A missed peroneal tendon injury: Is this the cause of inappropriate surgery and continued foot and ankle pain?

Ross A. Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C.

Peroneal tendon injury

If you are reading this article, it is likely that you have become an expert in peroneal tendon injury because you have tried many treatments and you are still researching why you still have pain and swelling on the outside of your foot, leg, and ankle. For many patients who reach out to us, their injury started with a rolled over to the inside ankle or degenerative wear and tear problem that one day finally popped.

Over time you may have become expert in things that were not helping you. Specifically the RICE protocol of Resting, Icing, Compression (ankle braces and ace bandages to support ankle instability), Elevation. You also know that acetaminophen (Tylenol), ibuprofen (Advil, Motrin), are only helping so much and you are worried that continued use of Nonsteroidal anti-inflammatory medicines (NSAIDs) will not only not help your situation but lead to side-effects.

This article will focus on the lead-up and post-surgical problems some patients may experience with peroneal tendon surgery and problems of peroneal tendinopathy.

Many people do very well with surgery, they are in a walking boot after 2 weeks, into physical therapy soon after, and for the most part, complete a successful recovery and are happy with their surgical outcomes. These are not the patients we see in our office. We see the people who had the surgery, the surgery was not as successful as everyone hoped. Post-surgical symptoms can range from general ankle and foot instability to consistent pain, tightness, and loss of mobility. This article is for those people.

“My problem is I have developed scar tissue”

The emails that are sent to us from people looking for options post-surgery go something like this:

I am about 10 months out after surgery. I had an injury, high ankle sprain. It was not responsive to conservative care treatments so I had the surgery. I still cannot bear full weight on my foot and I still have a lot of pain and swelling. I am also starting to get some numbness that I did not have before. I am being told that I may have scar tissue developing and this may need to be surgically removed.

Or like this:

I am about four months post-surgery and I have been told that I have developed scar tissue. It is causing a lot of pain. I have been walking around with a boot for months. Now I don’t know if I will be able to get this boot off. I cannot walk without it. I started physical therapy 2 months after the surgery, I have been going since and there has been no improvement. Now I am being told I MUST have a second surgery.

So why not get the second surgery? Concerns over the lack of the second surgery’s success and long postoperative rehabilitation

The reason we get these emails is that for some people, the discussion of the second surgery comes with many concerns. The major concern is that the second surgery may not be successful. For some, that is the only concern. When discussing surgery, it is always best to get surgical opinions and observations from surgeons.

In the journal Clinics in Podiatric Medicine and Surgery, May 2020, (1) the challenges of peroneal tendon revision surgery are described:

“Peroneal tendon tears that require revision are rare and often present a unique challenge for foot and ankle surgeons. Biomechanical issues that may be present or missed initially need to be addressed and evaluated thoroughly for an optimized outcome. Tendon degeneration is usually present, and planning for tendon transfer or tendon graft is necessary to improve mechanical strength. . . The postoperative rehabilitation is often longer and patient education is imperative to manage expectations of outcomes.”

Maybe it is was not the Peroneal Tendon after all – posterior ankle impingement may be the actual cause of pain.

One of the problems of surgery with less than hoped for results is that the surgery may have addressed the wrong problem. That your ankle pain is not really coming from a problem with your peroneal tendon is demonstrated in the title of a June 2020 paper published in the Journal of Clinical Orthopaedics and Trauma (2)  from Texas Children’s Hospital and the University of California at San Francisco. Here three young patients were examined.

“Posterior ankle impingement is a cause of posterior ankle pain common in those who perform frequent plantar flexion activities. Three young patients presented with posterior ankle pain which was initially attributed to peroneal tendon subluxation. However, detailed physical exam and imaging confirmed the diagnosis of posterior ankle impingement as the actual cause of pain.

The peroneal tendon subluxation was not causal (not causing) but an unrelated co-incidental finding. After failed prolonged conservative management (rest, immobilization and physical therapy), the patients underwent posterior ankle arthroscopic debridement for the impingement resulting in return to prior sporting activity without limitation and no recurrence of pain at 19 months follow-up. Posterior ankle impingement diagnosis could be masked by co-incidental asymptomatic peroneal tendon subluxation in pediatric patients.”

Below we will discuss whether similar outcomes can be achieved without surgery.

Continued ankle pain following talus fracture. Was injury to the peroneal tendon missed?

Let’s look at a May 2020 study in the journal International Orthopaedics.(3) Here, surgeons suggest that a lot of peroneal tendon dislocations are being missed following repair of a talus fracture.

Here are the research highlights:

  • While talus fractures are common injuries and one of the more serious fractures in the foot and ankle, peroneal tendon dislocation is one of the commonly missed soft tissue injuries which may have significant impact on the outcomes including persistent pain and swelling. They have been reported to be associated with calcaneum (heel fractures) as well as talus fractures.
  • The researchers examined the charts of people who underwent open reduction and internal fixation (hardware was used to hold the bones together).
  • Peroneal tendon dislocation was found in ten patients out of 50 (20%).
  • Risk of dislocation increased with the severity of the fracture
  • Most of the dislocations were missed by surgeons and radiologists, and no additional procedures were done to address such an injury.
  • Peroneal tendons dislocation is associated with as high as 20% of talus fractures. The authors of this study recommend carefully reviewing CT scans by surgeons and radiologists alike to avoid missing such injury and allow for appropriate surgical approach utilization.

Continued ankle pain following heel fracture. Was injury to the peroneal tendon missed?

A June 2018 study in The Journal of Foot and Ankle Surgery (4) suggested that a lot of peroneal tendon dislocation are being missed following repair of a heel fracture:

Here are the research highlights:

  • Peroneal tendon instability associated with an intraarticular calcaneal fracture is a common injury that still often passes undiscovered by both radiologists and orthopedic surgeons.
  • The researchers examined the charts of people who underwent surgery for calcaneus fracture.
  • The prevalence of peroneal tendon instability associated with intraarticular calcaneal fractures is high and increases with the increasing severity of the calcaneus fracture.

The problem of a missed peritoneal tendon injury in a heel fracture was also reported in The Journal of Bone and Joint Surgery (Amer).(5) Here are the learning points of this research:

  • Peroneal tendon displacement (subluxation or dislocation) accompanying an intra-articular calcaneal fracture (a heel fracture where the fracture causes cartilage damage as well). This injury (Peroneal tendon displacement) is is often undetected and under-treated.
  • In this study: 421 intra-articular calcaneal fractures were examined.
    • Peroneal tendon displacement was identified in 118 (28.0%) of the 421 calcaneal fracture cases.
    • Only twelve (10.2%) of the 118 cases of peroneal tendon displacement had been identified in the radiology reports.
    • Although sixty-five (55.1%) of the fractures with tendon displacement had been treated with internal fixation, the tendon displacement was treated surgically in only seven (10.8%) of these cases.

The peroneus brevis tendon injury and ankle ligament laxity – you can’t treat one without the other

One of the significant problems we see in the patients who come in for ankle or heel pain with a diagnosis of tendon or cartilage damage is that many do not have any diagnosis or discussion about ligament injury. One of the reasons these people reach out to us is that not only is the missed diagnosis of peroneal tendon damage a problem, but so is the missed diagnosis of ankle ligament injury.

There are two peroneus tendons. One is the peroneus brevis tendon, the shorter tendon that attaches to the outside middle of the foot and the aptly named peroneus longus (longer) tendon which runs under the foot and attaches near the inside of the arch. Injury to either of both these tendons which run down the leg and into the foot parallel to each other can easily be diagnosed as a lateral ankle sprain.

We are going to go back to a 1998 study (6) and then bring it forward 20 years. This study comes from the Department of Orthopaedics, Ostra University Hospital, Sweden. The theme of this study is that you can treat peroneus tendon injury and you can treat ankle ligament injury. But for best affect you must address both. Now this is for people undergoing the first surgery. Not a surgery to correct the first surgery. Let’s examine the study learning points:

  • “Chronic lateral ankle instability can be associated with a longitudinal rupture of the peroneus brevis tendon. Patients with these problems have atypical posterolateral (outside back) or retromalleolar pain (ankle pain at the retromalleolar pain that the peroneus tendons pass through) as well as clinical signs of ligamentous instability (weak ligaments).
  • This injury is frequently concomitant with lateral ligament injuries and the injury mechanism is similar; however, the tendon rupture is often missed.
    • (Note: Let’s point out again that this is a 1998 study. Above we cited a May 2020 study in which “the tendon rupture is often missed.” Twenty-two years later the same problem exists.)
  • Laxity or insufficiency of the superior peroneal retinaculum (also known as the external annular ligament) allows the unstable anterior part of the peroneus brevis tendon to ride upon the sharp posterior fibular edge (the outer shin bone or fibula’s rear portion), resulting in a longitudinal rupture of the tendon.
  • The study goes on to report on the results after surgical treatment in nine patients (10 ankles) with combined instability of the lateral ankle ligaments and longitudinal rupture of the peroneus brevis tendon. All these patients underwent surgical repair of the peroneus tendon, reconstruction of the superior peroneal retinaculum, removal of the sharp posterior edge of the fibula and correction of the ligamentous instability of the anterior talofibular and calcaneofibular ligaments.
  • One constant finding at surgery was a longitudinal intratendineal rupture of the peroneus brevis tendon combined with insufficiency of the superior peroneal retinaculum and insufficiency of the lateral ligaments. At follow-up 3 (2-5) years post-operatively, the functional results were excellent or good in nine ankles and fair in one.

Here, the surgeons addressed the problem of ligament laxity of ligament instability causing a hypermobile situation where the peroneus brevis tendon is damaged by an abnormal rubbing against the fibula. The problem is addressed by ligament reconstruction and shaving down bone.

Treating ankle ligaments and peroneus tendons non-surgically

In December 2018, The European Society of Sports Traumatology Knee Surgery and Arthroscopy, published in their Journal of Experimental Orthopaedics(7) these observations on chronic tendon injury. As we pointed out earlier in this article, your situation of continued ankle, heel, and foot pain before and after surgery may be the result of a missed peroneus tendon injury.

These are the learning points of this study:

  • The treatment of painful chronic tendinopathy is challenging.
  • Patients and health care providers have a choice to treat problems with multiple non-invasive (non-surgery) and tendon-invasive (surgery) methods.
  • When traditional non-invasive treatments fail, the injections of platelet-rich plasma autologous blood or cortisone have become increasingly favored. However, there is little scientific evidence from human studies supporting injection treatment.
  • As the last resort, open or arthroscopic surgery to the tendon, or surgery to the tendon and surrounding soft tissue are employed even though these also show varying results.

In the opening of this study, the surgeons acknowledge that helping people with tendinopathy is challenging. Non-surgical methods do not work that well, a 25% failure rate, and surgeries do not typically work that well either. Cortisone is usually not supported and the surgeons question the benefit of PRP injections. Which we will discuss.

  • Prolotherapy is the injection of a simple sugar, dextrose. The idea is that dextrose injections will cause a controlled inflammatory response that will focus on strengthening and rebuilding the damaged soft tissue surrounding the heel and the ankle in place. Strengthened soft tissue, i.e, ligaments, will stabilize the ankle/heel area and help pull things back into place and reduce destructive forces on the peroneus tendons.
  • PRP is Platelet Rich Plasma Therapy. PRP treatment re-introduces your own concentrated blood platelets into the ankle / heel area. Your blood platelets contain growth and healing factors. When concentrated through simple centrifuging, your blood plasma becomes “rich” in healing factors, thus the name Platelet RICH plasma.

In our 27 plus years of helping people with tendon injuries, we have found Prolotherapy and PRP treatments to be effective in helping these people’s goals of getting back to sports or work. The article you have just read is based on our years of experience in treating thousands of patients. The way we offer treatment is not how you may find this treatment offered at other clinics.

In June 2019, this very problem of lack of standardized in treatment was discussed by doctors at the University of Pittsburgh who published this paper: Myths and Facts of In-Office Regenerative Procedures for Tendinopathy: Literature Review., in the American Journal of Physical Medicine & Rehabilitation. Here is what the Pittsburgh doctors had to say:(8)

“Tendinopathy carries a large burden of musculoskeletal disorders seen in both athletes and aging population. Treatment is often challenging, and progression to chronic tendinopathy is common.  . . The field of regenerative medicine has taken the forefront, and various treatments have been developed and explored including prolotherapy, platelet rich plasma (PRP), stem cells, and percutaneous ultrasonic tenotomy. However, high-quality research with standardized protocols and consistent controls for proper evaluation of treatment efficacy is currently needed.”

Basically, there are many practitioners and researchers who are not sure what is the optimal standardized treatment is. In our experience, we find that the optimal standardized treatment is a comprehensive and customized treatment program based on the needs of the individual patient. Someone who runs marathons needs a customized treatment different that someone who simply wants to walk pain free. Your treatment is based on your treatment goals of resuming pain-free activity.

Peroneus Tendinitis and Peroneus Tendinosis non-surgical treatments

By the time a patient comes to Caring Medical with joint problems related to sports, an active lifestyle, or a physically demanding job and their diagnosis of one of the various tendinopathy issues described in this article, many of them will already have an advanced case. It will either be advanced tendinitis or advanced tendinosis. Again, their peroneus tendon problems had been missed and thus, the tendons continued their accelerated degeneration.

  • Tendinitis
    • The initial wear and tear and overuse injuries to tendons usually involve a degree of inflammation. This is the Tendinitis stage. This is where your health care provider will attack your problems with anti-inflammatory medications and possibly cortisone injections.
  • Tendinosis
    • You continue to have pain but not inflammation. In essence, your body has given up trying to repair the tendon because your body believes, it is “too far gone.”

A December 2018 study asked the question, “Can Elite Dancers Return to Dance After Ultrasound-Guided Platelet-Rich Plasma (PRP) Injections?” (9) One of the injuries dancers frequently get and was explored was peroneus brevis tendon injury. Here are the summary points of this study:

  • The goal of this study was to evaluate clinical improvement in a population of elite dancers following treatment with ultrasound-guided platelet-rich plasma (PRP) injections of various lower extremity sites by assessing when they were able to return to dance.
  • Nineteen dancers (13 female, 6 male; ages 15 to 42) were treated between 2009 and 2016 at sites that included: hamstring tendon (1), proximal iliotibial band (1), patellar tendon (3), posterior tibial tendon (5), peroneus brevis tendon (3), plantar fascia (3), and the first metatarsophalangeal (MTP) joint capsule (3).
  • All patients adhered to standard post-care instructions, including non-weight bearing and avoidance of NSAIDs for at least 2 weeks post-injection.
  • Eighteen subjects achieved a return to dance, 13 in 6 months or less, and the majority (10) within 3 months of injection.
  • Five subjects required more than 6 months recovery time. These cases all involved foot and ankle sites; of these, two subjects required repeat injections, and both returned to dance within 11 months of the second injection.
  • In the single case where PRP treatment failed, the injury treated was severe plantar fasciopathy with a high-grade central cord tear.

Here, PRP helped achieve the goal of returning high-level dancers back to dance including those with peroneus brevis tendon injury. We would like to point out that in our experience a more aggressive PRP treatment approach combined with concurrent Prolotherapy treatments may have achieved superior results.

PRP and high ankle sprain

High ankle sprain causes damage to the ligaments that connect the shin bones tibia to the fibula. Because of the high impact stress at the tibia and fibula junction, the syndesmosis joint, the high ankle sprain is difficult to heal. In recent research, doctors examined the success of platelet-rich plasma (PRP) into the injured antero-inferior tibio-fibular ligaments (AITFL) in athletes on return to play (RTP). They further studied the issues of ankle instability and stability before and after the PRP ankle injections.

Sixteen elite athletes with AITFL tears were randomized to a treatment group receiving injections of PRP or to a control group. All patients followed an identical rehabilitation protocol and RTP criteria. Patients were prospectively evaluated for clinical ability to return to full activity and residual pain.

Here are the results:

  • Early diagnosis and treatment lead to shorter Return to Play
  • Significantly less residual pain upon return to activity was found in the PRP group;

Athletes suffering from high ankle sprains benefit from ultrasound-guided PRP injections with a shorter RTP, re-stabilization of the syndesmosis joint and less long-term residual pain.(10)

We would like to point out that in our experience a more aggressive PRP treatment approach combined with concurrent Prolotherapy treatments may have achieved superior results.

A demonstration of how we offer PRP and Prolotherapy.

  • In this video, the treatment begins with an ultrasound examination to help guide some of the injections during the treatment.
  • Before the treatment begins the patient receives some numbing solutions in the form of injections, while the ultrasound examination continues. Not all patients request numbing solutions. It is an option that we do offer. Typically while the patients receive many injections, the treatment is tolerated quite well with or without being numbed.
  • At 0:45 we see the PRP / Prolotherapy treatment begin. Our PRP treatments are more than “one shot.” In our opinion to best treat ankle pain, injections are given into the joint as well as the outer and surrounding ligaments and the muscle/tendon attachments to the bone.
  • At 1:00 we see the Prolotherapy injections into the medial and lateral ankle, the inside and outside.
  • In this particular patient, he had suffered an ankle fracture 30 years prior and had a repair surgery. His range of motion had decreased significantly becoming harder for him to perform his job.
  • In total, this patient received 6 treatments over 6 months. The difference between surgery and our treatments was that he was able to continue to work during the treatment phase while his ankle pain and stability improved.

In this video, Danielle R. Steilen-Matias, MMS, PA-C demonstrates treatment to the lateral ankle – the area of the peroneus tendons

The treatment begins immediately in the video

This is comprehensive Prolotherapy, meaning there are a lot of injections. The patient getting the injections in this video is comfortable and tolerates the treatment well. The patient in this video is having the lateral or outer ankle treated.

  • The injections are given at the ligament attachment to the bone. This helps stimulate the healing and strengthening of the ankle ligaments.
  • At 0:48 the importance of treating the lateral ligaments of the ankle, the anterior talo-fibular ligament (ATFL), the calcaneo-fibular ligament (CFL) and the posterior talo-fibular ligament.
  • The patient is not sedated in anyway, once treatment begins patients are surprised that it is not as painful as it looks. We do offer various pre-treatment medications to help the patient including IV sedation. Especially those with a fear of needles.
  • This patient came to see us for an old ankle sprain injury causing chronic ankle instability and pain with running and lower body activities.
  • On his first physical exam he had some ligament laxity, a lot of tenderness and instability in his ankle. At that visit we treated the lateral side. This is a follow-up treatment.
  • Depending on the severity of the ankle sprain, it could take 3 to 8 treatments to affect a repair.

Danielle R. Steilen-Matias, MMS, PA-C. talks about knee pain specifically related to the peroneal nerve.

  • Patients who have chronic lateral knee pain can have this pain caused by many different problems: Meniscus tear, ligament injury on the lateral side of the knee for example.
  • But in cases where patients have no apparent meniscal tears or degenerative arthritis, and when we look at the knee ligaments and the movement of the bones under ultrasound and see the knee is stable and there is no apparent injury, we may suspect their chronic pain is coming from irritation from the peroneal nerve.
  • Patients that have numbness, burning or tingling nerve related symptoms can have injury or compression of the peroneal nerve. In some patients who suffer from knee instability and hypermobility of the knee, that extra motion of the bones may be banging against that nerve causing those symptoms.

Pain after knee replacement linked to peroneal nerve

  • I recently had a patient who underwent knee replacement surgery. After the surgery the patient had a new onset of lateral knee radiating pain.
  • In examination there wasn’t any kind of knee instability that would suggest the bones rubbing on the nerve but ultrasound showed that that nerve was really swollen. Somewhere at some point the patient had some kind of injury to that nerve.

Hydrodissection procedure

  • In that patient yet we did a hydrodissection procedure where we injected 5% dextrose solution and PRP cells from that patients on blood around the nerve with ultrasound guidance and by the next time I saw him in 3 weeks the pain with 50% better.
  • He could walk better he wasn’t getting as severe of that pain and so we repeated a procedure and expect him to continue on with great results

Nerve Release Injection Therapy (hydrodissection) of an entrapped nerve. In this image dextrose solution is injected around the nerve which releases or separates it from the surrounding tissue. The nerve, which is the central circular object has a dark ring forming around it, as seen strongly in the B image. That is the dextrose solution from the needle, the straight image from the right of the screen. The nerve as seen in B is now surrounded by the nerve release fluid and therefore “released.”

Nerve Release Injection Therapy (hydrodissection) of an entrapped nerve. In this image dextrose solution is injected around the nerve which releases or separates it from the surrounding tissue. The nerve, which is the central circular object has a dark ring forming around it, as seen strongly in the B image. That is the dextrose solution from the needle, the straight image from the right of the screen. The nerve as seen in B is now surrounded by the nerve release fluid and therefore "released."

Non-surgical application of Prolotherapy and Platelet Rich Plasma can help patients with a peroneal tendon injury and ankle instability. If you would like to explore these options Get Help & Information from our staff.

1 Nelson SC. Revision Surgery for Peroneal Tendon Tears. Clinics in Podiatric Medicine and Surgery. 2020 May 12. [Google Scholar]
2 Kushare IV, Allahabadi S, McKay S. Posterior ankle impingement disguised as peroneal tendon subluxation in young athletes – a case report. J Clin Orthop Trauma. 2020;11(3):479‐481. doi:10.1016/j.jcot.2020.03.008 [Google Scholar]
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9 Jain N, Bauman PA, Hamilton WG, Merkle A, Adler RS. Can Elite Dancers Return to Dance After Ultrasound-Guided Platelet-Rich Plasma (PRP) Injections?. J Dance Med Sci. 2018;22(4):225‐232. doi:10.12678/1089-313X.22.4.225 [Google Scholar]
10 Laver L, Carmont MR, McConkey MO, et al. Plasma rich in growth factors (PRGF) as a treatment for high ankle sprain in elite athletes: a randomized control trial. Knee Surg Sports Traumatol Arthrosc. 2015;23(11):3383‐3392. doi:10.1007/s00167-014-3119-x

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