Peroneal Tendon Injuries 

Dr. Harun Ar Rashid, MD - Arthritis, Bones, Joints Pain, Trauma, and Internal Medicine Specialist Dr. Harun Ar Rashid, MD - Arthritis, Bones, Joints Pain, Trauma, and Internal Medicine Specialist
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Rx Musculoskeletal System (A - Z)

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 setback in recovery. Non-compliance can double the recovery time and can be very frustrating for patients. Early and aggressive conservative treatment is recommended to prevent further tendon injury.

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

Other Names

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

Pathophysiology

  • This page refers to disorders of the Peroneal Tendons
    • This includes tendinopathies, subluxation, dislocation, and tearing
  • Only 60% of peroneal tendon disorders are accurately diagnosed at the first clinical 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 fibula
    • Chronic lateral ankle instability
    • Anatomic variants: abnormal fibular trimalleolar groove, hindfoot alignment or cavus foot

Peroneal Tendonitis

  • General
    • Characterized by the gradual onset 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 belly 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 ligament

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 lesion 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 Metatarsal
  • 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 calcaneus
    • 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 Fracture[9]
  • Systemic
    • Rheumatoid Arthritis[10]
    • Psoriasis
    • Hyperparathyroidism
    • Diabetic Neuropathy[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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