Review on Peroneal Tendinopathy
Peroneal tendonitis is a common source of lateral ankle pain that can be managed conservatively.
You are evaluating a dancer with worsening lateral ankle pain. You suspect an overuse injury. Repetitive friction of the peroneal brevis tendon can occur at what level of foot/ankle?
A) Sustentaculum tali
B) Retromalleolar groove
C) Os naviculare
D) Fifth metatarsal base
Every differential for lateral ankle pain should include injury to the peroneal tendons. The peroneal complex is made up of the peroneus longus and peroneus brevis. The two muscles make up the lateral compartment of the lower extremity (9). The peroneus brevis will insert at the lateral aspect of the fifth metatarsal base and the peroneus longus will insert on the medial cuneiform and base of the first metatarsal (3). The superior peroneal retinaculum, which is a stabilizing fascia, spans from the posterolateral surface of the fibula to the lateral calcaneus (1, 3). Both tendons will run posterior to the fibula within the retromalleoluar sulcus as they make their way to their insertion (5). The peroneal tendons act to produce hindfoot eversion (1) and also contribute to plantarflexion of the ankle (3).
The peroneus brevis is at risk for tendinopathy, as it can become entrapped by the peroneus longus against the fibula or the calcaneus (1). Both the peroneal brevis and longus are at risk for tendon tear. These tears can be acute or chronic in origin. The purpose of this review is to evaluate the non-traumatic overuse type injury of the peroneal tendons.
Image 1. Anatomy of the peroneal brevis and longus (8)
Peroneal tendinopathy should be considered in long distance runners, dancers, and soccer players with lateral ankle pain (1). Symptoms typically include lateral hindfoot pain, swelling of the ankle, and the subjective feeling of the ankle giving out (1).
Physical examination evaluation of the peroneal tendons should include evaluation of the hindfoot alignment. A varus hindfoot alignment has been found to be a risk factor for peroneal tendinopathy (1,9). The ankle should be tested for strength in resisted ankle eversion and first ray plantarflexion (5). Tenderness should also be assessed along the course of the peroneal tendon (6). Peroneal subluxation can also be provoked by everting the ankle and then actively plantarflexing and dorsiflexing the ankle (5).
Radiographs are done to evaluate for peroneal tubercle hypertrophy. A hypertrophied peroneal tubercle is a risk factor for peroneal tenosynovitis (4). Radiographs can also identify an os peroneum, which is a sesamoid bone found within the tendon of the peroneus longus (5). Radiographs can also find a fleck sign from the lateral malleolus, which can be a sign of peroneal tendon subluxation (9).
Image 2. Star indicates peroneal tubercle hypertrophy (4).
MRI is also used for evaluating the peroneal tendons. Tenosynovitis and tendinosis will show increased signal intensity within the tendon (1). The peroneal brevis can be found to have both tendinosis or partial tears due to repetitive friction within the retromalleolar groove (7).
Conservative first line treatment for peroneal tendinopathy includes rest, ice, anti-inflammatories, and bracing. Patients who have pain with ambulation can be placed in a tall walking boot acutely. If athletic activity needs to continue, then a patient can be placed in an ankle brace and lateral wedge orthotic to unload the peroneals (1).
For patients who fail first line therapies, an ultrasound guided peroneal tendon sheath injection can be considered. Positioning for a peroneal tendon sheath injection involves placing the patient in the lateral recumbent position with the affected side superior (2). The injection will be inserted in plane and can be injected at any point along the sheath (2). However, when injecting below the lateral malleolus, providers should take an anterior to posterior angle to avoid sural nerve injury (2). Platelet rich plasma injections can also be injected into the peroneal tendon sheath and the peroneal tendon.
Image 3. Positioning of ultrasound guided peroneal nerve injection (2)
Image 4. Needle track for peroneal tendon sheath injection (2)
Physical therapy can also be done for chronic peroneal tendinopathy. Therapists aim to identify imbalance between the anterior tibialis and/or posterior tibialis and the peroneal musculature (10). Other treatment modalities include eccentric strengthening, dexamethasone with iontophoresis treatment, graston scraping technique, and dynamic stretching (10).
The peroneal brevis and longus tendons are common sources of lateral ankle pain. They are typically injured due to repetitive overuse injuries in both young and old athletes. They can be managed conservatively with RICE and physical therapy. However, some patients may require peroneal tendon sheath injections. MRI can be used to better evaluate for tenosynovitis vs. peroneal tendon tear. Referral to foot and ankle surgery may be required in the setting of an acute peroneal tendon subluxation (9).
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