Article by Dr. Misako McLeod, DPM
The peroneal tendons run along the side of your leg and insert into the side and bottom of the foot. They control your ability to evert your foot and press your foot downward. These movements are necessary for walking and the gait cycle.
Peroneal tendons issues are very common and usually there is an underlying biomechanical issue that caused the problem. Peroneal tendons problems usually occur in athletes and people with high arches (pes cavus). Basic types of peroenal injuries include: tendoniitis, tears, and subluxation.
The most common problem, Peroneal tendoniitis, involves inflammation of the tendons, pain, and warmth. It can cause difficult walking and an aggravating chronic pain.
Common problem that involves pain, warmth, swelling and weakness or and instability of the foot and ankle. The patient may complain of the foot and ankle feeling as if it’s going to “give way.”
Degenerative changes or tendonosis
Chronic inflammation over the years can lead to degeneration of the tendons, over stretching, and fraying of the tendons. This causes weakness, intermittent pain and swelling, and difficulty walking.
The peroneal tendons run under a fibrous band called the retinaculum. When this retinaculum ruptures, the tendons may slip out of their normal position. The patient can often reproduce the symptoms by everting their foot. At that time, you can feel the tendons moving out of their normal position, and a snapping feeling around the ankle bone.
Although every condition has a different treatment regimen, most issues can be treated by immobilization, physical therapy, and anti-inflammatories. When these measures fail, surgery may be indicated and each condition requires a different surgical procedure.
During your examination, I will usually evaluate the course of the tendon with an ultrasound to check for large tears. Although an ultrasound cannot detect smaller intra substance tears, it provides a good overview of the tendons in general. Sometimes, I will then proceed with ordering an MRI to get a much more detailed evaluation of the tendons. However, keep in mind, that although MRIs may pickup larger, more obvious tears, the smaller longitudinal tears may not be detected. Technology has not advanced to the point where the smallest tears can be picked up by MRI at this point.
Each condition above has a different treatment regimen. This treatment protocol is individualized and depends upon the severity of the patient’s issue. Treatment may involve: casting, bracing, physical therapy, steroid injections, anti-inflammatories, and orthotics. If these conservative measures fail, surgery may be indicated.
If the peroneal tendons are torn or frayed, surgery will consist of removed all dead or weakened tendon, possible Topaz coblation to facilitate healing, and primary repair. Sometimes, stem call grafts are wrapped around the tendon to facilitate healing.
If the peroneal retinaculum is weakened or ruptured, the retinaculum will be reattached to the fibula bone with small tendon anchors to provide additional stability. A small groove may be created in the back of the fibula to allow the peroneal tendons to remain in place.
The patient will be immobilized and non-weightbearing for 4-6 weeks to allow the tendons to heal. Then, the patient will be placed in a removable cast boot and started on a program of gentle range-of-motion exercises, contrast soaks to reduce swelling, and physical therapy.
Once the patient is fully walking, I usually cast for orthotics to correct any pre-existing biomechanical issues which may have contributed to the issue.