II. Physiology

  1. Peroneus Longus and Brevis act function in ankle eversion and plantar flexion
  2. Images
    1. ankleMedialAndLateral.jpg

III. Mechanism

  1. Running Injury (overuse)
  2. Lateral Ankle Sprain (ankle inversion injury, esp. in first degree sprains)
    1. Injury may be to Peroneus Longus, or more commonly to Peroneus Brevis

IV. Risk Factors

  1. Varus hindfoot (heel varus)
  2. Forefoot striking pattern (esp. Running Injury)

V. Symptoms

  1. Chronic lateral ankle pain (retrofibular), popping and swelling
  2. Ankle instability

VI. Signs

  1. Observation with patient standing
    1. Hindfoot varus (heel varus) with inverted foot and ankle
    2. Peroneal tendon may be seen contracting, overcoming inversion while maintaining stance
  2. Palpation
    1. Pain and swelling posterior to the lateral malleolus at the lateral hindfoot
  3. Provocative maneuvers
    1. Passive stretch foot and ankle in inversion and dorsiflexion
      1. Positive if painful
    2. Resisted foot eversion and plantar flexion
      1. Positive if weak or painful
      2. Palpate during resistance for tenderness along fibular groove (posterolateral ankle)
        1. Pain indicates a positive peroneal compression test
    3. Circumduct ankle
      1. Observe for peroneal tendon subluxation over the lateral malleolus

VII. Differential Diagnosis

  1. Ankle Sprain
  2. Fibular Fracture
  3. Peroneal Subluxation
  4. Os perineum syndrome (plantar lateral Foot Pain)
  5. Rheumatoid Arthritis (consider if lack of Trauma)

VIII. Management

  1. RICE-M initially
  2. Modify activities
  3. Rehabilitation Exercises (consider physical therapy referral)
    1. Ankle Range of Motion
    2. Peroneal strengthening (Eversion strengthening and progressive loading)
    3. Proprioception Exercises
  4. Shoe Orthotic
    1. Lateral heel wedge to offload peroneal tendons
    2. First Metatarsal head recessed depression to increase foot valgus
    3. Heel cushion may offer comfort
  5. Peroneal Corticosteroid Injection
    1. Consider in refractory cases
    2. Appears effective and with low risk of tendon rupture
    3. Perform under Ultrasound guidance (consider Sports Medicine Referral)
    4. Fram (2019) Foot Ankle Int 40(8): 888-94 [PubMed]
    5. Muir (2011) Am J Phys Med Rehabil 90(7): 564-71 [PubMed]
  6. Orthopedic Referral Indications (possible surgical repair)
    1. Refractory to therapy above
    2. Inability to bear weight >1 to 2 weeks after injury
    3. Persistent or recurrent peroneal tendon instability
    4. Peroneal tendon rupture

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