AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Background

Injuries to the peroneal tendons are common but not always clinically significant. They are misdiagnosed as a lateral ankle sprain most of the time, because isolated injury to the peroneal tendons is rare. 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 rupture can be asymptomatic. Lesions have been seen in symptomatic patients, as well as in cadaver studies of patients who were presumably asymptomatic. 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 and recurrent subluxation of the peroneus brevis tendon. These chronic injuries are usually associated with ankle or subtalar arthritis and ankle instability.

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. Fallat et al noted over 33 months that out of 638 acute ankle "sprains" seen at the Oakwood Hospital Downriver Center Emergency Room and Occupational Medicine Clinic, only 83 involved damage to the peroneal tendons, while more than 450 involved the anterior talofibular ligament.

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, while the brevis originates from the distal two thirds of the fibula. They both have a musculotendinous portion that courses just below the lateral malleolus.

At the posterior aspect of the lateral malleolus, they lay within the fibular groove, with the brevis medial and anterior to the 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 brevis courses anteriorly crossing over the cuboid to insert on the fifth metatarsal styloid.

Inferior to the brevis, the 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 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, it plays 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.

CLINICAL

Section 3 of 11  

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• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

History

The histories for each type of peroneal injury have subtle differences. The key is to have a clinical suspicion and to listen carefully to the patient.

• Peroneal tendonitis
• • 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 prior to 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 amount. Note ecchymosis and any ankle or foot deformity (the foot is in varus for acute brevis tears). Note the position of 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 peroneal tendons down to their insertion sites. Palpate along the bony structures to identify possible fractures. Palpate 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 the nondominant hand as the dominant hand pulls the posterior aspect of the calcaneus forward. Laxity indicates an injury to the anterior talofibular ligament.
  
  
  
  • Tilt test: With the patient seated on the edge of the table with his or her legs dangling, hold the distal tibia stable with the nondominant hand. With the dominant hand holding the calcaneus, attempt to open the lateral ankle compartment. Opening indicates an injury to the calcaneofibular ligament.
  
  
  
  • 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.

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 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 injuries.

DIFFERENTIALS

Section 4 of 11  

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• Clinical
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• References

Other Problems to be Considered

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

WORKUP

Section 5 of 11  

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• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

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, talar instability that can lead to peroneal instability may be present.



• MRI is the criterion standard for identifying peroneal tendon injury. This injury is identified by the high signal intensity within tendon on T2-weighted axial views.



• Ultrasonography is useful for detecting all types of peroneal lesions. In particular, real-time ultrasonography can be performed to assess dynamic stability. 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.



• CT scanning is useful for evaluating bony irregularities and suspected fracture, particularly in the calcaneus.



• Tenography is useful for assessing large lesions of the tendons.

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

Section 6 of 11  

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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 has 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.

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 rupture, acute dislocation, anomalous peroneal brevis muscle hypertrophy and in peroneus longus tears associated with diminished function. 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.

Consultations

An orthopedist, 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, flexibility, and 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 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 tendonitis, 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 immobilization may be present.

Consultations

An orthopedist, 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 pre- and post-exercise ankle stretching and continued use of strengthening techniques learned in physical therapy. Bracing and taping should not be necessary if fully rehabilitated. Proprioceptive physiotaping can be used to speed recovery.

Consultations

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

MEDICATION

Section 7 of 11  

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• References

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

Drug Category: Nonsteroidal anti-inflammatory drugs

These medications have anti-inflammatory properties and reduce pain.

Drug Category: Analgesics

Narcotics are used for pain reduction. Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and enables physical therapy regimens. Many analgesics have sedating properties, which are beneficial for patients that experience pain.

FOLLOW-UP

Section 8 of 11  

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Return to Play

If surgery and/or casting is not required, the patient can usually return to activity in 1-2 weeks with 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 are progression of pain and instability, and possible 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 pre- and post-exercise stretching of the ankle, (2) gradually increasing the level of activity or training, and (3) fully rehabilitating 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), are also 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 acute dislocation 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 cornerstone in the prevention of peroneal tendon injuries. Further, stressing the need to stretch before and after exercise is also important.

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.

MISCELLANEOUS

Section 9 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Medical/Legal 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

Special Concerns

• Patients who have an unsteady gait, such as geriatric patients or patients with 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 not, 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

Section 10 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

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.
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Media type:  Image

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 towards the operator. From Karageanes SJ. Principles of Manual Sports Medicine, Lippincott Williams & Wilkins, 2005.
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Media type:  Image

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.
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Media type:  Image

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.
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Media type:  Image

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.
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Media type:  Image

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

• 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. Aug 1998;17(8):525-9. [Medline].
• DIGiovanni BF, Fraga CJ, Cohen BE, Shereff MJ. Associated injuries found in chronic lateral ankle instability. Foot Ankle Int. Oct 2000;21(10):809-15. [Medline].
• Fallat L, Grimm DJ, Saracco JA. Sprained ankle syndrome: prevalence and analysis of 639 acute injuries. J Foot Ankle Surg. Jul-Aug 1998;37(4):280-5. [Medline].
• Ho RT, Smith D, Escobedo E. Peroneal tendon dislocation: CT diagnosis and clinical importance. AJR Am J Roentgenol. Nov 2001;177(5):1193. [Medline].
• Major NM, Helms CA, Fritz RC, Speer KP. The MR imaging appearance of longitudinal split tears of the peroneus brevis tendon. Foot Ankle Int. Jun 2000;21(6):514-9. [Medline].
• Mendicino RW, Orsini RC, Whitman SE, Catanzariti AR. Fibular groove deepening for recurrent peroneal subluxation. J Foot Ankle Surg. Jul-Aug 2001;40(4):252-63. [Medline].
• Neustadter J, Raikin SM, Nazarian LN. Dynamic sonographic evaluation of peroneal tendon subluxation. AJR Am J Roentgenol. Oct 2004;183(4):985-8. [Medline].
• Omey ML, Micheli LJ. Foot and ankle problems in the young athlete. Med Sci Sports Exerc. Jul 1999;31(7 Suppl):S470-86. [Medline].
• Safran MR, O'Malley D Jr, Fu FH. Peroneal tendon subluxation in athletes: new exam technique, case reports, and review. Med Sci Sports Exerc. Jul 1999;31(7 Suppl):S487-92. [Medline].
• Sammarco GJ. Peroneal tendon injuries. Orthop Clin North Am. Jan 1994;25(1):135-45. [Medline].
• 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. Jan 1997;168(1):129-33. [Medline].
• Sobel M, Geppert MJ, Warren RF. Chronic ankle instability as a cause of peroneal tendon injury. Clin Orthop Relat Res. Nov 1993;(296):187-91. [Medline].
• van Dijk CN, Kort N. Tendoscopy of the peroneal tendons. Arthroscopy. Jul-Aug 1998;14(5):471-8. [Medline].
• Waitches GM, Rockett M, Brage M, Sudakoff G. Ultrasonographic-surgical correlation of ankle tendon tears. J Ultrasound Med. Apr 1998;17(4):249-56. [Medline].

Article Last Updated: Feb 10, 2006