Peroneal Tendon Syndromes 

Updated: Mar 07, 2018
Author: Steven J Karageanes, DO, FAOASM; Chief Editor: Craig C Young, MD 

Overview

Practice Essentials

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.

The image below depicts the anatomy of the lateral ankle.

Lateral ankle anatomy demonstrates the peroneal te 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.

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.

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, 14, 15, 16, 17]

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.

Surgery is indicated in the acute phase for peroneus brevis tendon rupture, acute dislocation, and anomalous peroneal brevis muscle hypertrophy and for peroneus longus tears that are associated with diminished function.[18, 19, 20]

For excellent patient education resources, visit eMedicineHealth's First Aid and Injuries Center. Also, see eMedicineHealth's patient education article Ankle Sprain.

Epidemiology

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.[21] 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. (See the following image.)

Lateral ankle anatomy demonstrates the peroneal te 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.

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.

A common variant in anatomy—the peroneus quartus muscle—occurs in approximately 6.6% of the population. Although the muscle may have a number of different attachments, it most commonly arises from the peroneus brevis muscle and is inserted into the retrotrochlear eminence of the calcaneus.

Sport-Specific Biomechanics

Basic

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.

Role of core stability

Somatic dysfunctions in the lumbosacropelvic region can inhibit muscle firing. One of the most common causes of dysfunctions in a patient who is active and typically has no functional issues is limping, something that happens quite frequently with traumatic ankle injuries.

When the core is destabilized, the following problems may develop, not all of which are conscious to the patient:

Gluteus medius muscle firing is slower and weaker, allowing more femoral adduction and internal rotation with gait. The tensor fascia latae tends to avoid such inhibition and instead tightens up. This is a common cause of lateral snapping hip syndrome.

Functional short leg may develop. This is related to rotation of the ilium, sacral torsion or shear, hypertonic psoas major, quadratus lumborum, or iliacus muscle, lumbar rotational dysfunction, or all of the above. This shifts load onto one side more than the other and rotates the talus within the mortise, thus increasing pronation.

Low back tightness or soreness with prolonged sitting or standing can develop, which restricts hip extension, leading to more stress on the ankle.

An astute physical therapist evaluates the kinetic chain for these problems. A rushed examination that targets only the location of pain misses all this and leads to prolonged pain and disability. Once the core muscles develop a maladaptive compensation pattern, the road to recovery becomes much longer.

 

Presentation

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 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.[22]

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.

Lateral ankle impingement

This injury is chronic and commonly seen far out from an acute injury, such as a lateral ligament sprain. Many times, the patient will be better for weeks after a sprain, only to have the pain increase with activity without any provocation.

The patient has pain with loading the foot, but it may not always be consistent during the day and week. Pain may be more pronounced after being sedentary or waking up in the morning, but it improves over time.

The location of pain is either posterior to the lateral malleolus along the peroneus tendon or at the anterior talofibular ligament. The latter is typically seen in a patient with a history of ankle sprain. However, the sprain can be remote.

The patient often assumes impingement pain is a sprain that has not yet healed or is due to "weak ankles." The physician must not make that same snap judgment before evaluation. Often, the pain is in the same area as the injury (ATF sprain), but impingement occurs only in small part to the thickening of the ligament. Making the assumption the pain is related to an inability of a ligament to heal can make the true biomechanical reason for the problem difficult to uncover and treat.

Physical

The examination should focus on the following 2 areas:

  • Ankle function and stability

  • Basic core alignment and stability

Ankle

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 is performed as follows:

  • 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 the image below.

Anterior drawer test, which assesses anterior talo 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 is performed as follows:

  • 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 the image below.

Tilt test. The operator tilts the talus and calcan 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 is performed as follows:

  • The operator holds 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 the image below.

Peroneal stability test. The patient pushes the fo 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.

Core stability

Standing flexion test is performed as follows:

  • The patient stands straight, feet shoulder width apart. The physician sits behind the patient.

  • The physician places thumbs on the posterior superior iliac spines (PSISs) bilaterally.

  • The patient bends forward to end range of motion, while the physician's thumbs stay on the PSISs.

  • Note symmetry in motion. A positive test is when one PSIS moves higher than the opposite one. Note the side that moves higher. This indicates either sacroiliac restriction or dysfunction, or a tight hamstring on that side.

Seated flexion test is performed as follows:

  • This is the standing test repeated with the patient sitting on a table, slid back far enough on the table so that the knees touch the edge of the table.

  • The physician has the patient slouch forward while the thumbs are on the PSISs.

  • This test takes out the hamstring as a cause of restriction, so a PSIS that moves more superiorly compared with the opposite side would be a positive test on that side and indicate lumbosacropelvic dysfunction on that side. Many times, this is positive on the same side as the injured or painful ankle.

Leg-length discrepancy testing is performed as follows:

  • The physician holds the ankles as the patient lies supine on the table.

  • The patient slides his or her feet towards his or her buttocks so the knees flex.

  • Have the patient lift his or her hips up in the air—bridging.

  • The patient brings his or her hips back down on the table.

  • The physician holds one ankle in each hand, pulling the legs towards him or her to take up slack.

  • The physician places thumbs on the inferior aspect of the medial malleoli and assesses for symmetry. Note the side with the malleolus that is more superior.

  • With the patient lying still, the physician moves to the pelvis and places his or her thumbs on both anterior superior iliac spines (ASISs). The thumbs should move from the inferior direction and push up against the protruding spines.

  • Several different findings may be seen on one ASIS is compared with the other—superior, superior-anterior, out-flared, inferior, inferior-posterior.

  • Note that this does not necessarily exclude an anatomic leg length discrepancy. A radiographic study would be necessary to rule that out, or a manipulative adjustment can be performed, and once the physician feels the dysfunctions are treated appropriately, the leg-length evaluation can be repeated.

Functional muscle testing is also performed as part of the core stability assessment.

Straight leg testing is performed as follows:

  • The patient is supine. The physician holds the ankle or lower leg superior enough to not be putting pressure on a painful area.

  • The physician instructs the patient to keep his or her leg completely straight (fully extended) and push his or her leg up as hard as he or she can.

  • The physician repeats on the other side. The physician may use 2 hands to apply enough force to keep the leg from moving up, or if the patient is strong.

  • Note differences in strength. Most differences are more subtle than +5/5 versus +4/5. Look for shakiness, an unstable effort, leg drifting medially, or a feeling from the patient that he or she "just can't push hard." Note quick fatigue against resistance. Even an elderly, weakened patient who has normal core function has a steady contraction against resistance without shakiness.

  • If the patient seems even on both sides, quickly repeat the test. An inhibited side fatigues quickly, usually after only 2-3 repetitions.

Hip abduction testing is performed as follows:

  • The patient lies on his or her side. Both legs are straight, and the torso should not be rotated.

  • The physician holds the top leg in the same area around the ankle.

  • The patient is instructed to keep the knee straight (fully extended) and extends the hip about 5-10°.

  • The physician instructs patient to lift the leg up to the ceiling as hard as he or she can. The physician may use both hands to ensure stability.

  • Note weakness, shakiness, or quick fatigue. Note any effort, intentional or not, of bringing the hip into flexion as the patient tries to abduct. That is a sign of compensation.

  • Be aware of the position of the leg when testing. If the leg with extended knee is flexed slightly past 0°, the tensor fascia latae is doing the majority of the abduction. Since it is rarely inhibited in dysfunctions, the physician may have a false-positive test result. Some patients have a flexor contracture, making this more difficult. However, that could also be a compensation for the ankle.

Hamstring strength testing is performed as follows:

  • The patient is prone with the knee flexed to no more than 10-20°. Any more flexion could make resisting the patient's hamstring difficult and potentially cause injury if the patient contracts without the physician being ready.

  • The physician places one hand on the distal hamstring for stability and the other around the ankle.

  • The physician instructs the patient to flex the knee hard against physician resistance.

  • The physician looks for quick fatigue, easy cramping (while the opposite side does not cramp), weakness, or shakiness.

The information obtained through these tests can be included on a physical therapy prescription if the physician is not trained to perform manual medicine to realign the patient and free-up the restrictions that lead to this inhibition. Once the inhibition is removed, the patient's strength and stability improves immediately.

Differences in these tests indicate core instability related to inhibition of muscle firing and contraction. The core strength may already be weak enough to allow chronic malalignment and dysfunctions to exist, but many of these patients function without difficulty. When an injury occurs, the homeostasis that the neuromuscular system achieves can be disrupted, leading to chronic problems long after an injury heals.

Any chronic core instability can lead to recurrent dysfunctions and malalignment, which can prolong the problem. Manual medicine treatment should be paired with rehabilitation to stabilize and balance the core mechanics through 3-dimensional functional training.

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. (See the image below.)

    Dislocated peroneal tendons. Left, Note the course 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.[23]

 

DDx

 

Workup

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, 14, 15, 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.[14]

  • Ultrasonography is useful for detecting all types of peroneal lesions. In particular, real-time ultrasonography can be performed to assess dynamic stability.[7, 11, 24, 25] 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.[26] 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.

 

Treatment

Approach Considerations

Chronic peroneal tendinopathy usually appears as tendinosis or tearing of varying degrees of severity. The pathology develops over time, with repetitive stress combined with dysfunctional mechanics to cause collagen breakdown.  

Overuse is rarely an actual cause, as many patients with most peroneal tendon syndromes developing from levels of exercise not too dissimilar from their peers. This is better explained as "repetitive use with biomechanical dysfunction." When treating this condition, one must find and treat the causes that lead to the tendinosis.

Acute peroneal tendon injuries require aggressive conservative treatment immediately in order to minimize functional loss, scarring, and atrophy. The typical mechanism of injury is inversion ankle injury, with an eccentric load on peroneal muscles that concentrically contract to prevent the inversion. Therefore, a complete ankle exam should be performed, and any injuries should be treated concomitantly. Any residual instability should be rehabilitated to prevent further inversion injuries.

 

 

Acute Phase

Acute management

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.

Short-term use of weight-bearing immobilization (walking boot) are effective in allowing ambulation while decreasing stress on the tendon structures. 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.

Physical Therapy

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.

Physical therapy must evaluate core biomechanics as previously discussed in this article. Patients with peroneal injuries can limp or favor that side, and many patients develop dysfunctions in the lumbosacropelvic region that inhibit muscle firing, shift functional leg lengths, and lead to problems in other regions, such as the lower back and knee. A comprehensive rehabilitation program must evaluate core stability and include core exercises in the rehabilitation program.

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, and anomalous peroneal brevis muscle hypertrophy and for peroneus longus tears that are associated with diminished function.[18, 19, 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] Patients have had excellent long-term functional outcomes with debridement and primary operative repair of peroneal tendon tears.[27]

A literature review by van Dijk et al found good outcomes following surgery for peroneal tendon dislocation, as well as a fast postsurgical return to sports. The study also found that the sports-return rate was significantly greater in patients who underwent a combination of groove deepening and superior peroneal retinaculum repair than in those managed with superior peroneal retinaculum repair alone.[28]

Other Treatment

Corticosteroids

Injection with corticosteroid is not recommended for the peroneal tendons, especially in the acute phase. 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.[29]

Osteopathic manipulative treatment

This treatment has been demonstrated to provide significant pain relief in acute ankle injuries.[30] The seeds of peroneal tendinopathy can be sown in ankle injuries that cause significant dysfunction to talar and subtalar motion. Dysfunctions along the kinetic chain from the foot through the sacroiliac joint and lumbar spine can alter gluteus medius firing and core stability, which then can lead to increased impingement of the peroneus longus and brevis laterally. Restoring normal biomechanics in the acute phase reduces the chance for peroneal impingement.

Recovery Phase

Physical Therapy

In the recovery phase, steps are taken to restore ankle strength and flexibility and to return the patient to their activity.[31, 32]

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.

A literature review by van Dijk et al of studies addressing rehabilitation following surgery for peroneal tears and ruptures found a possible trend toward shorter postsurgical immobilization periods and earlier initiation of range-of-motion (ROM) exercises, with ROM activity begun within 4 weeks postsurgery in 41% of the studies that discussed commencement of these exercises. The report found no consensus regarding optimal rehabilitation practices after peroneal tendon tear or rupture surgery.[33]

Immobilization

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.

Regenerative biologic agents

These treatments include such procedures as platelet-rich plasma, amniotic fluid, and stem cell from bone marrow aspirate concentrate show promise in healing tears and tendinosis. These are all considered experimental and not covered by major insurance carriers. However, these treatments are likely to become more commonplace as patients look to restore tissue health without invasive surgical disruption.[34, 35, 36, 37]

Percutaneous tenotomy

Percutaneous ultrasonic tenotomy is a procedure whereby ultrasonic energy is transmitted through a slender probe to debride tendinotic disease. This shows significant promise in restoring tendon function without an open surgical debridement, which has a longer recovery and larger price tag. This procedure is covered by most major insurances. Although the procedure is most successful treating the common extensor tendon origin (lateral epicondylitis) and plantar fasciitis, peroneal tendinopathy.[38]

Osteopathic manipulative treatment

Osteopathic manipulative treatment should be used throughout the recovery process to monitor and correct biomechanical dysfunctions that can lead to peroneal disorders, as previously mentioned in the Acute Phase section. Osteopathic manipulative treatment should be used in concert with physical therapy to minimize the number of times it is used by stabilizing the alignment through improvement in pain, core stability, and gait biomechanics.

Surgical Intervention

Chronic tears of the peroneal tendons with persistent pain and instability that fail conservative treatment should have a surgical evaluation.[39] Tendinosis may cause nodules or scar tissue that may need debridement. Longitudinal tears that fail treatment with immobilization may be present.

An orthopedic surgeon, or a foot and ankle surgeon, should be consulted in cases of ankle pain or instability that is unresponsive to conservative treatment. Conditions that would warrant surgical evaluation include talar instability, peroneal subluxation or dislocation, distal fibular fracture or nonunion, and full-thickness peroneal tendon tear.

For persistent symptoms with peroneal tendinitis, a tenosynovectomy is the procedure of choice. [40]

Maintenance Phase

Rehabilitation Program

Physical Therapy

The maintenance phase should be grounded in good pre-exercise and post-exercise ankle stretching and strengthening techniques. Bracing and taping should not be necessary if the ankle is fully rehabilitated. Proprioceptive physiotaping, such as KT taping, can be used to speed recovery and enhance stability. 

Performance training

Patients need to continue training the stability of the ankle long-term, especially with those who stress their ankles repetitively.[41]

 

 

Medication

Medication Summary

In the acute phase of any ankle injury, nonsteroidal anti-inflammatory medication such as ibuprofen and naproxen can be used to decrease pain and swelling. In cases of moderate pain, acetaminophen or tramadol may be used for a brief period. Opioid medication should be avoided except in cases with severe pain.

 

Nonsteroidal Anti-inflammatory Drugs

Class Summary

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.

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.

Analgesics

Class Summary

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.

Codeine/acetaminophen (Tylenol-3)

Indicated for the treatment of mild to moderate pain.

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

Drug combination indicated for moderate to severe pain.

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

Drug combination indicated for mild to moderate pain.

 

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.

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.

A study reviewed the long-term clinical and patient-reported outcomes of a cohort of patients with peroneal tendon tears treated with debridement and primary repair. The study of 18 patients with an average follow-up of 6.5 years found excellent long-term functional outcomes for patients with tears of the peroneal tendons treated with debridement and primary operative repair. The study also observed that the majority of patients returned to their previous level of activity without the need for reoperation or revision of the repair.[42]

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.

 

Questions & Answers

Overview

What are peroneal tendon syndromes?

What are acute injuries of the peroneal tendon?

What are chronic injuries of the peroneal tendon?

How are peroneal tendon syndromes diagnosed and managed?

What is the prevalence of peroneal tendon injuries in the US?

What is the functional anatomy relevant to understanding peroneal tendon syndromes?

What is the sport-specific biomechanics of peroneal tendon syndromes?

What is the role in biomechanics in determining the etiology of peroneal tendon damage?

What happens to the peroneal tendon when the core is destabilized?

Presentation

Which history is characteristic of peroneal tendonitis?

Which history is characteristic of peroneal tendon subluxation?

Which history is characteristic of peroneal tendon tears?

Which history is characteristic of anomalous peroneus brevis muscle injury?

Which history is characteristic of a lateral ankle impingement?

What should be the focus of the physical exam for a suspected peroneal tendon syndrome?

How is the ankle inspected and palpitated in the exam of a peroneal tendon injury?

What specific stability tests should be performed in the evaluation of peroneal tendon injury?

What is the role of a tilt test in the evaluation of peroneal tendon injury?

What is the role of a peroneal tendon stability test in the evaluation of peroneal tendon injury?

What are the possible etiologies of acute and chronic peroneal tendon injury?

Which biomechanical factors increase the risk for a peroneal tendon injury?

DDX

What are the differential diagnoses for Peroneal Tendon Syndromes?

Workup

What is the role of imaging studies in the evaluation of peroneal tendon injuries?

What is the role of electromyelography (EMG) in the evaluation of peroneal tendon injuries?

Treatment

What is the focus of management for chronic peroneal tendinopathy?

What is the focus of management for acute peroneal tendon injuries?

How is the acute phase of a peroneal tendon injury managed?

What is the role of physical therapy in the management of the acute phase of a peroneal tendon injury?

What are the possible complications of conservative or surgical treatment for peroneal tendon injury?

What is the role of surgery in the management of acute phase peroneal tendon injury?

What is the role of corticosteroids in the management of acute phase peroneal tendon injury?

What is the role of osteopathic manipulative treatment in the acute phase of a peroneal tendon injury?

What is the role of physical therapy in the recovery phase of peroneal tendon injury?

Why is proprioceptive rehabilitation needed during the recovery phase of peroneal tendon injury?

When is immobilization indicated in the recovery phase of peroneal tendon injury?

What is the role of regenerative biologic agents in the recovery phase of a peroneal tendon injury?

What is the role of percutaneous tenotomy in the recovery phase of a peroneal tendon injury?

What is the role of osteopathic manipulative treatment in the recovery phase of a peroneal tendon injury?

What is the role of surgery during the recovery phase of a peroneal tendon injury?

What is the role of physical therapy in the maintenance phase of a peroneal tendon injury?

Medications

Which medications are used in the treatment of peroneal tendon syndromes?

Which medications in the drug class Analgesics are used in the treatment of Peroneal Tendon Syndromes?

Which medications in the drug class Nonsteroidal Anti-inflammatory Drugs are used in the treatment of Peroneal Tendon Syndromes?

Follow-up

When should a patient return to regular activity after a peroneal tendon injury?

What are possible complications of peroneal tendon injury treatment?

How are peroneal tendon injuries prevented?

What is the prognosis of peroneal tendon injury?

What education about peroneal tendon injury should patients receive?