Medscape is available in 5 Language Editions – Choose your Edition here.


Peroneal Tendon Syndromes Workup

  • Author: Steven J Karageanes, DO, FAOASM; Chief Editor: Craig C Young, MD  more...
Updated: Jun 25, 2015

Imaging Studies

See the list below:

  • 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, 18, 19] 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, 20] 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.[21] 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.

Other Tests

See the list below:

  • 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.
Contributor Information and Disclosures

Steven J Karageanes, DO, FAOASM Director of Sports Medicine, St Mary Mercy Hospital Livonia; Regional Assistant Dean, Kansas City University of Medicine and Biosciences; Clinical Assistant Professor, Michigan State University College of Osteopathic Medicine

Steven J Karageanes, DO, FAOASM is a member of the following medical societies: American Medical Association, American Osteopathic Academy of Sports Medicine, American Osteopathic Association, Michigan State Medical Society

Disclosure: Nothing to disclose.


Kathleen Sharp, MD, CAQSM Staff Physician, Parkland Homes Program

Kathleen Sharp, MD, CAQSM is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, National Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Russell D White, MD Clinical Professor of Medicine, Clinical Professor of Orthopedic Surgery, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center-Lakewood

Russell D White, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Family Physicians, American Association of Clinical Endocrinologists, American College of Sports Medicine, American Diabetes Association, American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Chief Editor

Craig C Young, MD Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Medical College of Wisconsin

Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, Phi Beta Kappa

Disclosure: Nothing to disclose.

Additional Contributors

Gerard A Malanga, MD Founder and Partner, New Jersey Sports Medicine, LLC and New Jersey Regenerative Institute; Director of Research, Atlantic Health; Clinical Professor, Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey-New Jersey Medical School; Fellow, American College of Sports Medicine

Gerard A Malanga, MD is a member of the following medical societies: Alpha Omega Alpha, American Institute of Ultrasound in Medicine, North American Spine Society, International Spine Intervention Society, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine

Disclosure: Received honoraria from Cephalon for speaking and teaching; Received honoraria from Endo for speaking and teaching; Received honoraria from Genzyme for speaking and teaching; Received honoraria from Prostakan for speaking and teaching; Received consulting fee from Pfizer for speaking and teaching.

  1. Fallat L, Grimm DJ, Saracco JA. Sprained ankle syndrome: prevalence and analysis of 639 acute injuries. J Foot Ankle Surg. 1998 Jul-Aug. 37(4):280-5. [Medline].

  2. Heckman DS, Reddy S, Pedowitz D, Wapner KL, Parekh SG. Operative treatment for peroneal tendon disorders. J Bone Joint Surg Am. 2008 Feb. 90(2):404-18. [Medline]. [Full Text].

  3. Rosenfeld P. Acute and chronic peroneal tendon dislocations. Foot Ankle Clin. 2007 Dec. 12(4):643-57, vii. [Medline].

  4. van Dijk CN, Kort N. Tendoscopy of the peroneal tendons. Arthroscopy. 1998 Jul-Aug. 14(5):471-8. [Medline].

  5. Slater HK. Acute peroneal tendon tears. Foot Ankle Clin. 2007 Dec. 12(4):659-74, vii. [Medline].

  6. Major NM, Helms CA, Fritz RC, Speer KP. The MR imaging appearance of longitudinal split tears of the peroneus brevis tendon. Foot Ankle Int. 2000 Jun. 21(6):514-9. [Medline].

  7. Diaz GC, van Holsbeeck M, Jacobson JA. Longitudinal split of the peroneus longus and peroneus brevis tendons with disruption of the superior peroneal retinaculum. J Ultrasound Med. 1998 Aug. 17(8):525-9. [Medline].

  8. Sammarco GJ. Peroneal tendon injuries. Orthop Clin North Am. 1994 Jan. 25(1):135-45. [Medline].

  9. Sobel M, Geppert MJ, Warren RF. Chronic ankle instability as a cause of peroneal tendon injury. Clin Orthop Relat Res. 1993 Nov. 296:187-91. [Medline].

  10. Raikin SM, Elias I, Nazarian LN. Intrasheath subluxation of the peroneal tendons. J Bone Joint Surg Am. 2008 May. 90(5):992-9. [Medline].

  11. Neustadter J, Raikin SM, Nazarian LN. Dynamic sonographic evaluation of peroneal tendon subluxation. AJR Am J Roentgenol. 2004 Oct. 183(4):985-8. [Medline]. [Full Text].

  12. Mendicino RW, Orsini RC, Whitman SE, Catanzariti AR. Fibular groove deepening for recurrent peroneal subluxation. J Foot Ankle Surg. 2001 Jul-Aug. 40(4):252-63. [Medline].

  13. Schweitzer ME, Eid ME, Deely D, Wapner K, Hecht P. Using MR imaging to differentiate peroneal splits from other peroneal disorders. AJR Am J Roentgenol. 1997 Jan. 168(1):129-33. [Medline]. [Full Text].

  14. DiGiovanni BF, Fraga CJ, Cohen BE, Shereff MJ. Associated injuries found in chronic lateral ankle instability. Foot Ankle Int. 2000 Oct. 21(10):809-15. [Medline].

  15. Ribbans WJ, Garde A. Tibialis posterior tendon and deltoid and spring ligament injuries in the elite athlete. Foot Ankle Clin. 2013 Jun. 18(2):255-91. [Medline].

  16. Kijowski R, De Smet A, Mukharjee R. Magnetic resonance imaging findings in patients with peroneal tendinopathy and peroneal tenosynovitis. Skeletal Radiol. 2007 Feb. 36(2):105-14. [Medline].

  17. Campbell SE, Warner M. MR imaging of ankle inversion injuries. Magn Reson Imaging Clin N Am. 2008 Feb. 16(1):1-18, v. [Medline].

  18. Saxena A, Luhadiya A, Ewen B, Goumas C. Magnetic resonance imaging and incidental findings of lateral ankle pathologic features with asymptomatic ankles. J Foot Ankle Surg. 2011 Jul-Aug. 50(4):413-5. [Medline].

  19. Ma L, Meng Q, Chen Y, Zhang Z, Sun H, Deng D. Preliminary use of a double-echo pulse sequence with 3D ultrashort echo time in the MRI of bones and joints. Exp Ther Med. 2013 May. 5(5):1471-1475. [Medline]. [Full Text].

  20. Waitches GM, Rockett M, Brage M, Sudakoff G. Ultrasonographic-surgical correlation of ankle tendon tears. J Ultrasound Med. 1998 Apr. 17(4):249-56. [Medline].

  21. Ho RT, Smith D, Escobedo E. Peroneal tendon dislocation: CT diagnosis and clinical importance. AJR Am J Roentgenol. 2001 Nov. 177(5):1193. [Medline]. [Full Text].

  22. Squires N, Myerson MS, Gamba C. Surgical treatment of peroneal tendon tears. Foot Ankle Clin. 2007 Dec. 12(4):675-95, vii. [Medline].

  23. Kramer D, Solomon R, Curtis C, Zurakowski D, Micheli LJ. Clinical results and functional evaluation of the Chrisman-Snook procedure for lateral ankle instability in athletes. Foot Ankle Spec. 2011 Feb. 4(1):18-28. [Medline].

  24. Saxena A, Ewen B. Peroneal subluxation: surgical results in 31 athletic patients. J Foot Ankle Surg. 2010 May-Jun. 49(3):238-41. [Medline].

  25. Demetracopoulos CA1, Vineyard JC, Kiesau CD, Nunley JA 2nd. Long-Term Results of Debridement and Primary Repair of Peroneal Tendon Tears. Foot Ankle Int. December 2013. [Medline]. [Full Text].

  26. Muir JJ, Curtiss HM, Hollman J, Smith J, Finnoff JT. The accuracy of ultrasound-guided and palpation-guided peroneal tendon sheath injections. Am J Phys Med Rehabil. 2011 Jul. 90(7):564-71. [Medline].

  27. Eisenhart AW1, Gaeta TJ, Yens DP. Osteopathic manipulative treatment in the emergency department for patients with acute ankle injuries. J Am Osteopath Assoc. September 2003. 103:417-21. [Medline].

  28. Tzoanos G, Manidakis N, Tsavalas N, Katonis P. Non-operative treatment of peroneal split syndrome: a case report. Acta Orthop Belg. 2012 Dec. 78(6):804-7. [Medline].

  29. Cloak R, Nevill A, Day S, Wyon M. Six-Week Combined Vibration and Wobble Board Training on Balance and Stability in Footballers With Functional Ankle Instability. Clin J Sport Med. 2013 May 6. [Medline].

  30. Demetracopoulos CA, Vineyard JC, Kiesau CD, Nunley JA 2nd. Long-term results of debridement and primary repair of peroneal tendon tears. Foot Ankle Int. 2014 Mar. 35 (3):252-7. [Medline].

  31. Karageanes SJ. Principles of Manual Sports Medicine. Philadelphia, Pa: Lippincott Williams & Wilkins; 2005.

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.
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. 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.
Dislocated peroneal tendons. Left, Note the course of the tendons anterior to the lateral malleolus. Right, Image demonstrates manual relocation of the displaced tendons.
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.
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.