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 more expert in treatments and remedies 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. Eventually, you may be steered towards surgery because you may have developed long term-instability and a cavovarus foot or an arch that is too high is suspected as being a problem.

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

New research on peroneal tendon injury centers around dealing with complications of surgery

When reviewing the current and recent medical literature on helping people with a peroneal tendon injury, one can see that many of the most current articles deal with questions about the best surgical technique or complication following surgical intervention.

In March 2021 doctors at the Department of Orthopaedic Surgery, NYU Langone Health, and Robert Wood Johnson Barnabas Health, Jersey City Medical Center offered this summary of peroneal tendon surgery in The Journal of foot and ankle surgery. (1)

According to the researchers, the purpose of this study was to provide an overview of the available evidence on peroneal tendon tears and the outcomes after surgical intervention. To do this, they examined previously published outcome studies that were released within the past ten years. The researchers then isolated on: “a total of nine studies evaluating 336 patients (146 males/190 females) and 336 ankles.”

When someone has a complete rupture of the peroneal tendon, treatments are limited to the above-recommended surgeries. The realistic expectation a patient should have is that this can be a difficult recovery from a difficult and terrible injury. One of the suggestions we will make below is a rehabilitation program to include injections that can help strengthen the tendons and ligament attachments and make rehab or post-surgical recovery possibly more successful.

Symptoms, conditions, and treatments of Peroneal Tendon Tears.

Like many conditions and chronic problems, people with ankle area pain may receive different diagnoses to try to isolate their problem. Often these initial diagnoses are not accurate. This is perhaps why the treatments mentioned above have had limited success and surgery is often recommended.

When someone has ankle area pain the initial diagnosis usually focuses on the ankle sprain, especially if the person has suffered chronic ankle problems. Therefore a person with a peroneal tendon tear will have their ankle examined, perhaps have an ankle sprain ruled out, and then their doctors will try to determine if chronic ankle pain is the result of ankle ligament laxity. Not a tear, but stretching out of the ankle ligaments preventing the ligaments from holding the ankle complex together and in the proper place. Most commonly people will tell us that they have a “loose” ankle.

We must be careful with people who have ankle instability not to rule out ankle ligament involvement or peroneal tendon tears. These types of problems are usually not either-or. In people we see where peroneal tendon tears or tendinopathy is suspected, there is a great deal of ankle instability caused by ligament damage. We hear stories like this, which may sound familiar to your own where we also need to be careful to see problems developing on the other foot.

I injured my right ankle a few years back, I ruptured one of the ligaments. I was able to heal it without surgery however during this healing period I developed peroneal tendonitis in my left ankle that remained chronic. I had many physical therapy sessions, resorted to cortisone injections which I feel may have weakened my foot, spent long periods of time needing crutches, and now I have a burning pain that will not go away. Now I need surgery on my left foot.

Post-surgical problems

We get many emails sent to us from people looking for options post-surgery. While many people report very successful surgeries, some emails go something like this.

I was finally diagnosed with a tear of the peroneal tendon in my right ankle. I have had chronic ankle pain for years. Nothing worked for me. Again, finally, a few months ago, one of my doctors suggested it must be the peroneal tendon tear. I was sent right to surgery as this would fix my ankle pain once and for all. Following the surgery my pain continued, my ankle is swollen, this did not fix my problem at all, it made it worse. Now I get lots of medications and physical therapy sessions that are not helping.

“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, a 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, (2) 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 (3)  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, a 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 a 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. (4) Here, surgeons suggest that a lot of peroneal tendon dislocations are being missed following repair of a talus fracture.

Here are the research highlights:

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 (5) suggested that a lot of peroneal tendon dislocation are being missed following repair of a heel fracture:

Here are the research highlights:

The problem of a missed peritoneal tendon injury in a heel fracture was also reported in The Journal of Bone and Joint Surgery (Amer). (6) Here are the learning points of this research:

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

Above when we were discussing the different surgical outcomes we spoke about surgical intervention as the primary treatment for a complete rupture of the Peroneal tendon. We also spoke about complications and the possible need for a revision or second surgery. In this section, we will start identifying ankle ligament instability and the problems it can pose to the patient who had Peroneal tendon surgery or chronic tearing of the tendon that is not significant enough yet to warrant surgery.

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 (7) 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 effect, 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:

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 (8) 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:

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.

In our 28 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 standardization 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:(9)

“Tendinopathy carries a large burden of musculoskeletal disorders seen in both athletes and the 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 than 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.

A December 2018 study asked the question, “Can Elite Dancers Return to Dance After Ultrasound-Guided Platelet-Rich Plasma (PRP) Injections?” (10) One of the injuries dancers frequently get and was explored was peroneus brevis tendon injury. Here are the summary points of this study:

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 anteroinferior tibiofibular 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:

CONCLUSIONS:
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. (11)

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, 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.

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

Pain after knee replacement linked to the peroneal nerve

Hydrodissection procedure

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."

Summary and contact us. Can we help you?

We hope you found this article informative and it helped answer many of the questions you may have surrounding your ankle problems.  If you would like to get more information specific to your challenges of peroneal tendon injury and ankle instability, please email us: Get help and information from our Caring Medical staff

This is a picture of Ross Hauser, MD, Danielle Steilen-Matias, PA-C, Brian Hutcheson, DC. They treat people with non-surgical regenerative medicine injections.

Brian Hutcheson, DC | Ross Hauser, MD | Danielle Steilen-Matias, PA-C

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References

1 Mercer NP, Gianakos AL, Mercurio AM, Kennedy JG. Clinical Outcomes of Peroneal Tendon Tears: A Systematic Review. The Journal of Foot and Ankle Surgery. 2021 Mar 10. [Google Scholar]
2 Nelson SC. Revision Surgery for Peroneal Tendon Tears. Clinics in Podiatric Medicine and Surgery. 2020 May 12. [Google Scholar]
3 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]
4 Attia AK, Mahmoud K, Taha T, et al. Peroneal tendon dislocation in talus fracture and diagnostic value of fleck sign. Int Orthop. 2020;44(5):973‐977. doi:10.1007/s00264-020-04534-9 [Google Scholar]
5 Mahmoud K, Mekhaimar MM, Alhammoud A. Prevalence of Peroneal Tendon Instability in Calcaneus Fractures: A Systematic Review and Meta-Analysis. J Foot Ankle Surg. 2018;57(3):572‐578. doi:10.1053/j.jfas.2017.11.032 [Google Scholar]
6 Toussaint RJ, Lin D, Ehrlichman LK, Ellington JK, Strasser N, Kwon JY. Peroneal tendon displacement accompanying intra-articular calcaneal fractures. J Bone Joint Surg Am. 2014;96(4):310‐315. doi:10.2106/JBJS.L.01378 [Google Scholar]
7 Karlsson J, Brandsson S, Kälebo P, Eriksson BI. Surgical treatment of concomitant chronic ankle instability and longitudinal rupture of the peroneus brevis tendon. Scand J Med Sci Sports. 1998;8(1):42‐49. doi:10.1111/j.1600-0838.1998.tb00227.x [Google Scholar]
8 Abat F, Alfredson H, Cucchiarini M, Madry H, Marmotti A, Mouton C, Oliveira JM, Pereira H, Peretti GM, Spang C, Stephen J. Current trends in tendinopathy: consensus of the ESSKA basic science committee. Part II: treatment options. Journal of experimental orthopaedics. 2018 Dec 1;5(1):38. [Google Scholar]
9 Neph A, Onishi K, Wang JH. Myths and Facts of In-Office Regenerative Procedures for Tendinopathy. Am J Phys Med Rehabil. 2019;98(6):500‐511. [Google Scholar]
10 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]
11 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 [Google Scholar]

This article was updated June 21, 2021

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