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Peroneal Tendon Syndromes

Practice Essentials

Injuries to the peroneal tendons are common but not always clinically significant.
They are misdiagnosed as a lateral ankle sprain most of the time, because isolated injury to the peroneal tendons is rare.
Injury can occur in one or both peroneus longus and brevis tendons and is typically classified as acute or chronic. Function can be severely compromised by any tendon disruption; conversely, complete tendon rupture can be asymptomatic. Lesions have been seen in symptomatic patients, as well as in cadaver studies of patients who were presumably asymptomatic.
The reason for this variation is not known.

The image below depicts the anatomy of the lateral ankle.

Lateral ankle anatomy demonstrates the peroneal te

Lateral ankle anatomy demonstrates the peroneal tendons as they course beneath the superior retinaculum. The anterior talofibular, calcaneofibular, and posterior talofibular ligaments are also shown.

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Acute injuries of the peroneal tendons include tendinitis, tear/rupture, laceration, and dislocation/subluxation. Acute injuries typically have 1 of 2 mechanisms as the cause: (1) inversion ankle injury, which is often seen with associated anterior talofibular ligament and/or calcaneofibular ligament disruption, and (2) a powerful contraction of the peroneal muscles with a forcefully dorsiflexed foot.

Chronic injuries include longitudinal tears
and recurrent subluxation
of the peroneus brevis tendon.
These chronic injuries are usually associated with ankle or subtalar arthritis and ankle instability. People with “bad” or “weak” ankles may have peroneal tendon pathology. Core and lower extremity biomechanics must be evaluated in any chronic atraumatic peroneal tendinopathy, as flaws in those mechanics are usually the culprit.

Magnetic resonance imaging (MRI) is the criterion standard for identifying peroneal tendon injuries, which are demonstrated by the high signal intensity within the affected tendon on T2-weighted axial views.

In the acute phase, most ankle injuries are managed with rest, ice, compression, and elevation (RICE), with or without a short period of no weight bearing. Nonsteroidal anti-inflammatory drugs (NSAIDs) can also be prescribed to reduce inflammation and pain. Once the swelling and pain have decreased, a more extensive examination can be performed. If the symptoms are minimal and if no significant instability is present, a rehabilitation program can be started. This program should include an ankle strengthening, flexibility, and proprioception regimen.

Surgery is indicated in the acute phase for peroneus brevis tendon rupture, acute dislocation, and anomalous peroneal brevis muscle hypertrophy and for peroneus longus tears that are associated with diminished function.

For excellent patient education resources, visit eMedicineHealth’s First Aid and Injuries Center. Also, see eMedicineHealth’s patient education article Ankle Sprain.

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