If you’ve just received the diagnosis of peroneal tendon tear, you may be wondering whether this is a serious injury. ‘A tear’ sounds quite concerning, and you’re probably worried about treatment possibilities and potential consequences.
Let this text help you learn more about what to expect during and after diagnostics and treatment.
Understanding the Injury
Let’s start with the basic anatomy of what is hurt.
Peroneal tendons are the tendons of two muscles that run down the outer side of the lower leg: peroneus longus and peroneus brevis. These muscles, which allow you to move your foot downwards and outwards, turn to tendons near the ankle. The two peroneal tendons pass behind the lateral malleolus (the bony prominence on the outer side of your ankle). The tendon of the peroneus brevis then attaches to the fifth metatarsal (outer part of midfoot), while the tendon of the peroneus longus travels under the foot and attaches to the first metatarsal and cuneiforms (inner part of midfoot, near the arch).
Peroneal tendon tears are typical for active young people who take part in sports activities, which include running and jumping. They come as a result of repetitive ankle movement and overuse, sometimes combined with athletic injuries and ankle sprains. Tight calf muscles, high foot arches, and chronic ankle instability make an individual more likely to suffer from this type of injury, and poor training and inadequate footwear are significant contributing factors.
The tendons usually tear longitudinally (though transverse tears are possible as well), and they can be partial or full-thickness. Isolated longitudinal peroneus brevis tendon tears are by far the most frequent.
Common symptoms include:
- Pain and tenderness along the outer side of the ankle, which worsen with motion
- Ankle swelling and warmth
- Instability and weakness of the ankle
- Clicking and popping in the ankle during movement
Cadaveric studies have shown that peroneal tendon tears occur in 11-38% of the population. Since many patients have mild symptoms, or no symptoms at all, they are far less commonly seen in clinical practice.
Establishing the Diagnosis
Proper and timely diagnosis and adequate treatment are crucial for the outcome and misdiagnosed and untreated peroneal tendon tears may worsen over time. It is of key importance to see an orthopedic surgeon at the onset of early symptoms, especially clicking and popping.
The history is very important for the doctor to distinguish between different types of ankle injuries, which is why it is taken in detail. A thorough description of the symptoms, timing, conditions in which the injury occurred, and aggravating positions and movements will lead the doctor to the most likely diagnosis. To further evaluate the injury, the doctor will also perform certain physical tests. By palpating and moving the ankle in different directions, the doctor will estimate the range of motion, muscle strength, ankle stability, foot biomechanics, and other relevant factors.
However, the diagnosis cannot be established without the use of certain imaging techniques. The primary imaging modality in cases of suspected peroneal tendon injuries is the X-ray of the ankle, and another sovereign imaging method is ultrasound. Both methods are quick, painless, and comfortable for the patient. To fully evaluate the injury, certain patients require more advanced imaging studies, such as CT and MRI scans.
Treatment and Rehabilitation
In 2018, the European Society of Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA) published a guideline for peroneal tendon injuries management, and thus facilitated their proper treating.
According to it, the first line of management in cases of symptomatic peroneal tendon tears is conservative. Initial measures imply elevation, compression, and application of ice. Physiotherapy starts with weight-bearing, range of motion, and tendon-loading exercises, and continues with shock-wave therapy if the symptoms persist. Though common in clinical practice, this guideline states that immobilization should be avoided.
Conservative management can sometimes be successful in itself. However, in most cases peroneal tendon tears must be treated surgically, especially considering that most of the patients are young athletes who need to return to their activities as soon as possible.
The surgical method of choice mostly depends on the reparability and extensiveness of the injury in a particular patient. In simpler cases, the damaged part of the tendon is removed and the stitch is run along the tendon, which is known as tubularization. More complex cases require repairing the peroneal tendon damage with a graft - another tendon’s tissue (usually Achilles). Rarely, the tendon needs to be unattached from its insertion and attached to a different place, which is known as tenodesis.
Following the surgery, the patient starts a tailored, goal-based rehabilitation program, which comprises of 4-6 weeks of immobilization and physiotherapeutic exercises. For optimal results, range of motion exercises and physiotherapy are introduced as early as two weeks after surgery, as well as a weight-bearing cast or walking boot. Tendon loading exercises, on the other hand, are not encouraged until six weeks pass.
Prognosis and Potential Consequences
Overall, the prognosis is very good. Different studies showed that 87-98% of the patients return to full activities within a year from surgically treated peroneal tendon tear.
Around 10% of the patients experience recurrent tearing and prolonged symptoms as the main complications of the injury, as shown in a 2003 study by Dombek. Twenty percent more reported mild and transient symptoms.
Timely diagnosis and appropriate treatment play a key role in successful and predictable outcomes.
- Molini L, Bianchi S. US in peroneal tendon tear. J Ultrasound. 2014;17(2):125-134.
- Walt J, Massey P. Peroneal Tendon Syndromes. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-.
- Davda K, Malhotra K, O'Donnell P, et al. Peroneal tendon disorders. EFORT Open Rev. 2017;2(6):281-292.
- vanDijk PA, Lubberts B, Verheul C, et al. Rehabilitation after surgical treatment of peroneal tendon tears and ruptures. Knee Surg Sports TraumatolArthrosc. 2016;24(4):1165-1174.
- vanDijk PA, Miller D, Calder J, et al. The ESSKA-AFAS international consensus statement on peroneal tendon pathologies. Knee Surg Sports TraumatolArthrosc. 2018;26(10):3096-3107.
- Dombek MF, Lamm BM, Saltrick K, et al. Peroneal tendon tears: a retrospective review. J Foot Ankle Surg. 2003;42(5):250-8.