Peroneal Tendon Pathology Clinical Presentation

Updated: Nov 04, 2022
  • Author: Rajesh Malhotra, MBBS, MS; Chief Editor: Vinod K Panchbhavi, MD, FACS, FAOA, FABOS, FAAOS  more...
  • Print


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 ca 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.

A provocative test for peroneal pathology has been described. The patient's foot is examined hanging in a relaxed position with the knee flexed 90º. 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.