History

The patient with peroneal tendon pathology typically complains of laterally based ankle or hindfoot pain. The pain usually worsens with activity. However, presentation and diagnosis often are delayed. Patients may or may not recall a specific episode of trauma. Brandes and Smith reported that only nine of 22 patients with primary peroneus longus tendinopathy recalled an inciting event and that the event was an average of 4.3 months prior to presentation.^[5]

Peroneal tendon subluxation or dislocation may present acutely following a traumatic injury to the ankle. However, it is not uncommon for these to present later with an uncertain history of trauma. Patients also may complain of snapping or popping in the ankle.

Physical Examination

On physical examination, there usually is tenderness to palpation along the course of the peroneal tendons. Edema also may be present. These disorders require a high level of suspicion. Even frank dislocations may be missed if not specifically evaluated. (see the image below.)

Ganglion arising from peroneal tendon sheath as cause of painful swelling. Left image shows palpable tender swelling behind lateral malleolus; center image shows ganglion as seen intraoperatively; right image is view after excision.

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A provocative test for peroneal pathology has been described. The patient's foot is examined hanging in a relaxed position with the knee flexed 90^º. Slight pressure is applied to the peroneal tendons posterior to the fibula. The patient is then asked to forcibly dorsiflex and evert the foot. Pain may be elicited, or subluxation of the tendons may be felt.

Circumduction of the ankle may reveal dislocation of the tendons with dorsiflexion and eversion and relocation with inversion and plantarflexion. Chronic dislocation of the tendons may be associated with chronic swelling and a palpable ridge along the posterolateral fibula (the "secondary pseudogroove” of the lateral fibular cortex).

A complete examination of the ankle must always be performed to rule out pathologic conditions such as lateral ankle instability, syndesmotic injuries, and painful os trigonum, as well as fractures at the posterior process of the talus, the lateral process of the talus, the anterior process of the calcaneus, and the fifth metatarsal base.

Differential Diagnoses

Sharma A, Parekh SG. Pathologies of the Peroneals: A Review. Foot Ankle Spec. 2021 Apr. 14 (2):170-177. [QxMD MEDLINE Link].
Monteggia G. Instiuzioni Chirurgiche Parte Secondu. Milan: Gaspare Truffi; 1803. 336-41.
Slater HK. Acute peroneal tendon tears. Foot Ankle Clin. 2007 Dec. 12 (4):659-74, vii. [QxMD MEDLINE Link].
Res LCS, Dixon T, Lubberts B, Vicentini JRT, van Dijk PA, Hosseini A, et al. Peroneal Tendon Tears: We Should Consider Looking at the Muscle Instead. J Am Acad Orthop Surg. 2018 Nov 15. 26 (22):809-815. [QxMD MEDLINE Link].
Brandes CB, Smith RW. Characterization of patients with primary peroneus longus tendinopathy: a review of twenty-two cases. Foot Ankle Int. 2000 Jun. 21 (6):462-8. [QxMD MEDLINE Link].
Sobel M, Geppert MJ, Olson EJ, Bohne WH, Arnoczky SP. The dynamics of peroneus brevis tendon splits: a proposed mechanism, technique of diagnosis, and classification of injury. Foot Ankle. 1992 Sep. 13 (7):413-22. [QxMD MEDLINE Link].
Sobel M, Pavlov H, Geppert MJ, Thompson FM, DiCarlo EF, Davis WH. Painful os peroneum syndrome: a spectrum of conditions responsible for plantar lateral foot pain. Foot Ankle Int. 1994 Mar. 15 (3):112-24. [QxMD MEDLINE Link].
Eckert WR, Davis EA Jr. Acute rupture of the peroneal retinaculum. J Bone Joint Surg Am. 1976 Jul. 58 (5):670-2. [QxMD MEDLINE Link].
Oden RR. Tendon injuries about the ankle resulting from skiing. Clin Orthop Relat Res. 1987 Mar. 63-9. [QxMD MEDLINE Link].
Jahss M. Tendon disorders of the foot and ankle. Jahss M, ed. Disorders of the Foot and Ankle: Medical and Surgical Management. 2nd ed. Philadelphia: WB Saunders; 1991. 1461-512.
Kelikian AS, Sarrafian SK, eds. Sarrafian's Anatomy of the Foot and Ankle. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2011.
Saxena A, Pham B. Longitudinal peroneal tendon tears. J Foot Ankle Surg. 1997 May-Jun. 36 (3):173-9; discussion 255. [QxMD MEDLINE Link].
Sammarco GJ. Peroneus longus tendon tears: acute and chronic. Foot Ankle Int. 1995 May. 16 (5):245-53. [QxMD MEDLINE Link].
Thompson FM, Patterson AH. Rupture of the peroneus longus tendon. Report of three cases. J Bone Joint Surg Am. 1989 Feb. 71 (2):293-5. [QxMD MEDLINE Link].
Krause JO, Brodsky JW. Peroneus brevis tendon tears: pathophysiology, surgical reconstruction, and clinical results. Foot Ankle Int. 1998 May. 19 (5):271-9. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
van Dijk PA, Gianakos AL, Kerkhoffs GM, Kennedy JG. Return to sports and clinical outcomes in patients treated for peroneal tendon dislocation: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2016 Apr. 24 (4):1155-64. [QxMD MEDLINE Link].
Raikin SM, Fuchs D. Imaging studies of the foot and ankle. Chou LB, ed. Orthopaedic Knowledge Update Foot and Ankle 6. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2020. 23-36.
Sadamasu A, Yamaguchi S, Nakagawa R, Kimura S, Endo J, Akagi R, et al. The recognition and incidence of peroneal tendon dislocation associated with a fracture of the talus. Bone Joint J. 2017 Apr. 99-B (4):489-493. [QxMD MEDLINE Link].
Ketz JP, Maceroli M, Shields E, Sanders RW. Peroneal Tendon Instability in Intra-Articular Calcaneus Fractures: A Retrospective Comparative Study and a New Surgical Technique. J Orthop Trauma. 2016 Mar. 30 (3):e82-7. [QxMD MEDLINE Link].
Chen W, Li X, Su Y, Zhang Q, Smith WR, Zhang X, et al. Peroneal tenography to evaluate lateral hindfoot pain after calcaneal fracture. Foot Ankle Int. 2011 Aug. 32 (8):789-95. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Rosenberg ZS, Beltran J, Cheung YY, Colon E, Herraiz F. MR features of longitudinal tears of the peroneus brevis tendon. AJR Am J Roentgenol. 1997 Jan. 168 (1):141-7. [QxMD MEDLINE Link].
Park HJ, Lee SY, Park NH, Rho MH, Chung EC, Kwag HJ. Accuracy of MR findings in characterizing peroneal tendons disorders in comparison with surgery. Acta Radiol. 2012 Sep 1. 53 (7):795-801. [QxMD MEDLINE Link].
Wang XT, Rosenberg ZS, Mechlin MB, Schweitzer ME. Normal variants and diseases of the peroneal tendons and superior peroneal retinaculum: MR imaging features. Radiographics. 2005 May-Jun. 25 (3):587-602. [QxMD MEDLINE Link].
Sharpe J, Feltner M, Carroll P, Harrington T, Walker S, Bala V, et al. Comparison of Preoperative MRI With Intraoperative Findings for Peroneal Tendon Pathologies. J Foot Ankle Surg. 2022 Jul-Aug. 61 (4):680-685. [QxMD MEDLINE Link].
Ohashi K, Sanghvi T, El-Khoury GY, Ahn JM, Bennett DL, Geijer M, et al. Diagnostic accuracy of 3D color volume-rendered CT images for peroneal tendon dislocation in patients with acute calcaneal fractures. Acta Radiol. 2015 Feb. 56 (2):190-5. [QxMD MEDLINE Link].
Rockett MS, Waitches G, Sudakoff G, Brage M. Use of ultrasonography versus magnetic resonance imaging for tendon abnormalities around the ankle. Foot Ankle Int. 1998 Sep. 19 (9):604-12. [QxMD MEDLINE Link].
Mizel MS, Michelson JD, Newberg A. Peroneal tendon bupivacaine injection: utility of concomitant injection of contrast material. Foot Ankle Int. 1996 Sep. 17 (9):566-8. [QxMD MEDLINE Link].
Marmotti A, Cravino M, Germano M, Del Din R, Rossi R, Tron A, et al. Peroneal tendoscopy. Curr Rev Musculoskelet Med. 2012 Jun. 5 (2):135-44. [QxMD MEDLINE Link].
Truong DT, Dussault RG, Kaplan PA. Fracture of the os peroneum and rupture of the peroneus longus tendon as a complication of diabetic neuropathy. Skeletal Radiol. 1995 Nov. 24 (8):626-8. [QxMD MEDLINE Link].
Cushman DM, Carefoot A, Lisenby S, Caragea M, Fogg B, Conger A. A Systematic Review of the Efficacy of Corticosteroid Injections of Tendon Sheaths, Excluding Stenosing Tenosynovitis of the Wrist and Hand. Am J Phys Med Rehabil. 2021 Jul 1. 100 (7):683-688. [QxMD MEDLINE Link].
Fram BR, Rogero R, Fuchs D, Shakked RJ, Raikin SM, Pedowitz DI. Clinical Outcomes and Complications of Peroneal Tendon Sheath Ultrasound-Guided Corticosteroid Injection. Foot Ankle Int. 2019 Aug. 40 (8):888-894. [QxMD MEDLINE Link].
Grasset W, Mercier N, Chaussard C, Carpentier E, Aldridge S, Saragaglia D. The surgical treatment of peroneal tendinopathy (excluding subluxations): a series of 17 patients. J Foot Ankle Surg. 2012 Jan-Feb. 51 (1):13-9. [QxMD MEDLINE Link].
Coughlin MJ, Schon LC. Disorders of tendons. Coughlin MJ, Mann RA, Salzmann C, eds. Mann's Surgery of the Foot and Ankle. 9th ed. Philadelphia: Elsevier Saunders; 2014. 188-291.
Boya H, Pinar H. Stenosing tenosynovitis of the peroneus brevis tendon associated with hypertrophy of the peroneal tubercle. J Foot Ankle Surg. 2010 Mar-Apr. 49 (2):188-90. [QxMD MEDLINE Link].
Boffeli TJ, Collier RC. Surgical technique for combined Dwyer calcaneal osteotomy and peroneal tendon repair for correction of peroneal tendon pathology associated with cavus foot deformity. J Foot Ankle Surg. 2012 Jan-Feb. 51 (1):135-40. [QxMD MEDLINE Link].
Ferran NA, Maffulli N, Oliva F. Management of recurrent subluxation of the peroneal tendons. Foot Ankle Clin. 2006 Sep. 11 (3):465-74. [QxMD MEDLINE Link].
McLennan JG. Treatment of acute and chronic luxations of the peroneal tendons. Am J Sports Med. 1980 Nov-Dec. 8 (6):432-6. [QxMD MEDLINE Link].
Ogawa BK, Thordarson DB, Zalavras C. Peroneal tendon subluxation repair with an indirect fibular groove deepening technique. Foot Ankle Int. 2007 Nov. 28 (11):1194-7. [QxMD MEDLINE Link].
Saxena A, Ewen B. Peroneal subluxation: surgical results in 31 athletic patients. J Foot Ankle Surg. 2010 May-Jun. 49 (3):238-41. [QxMD MEDLINE Link].
Roth JA, Taylor WC, Whalen J. Peroneal tendon subluxation: the other lateral ankle injury. Br J Sports Med. 2010 Nov. 44 (14):1047-53. [QxMD MEDLINE Link].
Millar TM, Garg SK. The Singapore operation for chronic recurrent peroneal tendon subluxation--short-term follow-up in four patients. Foot Ankle Surg. 2009. 15 (3):146-8. [QxMD MEDLINE Link].
Mak MF, Tay GT, Stern R, Assal M. Dual-incision approach for repair of peroneal tendon dislocation associated with fractures of the calcaneus. Orthopedics. 2014 Feb. 37 (2):96-100. [QxMD MEDLINE Link].
Jones E. Operative treatment of chronic dislocations of the peroneal tendons. J Bone Joint Surg. 1932. 14A:574-576.
Kojima Y, Kataoka Y, Suzuki S, Akagi M. Dislocation of the peroneal tendons in neonates and infants. Clin Orthop Relat Res. 1991 May. (266):180-4. [QxMD MEDLINE Link].
Lootsma J, Wuite S, Hoekstra H, Matricali GA. Surgical treatment options for chronic instability of the peroneal tendons: a systematic review and proportional meta-analysis. Arch Orthop Trauma Surg. 2022 Mar 9. [QxMD MEDLINE Link].
Nishimura A, Nakazora S, Senga Y, Fukuda A, Kato K, Sudo A. Knotless Tendoscopic Peroneal Retinaculum Repair Technique for Recurrent Peroneal Tendon Dislocation. Arthrosc Tech. 2022 Aug. 11 (8):e1395-e1401. [QxMD MEDLINE Link]. [Full Text].
Gaulke R, Hildebrand F, Panzica M, Hüfner T, Krettek C. Modified rerouting procedure for failed peroneal tendon dislocation surgery. Clin Orthop Relat Res. 2010 Apr. 468 (4):1018-24. [QxMD MEDLINE Link]. [Full Text].
Kanakamedala A, Chen JS, Kaplan DJ, Colasanti CA, Dankert JF, Hurley ET, et al. In-Office Needle Tendoscopy of the Peroneal Tendons. Arthrosc Tech. 2022 Mar. 11 (3):e365-e371. [QxMD MEDLINE Link]. [Full Text].
Kennedy JG, van Dijk PA, Murawski CD, Duke G, Newman H, DiGiovanni CW, et al. Functional outcomes after peroneal tendoscopy in the treatment of peroneal tendon disorders. Knee Surg Sports Traumatol Arthrosc. 2016 Apr. 24 (4):1148-54. [QxMD MEDLINE Link].
Bernasconi A, Sadile F, Smeraglia F, Mehdi N, Laborde J, Lintz F. Tendoscopy of Achilles, peroneal and tibialis posterior tendons: An evidence-based update. Foot Ankle Surg. 2018 Oct. 24 (5):374-382. [QxMD MEDLINE Link].
van Dijk PA, Lubberts B, Verheul C, DiGiovanni CW, Kerkhoffs GM. Rehabilitation after surgical treatment of peroneal tendon tears and ruptures. Knee Surg Sports Traumatol Arthrosc. 2016 Apr. 24 (4):1165-74. [QxMD MEDLINE Link].

Media Gallery

Lateral view of ankle, with marking of distal fibula, base of fifth metatarsal, and intended incision.
Peroneus brevis degeneration forming ganglion-type mass.
Peroneus longus tendon next to peroneus brevis tendon.
Peroneus brevis above after resection of degenerative mass and peroneus longus below.
Partial repair of peroneal tendon sheath.
Repaired peroneal tendon sheath.
Skin closed over peroneal tendon repair.
Cystic mass (ganglion) on right arising from peroneal tendon (×40).
Ganglion with myxoid degeneration and connective tissue with myxoid material pools with cystic change (×400).
Appearance of normal peroneal tendons on MRI. Axial turbo spin-echo (TSE) T1-weighted image (left) shows peroneus brevis (short arrow). TSE proton density (PD)-weighted fat-suppressed (FS) image (center) shows peroneus longus (arrowhead). Sagittal TSE T2-weighted FS image (right) shows peroneus longus (arrowhead).
Turbo spin-echo (TSE) T1-weighted MRI shows hypointense peroneus quartus tendon (arrow) with muscle belly seen posterior to peroneus longus and peroneus brevis tendon.
Plain lateral radiograph (left) shows os peroneum. Axial CT (right) shows os peroneum adjacent to cuboid bone .
Axial turbo spin echo (TSE) T1-weighted and TSE T2-weighted fat-suppressed (FS) MRI shows split of peroneus brevis tendon into two subtendons.
Coronal short TI inversion recovery (STIR)-sequence MRI shows hyperintense calcaneofibular ligament at fibular attachment (left) and calcaneal attachment (right).
Ganglion arising from peroneal tendon sheath as cause of painful swelling. Left image shows palpable tender swelling behind lateral malleolus; center image shows ganglion as seen intraoperatively; right image is view after excision.

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Author

Rajesh Malhotra, MBBS, MS Professor and Head, Department of Orthopedics, All India Institute of Medical Sciences; Chief, JPN Apex Trauma Centre, India

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.

Chief Editor

Vinod K Panchbhavi, MD, FACS, FAOA, FABOS, FAAOS Professor of Orthopedic Surgery, Chief, Division of Foot and Ankle Surgery, Director, Foot and Ankle Fellowship Program, Department of Orthopedic Surgery, University of Texas Medical Branch School of Medicine

Vinod K Panchbhavi, MD, FACS, FAOA, FABOS, FAAOS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Orthopaedic Trauma Association, Texas Orthopaedic Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Styker.

Additional Contributors

James K DeOrio, MD Professor of Orthopedics, Director, Duke Foot and Ankle Fellowship, Duke University Medical Center, Duke University School of Medicine; Associate Professor, Mayo Clinic College of Medicine; Clinical Assistant Professor, F Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences

James K DeOrio, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Foot and Ankle Society, Association of Graduates, United States Air Force Academy, Doctors Mayo Society, Mayo Clinic Alumni Association, Society of Air Force Clinical Surgeons, Society of Military Orthopaedic Surgeons

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Exactech; Treace Medical; Additive; Mirus; Crossroads Orthopedics<br/>Serve(d) as a speaker or a member of a speakers bureau for: Exactech; Treace Medical; Additive; Mirus; WoultersKluwer; Crossroads Orthopedics<br/>Received income in an amount equal to or greater than $250 from: Exactech; Treace Medical; Additive; Mirus; WoultersKluwer; Crossroads Orthopedics.

Heidi M Stephens, MD, MBA Associate Professor, Department of Surgery, Division of Orthopedic Surgery, University of South Florida College of Medicine; Courtesy Joint Associate Professor, Department of Environmental and Occupational Health, University of South Florida College of Public Health

Heidi M Stephens, MD, MBA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Foot and Ankle Society, Florida Medical Association

Disclosure: Nothing to disclose.

Peroneal Tendon Pathology Clinical Presentation

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