Peroneal Tendon Tear

What is a peroneal tendon tear?

A peroneal tendon tear is an injury that affects one or both of your peroneal tendons in your foot. You have two peroneal tendons (peroneal brevis and peroneal longus). These strong bands of tissue connect muscles in your lower leg to bones in your foot and help stabilize your foot and ankle. They extend along your outer ankle bone and the side of your foot.

With a torn peroneal tendon, you feel pain along the outside of your ankle. Your foot may feel unstable or unsteady when walking. You might notice symptoms after a sudden injury to your foot or ankle (like a sharp roll of your ankle). Or symptoms may develop gradually due to long-term stress on your tendon.

Peroneal tendon tears often occur along with other ankle injuries. For example, rolling or twisting your ankle could lead to a sprained ankle (torn ligaments), as well as a torn peroneal tendon. Both injuries cause ankle pain, but you might think the pain is only from the sprain. So, peroneal tendon tears often hide behind other injuries and can be tricky to diagnose.

That’s why it’s essential to see a healthcare provider who’s specially trained in diagnosing and treating foot and ankle problems. If you have pain around your ankle, see a podiatrist, sports medicine physician or orthopaedist. Your provider will check your foot, determine what’s wrong and recommend treatment tailored to your needs.

Types of peroneal tendon tears

Peroneal tendon tears can be either acute or chronic.

• Acute tears: A traumatic injury causes an acute tear. For example, rolling your ankle inward (inversion injury) can force your peroneal tendon to quickly bring your foot back into alignment. This action may cause your tendon to overcompensate and stretch too far, leading to a tear. Usually, with an acute tear, you can pinpoint the moment it happened.
• Chronic tears: Chronic tears are more common. You might not remember rolling or hurting your ankle. These injuries happen slowly, over time, due to gradual stress and pressure on your tendon. Pain around your ankle may come and go, and you might not know what’s causing it.

Healthcare providers also classify peroneal tendon tears based on their severity.

• Grade 1 (mild): Your tendon is stretched more than normal, but it can still stabilize your foot and ankle. You may have mild tenderness and swelling.
• Grade 2 (moderate): Your tendon has a partial tear, and you have moderate tenderness and swelling. You may also have mild or moderate ankle instability.
• Grade 3 (severe): Your tendon has a complete tear. Providers also call this a rupture (your tendon is divided into two pieces). A complete tear usually requires surgery.

You can tear one or both of your peroneal tendons. Most often, people tear their peroneal brevis tendon.

What does a peroneal tendon tear feel like?

Symptoms of a peroneal tendon tear include:

• Pain along the outside of your ankle. With chronic tears, the pain may come and go.
• Instability or weakness in your ankle. This feels like your ankle could “give out” as you walk, especially on bumpy surfaces.
• Swelling.

What causes a peroneal tendon tear?

Causes of a peroneal tendon tear include:

• Sudden trauma to your ankle, such as an inversion ankle sprain (rolling your ankle inward).
• Chronic stress and pressure on your tendon from overuse.

What are the risk factors?

Factors that can raise your risk of a peroneal tendon tear include:

• Playing sports that involve repetitive, side-to-side ankle movements (like basketball).
• Having high arch feet.
• Having tight muscles in your lower legs/calves.
• Inappropriate footwear.
• Poor training form.

What are the complications of a peroneal tendon tear?

Without treatment, this injury can lead to:

• Repeated ankle sprains.
• Continued ankle/foot pain.
• Ongoing ankle instability.
• Tendon snapping or subluxation over the outer ankle bone.

How are peroneal tendon tears diagnosed?

Diagnosis begins with a physical exam. During an exam, a healthcare provider will:

• Ask about your symptoms, including when they started.
• Carefully examine your foot and ankle for signs of injury.
• Order imaging tests as needed.

You can expect your provider to manually (with their hands) test what causes discomfort in your foot or ankle. They do this by:

• Moving your foot and ankle into different positions.
• Putting gentle pressure on your foot to create resistance.
• Carefully pressing on different areas around your ankle.

These methods can help your provider find the cause of your symptoms. However, you may need imaging tests to confirm a diagnosis and rule out other issues.

What tests will be done to diagnose this condition?

Your provider may order one or more of the following tests:

• Foot X-rays.
• Ankle X-rays.
• Ultrasound.
• Magnetic resonance imaging (MRI).

How do you treat a torn peroneal tendon?

Healthcare providers treat a torn peroneal tendon with conservative (nonsurgical) measures, surgery or both. If your tear is mild, your provider may suggest conservative measures for several months to see if they help. If your tear is severe, your provider will likely suggest surgery as the first-line treatment.

Conservative measures include:

• Taking anti-inflammatory medications.
• Resting your foot and reducing your level of physical activity.
• Immobilizing your foot (keeping it still) in a brace or boot.
• Working with a physical therapist.
• Regenerative therapies like prolotherapy, PRP injections, dry needling and deep massage.

If these methods don’t help, or if your tear is severe, you likely need surgery. Surgeons use many different techniques to restore function to your peroneal tendon. Your surgeon will choose the best technique for you based on the severity of the tear (partial or complete).

Possible surgical techniques include:

• Removing the damaged part of your tendon and repairing what’s left.
• Removing the damaged part of one peroneal tendon and sewing the remaining part to the other peroneal tendon (healthcare providers call this method a side-to-side tenodesis).
• Transferring a tendon from elsewhere in your foot to take over the function of your peroneal tendon.
• Using tissue from a donor (allograft) to reconstruct your peroneal tendon.

Complications of treatment

Possible complications after surgery include:

• Ankle pain (most common).
• Persistent swelling.
• Skin numbness near your incision due to nerve damage.
• Incision infection.
• Deep vein thrombosis (rare).

Can a peroneal tendon tear heal without surgery?

It depends on the severity of the tear. Mild tears may heal with conservative treatment. However, severe tears (ruptures) need surgery.

Can peroneal tendon tears be prevented?

You can’t always prevent peroneal tendon tears. But you can take some steps to lower your risk for tears and other soft tissue injuries in your feet and entire body:

• Wear the right shoes. Make sure your shoes are comfortable and supportive for your foot anatomy (like high arch feet). Replace your shoes when they no longer fit well or have solid treads. Also, make sure the shoes match the activity. For example, sneakers meant for walking may not be your best bet for sports with lots of side-to-side motion, like tennis or pickleball.
• Have a balanced fitness routine. We’re always taught to eat a balanced diet. But it’s easy to forget that a balanced exercise routine is also important. It can help you prevent injury. Build a plan with a mix of aerobics (like walking), flexibility (like yoga) and strength training (like using resistance bands). Be sure to talk to a healthcare provider before starting a new routine to make sure it’s safe for you.
• Warm up before a workout. Don’t jump right into a run or even a yoga session. Spend a few minutes gently jogging in place or walking a lap around the block. Warmups help the many moving parts in your feet (and elsewhere) prepare for the intense activity to come.
• Cool down after a workout. Avoid stopping suddenly after a workout. If you’re running, transition to a slow jog and then a walk. Spend at least 10 minutes in a cooldown phase with less intense and slower movements.
• Stay flexible. Stretching is one of the most important things you can do to avoid injury. Learn proper techniques for stretching and make it part of your daily routine.

How long does a peroneal tendon tear take to heal?

Healing time depends on many factors, including the treatment method and the severity of your injury. It’s important to ask your provider about the expected recovery time in your individual situation. In general, peroneal tendon injuries can take one to three months to recover with noninvasive therapies. Most people who require surgery need at least several months to return to their usual activities, including work and sports.

As you recover from surgery, you can expect to:

• Gradually return to weight-bearing activities. After about four weeks, you may be able to put some weight on your foot (partial weight-bearing).
• Begin physical therapy after about six weeks. You’ll work with a physical therapist to gain back strength and range of motion in your foot. These sessions will help you safely return to your typical activities.

Ask your provider about your long-term outlook and how you can lower your risk of future injuries.

When should I see my healthcare provider?

Call a healthcare provider if you have symptoms of a peroneal tendon tear. The sooner you receive treatment, the quicker you can begin healing. If possible, see a provider who specializes in diagnosing foot and ankle injuries (such as a sports medicine specialist, orthopaedic surgeon or podiatrist).

Your provider will tell you how often you need to come back for follow-ups.

What questions should I ask my provider?

Questions that may help you learn more about your condition include:

• What foot and ankle injuries do I have?
• How severe are the injuries?
• What can I do at home to ease symptoms?
• What changes should I make to my activity level?
• How long should I wait before returning to my usual activities?
• What treatment do you recommend?
• What are the benefits and risks of treatment?
• How long will healing take?
• Can you recommend shoes or inserts that will support and comfort my feet?
• When can I return to sports or exercise?

What is the difference between a peroneal tendon tear and a peroneal tendon rupture?

Many people use these terms interchangeably. Healthcare providers may use “rupture” to refer to a complete tear (total separation of your tendon into two parts). This is the most severe form of a tendon tear (grade 3).