Peroneal Tears
The peroneus longus and peroneus brevis run along the outside (lateral) aspect of the ankle, just behind the fibula.
Anatomy and Pathology
Peroneal tendon tears are extraordinarily common causes of ankle pain and swelling. They cause pain on the lateral (or outside) aspect of the ankle — the side of the ankle that is furthest away from your other leg.
The pain is common with normal walking and in-line running, but is actually most commonly associated with walking on uneven surfaces and cutting or jumping. This is because the peroneal tendons are one of the main stabilizers of the ankle, so they are working hard when you need a little extra balance or change direction.
There are two peroneal tendons: The peroneus brevis (short) and the peroneus longus (long). They extend down from muscle bellies of the same names. The peroneus brevis attaches to the base of the 5th metatarsal and functions mostly to evert your foot. The peroneus longus runs all the way along the bottom of your foot and attaches to the 1st metatarsal.
The two tendons work in concert, and have pathology that can include, from least to most severe, simple tendonitis, tendinosis, a minor tear, a major tear, and complete rupture. Each of these pathologies has different diagnostic and treatment modalities. Dr. Bohl has extensive experience and has conducted several research studies focused on the diagnosis and treatment of peroneal tendon pathology. He is well equipped to help you treat your pain.
Diagnosis
MRI showing torn peroneus brevis (white/gray) with normal appearing peroneus longus (black) for comparison.
Physical examination is the most important part of diagnosis of peroneal tendon tears. Upon your presentation, he will conduct a series of examination manuvers designed to recreate your peroneal tendon pain. He will also test for peroneal muscle strength and examination for swelling within the peroneal tendon sheath.
During your visit, Dr. Bohl will also obtain x-rays of both your foot and ankle. While x-rays do not show the peroneal tendons themselves, they can provide important information about the bony structures that the peroneal tendons control. X-rays are also critical to rule out alternative pathology that could be causing pain in the same area.
Ultimately, if peroneal pathology is suspected and your symptoms are persistent, Dr. Bohl will likely recommend an MRI. An MRI can be of tremendous benefit in displaying the condition of the tendons in high resolution. Tendonitis, tendinosis, and tearing are all clearly revealed on a high-quality MRI.
If you have had an MRI performed at an outside facility, it is absolutely critical that you bring both the CD with the actual images as well as the paper radiologist’s report to your clinic visit. Please hand-carry these to the visit rather than relying on anyone to send them for you. Similarly, if you have had any surgical procedures in this area previously performed, please try to obtain your operative report and bring that as well.
Nonsurgical Treament
Dr. Bohl recommends nonsurigcal treatment first for all patients with new onset of peroneal tendon symtpoms.
Nonsurgical treatment consists of immobilization in a boot or brace and anti-inflammatory medications for 4-6 weeks. The purpose of nonsugical treatment is to diminish the inflammation of the tendonitis or tear, as the inflammation causes the pain. If you start in a boot and symptoms improve, Dr. Bohl will progress you to a lace-up ankle brace. If you do not improve from use of the boot or brace, and you have not already had an MRI, Dr. Bohl will likely order an MRI of the ankle to better characterize your tear.
Physical therapy is an option, although the inflammation must be substantially improved before a visit to a therapist will be tolerable.
Surgical Treatment
Patients do very well following peroneal tendon surgery, with most able to return to their pre-injury activities.
Surgical treatments for peroneal tendon tears have been around for a long time, and a treatment algorithm has been clearly established that is followed by most orthopaedic foot and ankle surgeons:
For minor tears of one tendon, the solution is to remove the most-damaged part of the tendon and repair the tendon with suture. This improves the gliding of the tendon around the bony structures of the ankle and diminishes inflammation and pain.
For severe tears of one tendon, the solution is to remove the damaged peroneal tendon and attach its associated muscle to the other peoneral tendon, a procedure called a “tenodesis.” For example, if the peroneus brevis tendon is irreparably torn and not functioning, it is excised, and the peroneus brevis muscle is attached to the peroneus longus tendon. Additionally, the peroneus longus tendon is attached to the base of the 5th metatarsal so that the full muscle-tendon unit again contributes to eversion of the foot, as it was designed to do.
Finally, for severe tears of both tendons, which are fortunately quite rare, major reconstruction is recommended. This consists of transfer of another tendon (typically the flexor hallicus longus) or use of a tendon graft to take the place of the irreparable peroneals.
Dr. Bohl has extensive experience surgically managing peroneal tendon tears, and will be happy to present you with your options.