If left untreated, peroneal tendonitis can lead to serious complications, including tendon tear and chronic pain. When you understand the risks early, it can help you take action and prevent long term damage. This article will break down the warning signs, why it is necessary to seek help early and protect your ankles so it doesn't affect your movement. 

Overview of peroneal tendonitis 

Location and function of the peroneal tendons 

There are two peroneal tendons both found in the outer part of the ankle.¹ One of them attaches to the outside area of the midfoot, while the other fastens near the inner arch of the foot. Their key function is to stabilise the ankle and foot, and to prevent injury, such as sprains.

When these peroneal tendons become inflamed, the condition is referred to as peroneal tendonitis.

Causes and risk factors 

Over time, when the peroneal tendons are constantly overused, it can lead to inflammation.² 

It could also happen suddenly after an injury affecting the ankle. 

Other factors could contribute. These include aging, being overweight, and having conditions like diabetes or inflammatory joint diseases such as rheumatoid or psoriatic arthritis. Weak or tight muscles in your legs or feet, wearing shoes that don’t support your feet properly, or suddenly doing a lot of walking, standing, or running can also put stress on the tendons. Poor workout habits, not giving your body enough time to rest between activities, and certain medications like long-term use of steroids or some antibiotics can play a role too. Previous injuries or surgeries involving the foot or ankle, as well as smoking, may also contribute.

Common symptoms 

• Peroneal tendonitis causes so much ankle pain

• This pain becomes so severe when one is carrying out a physical activity
• Instability while walking
• Difficulty balancing on a single leg with the affected leg
• The tendons get swollen, red and warm

Consequences of Untreated Peroneal Tendonitis 

Risk of tendon tear

This normally happens because the tendons are overused or injured. These tears can differ with respect to the extent to which it is severe, depending on the size, direction and location of the tear. It comes with discomfort and carrying out some kind of activities becomes harder. In severe cases, where the integrity of the tendon structure is affected, movement can be affected. This makes it tedious for the foot and ankle to carry the individual's weight. 

Peroneal tears can happen for several reasons, including injuries, overuse, and problems with foot movement. Although many people think peroneal tears happen suddenly, like during an ankle sprain, research shows that 40% to 80% of these tears actually develop slowly over time.³ Pain often becomes noticeable only when the damage has worsened, leading people to seek treatment.

Common causes of peroneal tears include:

• Repetitive foot and ankle movements: Activities such as running, jumping, or dancing can place repetitive stress on the peroneal tendons. Without enough rest, this repeated strain can weaken the tendons and cause tears
• Foot structure issues: People with high arches or flat feet are more likely to put extra pressure on their peroneal tendons, which increases the risk of tears
• Ankle sprains: Eversion sprain (when the ankle rolls outward) can cause stretching or tearing of the peroneal tendons because of the sudden twisting motion
• Poor footwear: Wearing shoes that lack proper support or cushioning can worsen existing foot problems and raise the risk of tendon tears
• Previous injuries: A history of ankle injuries or past tears can weaken the tendons through scar tissue or loss of strength, making them more vulnerable to tearing again

Symptoms of peroneal tears

The symptoms of a peroneal tear can differ depending on the severity of the injury. Common signs include:

• Pain: sharp or stabbing pain along the outer side of the ankle and foot, it might appear during specific movements (twisting the foot inward and the ankle outward) or weight-bearing activities in mild cases, however, in more severe cases, the pain may be chronic and more intense
• Swelling: may be isolated over the affected tendon or radiated throughout the whole ankle and lower leg
• Instability: due to the tendon's reduced ability to support the ankle joint, especially during weight-bearing activities or when changing direction
• Weakness in the ankle and foot muscles: particularly those that control inward and outward foot movements, leading to reduced joint awareness (proprioception) and difficulty performing activities that require balance and coordination
• Bruising: may be present around the ankle and foot due to internal bleeding in the tissues in some severe cases

The extent of symptoms usually shows how much the tendon is damaged. Partial tears may cause mild discomfort and swelling with a little impact on movement, while complete tears often result in serious pain, pronounced swelling, and major instability.

Treatment of peroneal tear

Treatment for a torn peroneal tendon may involve conservative methods (non-surgical), surgery, or both.⁴ It depends on the severity of the tear. 

Mild tears are often managed first with nonsurgical options, including anti-inflammatory medications, rest, reduced activity, immobilisation in a brace or boot, physical therapy, and regenerative therapies like prolotherapy, PRP injections, dry needling, or deep massage. If these measures are unsuccessful or if the tear is severe, surgery is recommended. 

Surgical options include repairing the damaged tendon, connecting it to the other peroneal tendon (side-to-side tenodesis), transferring another tendon, or using donor tissue (allograft) to reconstruct the peroneal tendon.

Chronic pain and stiffness in untreated peroneal tendonitis

When peroneal tendonitis is left untreated, one major complication that can arise is the development of chronic pain and stiffness. The inflammation that comes along peroneal tendonitis leads to progressive tendon degeneration, a condition often referred to as tendinosis, where the tendon fibers deteriorate over time.⁵

As the tendons weaken, they can’t handle normal stresses during activities like walking or standing. This ongoing damage promotes the formation of excess scar tissue within the tendons, fibrosis.⁶

Fibrosis stiffens the tendons and surrounding tissues, limiting their ability to stretch and move normally, which results in reduced ankle flexibility and persistent stiffness.

Additionally, chronic inflammation may sensitise the local nerves, contributing to a state known as chronic pain syndrome. In this state, pain continues even after the original injury has healed, greatly affecting a person’s quality of life and physical activity levels.⁷

If stiffness becomes severe, it can also alter the biomechanics of the foot and ankle, causing abnormal walking patterns and increasing the risk of further injuries like ankle sprains.

Therefore, early treatment of Peroneal Tendonitis is essential to avoid progression to chronic, disabling pain and movement limitations.

Long-term impacts on quality of life 

Peroneal tendon conditions can greatly affect mobility, balance, and overall well-being by:⁸

• Ankle instability: Injury or dysfunction of the peroneal tendons weakens their role in ankle stabilization, increasing the risk of ankle rolls and sprains
• Pain and discomfort: Tearing or inflammation within the tendons often causes persistent pain, especially during movement
• Altered gait: To manage pain or instability, individuals may unknowingly adjust their walking pattern, placing additional stress on surrounding muscles and joints
• Decreased athletic performance: Athletes, including runners and dancers, may struggle with reduced ankle strength and flexibility, hindering their ability to perform
• Permanent complications: Without proper treatment, issues like tendon tears or ongoing inflammation can cause lasting problems such as arthritis or structural deformities in the foot 

Summary

If peroneal tendonitis isn’t treated, it can cause serious problems over time. The tendons can tear from too much strain, leading to constant pain and difficulty walking. Sometimes, it could even need surgery. The ankle can also become weak and unstable, making it easy to twist or sprain. It also becomes not so capable of bearing the weight of the body again. If the nearby nerve gets affected, you might feel numbness, tingling, or weakness in your foot. Over time, the pain can become a daily issue, your walking style can change, and sports or exercise can get harder. In some cases, permanent damage like arthritis or foot deformities can develop, hurting your overall quality of life.