Introduction

Peroneal tendonitis is an inflammation of the tendons that run along the outer ankle bone and the side of the foot. These thick bands of tissue link the muscles in your lower leg to the bones in your foot. They support and balance your foot and ankle, keeping them safe from injury. 

This type of tendonitis that occurs in the foot is commonly caused by overuse, but it can also occur unexpectedly if you fall or hurt your foot.¹ Inflammation is the body's reaction to microtears that can occur when you hurt your tendon, and inflammation is a consequence that aims  to promote healing. However, if the inflammation and damage persist, it will result in tendonitis.²

Peroneal tendonitis is commonly overlooked or misdiagnosed because lateral ankle injuries may frequently resemble minor sprains or discomfort. Furthermore, ignoring your pain isn't the solution either; doing so could cause things to worsen and turn that bothersome discomfort into a more serious issue that may require significant attention down the road.³

Understanding peroneal tendonitis

Anatomy of the peroneal tendons

Two fibrous cords that run along the side of the foot and the outside of the ankle are called the peroneal tendons. The lateral muscular compartment of the lower leg contains the peroneus longus and peroneus brevis muscles, which continue as tendons to help attach them to bones in the foot.² 

They aid in ankle joint stabilisation, plantarflexion (pointing the foot downward), and eversion (turning the foot outward). The muscles that invert (opposite movement of evert) the foot or rock the foot inward from the ankle balance the action of the peroneal muscles during normal gait (walking).

Just behind the lateral malleolus (a part of the fibula, one of the 2 bones in your lower leg), are the two peroneal tendons, one on top of the other. Because they rub against one another beneath the ankle, their proximity may exacerbate issues with the peroneal tendons.⁴

Causes and risk factors

Numerous things can lead to peroneal tendinitis: 

• Overuse, especially while engaging in repetitive ankle motion activities
• Unexpected injuries 
• Increased force and resistance between the bone and the tendon

Peroneal tendinitis can also develop as a result of the following factors:²

• Inadequate footwear
• Incorrect training methods
• Abrupt increases in training duration or intensity
• A number of illnesses that can result in systemic inflammation include gout, diabetes, osteoarthritis, rheumatoid arthritis, and others

Symptoms

Symptoms of peroneal tendinitis usually include: 

• Pain
• Swelling
• Inflammation outside the ankle and around the back 
• General ankle weakness

The ankle may feel weak when the foot is turned inward, and it may hurt when the foot is turned outward. Additionally, the patient might experience heat emanating from their ankles. These symptoms can also be made worse by overuse.⁵

Conservative management: First line of treatment

The initial course of treatment for peroneal tendonitis is frequently non-surgical. Anti-inflammatory drugs (NSAIDs), stretching exercises, physical therapy, cold therapy, and rest are some examples of these treatments. To lessen the strain on the injured area while it heals, your doctor could also advise wearing a brace or splint to help support the ankle. 

Peroneal tendinitis and persistent pain can both be effectively treated with stem cell therapy. This non-surgical procedure targets and heals the painful spot using your body's stem cells.⁶

The goals of these therapies are to lessen discomfort, lessen inflammation, and encourage the peroneal tendons to recover. Additionally, they can lessen the chance of complications and stop additional tendon damage.²

Surgical options for peroneal tendonitis

Surgery might be helpful for people who have a major tear in their peroneal tendon or a bony protrusion that is physically irritating the tendon. Surgery is done to correct any severe tendon ripping, clean up the tendons themselves (debridement or synovectomy), and, if required, smooth out the tract in which the peroneal tendons run. 

If the tendon is torn, it is examined, and if less than 50% of it is torn, a portion may be removed. The tendon is debrided (cleaned up), and the affected tendon is sutured (transferred) to the other tendon if more than 50% of it is aberrant.⁷

Recovery timeline

Within a few weeks, the majority of those with peroneal tendonitis should begin to get better. You might wish to temporarily stop doing things that make your pain much worse while you heal.⁸ Depending on the type of surgery you underwent, recovery could take anywhere from 6 to 12 weeks or even up to 4 months. You would be prohibited from bearing any weight on your injured foot for several weeks while it is immobilised.⁹

Surgical techniques

To treat peroneal injuries, surgeons employ a variety of surgical procedures. Among these methods are:

Tendon debridement and synovectomy

Your surgeon will create an incision in your ankle to remove the damaged tendon membrane along with any deteriorated or inflammatory tissues. Tendonitis may be treated with it.

Tendon debridement and tubularization

Your tendon's damaged portion is taken out and sutured back into place. This kind of surgery can be used to fix a partially torn tendon.

Arthroscopic peroneal tendoscopy

Your tendon sheath is punctured with a lengthy, camera-equipped tube. Damaged tissue is removed using specialised instruments.

Endoscopic retinaculum repair

If your peroneal tendons shift from their normal position, the band of tissue holding them in place may sustain damage. It could be necessary to use an endoscopic surgery to surgically repair this tissue. An endoscope is a long, thin tube equipped with specialised equipment and a camera.

Reconstruction using autograft or allograft

Using connective tissue from another area of your body, an autograft repairs your tendon. An allograft uses donor tissue to fix it.

A surgeon performs a peroneal tenodesis, removing the injured tendon segment and joining the remaining ends.¹⁰

When to consider surgery?

Your doctor might suggest surgery if non-surgical treatments don't alleviate your problems after a few weeks or months of use. Surgery is often only taken into consideration when there is proof of severe damage to one or both tendons as a result of trauma-induced tissue rips or chronic overuse injuries.

The extent and location of the injury determine the type of surgery that is done, although standard procedures involve debridement (removal) of damaged tissue and repair/reconstruction using sutures or grafting techniques using donor tissues such as fascia latae (connective tissue).⁶

Post-operative rehabilitation

Your injured foot will be immobilised following surgery, and you won't be able to bear any weight on it for a few weeks. Your recuperation period will be prolonged if you resume early activities while the tendon is healing. Doing stretches and exercises is crucial as they will help you regain your foot's natural range of motion and build strength. 

Physical therapy might help you with your walking and running-related discomfort and function. The abnormalities that might be causing your tendon pain can be identified by your therapist. After that, they can recommend the appropriate exercises and therapies to help you safely and swiftly resume your pain-free life.¹¹ You might resume your workout regimen in six months if you adhere to your doctor's and physical therapist's advice.⁹

Following the surgery, you may need to wear a walking boot or soft cast for up to 8 weeks. When you quit wearing the walking boot or soft cast, you can gradually resume your daily activities. You might need to wear an ankle brace afterwards.⁹ 

Potential complications 

Following a proper diagnosis and consideration of surgical intervention, a number of issues pertaining to peroneal tendon surgery may reduce the likelihood of a successful outcome. 

Among the complications, there may be:¹²

• Ankle instability and recurring peroneal tendon tears ttempts to restore a tendon by revision repair may fail

Summary

Repairing one of the tendons of your peroneal muscles, also known as your fibularis muscles, is known as peroneal tendon surgery. For peroneal tendon injuries that have not improved or healed with more conservative treatment, surgery may be a very beneficial course of action. 

A doctor may recommend it for people who are generally healthy, as it is thought to be helpful with a minimal chance of major adverse effects. Treating the injury as soon as possible can help stop it from getting worse and leading to more complicated ailments, including full tendon tears.¹⁰

FAQ’s

How do I know if I need surgery for peroneal tendonitis?

An orthopaedic specialist may suggest surgery if you have not improved after many months of conservative treatment, such as physical therapy and rest, and imaging (MRI or ultrasound) reveals substantial tendon damage or instability.

How long does it take to fully recover from peroneal tendon surgery?

Depending on the surgical type, patient age, physical condition, and compliance with rehabilitation guidelines, recovery often takes three to six months.