. Once the boot is removed, therapy continues to progress until the patient has 80-90% of their strength and function as compared with the nonaffected ankle. The patient then may participate in activities with a brace or ankle taping. Bracing and taping has been recommended for as long as 6 months, depending on the surgical repair.

Proprioceptive rehabilitation is crucial because recurrent ankle sprains are related to poor muscle firing and balance. Every sprain can stretch and damage the peroneus tendon fibers, loosen the lateral supports, and create further instability. Athletes need to be aware that recurrent injury without proper rehabilitation can destabilize the ankle supports and create further problems.

Surgical Intervention

For persistent symptoms with peroneal tendinitis, a tenosynovectomy is the procedure of choice.

Chronic tears of the peroneal tendons with persistent pain and instability require surgical repair. Tendinosis may cause nodules or scar tissue that may need debridement. Longitudinal tears that fail treatment with immobilization may be present.

Consultations

An orthopedic surgeon, or a foot and ankle surgeon, should be consulted in cases of continued ankle pain or instability.

Maintenance Phase

Rehabilitation Program

Physical Therapy

The maintenance phase should be grounded in good preexercise and postexercise ankle stretching and continued use of strengthening techniques learned in physical therapy. Bracing and taping should not be necessary if the ankle is fully rehabilitated. Proprioceptive physiotaping can be used to speed recovery.

Consultations

An orthopedic surgeon, or a foot and ankle surgeon, should be consulted in cases of continued ankle pain or instability.

Medication

In the acute phase of any ankle injury, the medications of choice are NSAIDs. In cases of severe pain, narcotics may be used for a short period.

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Toxicity, Acetaminophen
Toxicity, Narcotics
Toxicity, Nonsteroidal Anti-inflammatory Agents

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Nonsteroidal Anti-inflammatory Drugs

NSAIDs have anti-inflammatory properties and reduce pain.

Ibuprofen (Advil, Motrin, Excedrin IB, Ibuprin)

DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Dosing

Adult

200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d

Pediatric

<6 months: Not established

6 months to 12 years: 4-10 mg/kg/dose PO tid/qid

>12 years: Administer as in adults

Interactions

Coadministration with aspirin increases the risk of inducing serious NSAID-related adverse effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when patient is taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Contraindications

Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in patients with congestive heart failure, hypertension, and decreased renal and hepatic function; caution in the presence of coagulation abnormalities or during anticoagulant therapy

Naproxen (Anaprox, Naprelan, Naprosyn)

For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing the activity of cyclooxygenase, which results in a decrease of prostaglandin synthesis.

Dosing

Adult

500 mg PO followed by 250 mg PO q6-8h; not to exceed 1.25 g/d

Pediatric

<2 years: Not established

>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d

Interactions

Coadministration with aspirin increases the risk of inducing serious NSAID-related adverse effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when patient is taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Contraindications

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of the drug.

Analgesics

Narcotics are used for pain reduction. Pain control is essential to quality patient care. Analgesics ensure patient comfort and have sedating properties, which are beneficial for patients who have sustained trauma or who have sustained injuries. Many analgesics have sedating properties, which are beneficial for patients who experience pain.

Acetaminophen (Tylenol, Feverall, Tempra, Aspirin Free Anacin)

DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, those with upper GI disease, or those taking oral anticoagulants.

Dosing

Adult

325-650 mg PO q4-6h or 1000 mg tid/qid; not to exceed 4 g/d

Pediatric

<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d

>12 years: 325-650 mg PO q4h; not to exceed 5 doses in 24 h

Interactions

Rifampin can reduce the analgesic effects; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity.

Contraindications

Documented hypersensitivity; known G-6-PD deficiency

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Hepatotoxicity is possible in patients with chronic alcoholism at various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; many OTC products contain acetaminophen, and combined use may result in cumulative doses that exceed the recommended maximum dose.

Acetaminophen and codeine (Tylenol-3)

Indicated for the treatment of mild to moderate pain.

Dosing

Adult

30-60 mg/dose PO based on codeine content q4-6h or 1-2 tab PO q4h; not to exceed 4 g/d of acetaminophen

Pediatric

0.5-1 mg/kg/dose PO based on codeine q4-6h; 10-15 mg/kg/dose based on acetaminophen content; not to exceed 2.6 g/d of acetaminophen

Interactions

The toxicity of codeine increases with CNS depressants, tricyclic antidepressants, MAOIs, neuromuscular blockers, CNS depressants, phenothiazines, and narcotic analgesics; rifampin can reduce the analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase the hepatotoxicity of acetaminophen.

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in patients who are dependent on opiates because substitution may result in acute opiate-withdrawal symptoms; caution in patients with severe renal or hepatic dysfunction; hepatotoxicity with acetaminophen is possible in patients with chronic alcoholism at various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; many OTC products contain acetaminophen, and combined use may result in cumulative doses that exceed the recommended maximum dose.

Hydrocodone and acetaminophen (Lorcet-HD, Vicodin, Lortab, Norcet)

Drug combination indicated for moderate to severe pain.

Dosing

Adult

1-2 tab or cap PO q4-6h prn pain

Pediatric

<12 years: 10-15 mg/kg/dose acetaminophen PO q4-6h prn; not to exceed 2.6 g/d acetaminophen

>12 years: 750 mg acetaminophen PO q4h; not to exceed 10 mg hydrocodone bitartrate per dose or 5 doses/24 h

Interactions

Coadministration with phenothiazines may decrease the analgesic effects; the toxicity increases with CNS depressants or tricyclic antidepressants.

Contraindications

Documented hypersensitivity; high altitude cerebral edema (HACE) or elevated intracranial pressure (ICP)

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

The tablets contain metabisulfite, which may cause hypersensitivity; caution in patients who are dependent on opiates, because this substitution may result in acute opiate-withdrawal symptoms; caution in patients with severe renal or hepatic dysfunction

Propoxyphene and acetaminophen (Darvocet-N, Darvocet-N 100, Propacet, Wygesic)

Drug combination indicated for mild to moderate pain.

Dosing

Adult

1-2 tab PO q4h prn; not to exceed 600 mg/d propoxyphene

Pediatric

Not established

Interactions

May increase the serum concentrations of MAOIs, tricyclic antidepressants, carbamazepine, phenobarbital, and warfarin

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in patients who are dependent on opiates, because this substitution may result in acute opiate withdrawal symptoms; caution in patients with severe renal or hepatic dysfunction

Follow-up

Return to Play

If surgery and/or casting is not required for a peroneal tendon injury, the patient can usually return to activity in 1-2 weeks with ankle bracing or taping until strength and function are back to 90-100% of the nonaffected ankle.

If surgery is performed, return to play with bracing or taping is usually allowed once the strength and function of the ankle has been rehabilitated to 90% of that in the nonaffected ankle. Once the ankle is close to 100%, the bracing/taping is usually not necessary but permitted.

In most sports injuries, return to play should be allowed when the ankle has a painless range of motion, normal or improved balance, preinjury muscle strength, and no pain with sport-specific functional testing.

Related Medscape topic:
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Complications

Complications of conservative treatment of a peroneal tendon injury are progression of pain and instability, and possible peroneal tendon rupture. Surgical complications vary depending on the procedure. A few common ones include sural nerve injury, progression of symptoms, chronic lateral ankle pain, and loss of range of motion. Any surgery poses a risk of infection and failure of the intent of the procedure.

Prevention

Several measures can be taken to prevent peroneal tendon injuries: (1) Good preexercise and postexercise stretching of the ankle, (2) a gradual increase in the level of activity or training, and (3) full rehabilitation of the ankle after any type of injury. These measures decrease the occurrence of ankle injury and, in turn, prevent peroneal tendon injury. Other interventions, such as attempting to correct foot abnormalities (eg, pes planus), also play an integral part in prevention.

Prognosis

The prognosis for improvement with conservative treatment is excellent if there is no functional instability requiring surgery. Surgical repairs for acute dislocation and chronic tears are also good. Casting for an acute dislocation has a success rate of only 50%. Therefore, this option should be reserved for patients with contraindications to surgery.

Education

Educating patients about the importance of ankle rehabilitation after an injury is the cornerstone in the prevention of peroneal tendon injuries. Further, stressing the need to stretch before and after exercise is also important.

Miscellaneous

Medicolegal Pitfalls

• Missed fracture, especially lateral malleolar and calcaneal fractures
• Injecting corticosteroids, which has a risk of fat necrosis and sural nerve damage
• Using a cast to treat an acute dislocation of the tendon when surgery is not contraindicated

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Resource Center Trauma
Specialty Site Orthopaedics
Specialty Site Surgery

Special Concerns

• Patients who have an unsteady gait, such as geriatric patients or patients with an acute injury to the ankle itself, may have difficulty ambulating.
  • Elderly patients are of particular concern because of the increased morbidity and mortality with falls and accidents in the home.
  • Ensure the patient has a stable gait when treating the ambulatory ankle injury. If the gait is not stable, make sure the patient has a 4-pronged cane, walker, or even a wheelchair.
• A subluxed or torn peroneal tendon has low morbidity, but a fat embolus from a hip or femur fracture caused by a fall could be deadly.

Multimedia

Media file 1: Lateral ankle anatomy demonstrates the peroneal tendons as they course beneath the superior retinaculum. The anterior talofibular, calcaneofibular, and posterior talofibular ligaments are also shown.

Media file 2: 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. ¹⁵

Media file 3: 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. ¹⁵

Media file 4: Dislocated peroneal tendons. Left, Note the course of the tendons anterior to the lateral malleolus. Right, Image demonstrates manual relocation of the displaced tendons.

Media file 5: 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. ¹⁵

References

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Keywords

peroneal tendon syndromes, peroneal tendon, ankle sprain, ankle instability, peroneal tendonitis, peroneal tendinitis, peroneal tendon tears, peroneal tendon subluxation, peroneal tendon dislocation, peroneal tendon strain, peroneal tenosynovitis, peroneal retinaculum tear, peroneal tendon pathology, peroneus brevis disorders, disruptions of the peroneus longus, disruptions of the peroneus brevis, fractured os peroneum, fragmented os peroneum, longitudinal tears of the peroneus longus, peroneus brevis tears, longitudinal tears of the peroneus brevis tendon,  primary peroneus longus tendinopathy, peroneus longus rupture, ankle pain, foot pain, tendon rupture, lateral ankle ligament tear, inversion injury

Contributor Information and Disclosures

Author

Steven Karageanes, DO, Director, Primary Care Sports Medicine Fellowship, Director, Sports Medicine Education, Center for Orthopedics and Neuroscience; Department of Medical Education, Oakwood Healthcare System
Steven Karageanes, DO is a member of the following medical societies: American Medical Association, American Osteopathic Association, and Michigan State Medical Society
Disclosure: Nothing to disclose.

Coauthor(s)

Kathleen Sharp, MD, Sports Medicine Fellow, Department of Family Practice, Henry Ford Hospital
Kathleen Sharp, MD is a member of the following medical societies: American Academy of Family Physicians and National Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Gerard A Malanga, MD, Founder and Director, New Jersey Sports Medicine Institute; Director of Pain Management, Overlook Hospital; Director of Sports Medicine, Sports Medicine Fellowship Director, Mountainside Hospital; Clinical Chief, Rehabilitation Medicine and Electrodiagnosis, St Michael's Medical Center; Medical Director, Consultant, Horizon Healthcare Worker's Compensation Services, Blue Cross and Blue Shield Worker's Compensation
Gerard A Malanga, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, North American Spine Society, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Russell D White, MD, Professor of Medicine, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center Lakewood
Disclosure: Nothing to disclose.

CME Editor

Jon B Whitehurst, MD, Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner and Executive Board Member, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital
Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD, Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago
Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

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