Peroneal Tendon Injuries 

Last updated: February 8, 2026Reviewed date: February 8, 2026Reading time: 7 min read
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Article Summary

Peroneal tendon injuries can be acute, meaning the injury occurred suddenly, or chronic, meaning that damage occurred over time. Symptoms of peroneal tendon injuries can include pain and swelling, weakness in the foot or ankle, warmth to the touch, and a popping sound at the time of injury. Peroneal tendinitis generally takes 6-8 weeks to improve and early activity on a healing tendon can result in a...

Key Takeaways

  • This article explains Other Names in simple medical language.
  • This article explains Pathophysiology in simple medical language.
  • This article explains Causes in simple medical language.
  • This article explains Risk Factors in simple medical language.
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Definition

Peroneal injuries can be , meaning the injury occurred suddenly, or , meaning that damage occurred over time. Symptoms of peroneal tendon injuries can include and , in the foot or ankle, warmth to the touch, and a popping sound at the time of injury. Peroneal generally takes 6-8 weeks to improve and early activity on a healing tendon can result in a setback in recovery. Non-compliance can double the recovery time and can be very frustrating for patients. Early and aggressive is recommended to prevent further tendon injury.

Treatment involves rest, ice, nonsteroidal drugs (NSAIDs) such as ibuprofen or naproxen, and a regimen that focuses on ankle range-of-motion exercises, peroneal strengthening, and proprioception (balance) training. More cases may require immobilization with a walking boot.

Other Names

  • Peroneal Tendon Disorders
  • Peroneal
  • Peroneal Tenosynovitis
  • Peroneal tendon subluxation
  • Peroneal tendon
  • Peroneal tendon split
  • Peroneal tendon tear
  • Peroneal tendinosis
  • Superior Peroneal Retinaculum (SPR) Injury

Pathophysiology

  • This page refers to disorders of the Peroneal
    • This includes tendinopathies, subluxation, dislocation, and tearing
  • Only 60% of peroneal tendon disorders are accurately diagnosed at the first evaluation
  • Most commonly seen young active patients (need citation)
  • Tears
    • Peroneus Brevis tear is more common than longus
    • Of 47 patients with lateral ankle complaints, 36% were found to have attrition of the peroneus brevis tendon
    • Retrospective review: 88% had brevis tears, 13% longus and 37% had both[5]
  • General
    • Often missed cause of lateral ankle pain

Causes

  • Acute
    • Sudden contraction of the peroneal muscle group
    • Inversion Ankle injury
  • Chronic
    • History of acute injury
    • Tendon rubbing over the posterolateral
    • Chronic lateral ankle instability
    • Anatomic variants: abnormal fibular trimalleolar groove, hindfoot alignment or cavus foot

Peroneal

  • General
    • Characterized by the gradual of pain, swelling, warmth of the posterolateral ankle
    • Lateral ankle instability can lead to laxity
    • Increased motion of the tendons around the fibula with stretched superior peroneal retinaculum
    • Low lying peroneus brevis muscle having to go through the narrow tendon sheath

Peroneal Tendon Subluxation

  • Acute instability can be
    • Rupture of the superior peroneal retinaculum (SPR)
    • Fibular groove avulsion
  • Chronic subluxation
    • Associated with fibular groove flattening and laxity of the superior retinacular retinaculum or

Peroneal Tendon Tear

  • General
    • Occurs at the musculotendinous junction
    • May be acute, vast majority are chronic[7]
    • Most tears are longitudinal and result from chronic subluxation over the distal fibula
    • Often related to a sentinel event which is remote relative to patient presentation
  • Location
    • Majority of tears at tip of fibula, bony prominence where pressure is applied against tendon
    • This suggests most tears are mechanical in etiology
  • Etiology: Peroneus brevis
    • Chronic: subluxing tendon can splay or split over the sharp posterolateral edge of the fibula
    • Acute: compression of the peroneus brevis tendon between the posterior fibula and peroneus longus tendon causes a split during an inversion injury
    • Both can lead to the so-called ‘split lesion’
  • Etiology: Peroneus Longus
    • Acute: laceration of the tendon, avulsion of the tendon at or through the os peroneum, or dislocation at the lateral malleolus

Pathoanatomy

  • Lateral Compartment of the Leg
    • Contains Peroneus Longus, Peroneus Brevis (sometimes referred to as Fibularis)
    • Functions: Eversion, weak ankle plantarflexion, dynamic ankle stabilizer
    • Both tendons cross the joint posteriorly to the lateral malleolus
    • Tendon orientation at the level of the ankle is brevis anterioromedial to longus
    • They share a common synovial sheath until they pass the fibula where they divide into separate sheaths
  • Peroneus Longus
  • Peroneus Brevis
    • Strongest abductor of the foot because it attaches on the 5th 
  • Os peroneum
    • Seen in about 20% of population[8]
    • Ossified sesamoid bone at the level of the calcaneocuboid joint
  • Peroneus Quartus
    • Most commonly runs from the peroneus brevis to the retrotrochlear eminence of the
    • Associated with peroneus brevis tears, and subluxation
  • Peroneal Tunnel
    • Superior peroneal retinaculum
    • Posterior fibula with a trimalleolar groove
    • Calcaneofibular Ligament

Risk Factors

  • Biomechanical/ Structural
    • Hindfoot Varus
    • Shallow or convex fibular groove
    • Compression by the peroneus longus in dorsiflexion
    • Hypertrophied peroneal tubercle and an enlarged retrotrochlear eminence
    • Bony spur at the posterior lateral fibular groove
    • Presence of peroneus Quartus muscle in the peroneal sheath
  • Orthopedic
    • Lateral Ankle Instability
    • Calcaneus [9]
    • [10]
    • Hyperparathyroidism
    • Diabetic [11]
  • Pharmacology
    • Fluoroquinolone Antibiotics

Differential Diagnosis

Differential Diagnosis Leg Pain

  • Fractures & Dislocations
    • Tibial Shaft Fracture
    • Fibular Fracture
    • Tibial Stress Fracture
    • Fibular Stress Fracture
    • Proximal Tibiofibular Joint Dislocation
  • Muscle and Tendon Injuries
    • Calf Strain
    • Calf Tear
    • Peroneal Tendon Injuries
    • Achilles Tendonitis
    • Achilles Tendon Rupture
    • Syndesmotic Sprain
  • Nerve Injuries
    • Peroneal Nerve Injury
    • Sural Nerve Injury
    • Saphenous Neuritis
  • Other
    • Medial Tibial Stress Syndrome
    • Acute Compartment Syndrome
    • Chronic Exertional Compartment Syndrome
    • Popliteal Artery Entrapment Syndrome
    • Ruptured Bakers Cyst
  • Pediatric Considerations
    • Tibial Tubercle Avulsion Fracture
    • Tibial Tuberosity Apophysitis
    • Toddlers Fracture (Tibial Shaft Fracture)

Differential Diagnosis Ankle Pain

  • Fractures & Dislocations
    • Distal Tibia Fracture
    • Distal Fibular Fracture
    • Talus Fracture
    • Calcaneus Fracture
    • Subtalar Dislocation
    • Ankle Fracture (& Dislocation)
    • Peroneal Subluxation
  • Muscle and Tendon Injuries
    • Peroneal Tendon Injuries
    • Achilles Tendonitis
    • Achilles Tendon Rupture
    • Posterior Tibial Tendon Dysfunction
    • Flexor Hallucis Longus Tendinopathy
  • Ligament Injuries
    • Lateral Ankle Sprain
    • Medial Ankle Sprain
    • Syndesmotic Sprain
    • Chronic Ankle Instability
    • Intersection Syndrome Foot
  • Bursopathies
    • Retrocalcaneal Bursitis
  • Nerve Injuries
    • Peroneal Nerve Injury
    • Tarsal Tunnel Syndrome
  • Arthropathies
    • Osteoarthritis of the Ankle
    • Osteochondral Defect Talus
  • Pediatrics
    • Fifth Metatarsal Apophysitis (Iselin’s Disease)
    • Calcaneal Apophysitis (Sever’s Disease)
  • Other
    • Haglunds Deformity
    • Posterior Ankle Impingement Syndrome
    • Sinus Tarsi Syndrome

Symptoms

  • History
    • Patients typically report posterolateral hindfoot or ankle pain
    • The tendon may look swollen or enlarged (more commonly in brevis than longus tears)
    • Patients may describe a snapping sensation
  • Physical Exam: Physical Exam Ankle
    • Swelling proximal to or at lateral malleolus: brevis pathology
    • Swelling at or distal to peroneal tubercle: longus pathology
    • Pain with resisted eversion, ankle dorsiflexion
    • Pain with passive inversion, ankle plantarflexion
    • Subluxation/ crepitus of the peroneal tendon over posterior fibula can sometimes be palpated
    • Strength may be diminished
    • The presence of eversion does not exclude rupture or tear
    • Rotate the ankle to see and feel if the tendons subluxate anteriorly over the lateral malleolus
  • Special Tests
    • Peroneal Tunnel Compression Test: the foot is dorsiflexed, everted with pressure applied to the retrobulbar region of the peroneal tendons
    • Plantarflex 1st Ray: loss or limitation of plantarflexion suggests dysfunction of peroneus longus

Radiographs

  • Standard Radiographs Ankle, Standard Radiographs Foot
    • Standard views
    • Axillary Heel View: can demonstrate the peroneal tubercle and the trimalleolar groove
  • Os Perineum
    • Seen in 20% of the population
    • visible on internal rotation oblique foot radiographs at the level of the calcaneocuboid joint
    • Migration of the os peritoneum proximal can suggest peroneal longus tendon disruption[13]

MRI

  • The imaging modality of choice
  • Findings of peroneal tendonitis/ tendinosis
    • Peritendinous fluid
  • Findings of peroneal subluxation/ dislocation
    • Information on the status of the SPR
    • Documenting the shape of the fibular groove
  • Findings of peroneus longus tear
    • Heterogeneity and/or discontinuity of the tendon
    • Empty, fluid-filled tendon sheath
    • Marrow edema along the lateral calcaneal wall
    • Hypertrophied peroneal tubercle
  • Diagnostic accuracy
    • Peroneus brevis tears diagnostic accuracy correlated to surgical findings[14]
      • Sensitivity: 93%
      • Specificity: 75%
    • Another study has reported that MRI does not reliably predict the degree of peroneal tendon pathology when compared with intraoperative findings
  • Magic Angle Effect
    • The factitious appearance of heterogeneity, increased the signal in a tendon when it intersects the main magnetic vector at an angle of 55°
    • Peroneal tendons are susceptible to this, especially at the tip of the lateral malleolus

Ultrasound

  • When comparing diagnostic ultrasound to the gold standard of operative exploration[17][18]
    • Sensitivity: 100%
    • Specificity: 85-90%
    • Diagnostic Accuracy: 90-94%
  • Findings
    • Peritendinous fluid is characteristic of tendonitis

Peroneal Scenography

  • Involves the injection of radiopaque contrast medium into peroneal tendon sheaths to allow visualization of the tendon
    • Infrequently used, a suboptimal diagnostic technique which makes it a limited method
    • Can co-administer local anesthetic and other medications

CT

  • Useful to evaluate bony pathology
  • Not generally indicated for peroneal tendon disease

Classification

  • Based on pathology
    • Tendinitis/ Tendinosis
    • Tendon Tears/ Ruptures
    • Tendon Dislocations/ Subluxation

Krause and Brodsky Classification for Tears

  • Designed to help guide surgical decision making[19]
  • Grade I are lesions that are less than 50% of the cross-sectional area
    • Intervention: tendon repair is recommended
  • Grade II are lesions that is more than 50% of the cross-sectional area
    • Intervention: tenodesis is recommended

Eckert and Davis Classification for Superior Peroneal Retinaculum

  • Classification for the degree of SPR injury
  • Grade I: SPR elevated from the fibula
  • Grade II: Fibrocartilaginous ridge elevated from fibula with SPR
  • Grade III: Cortical fragment avulsed with SPR

Treatment

Prognosis

  • Tendinosis/ Tendonitis
    • Majority of cases will resolve with conservative measures

Nonoperative

  • Indications
    • Vast majority of patients
    • Eckert type I injuries
  • Activity modification
  • Medications
    • NSAIDS
  • Immobilization
    • Tears: 4-8 weeks in a Tall Walking Boot or brace
    • Tendinosis: Consider Tall Walking Boot for 4-6 weeks in refractory cases
  • Physical Therapy
  • Lateral Heel Wedge
  • Corticosteroid Injection
    • Should be performed under ultrasound guidance and can be considered for tendinosis/ tendonitis

Operative

  • Indications
    • Failure of conservative measures
    • Acute subluxation/ dislocation
  • Tear: Techniques
    • Repair
    • Tenodesis
    • Reconstruction
    • Allograft Reconstruction
  • Tendonitis/ Tendinosis Techniques
    • Synovectomy
    • Excision of peroneus quartus muscle
    • Peroneal tubercle osteotomy
  • Subluxation/dislocation Techniques
    • Primary repair of SPR
    • Groove deepening procedures
    • Bone block
    • Tendon rerouting
    • Reconstruction of SPR
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A simple rural-patient checklist to help you explain symptoms clearly, ask better questions, and avoid unsafe self-treatment.

Safety note: This is not a prescription or diagnosis. For severe symptoms, pregnancy danger signs, children with serious illness, chest pain, breathing difficulty, stroke-like weakness, or major injury, seek urgent care.

Which doctor may help?

Start with a registered doctor or the nearest qualified health center.

What to tell the doctor

  • Write when the problem started and how it changed.
  • Bring old prescriptions, investigation reports, and current medicines.
  • Write allergies, pregnancy status, diabetes, kidney/liver disease, and major past illnesses.
  • Bring one family member if the patient is weak, elderly, confused, or a child.

Questions to ask

  • What is the most likely cause of my symptoms?
  • Which danger signs mean I should go to hospital quickly?
  • Which tests are necessary now, and which can wait?
  • How should I take medicines safely and what side effects should I watch for?
  • When should I come for follow-up?

Tests to discuss

  • Vital signs: temperature, pulse, blood pressure, oxygen saturation
  • Basic physical examination by a clinician
  • CBC, urine test, blood sugar, or imaging only when clinically needed

Avoid these mistakes

  • Do not use antibiotics, steroid tablets/injections, or strong painkillers without proper medical advice.
  • Do not hide pregnancy, kidney disease, ulcer, allergy, or blood thinner use.
  • Do not delay emergency care when danger signs are present.

Medicine safety and first-aid guide

This section is for patient education only. It does not replace a doctor, pharmacist, or emergency care.

Safe first steps

  • Avoid heavy lifting, sudden bending, and prolonged bed rest.
  • Use comfortable posture and gentle movement as tolerated.
  • Discuss physiotherapy, X-ray, or MRI only when clinically needed.

OTC medicine safety

  • For mild back pain, pain-relief medicine may be discussed with a doctor or pharmacist.
  • Avoid repeated painkiller use if you have kidney disease, stomach ulcer, uncontrolled blood pressure, or are taking blood thinners.

Avoid these mistakes

  • Do not start antibiotics without a proper medical decision.
  • Do not use steroid tablets or injections casually for quick relief.
  • Do not delay emergency care because of home remedies.

Get urgent help if

  • Back pain with leg weakness, numbness around private area, loss of urine/stool control, fever, cancer history, or major injury needs urgent care.
Medicine names, dose, and timing must be decided by a qualified clinician or pharmacist after checking age, pregnancy, allergy, other diseases, and current medicines.

For rural patients and family caregivers

Patient health record and symptom diary

Write your symptoms, medicines already taken, test results, and questions before visiting a doctor. This note stays on your device unless you print or copy it.

Doctor to discuss: Doctor / qualified healthcare provider
Tests to discuss with doctor
  • Basic vital signs: temperature, pulse, blood pressure, oxygen level if needed
  • Relevant blood, urine, imaging, or specialist tests only after clinical assessment
Questions to ask
  • What is the most likely cause of my symptoms?
  • Which warning signs mean I should go to emergency care?
  • Which tests are really needed now?
  • Which medicines are safe for my age, pregnancy status, allergy, kidney/liver/stomach condition, and current medicines?

Emergency warning signs such as chest pain, severe breathing difficulty, sudden weakness, confusion, severe dehydration, major injury, or loss of bladder/bowel control need urgent medical care. Do not wait for online information.

Safe pathway to proper treatment

Care roadmap for: Peroneal Tendon Injuries 

Use this simple roadmap to understand the next safe steps. It is educational and does not replace examination by a doctor.

Go to emergency care if you notice:
  • Severe or rapidly worsening symptoms
  • Breathing difficulty, chest pain, fainting, confusion, severe weakness, major injury, or severe dehydration
Doctor / service to discuss: Qualified healthcare provider; specialist depends on symptoms and examination.
  1. Step 1

    Check danger signs first

    If danger signs are present, seek emergency care and do not wait for online information.

  2. Step 2

    Record the symptom story

    Write when symptoms started, severity, medicines already taken, allergies, pregnancy status, and test results.

  3. Step 3

    Visit a qualified clinician

    A doctor, nurse, or qualified healthcare provider can examine you and decide which tests or treatment are needed.

  4. Step 4

    Do only useful tests

    Do tests after clinical assessment. Avoid unnecessary tests, random antibiotics, or repeated medicines without diagnosis.

  5. Step 5

    Follow up and return early if worse

    If symptoms worsen, new warning signs appear, or treatment is not helping, return for review quickly.

Rural patient practical tips
  • Take a written symptom diary and all previous prescriptions/test reports.
  • Do not hide medicines already taken, even herbal or over-the-counter medicines.
  • Ask which warning signs mean urgent referral to hospital.

This roadmap is for education. A real diagnosis and treatment plan requires history, examination, and clinical judgment.