Peroneal Tendinopathy

Aka: Peroneal Tendinopathy, Peroneal Tendonitis, Peroneal Tendinitis, Peroneus Longus Tenosynovitis, Peroneus Brevis Tenosynovitis, Peroneus Longus Tendinitis, Peroneus Brevis Tendinitis, Peroneal Tendon Injury

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II. Physiology

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

III. Pathophysiology

  1. Peroneal Tendon Injury includes peroneal tenosynovitis, subluxation and tendon tears

IV. Mechanism

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

V. Risk Factors

  1. Forefoot striking pattern (esp. Running Injury)
  2. Medication exposures
    1. Fluoroquinolones
    2. Corticosteroid Injections
  3. Chronic medical conditions
    1. Rheumatoid Arthritis
    2. Hyperparathyroidism
    3. Diabetes Mellitus

VI. Symptoms

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

VII. Signs

  1. Observation with patient standing
    1. Peroneal tendon may be seen contracting, overcoming inversion while maintaining stance
    2. Hindfoot varus (heel varus) with inverted foot and ankle
      1. High foot arch
      2. Cavus foot
      3. Heel oriented inward
  2. Palpation
    1. Pain and swelling posterior to the lateral malleolus at the lateral hindfoot (and over Cuboid tunnel)
  3. Provocative maneuvers
    1. Weakness and pain with active motor activity
      1. Ankle plantar flexion
      2. Foot eversion
    2. Passive stretch foot and ankle in inversion and dorsiflexion
      1. Positive if painful
    3. 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
    4. Circumduct ankle
      1. Observe for peroneal tendon subluxation over the lateral malleolus
    5. Compress superior peroneal Retinaculum
      1. Pain and crepitus may be present with peroneus brevis tears

VIII. 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)

IX. Imaging

  1. Ultrasound for peroneal instability
    1. Test Sensitivity: 100%
    2. Test Specificity: 85%
  2. MRI
    1. Consider in suspected peroneus brevis tears (Test Sensitivity: 83%)

X. Management

  1. RICE-M initially
  2. NSAIDs
  3. Modify activities
  4. Rehabilitation Exercises (consider physical therapy referral)
    1. Ankle Range of Motion
    2. Peroneal strengthening (Eversion strengthening and progressive loading)
    3. Proprioception Exercises
  5. 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
  6. 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]
  7. Immobilization (CAM Boot or Short Leg Walking Cast)
    1. Consider in refractory cases
  8. 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 suspected or confirmed (refer early)

XI. References

  1. Sammarco (1994) Orthop Clin North Am 25(1): 135-45
  2. Deu (2022) Am Fam Physician 105(5): 479-86 [PubMed]
  3. Morancie (2025) Am Fam Physician 112(6): 648-56 [PubMed]
  4. Simpson (2009) Am Fam Physician 80(10): 1107-13 [PubMed]

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