The peroneal tendons run behind the lateral (outer) aspect of the ankle and then along the outside of the foot.

There are 2 tendons:

  • Peroneus brevis which attaches to the base of the 5th metatarsal
  • Peroneus longus which attaches under the arch of the foot to the 1st metatarsal base

The function of the tendons is to assist in stabilising the foot and ankle.

Who has problems?

Peroneal tendon problems are common in:

  • A high arched foot and turned in heel (varus)
  • Ankle instability
  • Participation in twisting or physical sports
  • Overuse in older patients

What are the symptoms?

Symptoms may be acute after a specific injury or develop gradually due a degenerative process.

  • Pain along the line of the tendons
  • Swelling behind the outside of the ankle
  • Feeling of ankle instability or weakness

What problems can occur?

  • Tendonitis
  • Acute tear in a normal tendon
  • Degenerative tears

Tendonitis
This is inflammation of one or both tendons and the surrounding sheath ( tenosynovitis ).
The inflammation is caused by activities involving repetitive use of the tendon.

Acute tears in a normal tendon.
These occur after an injury.
Tears can range from longitudinal splits to complete rupture of the tendons.
Tendon rupture may lead to a change in the shape of the foot over time, in which the heel turns inwards.

Degenerative tears (tendinopathy)
Usually due to overuse or recurrent ankle instability and occurs over long periods of time.
In degenerative tears, the tendon becomes less elastic and the structure changes.
This weakens the tendon and places it at risk of injury with less force.
Tears can range from longitudinal splits to complete rupture of the tendons

Diagnosis

Xrays are useful for assessing the bony anatomy and foot shape

USS or MRI are the most useful at looking at the quality of the tendons and whether there is a split or tear.

It may be important to exclude other associated pathology of the ankle including:

  • Ligament injury
  • Damage to the ankle joint surface

Nonsurgical Treatment

Treatment depends on the type of peroneal tendon injury and includes the following.

  • RICE
  • Simple pain relief
    • Paracetamol
    • Short course anti inflammatories
  • Steroid injection – rarely
  • Activity modification
  • Physiotherapy
    • Swelling management
    • Range of motion exercises
    • Strengthening
  • Orthotics to offload the tendons
  • Ankle brace to aid stability of the ankle

Surgical considerations

There are other factors which may contribute to the need for surgery and the type of the surgery required.

  • Extent of tears
  • One or both tendons involved
  • Foot shape – varus heel
  • Bony anatomy
  • Ankle ligament insufficiency
  • Presence of arthritis

When is surgery considered?

  • A tendon is torn completely -definite indication
  • A tendon is split in association with an at risk foot shape
  • A tendon is split in association with recurrent ankle instability
  • When non surgical treatment has failed and the symptoms are interfering with function and quality of life

Surgical procedures

  • Tendon debridement and repair
  • Tendon transfer of the torn tendon to the remaining tendon
  • Removal of bony prominence on the outside of the calcaneus
  • Lateral ligament reconstruction
  • Osteotomy of the calcaneus to correct heel deformity
  • Surgery to address ankle or subtalar arthritis

What does the rehabilitation involve?

Rehabilitation and recovery times are determined by the specific surgery required.

Tendon debridement and repair surgery:

  • 1 night in hospital
  • 2 weeks in a cast non weightbearing with elevation of the foot
  • 4 weeks in a CAM Boot full weightbearing
  • Physiotherapy to begin at 2 weeks from surgery with active ankle dorsiflexion and plantarflexion
  • Physiotherapy to progressing to resistance exercises at 6 weeks from surgery
  • By 2-3 months returning to recreational walking
  • Return to sport by 4-5 months
  • Swelling resolution by 6- 9 months

Tendon transfer surgery

  • 1 night in hospital
  • 2 weeks in a cast non weightbearing with elevation of the foot
  • 4 weeks in a CAM Boot non weightbearing
  • Physiotherapy to begin at 4 weeks from surgery with active ankle dorsiflexion and plantarflexion
  • At 6 weeks transition into an ankle brace and progress to full weightbearing
  • Physiotherapy to progressing to resistance exercises at 8 weeks from surgery
  • By 3 months returning to recreational walking
  • Return to sport by 4-6 months
  • Swelling resolution by 6- 9 months

How long will I be off work?

This is dependent upon your occupation and the specific surgery.

  • Seated job 2-4 weeks
  • Standing job 8-12 weeks
  • Heavy lifting job 4-6 months

When can I drive?

This does depend on the specific surgery.

  • Manual car
    • No driving for 7-9 weeks
  • Automatic car
    • Left foot no driving for 2 weeks
    • Right foot no driving for 7-9 weeks

What are the risks of the procedure?

General risks of surgery

  • Infection and wound healing problems
  • Nerve injury and scar sensitivity
  • Blood clots to the leg
  • Anaesthetic problems
  • Incomplete resolution of symptoms
  • Persistent pain

Specific risks of surgery

  • Ankle stiffness
  • Weakness
  • Failure of the tendon transfer
  • Rupture or re-tearing of a repaired tendon
This is an overview of Peroneal Tendon Disorders and is not all inclusive.

If you have any questions please contact Mr Curry’s rooms on (03) 99286560