Review Article

Peroneal Tendon Injuries

Abstract
Terrence M. Philbin, DO
Geoffrey S. Landis, DO
Bret Smith, DO

Peroneal tendon injuries are underdiagnosed and should be

considered in every patient who presents with chronic lateral ankle
pain. Ankle sprains are common, and up to 40% of affected
individuals experience subsequent chronic ankle pain. Identifying
the source of chronic ankle pain can be difficult because of the
large number of possible causes. The peroneal tendons are the
primary evertors of the foot and function as lateral ankle stabilizers.
A careful physical examination, along with a thorough patient
history and imaging studies, are critical in arriving at an accurate
diagnosis. Understanding the anatomy of the peroneal tendons and
knowledge of current treatment approaches for peroneal tendon
tears, subluxation and dislocation of the tendons, and peroneal
tenosynovitis are of great importance in achieving a favorable
outcome. Low-demand patients do well with a nonsurgical
approach; high-demand patients may benefit from surgery.

P
Dr. Philbin is Fellowship Director,
Orthopedic Foot and Ankle Center,
Columbus, OH. Dr. Landis is
Attending Surgeon, Tucson
Orthopaedic Institute, Tucson, AZ.
Dr. Smith is Attending Surgeon,
Moore Orthopaedic Clinic, Columbia,
SC.
None of the following authors or a
member of their immediate families
has received anything of value from
or owns stock in a commercial
company or institution related
directly or indirectly to the subject of
this article: Dr. Philbin, Dr. Landis,
and Dr. Smith.
Reprint requests: Dr. Philbin,
Orthopedic Foot and Ankle Center,
6200 Cleveland Avenue, Columbus,
OH 43235.
J Am Acad Orthop Surg 2009;17:
306-317
Copyright 2009 by the American
Academy of Orthopaedic Surgeons.

306

eroneal tendon disorders are a

significant but often overlooked
cause of lateral ankle pain. These injuries are more common than typically realized and must be considered
in every person who presents with
lateral ankle pain, particularly in
those who report a history of ankle
sprain. Ankle sprains are common
athletic injuries. It is not uncommon
for persons with ankle sprains to experience subsequent chronic lateral
ankle pain. The differential diagnosis
of lateral ankle pain is extensive.

Anatomy
The perforating branches of the anterior tibial and peroneal arteries supply blood to the lateral compartment
of the leg. The superficial peroneal
nerve, a branch of the common peroneal nerve, innervates the peroneus
brevis and the peroneus longus muscles. The primary action of these
muscles is, respectively, eversion and
pronation of the foot, with a second-

ary action of weak plantar flexion.

Together, the peroneal tendons provide supplemental lateral ankle stability, especially during the midstance and heel-raise portions of gait.
The peroneus brevis becomes tendinous 2 to 3 cm proximal to the tip
of the fibula. The tendon lies anterior and medial to the peroneus longus tendon at the level of the lateral
malleolus and inserts onto the
dorsal-lateral surface of the tuberosity of the fifth metatarsal base. Here
the rare os vesalianum pedis is found
in <1% of the population.1 This is
important to consider because the
ossicle must be differentiated from
an acute fracture of the base of the
fifth metatarsal. The peroneus brevis
muscle functions as the primary evertor of the foot.
The peroneus longus muscle
courses down the spiral twist of the
fibula, becoming lateral at midtibia
and posterior to the peroneus brevis
at the lateral malleolus. The tendon
passes beneath the peroneal troch-

Journal of the American Academy of Orthopaedic Surgeons

Terrence M. Philbin, DO, et al

Figure 1

A, Lateral view of the ankle demonstrating the peroneal tendons beneath the superior and inferior peroneal retinacula.
B, Superior view demonstrating the position of the peroneus brevis tendon anterior to the peroneus longus tendon.
(Reproduced with permission from Coughlin MJ, Schon LC: Disorders of tendons, in Coughlin MJ, Mann RA, Saltzman
CL [eds]: Surgery of the Foot and Ankle, ed 8. Philadelphia, PA: Mosby Elsevier, 2007, vol 1, p 1210.)

Peroneal Tendons and

Retinacula

fibula in the area of the retromalleolar sulcus. The peroneal retinaculum consists of superior and inferior
portions. The SPR is a fibrous band
of tissue that travels from the posterior ridge of the fibula to the lateral
wall of the calcaneus. It acts as the
primary restraint to subluxation and
dislocation of the tendons as they
course around the tip of the fibula.
Davis et al5 reported five anatomic
variations of the insertion of the
SPR. The inferior peroneal retinaculum is distal to the tip of the lateral
malleolus. The fibers forming the
inferior peroneal retinaculum are
blended from the fascia overlying the
anterior ankle joint and are known
as the cruciate crural ligament anteriorly.

The peroneus brevis and longus tendons share a common synovial

sheath from a point 4 cm above the
distal fibula. This sheath bifurcates
at the level of the peroneal tubercle
distally. The sheath passes through a
fibro-osseous tunnel that is reinforced by the superior peroneal retinaculum (SPR), the posterior talofibular ligament, the calcaneofibular
ligament, and the posterior inferior
tibiofibular ligament4 (Figure 1). Anteriorly, the sheath is bordered by the

The sulcus in the posterior aspect

of the distal fibula is typically concave, with a width of 5 to 10 mm
and a depth of up to 3 mm.2 The
lack of concavity of the posterior distal fibula, as seen in a cadaveric
study, may predispose to tendon dislocation.6 This same study reported
an absence of a fibular groove in
11% of the specimens and a convexity in 7%. In addition to the fibular
groove, a fibrocartilaginous rim,
which deepens the groove by 2 to 4

lear process on the lateral side of the

calcaneus, over the peroneal tubercle, and then turns to the cuboid tunnel, where it runs obliquely across
the plantar aspect of the foot. It inserts on the plantar proximal surface
of the first metatarsal and the lateral
border of the medial cuneiform.2 The
peroneus longus is a plantar flexor of
the ankle joint and a primary plantar
flexor of the first metatarsal. Located
within the substance of the peroneus
longus, the os peroneum is found in
20% of the population and is usually located plantar to the cuboid,
lateral to the calcaneus, or at the calcaneocuboid articulation.3

May 2009, Vol 17, No 5

mm, provides additional stability to

the tendons.

Anomalous Anatomy
Anomalous anatomy that may be involved in peroneal pathology includes a low-lying muscle belly of the
peroneus brevis, presence of a peroneus quartus muscle, and a hypertrophied peroneal tubercle. The peroneus quartus has a varied origin but
most commonly arises on the peroneus brevis and inserts in the retrotrochlear eminence of the calcaneus.7 It has a reported incidence of
13% in the general population.8 Sobel et al9 found it to be present in 27
of 124 cadaver dissections (21.8%).
The peroneus quartus muscle was
identified on magnetic resonance imaging (MRI) in 10% of patients in
one report10 and, more recently, in
6.6% of evaluations.7 Other anomalous peroneal musculature has been
described, most notably the peroneus
digiti quinti muscle of Testut and the
peronealcalcaneus muscle of Hecker.11 The presence of a low-lying
muscle belly or a peroneus quartus
might increase the risk of SPR laxity, with resultant peroneal pathology.12,13
Hyer et al14 performed a cadaveric

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Peroneal Tendon Injuries

Figure 2

Anteroposterior radiograph
demonstrating fleck avulsion of the
distal fibula.

study of 114 calcanei and identified

three main anatomic variants of
the peroneal tubercle: flat, 42.7%;
prominent, 29.1%; and concave,
27.2%. Their study demonstrated
the possibility of a bony tunnel in
one specimen (1%) that could easily
result in peroneal disease.

tendons to increased forces that predispose the tendons to injury.15 Patients with hindfoot varus should be
evaluated for underlying neuromuscular disorders, such as CharcotMarie-Tooth disease and related motor neuropathies. This subset of
patients may have a unique pathology, and a missed diagnosis may result in unpredictable outcomes.
Peroneal disorders include swelling
posterior to the fibula or along the
lateral wall of the calcaneus; tenderness to palpation along the course of
the peroneal tendons; the presence of
a pseudotumor; and pain with resisted eversion, passive inversion
stretch, or resisted plantar flexion of
the first metatarsal.16 Sobel et al13 described the peroneal compression
test, which is used to assess pain,
crepitus, and popping at the posterior edge of the distal fibula during
forceful eversion and dorsiflexion of
the ankle.

Imaging Studies
Physical Examination
A complete, well-organized history
and physical examination of the affected foot and ankle, as well as of
the contralateral foot and ankle, is
essential. A thorough history can
provide direction in forming differential diagnoses, especially in regard
to long-term issues such as chronic
lateral ankle pain. The examination
for lateral ankle pain should be
focused primarily on the ankle and
its function. Overall function and
strength of the peroneal tendons, as
well as the integrity of the lateral ligamentous complex, are evaluated.
Signs and symptoms of subluxated
tendons and ligamentous instability
of the ankle should be assessed. Specific attention should be given to the
hindfoot in both static and dynamic
positioning. Individuals with hindfoot varus may subject the peroneal

308

Standard three-view, weight-bearing

radiographs of the foot and ankle are
mandatory for proper evaluation.
Radiographs can reveal avulsions
around the base of the fifth metatarsal, which can indicate an eversion
type of ankle injury; this subjects the
peroneus brevis tendon to increased
stress and possible injury. Similarly,
injury to the peroneus longus tendon
is suspected in the presence of a fracture of an os peroneum. It is frequently necessary to obtain radiographs of the contralateral extremity
for comparison. Tendon subluxation
and dislocation should be suspected
when radiographs show a fleck avulsion of the distal fibula (Figure 2);
this is indicative of an injury to the
SPR and is best recognized on an internal rotation view. Hypertrophy of
the peroneal tubercle can raise suspicion of tendinosis and tears of the

peroneal tendons.17
Ultrasonography may be useful as
an imaging modality for peroneal
tendon evaluation. In homogeneous
regions with hypoechoic areas, >1
mm of fluid collection and/or tendon
thickening indicates tendinosis. Ultrasonography is helpful in diagnosing subluxation of peroneal tendons,
and it has shown promise as a dynamic imaging modality; it was used
to correctly diagnose 12 patients
with positional subluxation of the
peroneal tendons.18 Grant et al19 reported 90% accuracy for ultrasonography in diagnosing peroneal tendon
tears.
Computed tomography is best
suited for visualizing detailed osseous anatomy. It is used to delineate
bony abnormalities associated with
peroneal tendon disorders, such as
peroneal tubercle hypertrophy, calcaneal fractures, and convexity of the
distal fibular groove.
MRI offers an adjunctive imaging
technique for diagnosing peroneal
tendon disorders.20 The transaxial
plane with the foot in slight plantar
flexion is the most useful view for
evaluating the integrity of the peroneal tendons.21,22 Normal tendons
should exhibit homogeneous lowsignal intensity on T1- and T2weighted and short tau inversion recovery (STIR) images.22 It is normal
for T2-weighted and STIR images to
exhibit a thin area of high signal intensity surrounding the tendon in the
tendon sheath.22 Areas of increased
signal on T2-weighted and STIR images, as well as loss of homogenous
signal, may indicate tenosynovitis,
tendinosis, or a tear.21 Tendinosis and
tenosynovitis are best visualized on
T2-weighted or axial proton densityweighted images and are characterized by increased intermediate signal intensity.23 Circumferential fluid
within the common peroneal tendon
sheath wider than 3 mm is highly
specific for peroneal tenosynovitis.23

Journal of the American Academy of Orthopaedic Surgeons

Terrence M. Philbin, DO, et al

Consideration must be given to the

magic angle effect. This phenomenon is seen as variations in signals,
especially T1-weighted images, from
tendons that have acute angulations
(approximately 55 to the magnetic
field)that is, the peroneal tendons
as they proceed behind the lateral
mallelous.21,22,24
In addition to imaging tendinosis
and tears, MRI can be used to evaluate the possibility of tendon subluxation and dislocation. MRI scans can
also show variations in normal anatomy, such as a low-lying muscle
belly of the peroneus brevis, presence
of a peroneus quartus muscle, and
hypertrophied peroneal tubercle.22

Peroneal Tendon
Pathology
Tenosynovitis of the peroneal tendons is usually the result of a repetitive or prolonged activity, although it
can also occur after direct trauma.
Additionally, anatomic variations,
such as a hypertrophied peroneal tubercle or osseous calcaneal tunnel,
may predispose an individual to
stenosis and development of this
tenosynovitis.11,12 Affected patients
report pain, swelling, and point tenderness over the peroneal tendons at
the posterolateral aspect of the ankle. The patient history may reveal a
recent inversion injury or a recent increase in athletic endeavors. Commonly, pain is exacerbated by forced
plantar flexion and inversion or by
resisted dorsiflexion and eversion.
MRI can be useful in differentiating
tendinosis and tenosynovitis from
longitudinal or complete tendon
tears.
Treatment begins with rest, ice, nonsteroidal anti-inflammatory drugs,
physical therapy, and, possibly, use of
an ankle brace and a lateral heel wedge
orthosis. Further nonsurgical treatment
can include an orthotic rocker-bottom
May 2009, Vol 17, No 5

boot or a short leg cast for 3 to 4 weeks.

Corticosteroid injections into the tendon sheath should be used judiciously,
if at all. Nonsurgical treatment of peroneal tenosynovitis is usually successful. When symptoms persist, surgical intervention may be indicated. It is
imperative that a surgical plan address
both the tendon pathology (ie, repair,
dbridement) and any underlying disorder such as instability or varus positioning. If present, a low-lying peroneus
brevis muscle belly (in the retromalleolar region) or a peroneus quartus
should be dbrided. A hypertrophied
peroneal tubercle should be excised. A
complete tenolysis and tenosynovectomy should also be done.

Peroneus Brevis Tears

Peroneus brevis tears were first described by Meyer25 in 1924. Studies
exploring the causes of peroneus
brevis tears have focused primarily
on hypovascularity, lateral ankle instability, and extrinsic compression
phenomenon. Sobel et al26 reported
that hypovascularity did not play a
role in peroneus brevis tears. Their
cadaveric study showed an ample
source of blood supply in the region
of the tear, leading the authors to
conclude that the primary mechanism was a mechanical disruption.
Sammarco and DiRaimondo27 reported on several athletes who displayed peroneus brevis tears while
being treated for lateral ankle instability. Krause and Brodsky28 reported
on 20 patients who all had redundancy of the SPR. The level of the
tears all corresponded to the distal 3
cm of the fibula, where the tendon
appeared to be compressed over the
edge of the fibula. Sobel et al13 performed a cadaveric study in which
tension on the peroneus longus with
the foot in inversion resulted in compression of the peroneus brevis in the
fibular groove. The flattening and
splaying of the peroneus brevis over

the anterior lip of the fibula led the

authors to conclude that longitudinal
tears or splits in the peroneus brevis
tendon were caused by acute or repetitive mechanical trauma. Geller
et al12 recently described the effect of
the low-lying muscle belly with resulting pressure on the SPR, subsequent instability, and peroneal tear.
Extrinsic compression has been
noted to come from sources other
than the peroneus longus tendon, including anomalous anatomy.
The patient who presents with peroneus brevis tear may report a specific
traumatic event, failure to improve after treatment for tenosynovitis, repeated
ankle sprains, and chronic lateral ankle pain and swelling. On examination,
the patient has swelling and pain with
palpation over the peroneal tendons,
pain with resisted eversion, and weakness. A bulbous pseudotumor in the
area of the peroneus brevis has been described by Webster.29 Mizel et al30 injected bupivacaine into the sheath to
aid in diagnosis. MRI scans in addition to plain radiography aid in the
diagnosis of peroneus brevis tears.
Treatment of this condition may
initially be nonsurgical, but surgical
procedures should be considered
when symptoms are recalcitrant to
nonsurgical management. Krause
and Brodsky28 reported an 83% failure rate with the use of nonsteroidal
anti-inflammatory drugs, activity
modification, lateral heel wedges,
and a walking boot or cast to treat
peroneus brevis tears in the presence
of ankle instability. Because the outcome of nonsurgical treatment of a
known peroneus brevis tear may be
less than satisfactory, surgical intervention should be considered. Given
the likelihood that nonsurgical management of peroneus brevis tear will
be unsatisfactory, serious consideration should be given to surgical intervention as the initial course of action.
Surgical treatment of peroneus

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Peroneal Tendon Injuries

Figure 3

Surgical techniques for managing single longitudinal tears of the peroneus

brevis tendon (A). Steps may include dbridement (B), repair (C), and
tubularization (D) of the tendon. (Reproduced from Chiodo CP: Acute and
chronic tendon injury, in Richardson EG [ed]: Orthopaedic Knowledge
Update: Foot and Ankle 3. Rosemont, IL: American Academy of Orthopaedic
Surgeons, 2003, pp 81-89.)

brevis tears depends on the type of

tear found at exploration. Single longitudinal tears can undergo dbridement, repair, and tubularization of
the tendon31 (Figure 3). We use a 3-0
absorbable suture for a core repair,
then tubularize with 3-0 monofilament absorbable suture. Multiple
longitudinal tears with significant
tendinosis (ie, >50% of the cross section of the tendon) and fibrillation
may undergo dbridement and either
direct repair of or, more commonly,
tenodesis to the peroneus longus tendon. Tenodesis consists of excising
the degenerated portion of the tendon and suturing the proximal and
distal ends of the brevis tendon to
the peroneus longus.
Krause and Brodsky28 graded peroneus brevis tears according to the
cross-sectional area of involvement.
Grade 1 tears were those with <50%
involvement, and grade 2 tears had
>50% involvement. Grade 1 tears
underwent direct repair, and grade 2
lesions underwent tenodesis. When
the tear is peripheral, up to 50% of
the outer tendon can be excised.
Steel and DeOrio32 reported that 9 of
10 patients treated with surgical re-

310

pair were able to return to work

(90%), but only 46% were able to
return to sports at their preoperative
level. Other studies have shown an
85% to 95% return to athletic and
fitness activities with surgical repair
of peroneal tendon tears.33,34

Peroneus Longus Tears

Tears of the peroneus longus are uncommon. Diabetes mellitus, hyperparathyroidism, rheumatoid arthritis, and psoriasis can predispose
individuals to peroneus longus tears.
Other conditions associated with
peroneus longus tears include ankle
instability, hindfoot varus, and a hypertrophied peroneal tubercle. Peroneus longus tears are most commonly related to direct trauma or
sports injuries. Chronic tears are associated with mechanical irritation,
most commonly occurring at the
cuboid tunnel, and longstanding
tenosynovitis.
Patient history usually reveals either an acute traumatic event or a
slow, progressive, insidious course.
In addition to swelling and tenderness over the lateral ankle, individu-

als with peroneus longus tears have

weakness and pain with resisted
eversion, tenderness distal to the fibula, and pain with resisted plantar
flexion of the first metatarsal. Fracture of the os peroneum can be an
indicator of peroneal pathology. Hypertrophy of the peroneal tubercle
can also be seen on plain radiographs and is commonly believed to
be a contributing factor to peroneus
longus tenosynovitis, tears, and rupture. Boles et al17 recommend the use
of Harris-Beath views to evaluate for
tubercle enlargement. MRI is recommended when confirmation of the
pathology is indicated because it allows easier evaluation of injury to
the tendon.
Treatment is based on the type of
the tear and factors such as patient
age, activity level, and duration of
symptoms. Nonsurgical management
may be considered for patients with
minimal symptoms and no loss of
function. When symptoms persist,
surgical options to consider for longitudinal tears and acute ruptures include dbridement, tubularization,
and end-to-end repair. For distal ruptures near the insertion at the base of
the first metatarsal, and chronic injuries with persistent symptoms and in
which the tear is not amenable to
end-to-end repair, tenodesis to the
peroneus brevis tendon is recommended. Commonly, the diseased
portion of the tendon is excised, and
the proximal and distal ends of the
peroneus longus tendon are sutured
side-to-side with the peroneus brevis.

Painful Os Peroneum
Syndrome
Sobel et al3 described painful os peroneum syndrome in 1994. Clinical
entities involving the os peroneum
and the peroneus longus tendon include an acute fracture of the os peroneum or an acute diastasis of a
multipartite os peroneum; chronic os

Journal of the American Academy of Orthopaedic Surgeons

Terrence M. Philbin, DO, et al

Figure 4

Algorithm for the intraoperative assessment of peroneal tendon tear. (Adapted with permission from Redfern D,
Myerson M: The management of concomitant tears of the peroneus longus and brevis tendons. Foot Ankle Int
2004;25:695-707.)

peroneum fracture resulting in

stenosing tenosynovitis; a partial or
overuse rupture of the peroneus longus tendon; gross discontinuity of
the peroneus longus tendon; and a
hypertrophied peroneal tubercle that
entraps the peroneus longus tendon
during its excursion.3 Patients with
acute painful os peroneum syndrome
have a history of direct trauma or a
supination-inversion injury. Symptoms include tenderness along the
tendon distal to the fibula and paresthesias along the course of the sural
nerve distal to the lateral wall of the
calcaneus. On examination, resisted
plantar flexion or inversion stress of
the first ray will exacerbate the
symptoms. There may also be weakness and pain on active eversion. Diagnostically, radiographs show migration of the os peroneum, the
presence of a multipartite os, and/or
May 2009, Vol 17, No 5

an enlarged peroneal tubercle. The

images should be compared with radiographs of the contralateral foot.
Treatment may be nonsurgical; however, Sobel et al3 found that only
20% of patients treated nonsurgically had acceptable results. Surgical
treatment includes excision of the os
with dbridement and repair of the
tendon, depending on the severity of
the peroneus longus disorder.

Concomitant Tears of the

Peroneal Tendons
The diagnosis and treatment of concomitant tears of the peroneal tendons
is a relatively new topic, and little has
been written about these injuries. Tears
of both tendons can be attributed to steroid injection, diabetes mellitus, rheumatoid arthritis, and injuries associated
with peroneal tendon subluxation, dis-

location, and instability. Diagnosis of

these injuries can be made through history, physical examination, and imaging studies.
Redfern and Myerson35 developed
a treatment algorithm for concomitant tears of the peroneal tendons
(Figure 4). The tears are classified as
type I, in which both tendons are repairable; type II, in which only one
tendon is repairable and usable; and
type III, in which both tendons are
unusable. Type III tears are subdivided into types IIIa and IIIb. Type
IIIa tears have no proximal muscle
excursion and, therefore, are candidates for tendon transfer. Type IIIb
tears have proximal peroneal muscle
excursion and can be treated with either single-stage or delayed allograft
repair. Treatment results depend on
the treatment of simultaneous injury,
such as a cavovarus deformity, ankle

311

Peroneal Tendon Injuries

instability, and peroneal dislocation.

These same disorders can occur with
all peroneal pathology and must be
considered. Redfern and Myerson35
treated 29 feet for tears of both tendons, reporting a mean postoperative American Orthopaedic Foot and
Ankle Society score of 82, compared
with a preoperative mean of 61.
Wapner et al33 recently reported
the results of treating concomitant
tears with a Hunter rod and a flexor
hallucis longus (FHL) transfer as a
salvage procedure. They concluded
that patients with failed previous surgery present several surgical challenges, including the need to create a
viable tendon sheath for free movement and to reestablish a restraint to
tendon dislocation, to reestablish
tendon stability, and to provide a viable motor to replace the atrophied
peroneal tendons. The surgeons performed a two-stage procedure in
seven patients, with initial placement
of a Silastic rod attached distally to
the free end of the tendon to establish a synovial sheath. The second
surgery occurred 3 months later,
with an FHL harvest and Pulvertaft
weave to reconstruct the peroneal
tendons. At an average 8.5-year
follow-up, six of the seven patients
were pain-free.33
Hansen36 has advocated a singlestage FHL transfer to the peroneus
brevis. Flexor digitorum longus
transfer and free gracilis tendon autograft have been described for concomitant peroneal tears.

Subluxation and Dislocation

Peroneal tendon subluxation and
dislocation are often differentiated as
acute or chronic injury. Although
subluxation and dislocation are uncommon causes of lateral ankle pain,
both can be significantly disabling.
Also, because they may be associated
with lateral ankle instability, these
injuries are easily misdiagnosed.

312

Quite often they occur in athletes;37

skiing has frequently been cited as
one of the sports in which they occur.38,39 The mechanism for subluxation and dislocation is commonly a
history of a forceful dorsiflexion and
eversion injury.39
Injured patients report a snapping
and popping or giving way in the ankle and often have a history of previous ankle injury. Active circumduction of the foot starting in plantar
flexion and eversion may recreate the
symptoms. Recreation of subluxation can also be done via forced
dorsiflexion or resisted plantar flexion with eversion.40 Fullness or swelling and tenderness just posterior to
the distal fibula are good indicators
of peroneal tendon pathology. Hindfoot alignment should be evaluated
for varus, and the examiner should
assess lateral ankle stability. Many
patients have ligamentous injury in
conjunction with peroneal tendon injuries.41
In 1976, Eckert and Davis39 evaluated 73 patients with injury to the
SPR and classified three types of injury. Grade I injuries (51%) were
those resulting in elevation of the retinaculum from the lateral malleolus,
with the tendons lying between the
bone and periosteum. Grade II injuries (33%) were characterized by the
fibrocartilaginous ridge elevated
with the retinaculum attached and
the tendons subluxated between the
fibrocartilaginous ridge and the fibula. Grade III injuries (16%) represented a thin cortical fragment of
bone avulsed from the fibula, with
the tendons displaced beneath the
fibular fragment. In 1987, Oden42
added grade IV to this classification
system to describe an injury in which
the SPR is torn from its posterior attachment to the calcaneus and deep
investing fascia of the Achilles tendon, with the retinaculum lying deep
to the dislocating tendon (Figure 5).

Treatment
Treatment should be based on several factors: whether the injury is
acute or chronic, the timing of the
injury, the associated clinical findings, and the age and activity level of
the patient.31 Treatment in acute
cases may consist of placing the foot
and ankle in a plantarflexed, inverted, below-knee cast for 6 weeks.
It is essential that the tendons be in a
reduced position before casting is
done.
Nonsurgical treatment has demonstrated a significant failure rate in
patients with chronic injury. Eckert
and Davis,39 as well as Stover and
Bryan,43 consider nonsurgical treatment futile; they report a <50% success rate with nonsurgical management in patients with chronic
disorders. Surgical treatment is usually preferred in these patients. Most
patients are young, athletic, and active, and they desire a rapid return to
an active lifestyle. Direct repair of
the SPR is used most commonly for
acute subluxation or dislocation injuries. Excellent results and rapid recovery have been reported with direct repair.37,44
Many surgical treatments have
been discussed for chronic injuries,
such as tissue transfer, bone block
procedures, and groove deepening.
These can be classified into several
categories, which address primary
repair of the SPR versus the need for
additional support to the SPR repair.

Tissue Transfer
Tissue transfer techniques can be
used to reinforce the SPR. Jones45
and Escalas et al38 used Achilles tendon tissue to reinforce their repair
(Figure 6). Other tissues used include
the plantaris,46 and the peroneus
brevis or quartus.47
The authors preferred method of
SPR repair begins with sharp excision of retinacular tissue from the

Journal of the American Academy of Orthopaedic Surgeons

Terrence M. Philbin, DO, et al

Figure 5

Figure 6

The Ellis-Jones technique for

reconstructing the peroneal
retinaculum, using a portion of
Achilles tendon. The inset shows
the bony tunnel that is created to
pass the harvested section of
Achilles tendon, recreating a
restraint for the peroneal tendons.
(Reproduced with permission from
Coughlin MJ, Schon LC: Disorders
of tendons, in Coughlin MJ, Mann
RA, Saltzman CL [eds]: Surgery of
the Foot and Ankle, ed 8.
Philadelphia, PA: Mosby Elsevier,
2007, vol 1, p 1215.)

act as reinforcement. During primary

repair of the SPR, a thorough evaluation of the retromalleolar groove is
appropriate (Figure 7). Many techniques have rerouted the tendons
and used other structures to stabilize
the tendons. Platzgummer48 used the
calcaneofibular ligament to reinforce
the tendons (Figure 8).
Classification of injuries to the superior peroneal retinaculum (SPR). Grade I,
injury resulting in elevation of the retinaculum from the lateral malleolus, with
the tendons lying between the bone and periosteum. Grade II, the
fibrocartilaginous ridge is elevated, with the retinaculum attached and the
tendons subluxated between the fibrocartilaginous ridge and the fibula.
Grade III, a thin cortical fragment of bone is avulsed from the fibula, with the
tendons displaced beneath the fibular fragment. Grade IV, the SPR is torn
from its posterior attachment to the calcaneus and deep investing fascia of
the Achilles tendon, with the retinaculum lying deep to the dislocating tendon.
(Adapted with permission from Coughlin MJ, Schon LC: Disorders of
tendons, in Coughlin MJ, Mann RA, Saltzman CL [eds]: Surgery of the Foot
and Ankle, ed 8. Philadelphia, PA: Mosby Elsevier, 2007, vol 1, p 1211.)

fibula. The tendons are evaluated,

and repair or dbridement of the tendons is performed. When the retinaculum is amenable to primary repair,
May 2009, Vol 17, No 5

the edge of the fibula is shaved down

to a fresh bleeding bed, and a pantsover-vest repair is performed, allowing the excess retinacular tissue to

Bone Block Procedures

Bone block procedures that involve
osteotomies of the fibula attempt to
provide a bony lip at the distal fibula
to help prevent subluxation and dislocation of the peroneal tendons
(Figure 9). Despite good results in
most patients, these procedures have
high complication rates because of
the internal fixation that is used.47
Groove Deepening
Groove deepening has also been proposed as a mechanism for providing
increased stability to the peroneal
tendons (Figure 10). In 1979, Zoell-

313

Peroneal Tendon Injuries

Figure 7

Primary repair of acute peroneal tendon dislocation. A, A curvilinear incision is made over the peroneal tendons
(arrows). The dislocated peroneal tendons are identified along with the tear in the superior peroneal retinaculum
(SPR). B, Placement of the incision in the SPR. Inset, View of the position of the peroneal tendons in a dislocated
position. C, The peroneal tendons are then relocated, and the SPR is primarily repaired. Inset, Primary repair of the
SPR and repair of the avulsed retinacular sleeve. (Reproduced with permission from Coughlin MJ, Schon LC:
Disorders of tendons, in Coughlin MJ, Mann RA, Saltzman CL [eds]: Surgery of the Foot and Ankle, ed 8. Philadelphia,
PA: Mosby Elsevier, 2007, vol 1, p 1214.)

ner and Clancy49 described the first

groove-deepening procedure with the
goal of increasing the depth of the
groove by 6 to 9 mm. They advocated plication of the SPR to augment the repair. However, despite the
success of this procedure, McGarvey
and Clanton50 reported a 30% complication rate with groove-deepening
procedures.
A newer technique has been described by Shawen and Anderson.51
The fibula is sequentially reamed out
from the tip in line with the peroneal

314

groove; then the thinned cortical rim

is impacted. This allows the smooth
posterior surface of the fibula to remain undisturbed. Porter et al52 recently described a groove-deepening
procedure that involves removing a
bone flap, excavating the subchondral bone from the distal posterior
fibula, and reattaching the flap
within the deepened groove and reconstructing the SPR. The authors
reported good results with an accelerated rehabilitation protocol. Their
preferred method is to ream the tip

of the fibula, then impact the posterior surface as described by Shawen

and Anderson.51 All patients are
carefully evaluated for any underlying disease of the foot before any operation is performed to repair the
retinaculum or the tendons.
Any evidence of hindfoot varus
must be surgically corrected. We perform a lateralizing Dwyer calcaneal
osteotomy. In the presence of lateral
ligament instability, a lateral ligament reconstruction, such as a Brostrm procedure, is completed.

Journal of the American Academy of Orthopaedic Surgeons

Terrence M. Philbin, DO, et al

Figure 8

Figure 10

Platzgummer method of tendon rerouting. A, The dislocated peroneal

tendons are identified, and the calcaneofibular ligament is divided. B, The
peroneal tendons are relocated, and the calcaneofibular ligament is
reattatched to the distal fibula (arrow), keeping the tendons in position.
(Reproduced with permission from Coughlin MJ, Schon LC: Disorders of
tendons, in Coughlin MJ, Mann RA, Saltzman CL [eds]: Surgery of the Foot
and Ankle, ed 8. Philadelphia, PA: Mosby Elsevier, 2007, vol 1, p 1215.)
Figure 9

Bone block procedures for repairing subluxating peroneal tendons. A, A

sagittal cut is made in the distal portion of the fibula, and the bone is rotated
back, creating a block to prevent the peroneal tendons from disclocating.
B, In an alternative technique, a small wedge of fibula is displaced
posteriorly (arrow) so as to create a similiar block. (Reproduced with
permission from Coughlin MJ, Schon LC: Disorders of tendons, in Coughlin
MJ, Mann RA, Saltzman CL [eds]: Surgery of the Foot and Ankle, ed 8.
Philadelphia, PA: Mosby Elsevier, 2007, vol 1, p 1217.)

Postoperative Care
Most of the SPR and peroneal tendon repair procedures have a similar
postoperative course. In the operating room, a Jones dressing with posterior splint is applied. The foot is
placed in neutral to a slightly inMay 2009, Vol 17, No 5

verted position and the ankle at 90.

The patient is nonweight bearing,
and sutures are removed 10 days
postoperatively. The leg is then
placed in a nonweight-bearing,
below-knee fiberglass cast, with the
foot in neutral to slight inversion and
the ankle at 90, for 4 to 6 weeks, after which the patient is transitioned

Groove-deepening procedure with

osteoperiosteal flaps. The
osteoperiosteal flap is created on
the posterior aspect of the fibula at
the retromalleolar groove. The flap
is elevated (inset a), and the
cancelleous bone is removed (inset
b). The osteoperiosteal flap is then
tamped into the created void
(arrow) and the peroneal tendons
relocated (inset c). Note the repair
of the superior peroneal
retinaculum in the final inset (*).
(Reproduced with permission from
Coughlin MJ, Schon LC: Disorders
of tendons, in Coughlin MJ, Mann
RA, Saltzman CL [eds]: Surgery of
the Foot and Ankle, ed 8.
Philadelphia, PA: Mosby Elsevier,
2007, vol 1, p 1217.)

out of the cast into a high-top walking boot. The patient may begin
weight bearing at 4 to 6 weeks in the
walking boot. This may be modified
when an additional procedure (eg,
osteotomy) has been performed.
Physical therapy focusing on range
of motion is started under the guidance of the therapist when the patient is placed in the walking boot at
8 weeks postoperatively. We recommend three 2-week phases of physical therapy. The initial phase focuses
on progressive weight bearing in a
regular shoe as well as joint mobilization. We often fit our patients for a
functional athletic ankle brace to use
during activities. The second phase
focuses on improving range of motion and proprioception, with normal gait pattern. The final phase of
physical therapy focuses on increasing strength and returning to activity.

315

Peroneal Tendon Injuries

At approximately 3 months after surgery, the patient is evaluated for

return-to-activity status. Prior to return to activity, the patient is evaluated for orthoses. For dbridement
of tenosynovitis only, without repair,
an accelerated postoperative protocol is used. The patient is transitioned out of the postoperative dressing directly into a removable walking
boot, and physical therapy is started
approximately 3 to 4 weeks after
surgery, with a similar prescription
of three 2-week phases.

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