Peroneus (Peroneal) Tendinopathy
Tendinopathy of the lateral ankle tendons, which act as dynamic stabilisers. Often mistaken for a lateral ankle sprain.
Two entities
- Peroneus brevis: at the lateral malleolus, often with a longitudinal tear.
- Peroneus longus: at the peroneal tubercle or os peroneum, linked to plantarflexion and first-ray loading.
Mechanism
- Repetitive eversion and plantarflexion (overuse)
- Acute inversion injury or chronic lateral ankle instability, a major predisposing factor
- Subluxation or dislocation: superior peroneal retinaculum rupture after forced dorsiflexion-inversion
- Cavovarus hindfoot increases peroneal loading
- Sports: running (especially trail), basketball, football, tennis, skiing, dance
Risk factors
| Anatomical | Modifiable | Systemic and drugs |
|---|---|---|
| Cavovarus or cavus foot, low-lying brevis muscle belly, peroneus quartus, os peroneum, shallow retromalleolar groove | Poor ankle control, previous sprain, training errors | Inflammatory arthropathy, diabetes, fluoroquinolones, corticosteroids |
Presentation
- Retrofibular pain (or lateral foot pain for longus), worse with resisted eversion, push-off and uneven ground
- Swelling and tenderness along the tendon
- Reduced eversion strength (compare sides). Assess hindfoot alignment.
- Visible or palpable snapping on dorsiflexion-eversion indicates retinacular injury and tendon instability, not simple tendinopathy.
- Persistent lateral pain after a “sprain” should raise suspicion.
Management
- Activity modification: first-line.
- Eccentric and progressive strengthening, plus proprioception: the cornerstone.
- Treat underlying ankle instability.
- Orthoses: lateral wedge or post for cavus or cavovarus feet.
- Short immobilisation for acute subluxation or severe pain.
- Shockwave, PRP: weak evidence.
- Surgery (retinaculum repair, groove deepening, tendon repair or reconstruction): confirmed subluxation, tears, or failed conservative care.
Practical warning
avoid corticosteroid injection into the peroneal tendons. Rupture risk is high and the functional consequences are severe. Some sources describe ultrasound-guided injection for refractory cases, but most consensus advises against it.
References
- van Dijk et al., ESSKA-AFAS consensus, KSSTA 2018, doi:10.1007/s00167-018-4971-x
- Peroneal tendon disorders, EFORT Open Rev 2017, doi:10.1302/2058-5241.2.160047
- Foot Ankle Spec 2021, doi:10.1177/1938640020916278
Related
Medical disclaimer: this article is general information, not personal medical advice. Always consult a qualified doctor about your own situation.