Foot & Ankle International

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Current Concepts Review: Peroneal Tendon Disorders

Edvin Selmani, Vladimir Gjata and Eduard Gjika
Foot Ankle Int 2006 27: 221
DOI: 10.1177/107110070602700314
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FOOT & ANKLE INTERNATIONAL

Copyright 2006 by the American Orthopaedic Foot & Ankle Society, Inc.

Current Concepts Review: Peroneal Tendon Disorders

Edvin Selmani, M.D.1 ; Vladimir Gjata, M.D.2 ; Eduard Gjika, M.D.3
Tirana, Albania

INTRODUCTION

ANATOMY

Peroneal tendon disorders are a common source of lateral

hindfoot pain and dysfunction. To date, most of the literature on peroneal tendon disorders is in the form of case
reports.29,47 The purpose of this review is to provide a
comprehensive review of peroneal tendon pathology and
its treatment. There are three broad categories of peroneal
tendon pathology: peroneal tendinitis, peroneal subluxation,
and peroneal tendon tears.
Often these categories are interrelated. For example, a
varus hindfoot subjects the peroneal tendons to higher forces,
which, in turn, may predispose to the development of
tendinitis.8,33 These same forces also may lead to subluxation of the tendon if chronic loading produces incompetence
of the superior peroneal retinaculum. Finally, longitudinal
peroneal tendon tears often occur in the setting of a subluxing
tendon.

The peroneal muscles make up the lateral compartment

of the leg. The peroneus longus muscle originates proximally from the lateral condyle of the tibia and the head
of fibula. The peroneus brevis originates from the fibula
in the middle third of the leg. At the level of the ankle
joint the peroneus longus tendon is posterior and lateral
to the peroneus brevis tendon. The musculotendinous junctions of both tendons usually are located proximal to the
superior peroneal retinaculum (SPR). Occasionally there is a
low-lying peroneus brevis muscle belly, which can become
symptomatic. In the foot, the peroneal tendons traverse
the lateral aspect of the calcaneus where the two tendons
are separated by the peroneal tubercle of the calcaneus.
The peroneus brevis inserts onto the tuberosity of the fifth
metatarsal and functions to evert and plantarflex the foot.
The peroneus longus tendon turns sharply medially at the
cuboid groove and inserts into the lateral aspect of the plantar
first metatarsal and medial cuneiform. In approximately 20%
of the population, an ossified sesamoid bone exists at the

HISTORICAL REVIEW

The first reported peroneal tendinopathy was a peroneal

tendon subluxation, described by Monteggia in 1803.37 The
first description of an isolated split of the peroneal tendon
was published in 1924 by Meyers.34 In 1932, Jones described
an operative treatment of chronic dislocations of peroneal
tendons.23 In 1934, Burman10 described three regions of
peroneal tendons that are associated with an increased incidence of tenosynovitis: 1) posterior to the lateral malleolus,
2) at the peroneal trochlea of the calcaneus (peroneus longus),
and 3) under the cuboid (peroneus longus).
1

International Fellow Foot and Ankle Surgery, Campbell Clinic, Memphis, Tennessee
Associate Professor of Orthopaedic Surgery, University Hospital Center Mother
Theresa, Tirana, Albania
3
Associate Professor of Orthopaedic Surgery, Chief of Orthopaedic and Trauma
Service, University Hospital Center Mother Theresa, Tirana, Albania
2

Corresponding Author:
Edvin Selmani, M.D.
Kutia Postare 8174
Tirana, Albania
For information on prices and availability of reprints, call 410-494-4994 X226

Edvin Selmani, M.D.

221
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Table 1: Level of Evidence and Grades of

Recommendation
Level of Evidence
- Level I: high quality prospective randomized clinical
trial
- Level II: prospective comparative study
- Level III: retrospective case control study
- Level IV: case series
- Level V: expert opinion
Grades of Recommendation (given to various
treatment option based on level of evidence
supporting that treatment)
- Grade A treatment options are supported by strong
evidence (consistent with level I or II studies)
- Grade B treatment option are supported by fair
evidence (consistent with level III or IV studies)
- Grade C treatment option are supported by either
conflicting or poor quality evidence (level IV studies)
- Grade I when insufficient evidence exist to make a
recommendation

level of calcaneocuboid joint, called an os peroneum.63 The

peroneus longus tendon everts the foot and helps plantarflex
the ankle. It also functions to plantarflex the first ray, and in
this capacity it serves as an antagonist to the anterior tibial
muscle.
The peroneal tendons share a common tendon sheath
until they reach the tip of the lateral malleolus where they
divide into separate tendon sheaths. Proximally, the common
peroneal sheath passes through a tunnel that is created by the
superior peroneal retinaculum (SPR) posterolaterally and the
posterior surface of distal fibula anteriorly. This is called
the retromalleolar groove and can vary widely in depth and
shape. This fibular groove is covered with fibrocartilage.
The SPR is a fibrous band, 1 to 2 cm wide, that originates
from the posterolateral aspect of the fibula and inserts onto
the calcaneus.13 The SPR acts as the primary restraint to
tendon subluxation, with five different insertional variations
being reported.16 In 13% to 22% of ankles, a peroneus
quartus muscle is present in the lateral compartment of the
leg.62 This muscle originates from the muscle belly of the
peroneus brevis tendon and inserts into the peroneal tubercle
of the calcaneus. The presence of a peroneus quartus has
been associated with peroneal tubercle hypertrophy and the
development of stenosing tenosynovitis.62
Both peroneal muscles are innervated by the superficial
peroneal nerve and receive their blood supply from the posterior peroneal artery and branches of the medial tarsal artery.
However, there have been contradictory reports regarding
the blood supply of the peroneals. Sobel et al. used injection
techniques to describe the microvasculature of the peroneal
tendons.60 These studies suggested that the peroneal tendons

have a complete vascular network without any avascular

zones. However, it has been noted that the injection techniques used in this study may lead to false negative or false
positive results.42,43,52 Other authors have reported similar
results suggesting that there are no avascular or hypovascular
zones in the peroneal tendons.39,55
However, a more recent study suggested that the distribution of blood vessels supplying the peroneal tendons is
not homogenous and three distinct avascular zones exist.41
The peroneus brevis tendon has one avascular zone in the
region where the tendon turns around the lateral malleolus.
The peroneus longus has two avascular zones. One region
begins where the tendon turns around the lateral malleolus and extends to the peroneal tubercle of the calcaneus.
The second avascular zone occurs where the tendon turns
around the cuboid. These zones correspond well with the
most frequent locations of peroneal tendinopathy.41
The studies that demonstrated regions of hypovascularity
in the gliding zones of the tendon are supported by the findings of Benjamin et al.4 An analysis of oxygen consumption
of tendons and ligaments showed that, in general, it was
7.5 times lower than that of skeletal muscles.69 The low
metabolic rate and well-developed anaerobic energy generation capacity are essential to carry loads and maintain tension
for long periods, reducing the risk of ischemia and necrosis,
and may explain the slow healing after injury.72
BIOMECHANICS

The main function of the peroneals is hindfoot eversion,

but they also plantarflex the ankle. In addition, the peroneus
longus functions as a plantarflexor of the first ray. The
peroneal muscles are antagonists to the posterior tibial, flexor
hallucis longus, flexor digitorum longus, and anterior tibial
muscles. Together, they provide 63% of hindfoot eversion,
with the peroneus longus providing 35% and the peroneus
brevis 28%.33 With regard to plantarflexion, the peroneal
muscles provide only 4% of total plantarflexion strength,
with the gastrocsoleus complex providing 87% of the overall
strength.
The peroneus longus musculotendinous unit also functions
to plantarflex the first ray. Plantarflexion of the first ray can
produce a forefoot valgus position. With weightbearing this
can lead to a compensatory hindfoot varus. Brandes and
Smith identified a cavovarus foot position as a predisposing
factor in peroneus longus tendon dysfunction.8 The cavovarus foot position places the peroneus longus tendon at
a mechanical disadvantage, reducing its moment arm and
increasing frictional forces on the tendon at the level of the
lateral malleolus, peroneal tubercle, and cuboid notch.
PATIENT ASSESSMENT

Obtaining a thorough patient history is essential in making

an accurate diagnosis. Peroneal tendinitis is characterized

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Foot & Ankle International/Vol. 27, No. 3/March 2006

by the gradual onset of pain, swelling, and warmth in the

posterolateral ankle. Pain is exacerbated by passive hindfoot
inversion and ankle plantarflexion and by active hindfoot
eversion and ankle dorsiflexion. Symptoms may be precipitated by repetitive or prolonged activity or an acute traumatic
event. Peroneal tendon tears and ruptures may be acute or
chronic. Often the main complaint for patients with peroneus
brevis tendon tears is persistent swelling along the peroneal
tendon sheath.29 Alternatively, retromalleolar pain or ankle
instability may be the main complaint.6 Peroneus longus
tendon ruptures usually are characterized by pain in the
cuboid groove or the plantar aspect of the foot where the
tendon inserts distally. Some patients do not complain of
lateral ankle pain, but rather pain in the medial side of the
foot, imitating posterior tibial tendon symptoms.
Patients should be asked about other associated conditions. A history of rheumatoid arthritis, psoriasis, hyperparathyroidism, diabetic neuropathy, calcaneal fractures, and
local steroid injection have all been associated with an
increase in peroneal tendon dysfunction.7,50,68,70,74 In addition, ciprofloxacin and other fluoroquinolones have been
associated with an increased rate of tendon rupture and
tendinopathy.57
Patients with peroneal tendon subluxation or dislocation
also may describe a snapping sensation and pain in the lateral
hindfoot. A history of an acute injury may be described by
patients with a rupture of the superior peroneal retinaculum.
However, some patients have a more chronic presentation
and cannot recall a specific traumatic episode. Congenital
dislocations also have been reported.28
Physical Examination

Inspection should assess for posterolateral hindfoot swelling. The hindfoot alignment should be noted, because a
varus postion is associated with an increased rate of peroneal
tendon disorders.33 Palpation along the course of the peroneal
tendons should be performed to identify areas of tenderness. Swelling or thickening within the tendon also may
be palpable. In patients with peroneal tendinitis, peroneal
muscle strength may be decreased because of either pain
or tendon rupture. However, an absence of marked eversion weakness does not preclude a peroneal tendon tear or
rupture. Because the peroneus tertius, extensor digitorum
longus, and even the extensor hallucis longus provide some
eversion function, it is possible to have a gross rupture of
both peroneal tendons identified intraoperatively despite a
preoperative physical examination that demonstrated 4+/5
eversion strength. The neurovascular status of the foot also
should be assessed. The sural nerve runs in the vicinity of
the peroneal tendons, and sural neuritis should be considered
in the differential diagnosis of posterolateral ankle pain.
Special tests have been described to assess for specific
conditions related to the peroneal tendons. Sobel et al.59
popularized a diagnostic test for peroneus brevis tendinitis
known as the peroneal tunnel compression test. In this

PERONEAL TENDON DISORDERS

223

provocative maneuver, the foot is dorsiflexed and everted

while manual pressure is applied along the retrofibular region
to the peroneal tendons to determine if pain is elicited.
Another special test involves having the patient plantarflex
the first ray. Loss or limitation of plantarflexion of the first
ray is consistent with dysfunction of the peroneus longus
tendon. Peroneal tendon dislocation or subluxation can be
identified by rotating the ankle to see and feel whether the
tendons subluxate anteriorly to the lateral malleolus.
Imaging Studies

All patients with lateral ankle pain should have weightbearing anteroposterior and lateral radiographs of the symptomatic ankle. In addition, an axillary heel view can demonstrate the peroneal tubercle and the retromalleolar groove.
An anteroposterior oblique view of the foot may provide
additional information on the architecture of the foot. Radiographs allow for the assessment of acute injuries such
as calcaneal fractures, os peroneum fractures, and lateral
malleolar avulsion fractures. Chronic conditions such as
lateral ankle impingement, a hypertrophic peroneal tubercle,
bony spurring at the posterior lateral fibular groove of
the calcaneus, prominent exostoses, hindfoot arthrosis, or
tumors also may be identified on plain radiographs. A more
detailed assessment of the peroneal tendons can be obtained
using other imaging modalities including magnetic resonance
imaging (MRI), computed tomography (CT), ultrasounography, or peroneal tenography.
MRI has emerged as the modality of choice for obtaining
a detailed assessment of the peroneal tendons. It provides
multiplanar imaging and does not expose the patient to
ionizing radiation. In one study, MRI of peroneus brevis
tendon tears showed 83% sensitivity and 75% specificity
compared to intraoperative findings.30 MRI in both dorsiflexion and plantarflexion showed flattening of the peroneus
brevis tendon in dorsiflexion. This finding supports the theory
that longitudinal splits of the peroneus brevis tendons occur
under dynamic compression of the peroneus longus tendon
during dorsiflexion.51 In dorsiflexion the peroneus brevis
is C-shaped and partially envelopes the peroneus longus
tendon.49,51 With peroneus longus tendon tears, additional
oblique coronal midfoot MRI may help in assessing the
extent of the tear.46 MRI findings suggestive of a peroneus
longus tendon tear include heterogeneity or discontinuity
of the tendon, a fluid-filled tendon sheath, marrow edema
along the lateral calcaneal wall, and hypertrophied peroneal
tubercle. MRI is useful in identifying the appearance of
longitudinal split tears of the peroneal tendons and in differentiating this entity from other causes of chronic lateral
ankle pain.32 However, one study reported that MRI did
not reliably predict the degree of peroneal tendon pathology
when compared with intraoperative findings.47 Often the
MRI underestimates the extent of pathology, predominantly
with regard to tears of the peroneus longus tendon.47

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CT scanning is valuable in defining bony abnormalities,

such as enlargement of peroneal tubercle or retrotrochlear
eminence, calcaneal fractures, os peroneum fracture, or avulsion of the lateral malleolus. However, the CT scan is limited
in its ability to identify tendon disorders. Limitations in softtissue resolution may not allow differentiation of the tendons
from surrounding edematous tissue, and CT scanning cannot
be performed in all planes. Nevertheless, some authors have
concluded that CT scanning is the preferred method of evaluation of peroneal tendon lesions that are associated with
bony abnormalities.49
Ultrasonography has three advantages: its noninvasive
nature, absence of ionizing radiation, and relatively inexpensive costs. Two studies reported the accuracy, sensitivity, and
specificity of ultrasonography in detecting tendon tears.71,76
The actual state of the tendons was determined at the time
of surgical exploration. Accuracy was reported as 90% and
94%, specificity as 85% and 90%, and sensitivity as 100% in
both studies. However, ultrasonography has limitations. The
examination is operator-dependent, with a variable learning
curve. Also, the amount of time required for the study can be
30 to 45 minutes, including the contralateral ankle. Finally,
this technique is unable to image deeper tissues and bones
around the ankle.
Peroneal tenography is an infrequently used, invasive
imaging method that involves the injection of radiopaque
contrast medium into the peroneal tendon sheaths to allow
examination of the tendons. This technique can be combined
with a diagnostic injection of local anesthetic, which can
provide potentially important information about concordant pain relief.36 However, peroneal tenography is associated with an extravasation rate of 10% and incomplete
sheath filling in 5%. Furthermore, intratendinous abnormalities usually cannot be viewed directly. As such, this method
is of limited use.
CLINICAL CONDITIONS
Peroneal Tendinitis-Tendinosis

Peroneal tendinitis and peroneal tendonosis are diagnosed

based on the patients history, physical examination, and
imaging studies. Pain over the peroneal tendons is characteristic of tendinitis. A palpable mass that moves with the
tendon is suggestive of peroneal tendonosis. If necessary,
MRI can be used to confirm the diagnosis and identify
whether a tear is present. Fluid around the peroneal tendon
without evidence of a tear is consistent with peroneal
tendinitis. Treatment of tenosynovitis consists of nonsteroidal
anti-inflammatory medication, rest, activity modification, and
a lateral heel wedge in mild cases. In advanced or refractory,
cases immobilization in a short-leg cast or CAM walker for
6 weeks may be helpful. The use of corticosteroid injection
must be undertaken with extreme caution to avoid iatrogenic
rupture. Any underlying medical problem (e.g., diabetes,
rheumatoid arthritis) should be medically controlled.

Nonoperative treatment of tenosynovitis alone often is

successful. If nonoperative treatment fails, surgery typically
consists of an open synovectomy. The tendon sheath is
opened longitudinally, and each tendon is examined. Any
degenerated area of tendon is debrided. If a peroneus quartus
muscle is present it can be excised. If the peroneal tubercle is
prominent, it can be smoothed or leveled. The tendon sheath
is left unrepaired. Postoperatively, the patient is placed in a
short-leg cast. Weightbearing in the cast may begin after 2
weeks. Range of motion and strengthening are started after
casting is discontinued at 4 to 6 weeks.
Peroneal Tendon Tears and Ruptures

The etiology of peroneal tendon ruptures remains controversial. Munk and Davis suggested two possible pathogenic
mechanisms for split lesions of the peroneus brevis tendon.39
One mechanism is that subluxation of the peroneus brevis
tendon occurs as a result of the laxity or tearing of the
superior peroneal retinaculum (SPR) from chronic ankle
instablitiy or inversion injuries. As the tendon subluxes, the
peroneus brevis tendon can splay or split over the sharp
posterolateral edge of the fibula. In this theory, the split lesion
follows the subluxation.16,21,29,34,39,59,61
The second mechanism is that compression of the peroneus
brevis tendon between the posterior fibula and peroneus
longus tendon causes a split during an inversion injury.3,6,35
In this proposed mechanism, the subluxation of the lateral
portion of the peroneus brevis tendon follows the split lesion.
The second mechanism explains why peronues brevis tendon
splits are found in the absence of overt tendon subluxation.
Other anatomic factors also may contribute to peroneal
tendon tears including:
1) a shallow or convex fibular groove, which may contribute to the incompetency of the SPR and the subsequent
subluxation of peroneal tendons,12,18,30,57,59
2) compression by the peroneus longus in dorsiflexion,34,35,39,51,59
3) hindfoot varus leading to increased force through the
peroneal tendons,33
4) hypertrophied peroneal tubercle and an enlarged retrotrochlear eminence,9,10,12,30,45 the enlarged retrotrochlear eminence may suggest a taut calcaneofibular
ligament secondary to chronic ankle sprains or hindfoot
varus foot type,
5) a bony spur at the posterior lateral fibular groove,30,56
6) lateral ankle instability,1,24,30,61,73
7) the presence of a peroneus quartus muscle in the
peroneal sheath;6,12,14,15,30,38,62 the low-lying muscle
belly increases the pressure in the peroneal tunnel in
dorsiflexion and predisposes the peroneus brevis to
splits.20,26,30,48,59
Peroneus longus tendon ruptures may be acute or chronic.
Acute tears of the peroneus longus tendon usually are the

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result of sports injury or trauma.27,67 They may include

laceration of the tendon, avulsion of the tendon at or
through the os peroneum, or dislocation at the lateral
malleolus.19,27,53,54,67 Ruptures usually occur at the level of
the cuboid or as a fracture through the os peroneum.5,40,66
The high shear stresses within the tendon as it turns beneath
the foot may be a major factor contributing to the pathomechanics of longitudinal tears. The presence of an os
peroneum does not seem to predispose the tendon to a tear,
nor is the os peroneum involved in most tears.46,53 Any
condition that leads to overuse of the peroneus longus may
produce a chronic injury. This would explain why weakness
or absence of the supporting lateral ankle ligament structures
appears to have a relationship to tears of the peroneus longus
tendon.22,54 In addition, a relationship between peroneus
longus tendon ruptures and a cavovarus type foot has been
reported.8,53
Krause and Brodsky29 proposed a classification system
to guide surgical decision-making in patients with peroneal
tendon tears. This system is based on the transverse (crosssectional) area of viable tendon that remains after debridment
of the damaged portion of the tendon. This presumes that
the retained portion of the tendon has no longitudinal tears.
Grade I lesions are less than 50% of the cross-sectional
area and tendon repair is recommended. Grade II lesions are
more than 50% of the cross-sectional area and tenodesis is
recommended.
Redfern and Myerson47 suggested an algorithm for the
surgical treatment of peroneal tendon tears. Factors they
considered important include the presence of a functioning
tendon or tendons, mobility of the remaining peroneal musculature, ankle stability, and position of the heel. If both
tendons are grossly intact, they should be repaired in a
standard manner by excising the longitudinal tear and tubularizing the remaining tendon with a running 4 0 nylon
suture. If one tendon is completely torn and irreparable,
but the other tendon is considered functional (useable)
then a tenodesis can be performed proximally using the
musculotendinous tissue. If the distal aspect of the tendon
is healthy, it also can be tenodesed. The decision to include
a tenodesis is based on the state of the muscle. No tenodesis
should be done if muscle excursion of either tendon is absent
secondary to scarring and fibrosis. However, if the other
tendon is nonfunctional (unuseable), then a tendon graft
or tendon transfer (FDL to peroneus brevis) is suggested.
The choice is based on the presence of any excursion
of the proximal muscle. In the presence of excursion, a
tendon graft (such as the semitendinosis) is more likely
to be successful, but this procedure is contraindicated in
the absence of excursion. Surgery to treat peroneal tendon
tearing also should correct associated pathology, such as
chronic ankle instability, prominent osteophyte formation,
and other overcrowding factors. In addition, if there is hindfoot varus consideration should be given to adding a lateralizing calcaneal osteotomy. Their postoperative protocol

PERONEAL TENDON DISORDERS

225

includes early range of motion with protected ambulation.

For traumatic acute ruptures of both peroneal tendons,
when the diagnosis is made early, an end-to-end suture
can be done.44 When end-to-end suturing is not possible,
transfer of the FDL to the peroneus brevis tendon has
been advocated.7 The FDL tendon is considered to be
suitable because the excursion and work percentage of
peroneus brevis and FDL are similar.58 To date all studies
outlining the surgical management of peroneal tendon tears
are either retrospective reviews (Level IV evidence) or case
reviews (Level V evidence). Therefore there is insufficient
evidence to recommend for or against any specific treatment
(Grade I).
Peroneal Tendon Dislocation/Subluxation

Subluxation of the peroneal tendons results from disruption of the SPR and usually involves avulsion of the retinaculum from its fibular insertion. The mechanism of injury
typically involves an inversion injury to the dorsiflexed ankle
with concomitant forceful contraction of the peroneals.
Eckert and Davis17 classified superior peroneal retinaculum pathology into three types: grade I, SPR elevated from
the fibula; grade II, fibrocartilaginous ridge elevated from the
fibula with the SPR; and grade III, cortical fragment avulsed
with the SPR.
An inadequate groove for the peroneals in the posterolateral fibula may increase the risk of subluxation. Diagnosis
is made by physical examination. Forceful eversion or rotation of the ankle combined with palpation of the tendon may
precipitate tendon subluxation during the examination. MRI
may be helpful by providing information on the status of
the SPR, documenting the shape of the fibular groove, and
identifying any tears in the peroneal tendons.
Nonoperative treatment may be indicated for acute grade
I injuries, and possibly type III injuries. Immobilization
for 6 weeks in a short-leg cast with the foot in neutral
to slight inversion may allow the SPR to adhere to the
posterolateral aspect of the fibula.11 Pain is the primary indication for treatment. The nonoperative treatment of acute
peroneal tendon subluxation has minimal risks, but it may
be associated with a high rate of failure.17 Surgical treatment often is required to correct subluxing or dislocating
peroneal tendons. If dislocation of the tendons is diagnosed early, acute repair of the peroneal retinaculum may
be beneficial; however, often operative intervention occurs
later.
Acute repair of superior peroneal retinaculum

The incision is made in line with the peroneal tendons

from 6 cm proximal to the tip of the fibula to 2 cm distal
to it. The SPR is identified and sharply removed from the
fibula. A bony trough then is created on the posterolateral
fibula parallel with the remaining edge of the retinaculum just
posterior to it. This can be done with an osteotome or with a

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burr. Three or four holes then are drilled in the fibula along
the trough. A nonabsorbable suture is used to approximate
the retinaculum to the fibula by passing it through both of
the holes and the retinaculum. The retinaculum then is further
imbricated to the portion that is still attached to the fibula
with an absorbable suture. The skin is closed in a routine
manner. If a large piece of the fibula has been avulsed, it
may be internally fixed with a small fragment bone screw,
making true repair of the retinaculum unnecessary. If the
screw is difficult to place, another option is wiring or suturing
the bone fragment back in place. Postoperatively, a short-leg
cast is worn for 6 weeks, with weightbearing allowed after
4 weeks.
Surgical options for chronic dislocation

Surgical options for chronic dislocation can be grouped

into five categories.
1. Superior peroneal retinaculum repair. Direct retinacular repair is the most anatomic and probably the
easiest procedure to perform with the least chance of
complications.17 The procedure is identical to the one
described for acute repairs.
2. Direct and indirect groove-deepening procedures.2,75
A 10-cm incision is made in line with the peroneal
tendon and centered over the distal posterior border
of the fibula. The SPR is incised and the tendons
are dislocated anteriorly and inspected. With a sharp
osteotome, a bony flap is raised from the posterolateral corner of the fibula over a distance of approximately 3 cm. The posteromedial bony flap should be
kept intact so that it can act as a hinge. A burr is
used to remove cancellous bone beneath the flap to
a depth of 4 to 5 mm. The flap is then reduced and
impacted with a bone tamp. A screw can be used to
add stability. The SPR then is repaired and the skin is
closed.
3. Bone block procedures:25 These techniques involve
partial or complete sagittal osteotomy of the fibula, with
posterior displacement or rotation of the more lateral
fragment to serve as a mechanical block to prevent
anterior subluxation of the tendons. Bone displacement
usually is secured with screws.
4. Tendon rerouting. The tendons can be rerouted beneath
the calcaneofibular ligament.65 This procedure involves
cutting the peroneal tendons with subsequent repair
after rerouting.11 This may be difficult because the
calcaneofibular ligament can be tight.
5. Tissue transfer to reinforce the superior peroneal retinaculum. Transfers have been described using the
Achilles tendon, as well as the plantaris and peroneus
brevis tendons. They all basically involve taking a strip
of free tissue (plantaris) or a strip of tendon in continuity (Achilles) and reconstructing a portion of the retinaculum to prevent subluxation.23 These procedures are

mentioned only for completeness and are not currently

recommended.11
If hindfoot varus is present, a calcaneal osteotomy may
improve the surgical results. Commonly a lateralizing calcaneal osteotomy is done through a seperate oblique lateral
hindfoot incision. The osteotomy itself is made through
the midportion of the calcaneal tuberosity and is placed
perpendicular to the axis of the tuberosity.33 Other authors
have used a closing wedge biplanar calcaneal osteotomy
through the same incision used for the peroneal tendon
repair.47
If concomitant lateral ankle ligament instability is present,
the tendon injury should be repaired at the same time as
ligament stabilization. Sobel and Geppert64 recommended a
modification of the Brostrom-Gould procedure, while others
have used the Chrisman-Snook procedure or a modification.6,11,47
SUMMARY POINTS

1. Peroneal tendon problems can be divided into three

categories, which may be interrelated: 1) peroneal
tendonitis or tendinosis, 2) peroneal tendon tears, and
3) peroneal tendon subluxation or dislocation.
2. Pain in the posterolateral aspect of the ankle is the main
presenting complaint.
3. The presence of chronic ankle instability, or a hindfoot
varus deformity, or both predisposes the patient to
peroneal tendon pathology.
4. A good physical examination can be diagnositic. MRI
can confirm the diagnosis and help in planning an
appropriate surgical treatment if nonoperative management is not successful.
5. Various surgical treatments have been recommended
depending on the specific pathology. These include
tendon debridment or tubularization, tenodesis, tendon
transfer or graft, superior retinaculum repair, and lateralizing calcaneal osteotomy
6. Return to maximal function after surgery is prolonged.
Early range of motion with protected ambulation will
help prevent adhesions.
7. Most of the literature on the treatment of peroneal
tendon pathology consists of retrospective case series
(Level IV evidence), case reports (Level V evidence),
and cadaver studies.
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