Introduction

Although relatively uncommon compared to other ankle pathologies, peroneal tendon injuries can significantly impair ankle stability and function, especially in physically active individuals. These tendons, namely the peroneus longus and peroneus brevis, play a pivotal role in foot eversion (turning the foot outward), ankle stabilisation, and the overall biomechanics of gait. They contribute to lateral ankle support, particularly during dynamic activities, such as running, cutting, or jumping.^1,2 

Surgical intervention is often required when conservative treatments fail, or in cases involving tendon rupture, subluxation, dislocation, or severe tendinopathy. However, surgery is merely the first step in restoring full function.¹ Post-operative rehabilitation is crucial for optimal recovery and for preventing complications, recurrence, or chronic dysfunction. Rehabilitation after peroneal tendon surgery requires a comprehensive and progressive approach that addresses not only the healing of the surgical site but also the restoration of strength, proprioception, range of motion (ROM), and overall functional integration.³ 

This process is highly individualised, influenced by the type of surgical procedure performed (such as debridement, tenodesis, tendon repair, or groove deepening) and by patient-specific factors, such as age, comorbidities, fitness level, and activity goals. Rehabilitation must consider the biomechanical demands placed on the ankle during various levels of activity and tailor the approach accordingly.³

Post-operative care and early rehabilitation

Following surgery, the immediate focus is on protecting the repair, controlling pain and inflammation, and preventing complications. This includes deep vein thrombosis (DVT), wound infection, or cast-related pressure injuries. The affected limb is typically immobilised in a non-weight-bearing cast or a removable walking boot to limit movement and allow the tendons to heal in a tension-free, neutral position. This initial phase typically spans the first two to four weeks post-surgery, during which weight-bearing is strictly limited, often progressing gradually according to the surgeon’s protocol and the quality of tissue healing.³

Pain management during this phase involves a multimodal strategy that may include Non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, nerve pain modulators, and in some cases, regional anaesthesia or nerve blocks. Cryotherapy, limb elevation and compression can further assist in managing swelling and discomfort. Isometric exercises for the quadriceps, hamstrings, and gluteal muscles are introduced early to maintain muscle activity in the kinetic chain, prevent disuse atrophy, and maintain cardiovascular conditioning through upper body ergometry or seated exercises.³

Passive and active ROM exercises for the toes and unaffected joints are encouraged to promote blood flow and prevent joint stiffness. Neuromuscular stimulation may also be utilised in the early phases to enhance muscle recruitment and circulation. Patient education plays a critical role at this stage. Explaining the stages of healing, expected timelines, signs of complications, and the importance of adhering to post-operative restrictions can enhance engagement, compliance, and overall recovery success.³

Exercise program and functional recovery

Progressive loading is the cornerstone of tendon rehabilitation. Once adequate healing has occurred, typically by week four to six, the patient transitions from complete immobilisation to a functional brace or walking boot that allows for partial weight-bearing. This shift marks the beginning of more active rehabilitation and is tailored to avoid excessive tensile forces on the healing tendon. Controlled ROM exercises are introduced to gradually restore ankle mobility in dorsiflexion, plantarflexion, inversion, and eversion, with close monitoring for any signs of pain, stiffness, or joint crepitus.^2,3,4

As the ROM normalises, attention shifts to neuromuscular re-education and strengthening. Isolated resistance exercises targeting the peroneal muscles (especially eversion against theraband resistance) are commonly prescribed, with progression to closed-chain exercises like heel raises, mini-squats, and controlled step-ups. The rehabilitation plan should also emphasise strengthening the surrounding musculature, including the tibialis anterior, gastrocnemius-soleus complex, and intrinsic foot muscles, to restore balanced force distribution across the ankle and foot.^2,3

Proprioceptive training becomes increasingly important to re-establish joint position sense and dynamic control. Early proprioceptive interventions may include static balance tasks on a firm surface, gradually evolving into more complex challenges, such as single-leg stance on foam pads, the use of wobble boards, and perturbation training. The integration of multi-planar movements, hopping drills, and agility ladders can be introduced later as the patient demonstrates sufficient strength and neuromuscular control.^2,3

Throughout this phase, the intensity and complexity of exercises increase gradually, guided by the patient’s symptom response, strength gains, and clinical assessment. Careful monitoring of tendon irritability through pain levels, localised swelling, and morning stiffness helps dictate the pace of progression. Functional assessments, such as single-leg squats and dynamic balance tests, are utilised to measure milestones and readiness for higher-level tasks.^2,3

Managing post-operative challenges

Rehabilitation is not always a linear trajectory. Setbacks and complications can occur and must be addressed promptly to ensure ongoing recovery. Among the most common issues encountered during peroneal tendon rehabilitation are persistent swelling, scar tissue formation, joint stiffness, and deficits in strength or proprioception. An effective management plan requires an early identification and a multidisciplinary approach.^2,3

Swelling that persists beyond the expected post-operative period may indicate inadequate limb elevation, poor lymphatic drainage, or excessive activity. In these cases, rest modifications, manual lymphatic drainage, compression bandaging, and low-intensity aquatic therapy may be helpful. Scar management, including cross-friction massage and silicone sheeting, can reduce adhesions and improve tissue pliability.^2,3

In cases of stiffness, particularly involving the subtalar joint or ankle mortise, manual therapy techniques, such as joint mobilisations, soft tissue release, and facilitated stretching, can improve ROM. It is essential to remain cautious and avoid overly aggressive interventions that could compromise surgical repair or provoke inflammation. Addressing neuromuscular deficits through guided movement retraining, biofeedback, and progressive loading strategies helps restore normal movement patterns and functional independence.^2,3

Some patients may develop tendon adhesions, where the repaired tendon does not glide freely through its sheath. These can severely limit movement and function. To address this, a combination of soft tissue mobilisation techniques, active-assisted stretching, and sometimes ultrasound-guided hydrodissection may be employed. Home exercise program adherence and proper load dosing remain foundational to successful recovery.^2,3

Psychosocial aspects should also be considered. Many patients experience anxiety, fear of re-injury, or frustration with the prolonged recovery process. These emotional factors can influence pain perception, compliance, and outcomes. Integrating behavioural strategies, motivational interviewing, and regular goal setting helps maintain engagement and a positive mindset throughout the recovery.^2,3

Return to activity and sport

The transition from clinical rehabilitation to full activity is a nuanced phase that must be based on objective criteria rather than arbitrary time frames. While some patients may resume full activity between 12 and 24 weeks post-surgery, others may require extended rehabilitation depending on their sport, level of competition, and individual response to training. A phased return is strongly advised, ensuring that physical readiness aligns with the demands of the chosen activity.³

A comprehensive return-to-play assessment typically includes strength testing (aiming for at least 90% symmetry with the contralateral limb), endurance testing (such as repeated heel raises or shuttle runs), and dynamic functional testing. Tasks such as single-leg hop tests for distance, lateral bounding, agility drills, and change-of-direction exercises provide insight into performance capacity and any residual deficits.^2,3,5

Equally important is psychological readiness. Tools such as the Ankle Instability Instrument, Tampa Scale of Kinesiophobia, or the Return to Sport Index can be utilised to assess fear-avoidant behaviours and mental preparedness. A patient who demonstrates strong physical performance but exhibits apprehension or low confidence may benefit from graded exposure to sport-specific tasks in a controlled environment before full participation.³

Sport-specific reintegration should begin with low-impact, non-contact training sessions, gradually increasing intensity, complexity, and duration under professional supervision. For athletes, this includes position-specific drills, tactical movement, and return to team training before competitive play. Continued emphasis on peroneal muscle conditioning, proprioceptive training, and footwear modification can help minimise the risk of re-injury.³

Summary

Rehabilitation following peroneal tendon surgery is a complex, dynamic, and highly individualised process that extends far beyond the operating room. From the early stages of protection and immobilisation to advanced stages of functional training and return to activity, the rehabilitation pathway requires careful planning, clinical reasoning, and patient collaboration. A successful outcome is contingent on the synergy between the surgical procedure, a structured rehabilitation protocol, and the patient’s adherence and motivation.

Clinicians must skillfully balance tissue healing timelines with the restoration of function, addressing complications proactively and supporting the patient’s psychological well-being. Ultimately, a patient-centred, criteria-based approach that promotes progressive loading, functional integration, and sport-specific readiness offers the best chance for a full return to activity with minimised risk of re-injury.