Peroneal Tendon Injuries

By Dr Owen Mattern MBBS | Unaccredited Orthopaedic Registrar

References

  • JAAOS 2009;17:306-317
  • Campbell’s Operative Orthopaedics 11th Ed
  • DeLee and Drez’s Orthopaedics Sports Medicine 3rd Edition

Anatomy

  • Peroneus brevis and longus
    • Primary action eversion and pronation
    • Weak plantar flexors
    • Lateral ankle stabilisers
    • Supplied by superficial peroneal nerve
    • Blood supply by perforating branches anterior tibial and peroneal arteries
    • Stability – midstance and heel-raise portions of gait
    • Cross ankle joint in common tunnel and sheath
      • Sheath bifurcates at peroneal tubercle
  • Peroneus Brevis Tendon
    • Anterior and medial to PLT
    • Inserts into dorsolateral tubercle 5th MT
  • Peroneus Longus Tendon
    • Lateral and posterior to PBT
    • Inserts into lateral base 1st MT and medial cuneiform
  • Both have good blood supply
  • Superior Peroneal Retinaculum
    • Fibrous band that blends with periosteum
    • Posterior ridge of fibula to lateral wall calcaneum
    • Attached to a fibrocartilaginous rim that deepens groove in posterior fibula
  • Anomalous Anatomy
    • Some variants may predispose to lax SPR increasing risk of pathology
      • Anomalous muscle
        • Peroneus quadratus (13-21%)
        • Peroneus digiti quinti (of Testut)
        • Peronealcalcaneus muscle (of Heckman)
      • Low lying PB muscle belly
    • Possible bony tunnel causing impingement

Classification

Disorders of peroneal tendons

DisorderFeatures
Tendinitis without subluxationMiddle-aged athletes. Attritional ruptures can occur
Tendinitis with peroneal tendon instability at SPRYoung athletes, acute ankle injury or chronic ankle instability. Rupture of SPR
Stenosing tenosynovitis of PLTOften with painful os peroneum. Secondary to bony tunnel at the level of cuboid

Examination

  • Often have concomitant lateral ankle instability
  • Need to check for tendon subluxation
  • Tendon strength, subluxation, peroneal compression test (popping, pain and crepitus at posterior distal fibula on forced eversion), pain and swelling along tendon, pseudotumour
  • Hindfoot varus – need to assess for charcot marie tooth and other motor neuropathies
  • Assess for hindfoot varus, high arch, limitation of subtalar movement in eversion
  • All predispose to peroneal pathology due to increased forces through the tendons

Investigations

  • Plain X-rays – MUST INCLUDE WB
  • Ultrasound
    • >1mm of fluid of tendon thickening indicates tendinosis
    • Can help diagnose subluxing tendons
  • CT
    • Especially for bony abnormalities
  • MRI
    • Normal tendon low signal intensity in T1, T2 and STIR
    • Increased intensity on T2/STIR may indicate tear, tendinosis or tenosynovitis

Treatment

Tenosynovitis/Tendinitis

  • Result of repetitive or prolonged activity
  • Pain, swelling and point tenderness often wit recent trauma
  • Rx
    • RICE, NSAID’s, ankle brace, lateral heel wedge orthosis
    • Any surgery needs to address underlying problem as well as treating and debriding tendon/tendon sheath
      • Often surgery is for tears

Partial Tears

  • Cadaveric study showed tendon to splay and flatten after compression over fibular groove
    • Most commonly PBT
  • Up to 83% failure rate for conservative Rx
  • Good return to work (90%) but variable return to sport following repair (46-95%)
  • Krause and Brodsky grading system
    • Grade 1 <50%
      • Direct repair
    • Grade 2 >50%
      • tenodesis

Complete Tears

  • More common in
    • T2DM, RA, steroid injection, injuries associated with tendon subluxation
  • Concomitant tears graded by Redfern and Myerson
    • Grading
      • Type 1 – both tendons repairable
      • Type 2 – one tendon repairable
      • Type 3 – neither tendon repairable
    • Treated 29 patients according to protocol and had a mean improvement from 61 to 82 of AOFAS score
  • Wapner
    • Wapner reported method for treatment of concomitant tears
      • 2-stage procedure
      • Silastic rod attached distally to tendon to create synovial sheath
      • 3/12 later FHL tendon transfer and reconstruction to distal tendon
      • 6/7 patients pain-free at 8.5 years

Subluxation and Dislocation

  • Commonly reported in skiers
    • 0.5% of all skiing injuries are complete peroneal dislocation
    • Result of forceful dorsiflexion and eversion
    • Recreated by circumduction and eversion
  • Often mis-diagnosed as ankle sprain in acute injury
  • Four grades (Eckert and Davis 1976, Oden 1987)
    • Grade 1 – elevation of SPR and periosteum with tendon lying between periosteum and bone
    • Grade 2 – elevation of SPR with fibrocartilage ridge
    • Grade 3 – Cortical avulsion fracture
    • Grade 4 – tear of SPR from calcaneal and achilles tendon
  • Rx of acute dislocations controversial
    • Small sample sizes with mixed outcomes
    • Some efficacy for plaster 5-6/52
    • Poor responses to taping
    • Overall poor response in up to 50% of cases
    • Still recommend trial non-operative
      • 4- 6/52 in BKPOP with tendons reduced
    • Surgical Rx often involves direct repair SPR

Chronic Dislocation

  • >50% poor results
  • Rx options
    • SPR reconstruction with tendon sling
    • Bone blocks
    • Groove deepening procedures
    • Rerouting procedures
    • SPR reattachment and reinforcement with local tissue
  • Jones tissue transfer technique
    • described in 1932
      • slip of achilles passed 1 inch above lateral malleolus
      • Tendon slip needs to be anchored with foot in dorsiflexion and supination
      • 6/52 in short leg POP
    • Results: Escalas 1980
      • 28 procedures.
      • 15 patients were followed for 6.8years.
      • 14/15 excellent results.
      • 1/15 reported instability of lateral ankle but none found clinically.
      • 3/15 decrease in hindfoot inversion, 4/15 lost 7degrees of dorsiflexion
    • CAN ALSO USE OTHER TENDONS – redundant peroneus quartus to reconstruct SPR
  • Kelly bone block procedure and modification – 1920
    • Modification eliminated surgical fixation
      • DuVries modification
        • Marti 1977, Micheli et al 1989 and Mason et al 1996 – good results.
        • Some crepitation of tendons thought to result from inferior posterior displacement.
        • Immobilised for 5-8/52
  • Groove Deepening
    • Zoellner/Clancy –
      • raise an osteoperiosteal flap,
      • cancellous bone removed 6-9mm and flap reimpacted.
      • Excellent results in 10 patients.
      • Immobilised for 3-6/52 in POP then ankle hinge.
      • Other studies of 17 patients reported excellent results.
      • Can be used in conjunction with a periosteal flap

Summary

  • Uncommon injuries
  • Tears often need to be debrided +/- tenodesis
  • Acute subluxation of tendons can trial non-operative management
  • Chronic subluxation of tendons needs a surgical intervention
    • No strong evidence for any procedure over others
  • In all cases you need to correct any underlying foot deformity for best outcome

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.