Peroneal Tendon Tears / Subluxation
The peroneal tendons are frequently injured, frequently missed, and frequently attributed to a "chronic ankle sprain." Peroneus brevis longitudinal split tears, peroneus longus tears, and subluxation of the tendons out of their fibular groove are distinct injuries with specific examination findings. They will not resolve with generic ankle sprain rehabilitation. At Maryland Orthopedic Specialists, we identify and treat peroneal pathology precisely, from targeted physical therapy to surgical tendon repair and retinacular reconstruction.
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What is peroneal tendon tears / subluxation?
The peroneus brevis (PB) and peroneus longus (PL) tendons run posterior to the lateral malleolus, held in a groove on the fibula by the superior peroneal retinaculum (SPR). They are the primary evertors of the foot and lateral ankle stabilizers.
The peroneus brevis (PB) and peroneus longus (PL) tendons run posterior to the lateral malleolus, held in a groove on the fibula by the superior peroneal retinaculum (SPR). They are the primary evertors of the foot and lateral ankle stabilizers.
Peroneus brevis longitudinal split tears: The most common peroneal injury. The PB tendon, sandwiched between the fibular groove and the PL tendon, develops a longitudinal split: a "C-shape" or boomerang morphology on cross-section. Caused by chronic friction and repetitive eversion loads. Associated with hindfoot varus, lateral ankle instability, and a shallow fibular groove. Patients report lateral ankle pain and weakness; physical examination shows tenderness directly over the posterior fibula along the PB.
Peroneus longus tears: Less common; may occur at the os peroneum (a sesamoid bone in the PL as it curves under the cuboid) or along the lateral foot. Painful os peroneum syndrome and PL tears cause lateral foot and midfoot pain distinct from the typical posterior fibular pain of PB pathology.
Peroneal tendon subluxation / dislocation: The SPR is torn (typically in a sudden, forceful dorsiflexion-eversion mechanism, common in skiing and football), allowing the tendons to snap anteriorly over the fibular tip. Patients often describe a "pop" and feel the tendon "flipping" over the ankle bone with certain movements. SPR tears are commonly missed acutely, mistaken for a simple ankle sprain.
Association with lateral ankle instability: Peroneal tendon pathology and chronic lateral ankle instability frequently coexist. Up to 25% of patients undergoing lateral ligament reconstruction have concurrent peroneal pathology identified at surgery.
Symptoms — do you recognize these?
- Lateral ankle and posterior fibular pain — distal to the fibula, slightly posterior (distinguishes from ATFL sprain, which is anterior to the fibula)
- Pain with resisted eversion
- Swelling along the peroneal tendon sheath (tenosynovitis)
- For subluxation: snapping or "popping" sensation over the lateral malleolus with active dorsiflexion and eversion; patient may be able to voluntarily demonstrate the subluxation
- Lateral ankle instability symptoms may coexist
Call us at (301) 515-0900. Same-day appointments available at our Bethesda and Germantown locations. Recurrent lateral ankle pain after a "sprain" deserves peroneal tendon evaluation.
How we diagnose it
Clinical examination: Palpation along the peroneal tendon sheath posterior to the fibula; resisted eversion strength testing; peroneal subluxation provocation (active dorsiflexion + eversion with examiner stabilizing the fibula). Circumduction of the foot may reproduce snapping over the lateral malleolus.
MRI: The gold standard for peroneal tendon assessment. Reveals longitudinal split tears (C-shaped or bifid PB on axial images), PL tears, tenosynovitis (fluid in the sheath), and SPR disruption. MRI is performed at MOS prior to any surgical planning.
Ultrasound: Dynamic real-time imaging visualizes tendon tears and demonstrates peroneal subluxation during active motion. This is a unique advantage over static MRI. Highly valuable in experienced hands.
Weight-bearing X-rays: Assess for hindfoot alignment (varus increases PB tear risk), os peroneum location, and fibular groove morphology.
Treatment options
Many peroneal tendon injuries improve with conservative care, though tears with significant instability typically require surgery.
Non-Operative Management
A walking boot or cast rests the tendons and reduces inflammation during the acute phase. Physical therapy focusing on peroneal strengthening and balance training helps restore function. An ankle brace provides ongoing support during return to sport.
Peroneal Tendon Repair
Repair of longitudinal peroneal tendon tears combined with reconstruction of the superior peroneal retinaculum to prevent recurrent subluxation. Addresses both the tendon damage and the anatomic instability responsible for the condition.
Click for more Surgical ProcedureAnkle Arthroscopy
Minimally invasive joint scope to treat intra-articular ankle pathology (osteochondral lesions, anterior bony impingement, and synovitis) through small portals with same-day discharge at our ambulatory surgery center.
Click for moreRecovery & rehabilitation
- PT-only: 6–8 weeks to meaningful improvement; athletic bracing ongoing
- Peroneal tendon surgery: Boot 4–6 weeks; progressive PT beginning at 4–6 weeks; return to sport 4–6 months
- SPR reconstruction: Non-weight-bearing 2 weeks → boot 4–6 weeks → return to athletic activity 4–6 months
Frequently Asked Questions
Is peroneal subluxation the same as a sprain?
Can peroneal tendon tears heal on their own?
What happens if subluxation is untreated for years?
Will I need surgery for a peroneal tendon tear or subluxation?
How long is recovery after peroneal tendon surgery?
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References
- Roster B, Michelier P, Giza E. Peroneal tendon disorders. Clinics in Sports Medicine. 2015;34(4):625–641. doi:10.1016/j.csm.2015.06.003
- Demetracopoulos CA, Vineyard JC, Kiesau CD, Nunley JA. Long-term results of debridement and primary repair of peroneal tendon tears. Foot & Ankle International. 2014;35(3):252–257. doi:10.1177/1071100713513183
- van Dijk PA, Lubberts B, Verheul C, DiGiovanni CW, Kerkhoffs GM. Outcome of peroneal tendon surgery: a systematic review. Acta Orthopaedica. 2016;87(2):198–204. doi:10.3109/17453674.2015.1110278
- OrthoInfo. AAOS. Peroneal Tendon Injuries. Available at: https://orthoinfo.aaos.org/en/diseases--conditions/peroneal-tendon-injuries