Peroneal Tendon Problems
Other Popular Names
Who does it affect?
Peroneal tendon injuries may be acute (occurring suddenly) or chronic (developing over a period of time). They most commonly occur in individuals who participate in sports that involve repetitive ankle motion. In addition, people with higher arches are at risk for developing peroneal tendon injuries. Basic types of peroneal tendon injuries are tendonitis, tears, and subluxation.
What Are the Peroneal Tendons?
A tendon is a band of tissue that connects a muscle to a bone. The two peroneal tendons in the foot run side-by-side behind the outer ankle bone. One peroneal tendon attaches to the outer part of the midfoot, while the other tendon runs under the foot and attaches near the inside of the arch. The main function of the peroneal tendons is to stabilize the foot and ankle and protect them from sprains.
Symptoms of Peroneal Tendon Injuries
Tendonitis is an inflammation of one or both tendons. The inflammation is caused by activities involving repetitive use of the tendon, overuse of the tendon, or trauma (such as an ankle sprain). Symptoms of tendonitis include:
- Warmth to the touch
Acute tears are caused by repetitive activity or trauma. Immediate symptoms of acute tears include:
- Weakness or instability of the foot and ankle
As time goes on, these tears may lead to a change in the shape of the foot, in which the arch may become higher.
Degenerative tears (tendonosis):
Degenerative tears (tendonosis) are usually due to overuse and occur over long periods of time – often years. In degenerative tears, the tendon is like taffy that has been overstretched until it becomes thin and eventually frays. Having high arches also puts you at risk for developing a degenerative tear. The symptoms of degenerative tears may include:
- Sporadic pain (occurring from time to time) on the outside of the ankle
- Weakness or instability in the ankle
- An increase in the height of the arch
Sublaxation - one or both tendons have slipped out of their normal position. In some cases, subluxation is due to a condition in which a person is born with a variation in the shape of the bone or muscle. In other cases, subluxation occurs following trauma, such as an ankle sprain. Damage or injury to the tissues that stabilize the tendons (retinaculum) can lead to chronic tendon subluxation. The symptoms of subluxation may include:
- A snapping feeling of the tendon around the ankle bone
- Sporadic pain behind the outside ankle bone
- Ankle instability or weakness
Early treatment of a subluxation is critical, since a tendon that continues to sublux (move out of position) is more likely to tear or rupture. Therefore, if you feel the characteristic snapping, see a foot and ankle consultant immediately.
Because peroneal tendon injuries are sometimes misdiagnosed and may worsen without proper treatment, prompt evaluation by a foot and ankle consultant is advised. To diagnose a peroneal tendon injury, the consultant will examine the foot and look for pain, instability, swelling, warmth, and weakness on the outer side of the ankle. In addition, an x-ray or other advanced imaging studies may be needed to fully evaluate the injury. The foot and ankle consultant will also look for signs of an ankle sprain and other related injuries that sometimes accompany a peroneal tendon injury. Proper diagnosis is important because prolonged discomfort after a simple sprain may be a sign of additional problems.
Treatment depends on the type of peroneal tendon injury. Options include:
- Immobilization. A cast or splint may be used to keep the foot and ankle from moving and allow the injury to heal.
- Medications. Oral or injected anti-inflammatory drugs may help relieve the pain and inflammation.
- Physical therapy. Ice, heat, or ultrasound therapy may be used to reduce swelling and pain. As symptoms improve, exercises can be added to strengthen the muscles and improve range of motion and balance.
- Bracing. The consultant may provide a brace to use for a short while or during activities requiring repetitive ankle motion. Bracing may also be an option when a patient is not a candidate for surgery.
In some cases, surgery may be needed to repair the tendon or tendons and perhaps the supporting structures of the foot. The foot and ankle consultant will determine the most appropriate procedure for the patient’s condition and lifestyle. After surgery, physical therapy is an important part of rehabilitation.
- Tendon Release
When the lining of the tendon is painful and inflamed (as in tenosynovitis), the goal of surgery is to remove the irritated tissue from around the tendon. This operation is called tendon release. This procedure is done by carefully dividing the tendon sheath that encloses the tendon. Once the sheath is opened, the irritated tissues around the tendon are cleared away. The sheath is not stitched back together. The gap in the sheath will eventually fill in with scar tissue. The skin is closed with sutures.
The procedure for surgically treating tendonosis is similar to the method used for tenosynovitis. However, extra measures are taken to thoroughly remove (debride) the degenerated tissue around and within the involved tendon.
- Tendon repair
Tendonosis may require repair if a preoneal tendon is split down its length. This type of tear mainly affects the peroneus brevis. The consultant fixes this problem by first dividing the sheath around the tendons. If the split is smaller than one-third the width of the tendon, the torn portion may simply be removed. Larger splits are sutured along the length of the tendon. The tendon sheath is repaired, and the skin is closed with sutures.
- After surgery
Patients are usually placed in a short-leg cast for four to six weeks after surgery. A special walking boot is worn for another four weeks. Patients usually take part in formal physical therapy once the cast is removed. Rehabilitation after surgery can be a slow process. You will probably need to attend therapy sessions for one to two months, and you should expect full recovery to take up to four months.
Many patients with peroneal tendon subluxation will eventually require surgery, especially when symptoms have not been controlled with nonsurgical measures.
- Retinaculum repair
Retinaculum repair is gaining popularity. This procedure restores the normal anatomy of the retinaculum that covers and reinforces the tendon sheath around the peroneal tendons.
In surgery to repair the retinaculum, an incision along the back and lower edge of the fibula bone is made first. This lets the surgeon see the spot where the retinaculum is torn.
A burr is used to create a trough along the fibula bone next to the original attachment of the retinaculum. The torn edge of the retinaculum is then pulled into the trough and sutured in place. The skin is closed with stitches.
- Groove reconstruction
Groove reconstruction is done to deepen the groove so the peroneals stay in place behind the bottom tip of the fibula. In this procedure, an incision along the back and lower edge of the fibula bone is made first.
The consultant cuts a small flap in the bone near the bottom corner of the fibula. The consultant then carefully folds the flap back, like a hinge. With the hinge held open, he scoops out a small amount of bone under the flap to deepen the groove.
The flap is closed on its hinge and tamped in place. A screw may be used to hold the flap down.
Next, the tendons are returned to their location behind the tip of the fibula. Repair of the retinaculum may also be required with this procedure (see above). The skin is closed and sutured.
- Bony blocks
The purpose of a bony block is to form a barrier that keeps the tendons from slipping out of place. The block is usually formed with bone taken from the lower end of the fibula bone.
To create a bony block, the surgeon opens the skin along the lower edge of the fibula. A small area on the back of the fibula, near the lower tip of the bone is measured. A special tool is used to cut this small section of the fibula. The cut only goes partway through the bone.
The small block of bone is slided backward, out of its original spot. The bone may be rotated slightly to create a solid barrier that will help keep the tendons from sliding around the lower edge of the fibula. A screw is inserted through the small block of bone into the fibula. The screw keeps the bony block in its new location until it heals.
The consultant checks the fit to make sure the tendons can glide behind the new block of bone without slipping out of place. The skin is then closed and sutured.
- After surgery
Patients who have surgery are usually placed in a short-leg cast for six weeks. A special walking boot is then worn for another four weeks. Patients usually start formal physical therapy once the cast is removed. Rehabilitation after surgery can be a slow process. You will probably need to attend therapy sessions for two to three months, and you should expect full recovery to take up to six months.
Peroneal tendon tear
During the surgery tendons with minor tears can be repaired by stitching them back together. If they are severely torn, they need to be replaced with new tendon tissue. Usually tendon tissue can be obtained from the thick achilles tendon in the same leg. It will be stitched onto the muscle and held in place on the bone with staples or small screws.
For minor peroneal tendon tears, you should be able to put weight on your foot 48 hours after surgery. You will need physiotherapy for up to six weeks after this. A tendon graft will take longer to heal. After surgery, you will wear a cast for up to six weeks after surgery, when you will transfer to a lightweight aircast walking boot. It may be 12 weeks before you are able to put full weight on the foot. Sports can be resumed after six months.
Possible Complications include:
• Sural nerve paresthesia (numbness)
• Recurrent Peroneal Tendon Instability
• Ankle Joint Stiffness
• Tendon Rupture