Lateral Tendon Disorders

Peroneal Tendinopathy

Differential Diagnosis

Ankle Sprain / Fracture Stress Fracture Peroneal Tendon dislocation

Os peroneum Apophysitis of 5th Neuropathy

Metatarsal

Description
The peroneal tendons originate off the proximal fibula and receive their innervation
from the superficial peroneal nerve and reside in the lateral compartment of the lower limb.
They are contained within a tendon sheath which courses around the distal fibula leading to
their insertions in the foot. At the level of the distal fibula both tendons are maintained in
the retromalleolar groove in which they travel by the superior peroneal retinaculum (SPR).
The peroneus brevis at the level of the ankle runs with but anterior to the peroneus
longus inserting into the base of the 5th metatarsal. The peroneus longus dives medial under
the cuboid traversing the cuboid tunnel to insert onto the base of the 1 st metatarsal and
medial cuneiform. Being muscles of the lateral compartment, they provide the ability to
evert the foot. This allows our ankle to be balanced against the muscles of the anterior
compartment. However the predominate force for eversion is provided the peroneus brevis
as the peroneus longus direction of pull is on a tangent due to its insertion onto the 1 st
metatarsal Thus it provides plantarflexion at the 1st metatarsal which thereby induces
plantarflexion at the ankle and subsequent eversion as it pulls through the cuboid tunnel.
Within the substance of the peroneal longus, as it is about to enter the cuboid tunnel, an
accessory ossicle may be present. This is called the os peroneum. Fractures of the os
peroneum can result in pain in the lateral aspect of the ankle.
The true incidence of peroneal tendinopathy was traditionally described to be
uncommon however cadaveric studies have reported tears between 11-38%. 1 However a
MRI study of 294 patients for hindfoot pathology found a 35% incidence of radiological
changes in the peroneal tendons, however the patients reported no symptoms or preceding
injuries.2 Peroneal tendinopathy has been documented as a overuse injury with rupture of
the SPR noted in forceful contraction of the tendon during eccentric loading. 3 This can result
in the more commonly reported dislocation of the peroneal tendons out of the sheath after
a rupture of the overlying SPR. This has been classified by Eckert and Davis. 3,4
Grade 1 – Elevation of the SPR from the fibula along with periosteum
Grade 2 – Further involvement of the changes found in Grade 1 with the
fibrocartilaginous area of tissue bordering the lateral aspect of the fibula
Grade 3 – Avulsion of cortical bone from the lateral aspect of the fibula allowing
tendon displacement
Grade 4 – Full tear of the SPR allowing peroneal tendons to dislocate.

Diagnostic Workup
Initial diagnostic imaging starts with standard weightbearing radiographs of the foot
and ankle with orthogonal views. These can reveal other conditions in the area such as ankle
fractures. Uncommonly these can sometimes reveal a fleck sign lateral to the distal fibula
which would be suggestive avulsion of the peroneal retinaculum. Magnetic resonance
imaging for distal peroneal tendons has been reported to be difficult due to the magic angle
effect. This effect results in hyperintense signals when the tendon runs at a 55 degree angle
to the scanner.5 Both ultrasonography and magnetic resonance imaging are suitable for the
imaging of peroneal tendons, however the reliability of ultrasonography dependent on the
user.6

Clinical Presentation
Patients typically present with complaints of worsening lateral ankle pain which tend
to be exacerbated with use. This can result in the patient walking with an antalgic gait. The
typically history is progressive without any identifiable preceding traumatic event. Some
patients can complain of a sensation of crepitus along the lateral ankle and on palpation will
report tenderness posterior to the lateral malleolus and often times distally along the
tendon itself. Due to this, peroneal tendon tears tend to have a delayed diagnosis.
Sammarco et al reported an average duration of 7-48 months prior to diagnosis with only
one patient acutely, under 2 weeks, from a preceding injury.7 Unfortunately these patients
are often labelled with a sole diagnosis of an ankle sprain but not peroneal pathology due to
the overlap of symptoms.
As these patients have wait a significant time prior to presentation to either a
primary care provider or for specialist review, often these patients present with symptoms
of lateral ankle instability with the ankle giving way paired with vague, non-specific
symptoms.

Examination
Inspection of the affected limb can reveal cavovarus alignment of the foot in as
hindfoot varus position is thought of as a predisposing factor to peroneal irritation. The
location of swelling can also be utilised as a guide as retrofibular swelling has been reported
to be commonly seen in peroneal brevis tears while peroneal longus tears are more
localised to the base of the fifth metatarsal. Swelling near the fibula tear is reported have
involvement of both tendons.8
The symptoms can be reproduced with resisted active dorsiflexion and eversion of
the ankle. Pain on passive inversion and/or eversion may be indictive of severe
tendinopathy. Pain can also be noted on palpation over the peroneal tubercle as the
peroneal longus enters the cuboid tunnel.

Treatment
Medical Management
Initial management for peroneal tendinopathy would be conservative management.
As with all acute tendonitis treatment, initial management is conservative with offloading of
the affected limb in order to rest the affected tendon. With peroneal tendinopathy
application of an offloading lateral splint for bracing and eccentric strengthening exercises
to rehabilitate the lateral compartment. With peroneal tenosynovitis, conservative
management would consist of immobilising the foot to allow a period of rest to resolve the
symptoms. Controversially, corticosteroid injections have suggested to attempt to manage
recurrent cases but will require foot and ankle immobilisation to minimise the risk of tendon
rupture.9 Unfortunately there has been no studies looking into effectiveness comparing
corticosteroid injection to standard management.
Lateral compartment eccentric exercises require movements whilst the foot is
everted. Eccentric exercises can be performed with the assistance of resistance bands, With
the band looped around the foot and the fixed to a stationary object, tension the band so
the foot and ankle is turned inwards. With the heel planted, external rotation and
dorsiflexion of the foot against the band.

Surgical Management

Chronic tendonitis of the peroneal tendons can progress to tendon tears. Though
peroneal tendon tears are typically splits along the course of the tendon in comparison to
Achilles tendons which rupture. Surgical management of peroneal tendon tears can range
from repair of short segment of the tear, tubularisation of the tendon or excision of the
degenerative area. Rehabilitation after tendon repair has been studied in the upper limb,
the lessons and principles that have been learned from are applied to the lower limb. Thus,
the early range of movement and mobilisation have been studied in peroneal tendon
reconstruction however in a systematic review in 2016 has found large variations of
practice.10 Larger segments can potentially require sacrifice of the tendon with the goal to
maintaining or restoring peroneal brevis function as it is the sole muscle responsible for
eversion of the foot.
Chronic subluxation of the peroneal tendons can be addressed with either recreation
of the retinaculum overlying the peroneal tendons or deepening the retromalleolar groove
in which the tendons travel in. Suh et al. in 2018 has reported good outcomes from 34
patients studied retrospectively with 0 reports of recurrence of subluxation. 11

Sinus Tarsi Syndromes

The sinus tarsi is an anatomical location that is anterior and inferior to the lateral
malleolus. Sinus tarsi syndrome has been described as a result of lateral ankle stress
resulting from excessive pronation at the subtalar joint due to instability. 1 Anatomically
during this movement, the cuboid and lateral calcaneus compress the sinus tarsi. The results
in swelling and inflammation.
Classically the history is described as intermittent discomfort localised directly over
the sinus tarsi. This may become swollen and puffy on inspection. The walking gait of the
patient may be altered as the patient will pronate the foot to avoid ground contact with the
lateral aspect of the foot.
Treatment is largely around symptomatic management to with rest, compression
and elevation to reduce swelling. Local corticosteroid injections can be considered to
manage the pain however surgery is not recommended for acute presentations. The
literature has reported success in managing this condition with arthroscopic debridement of
the sinus tarsi however it is to note that the arthroscopic procedure has altered the
diagnosis in a significant number of cases potentially decreasing its actual effectiveness in
management of sinus tari syndrome itself.2
1. Miura K, Ishibashi Y, Tsuda E, Kusumi T, Toh S. Split lesions of the peroneus brevis tendon
in the Japanese population: an anatomic and histologic study of 112 cadaveric ankles.
Journal of Orthopaedic Science. 2004;9(3):291-295.

2. O’Neil J, Pedowitz D, Kerbel Y, Codding J, Zoga A, Raikin S. Peroneal Tendon Abnormalities

on Routine Magnetic Resonance Imaging of the Foot and Ankle. Foot & Ankle International.
2016;37(7):743-747.

3. Eckert W, Davis E. Acute rupture of the peroneal retinaculum. The Journal of Bone & Joint
Surgery. 1976;58(5):670-672.

4. ODEN R. Tendon Injuries about the Ankle Resulting from Skiing. Clinical Orthopaedics and
Related Research. 1987;&NA;(216):63-69.

5. Hayes C, Parellada J. The Magic Angle Effect in Musculoskeletal MR Imaging. Topics in

Magnetic Resonance Imaging. 1996;8(1):51-56.

6. Kumar Y, Alian A, Ahlawat S, Wukich D, Chhabra A. Peroneal tendon pathology: Pre- and
post-operative high resolution US and MR imaging. European Journal of Radiology.
2017;92:132-144.

7. Sammarco G. Peroneus Longus Tendon Tears: Acute and Chronic. Foot & Ankle
International. 1995;16(5):245-253.

8. Bahad S, Kane J. Peroneal Tendon Pathology. Orthopedic Clinics of North America.

2020;51(1):121-130.

9. Coughlin M, Saltzman C, Anderson R, Mann R. Mann's surgery of the foot and ankle.
Philadelphia: Saunders/Elsevier; 2014.

10. van Dijk P, Lubberts B, Verheul C, DiGiovanni C, Kerkhoffs G. Rehabilitation after surgical
treatment of peroneal tendon tears and ruptures. Knee Surgery, Sports Traumatology,
Arthroscopy. 2016;24(4):1165-1174.

11. Suh J, Lee J, Park J, Choi W, Han S. Posterior Fibular Groove Deepening Procedure With
Low-Profile Screw Fixation of Fibrocartilaginous Flap for Chronic Peroneal Tendon
Dislocation. The Journal of Foot and Ankle Surgery. 2018;57(3):478-483.

Sinus Tarsi

1. Helgeson K. (2009). Examination and intervention for sinus tarsi syndrome. North
American journal of sports physical therapy : NAJSPT, 4(1), 29–37.

2. Oloff, L. M., Schulhofer, S. D., & Bocko, A. P. (2001). Subtalar joint arthroscopy for
sinus tarsi syndrome: a review of 29 cases. The Journal of foot and ankle surgery :
official publication of the American College of Foot and Ankle Surgeons, 40(3), 152–
157.