Peroneal Tendons Tendinopathy

  • Pim A. D. van Dijk
  • Cornelis Nicolaas van DijkEmail author


Peroneal tendon pathologies account for a preponderance of posterolateral ankle complaints and can turn into serious disability if not addressed properly. In order to prevent further impairment of the tendon tissue and, moreover, to prevent chronic pain, adequate treatment in an early stage is essential. Careful patient history and clinical examination is often the key to the diagnosis. Peroneal tendoscopy is an adequate instrument to confirm the clinical diagnosis or to provide insight when in doubt. It allows visualization of the peroneal tendons from the myotendinous junction to the peroneal tubercle without damaging the soft tissue around the tendons. Moreover, it provides proper dynamic evaluation of the tendons.

Tendinopathies linked to the peroneal tendons are generally classified into three main categories: (1) tendinopathies (tendinitis, tenosynovitis, tendinosis, and stenosis), (2) (partial) tears and ruptures, and (3) subluxation and dislocation. Treatment of these pathologies is primarily indicated by pain. In general, the first choice of treatment is conservative, but surgical intervention is recommended if this fails. Traditional open treatment is associated with complications including damage to the superior peroneal retinaculum, surgical scar formation, adhesions of the tendons, and peroneal nerve dysaesthesia, so the need for less invasive options became bigger. In comparison to open surgery, peroneal tendoscopy is associated with less morbidity, smaller scars, less postoperative pain and complications, a functional rehabilitation and good functional outcomes.

This chapter provides an overview of the anatomy, patient history, clinical examination, and diagnostics of peroneal tendon pathologies and proposes a technique for peroneal tendoscopy.


Peroneal Tendon Tendoscopy Diagnostic method Treatment Lateral ankle pain 

Supplementary material

Video 28.1

Peroneal tendoscopy (MP4 515,831 kb)


  1. 1.
    Demetracopoulos CA, et al. Long-term results of debridement and primary repair of peroneal tendon tears. Foot Ankle Int. 2014;35(3):252–7.PubMedCrossRefGoogle Scholar
  2. 2.
    Krause JO, Brodsky JW. Peroneus brevis tendon tears: pathophysiology, surgical reconstruction, and clinical results. Foot Ankle Int. 1998;19(5):271–9.PubMedCrossRefGoogle Scholar
  3. 3.
    Redfern D, Myerson M. The management of concomitant tears of the peroneus longus and brevis tendons. Foot Ankle Int. 2004;25(10):695–707.PubMedCrossRefGoogle Scholar
  4. 4.
    van Dijk PA, et al. Peroneal tendon disorders. Athletic injuries of the ankle, May 2014 edn. Luxembourg: ESSKA; 2014.Google Scholar
  5. 5.
    Marmotti A, et al. Peroneal tendoscopy. Curr Rev Musculoskelet Med. 2012;5(2):135–44.PubMedPubMedCentralCrossRefGoogle Scholar
  6. 6.
    Sammarco VJ. Peroneal tendoscopy: indications and techniques. Sports Med Arthrosc Rev. 2009;17(2):94–9.PubMedCrossRefGoogle Scholar
  7. 7.
    Scholten PE, van Dijk CN. Tendoscopy of the peroneal tendons. Foot Ankle Clin. 2006;11(2):415–20.PubMedCrossRefGoogle Scholar
  8. 8.
    Vega J, et al. Tendoscopic treatment of intrasheath subluxation of the peroneal tendons. Foot Ankle Int. 2011;32(12):1147–51.PubMedCrossRefGoogle Scholar
  9. 9.
    Sammarco GJ, DiRaimondo CV. Chronic peroneus brevis tendon lesions. Foot Ankle. 1989;9(4):163–70.PubMedCrossRefGoogle Scholar
  10. 10.
    DiGiovanni BF, et al. Associated injuries found in chronic lateral ankle instability. Foot Ankle Int. 2000;21(10):809–15.PubMedCrossRefGoogle Scholar
  11. 11.
    Molloy R, Tisdel C. Failed treatment of peroneal tendon injuries. Foot Ankle Clin. 2003;8(1):115–29.PubMedCrossRefGoogle Scholar
  12. 12.
    Sobel M, et al. The dynamics of peroneus brevis tendon splits: a proposed mechanism, technique of diagnosis, and classification of injury. Foot Ankle. 1992;13(7):413–22.PubMedCrossRefGoogle Scholar
  13. 13.
    Cardone BW, et al. MRI of injury to the lateral collateral ligamentous complex of the ankle. J Comput Assist Tomogr. 1993;17(1):102–7.PubMedCrossRefGoogle Scholar
  14. 14.
    Strauss JE, et al. Chronic lateral ankle instability and associated conditions: a rationale for treatment. Foot Ankle Int. 2007;28(10):1041–4.PubMedCrossRefGoogle Scholar
  15. 15.
    van Dijk CN. Hindfoot endoscopy for posterior ankle pain. Instr Course Lect. 2006;55:545–54.PubMedGoogle Scholar
  16. 16.
    Dombek MF, et al. Peroneal tendon tears: a retrospective review. J Foot Ankle Surg. 2003;42(5):250–8.PubMedCrossRefGoogle Scholar
  17. 17.
    van Dijk CN. Ankle arthroscopy: techniques developed by the Amsterdam Foot and Ankle School. Berlin: Springer; 2014.CrossRefGoogle Scholar
  18. 18.
    Selmani E, et al. Current concepts review: peroneal tendon disorders. Foot Ankle Int. 2006;27(3):221–8.PubMedCrossRefGoogle Scholar
  19. 19.
    van Dijk PA, et al. Return to sports and clinical outcomes in patients treated for peroneal tendon dislocation: a Systematic Review. Knee Surg Sports Traumatol Arthrosc. 2016;24:1155–64. Scholar
  20. 20.
    Abraham E, Stirnaman JE. Neglected rupture of the peroneal tendons causing recurrent sprains of the ankle. Case report. J Bone Joint Surg Am. 1979;61(8):1247–8.PubMedCrossRefGoogle Scholar
  21. 21.
    Saxena A, Cassidy A. Peroneal tendon injuries: an evaluation of 49 tears in 41 patients. J Foot Ankle Surg. 2003;42(4):215–20.PubMedCrossRefGoogle Scholar
  22. 22.
    Steel MW, DeOrio JK. Peroneal tendon tears: return to sports after operative treatment. Foot Ankle Int. 2007;28(1):49–54.PubMedCrossRefGoogle Scholar
  23. 23.
    Guillo S, Calder JD. Treatment of recurring peroneal tendon subluxation in athletes: endoscopic repair of the retinaculum. Foot Ankle Clin. 2013;18(2):293–300.PubMedCrossRefGoogle Scholar
  24. 24.
    Jerosch J, Aldawoudy A. Tendoscopic management of peroneal tendon disorders. Knee Surg Sports Traumatol Arthrosc. 2007;15(6):806–10.PubMedCrossRefGoogle Scholar
  25. 25.
    Lui TH. Endoscopic management of recalcitrant retrofibular pain without peroneal tendon subluxation or dislocation. Arch Orthop Trauma Surg. 2012;132(3):357–61.PubMedCrossRefGoogle Scholar
  26. 26.
    Michels F, et al. Endoscopic treatment of intrasheath peroneal tendon subluxation. Case Rep Med. 2013;2013:274685.PubMedCrossRefGoogle Scholar
  27. 27.
    van Dijk CN, Kort N. Tendoscopy of the peroneal tendons. Arthroscopy. 1998;14(5):471–8.PubMedCrossRefGoogle Scholar
  28. 28.
    Edwards M. The relations of the peroneal tendons to the fibula, calcaneus, and cuboideum. Am J Anat. 1928;42:213–53.CrossRefGoogle Scholar
  29. 29.
    Freccero DM, Berkowitz MJ. The relationship between tears of the peroneus brevis tendon and the distal extent of its muscle belly: an MRI study. Foot Ankle Int. 2006;27(4):236–9.PubMedCrossRefGoogle Scholar
  30. 30.
    Saupe N, et al. Anatomic variants associated with peroneal tendon disorders: MR imaging findings in volunteers with asymptomatic ankles. Radiology. 2007;242(2):509–17.PubMedCrossRefGoogle Scholar
  31. 31.
    Mota J, Rosenberg ZS. Magnetic resonance imaging of the peroneal tendons. Topics Magnet Reson Imaging. 1998;9(5):273–85.Google Scholar
  32. 32.
    Kumai T, Benjamin M. The histological structure of the malleolar groove of the fibula in man: its direct bearing on the displacement of peroneal tendons and their surgical repair. J Anat. 2003;203(2):257–62.PubMedPubMedCentralCrossRefGoogle Scholar
  33. 33.
    Athavale SA, et al. Anatomy of the superior peroneal tunnel. J Bone Joint Surg Am. 2011;93(6):564–71.PubMedCrossRefGoogle Scholar
  34. 34.
    van Dijk PA, et al. Peroneal tendons well vascularized: results from a cadaveric study. Knee Surg. 2016;24:1140–7. Scholar
  35. 35.
    Petersen W, et al. Blood supply of the peroneal tendons: injection and immunohistochemical studies of cadaver tendons. Acta Orthop Scand. 2000;71(2):168–74.PubMedCrossRefGoogle Scholar
  36. 36.
    Borton DC, et al. Operative reconstruction after transverse rupture of the tendons of both peroneus longus and brevis. Surgical reconstruction by transfer of the flexor digitorum longus tendon. J Bone Joint Surg. 1998;80(5):781–4.CrossRefGoogle Scholar
  37. 37.
    Brandes CB, Smith RW. Characterization of patients with primary peroneus longus tendinopathy: a review of twenty-two cases. Foot Ankle Int. 2000;21(6):462–8.PubMedCrossRefGoogle Scholar
  38. 38.
    Rosenberg ZS, et al. Peroneal tendon injury associated with calcaneal fractures: CT findings. AJR Am J Roentgenol. 1987;149(1):125–9.PubMedCrossRefGoogle Scholar
  39. 39.
    Truong DT, et al. Fracture of the os peroneum and rupture of the peroneus longus tendon as a complication of diabetic neuropathy. Skelet Radiol. 1995;24(8):626–8.CrossRefGoogle Scholar
  40. 40.
    Vainio K. The rheumatoid foot. A clinical study with pathological and roentgenological comments. Clin Orthopaed Relat Res. 1956;265:4–8.Google Scholar
  41. 41.
    Wright DG, Sangeorzan BJ. Calcaneal fracture with peroneal impingement and tendon dysfunction. Foot Ankle Int. 1996;17(10):650.PubMedCrossRefGoogle Scholar
  42. 42.
    Safran MR, et al. Peroneal tendon subluxation in athletes: new exam technique, case reports, and review. Med Sci Sports Exerc. 1999;31(7 Suppl):487–92.CrossRefGoogle Scholar
  43. 43.
    Church CC. Radiographic diagnosis of acute peroneal tendon dislocation. AJR Am J Roentgenol. 1977;129(6):1065–8.PubMedCrossRefGoogle Scholar
  44. 44.
    Heckman DS, et al. Operative treatment for peroneal tendon disorders. J Bone Joint Surg Am. 2008;90(2):404–18.PubMedCrossRefGoogle Scholar
  45. 45.
    Rosenberg ZS, et al. MR features of longitudinal tears of the peroneus brevis tendon. AJR Am J Roentgenol. 1997;168(1):141–7.PubMedCrossRefGoogle Scholar
  46. 46.
    Schweitzer ME, et al. Using MR imaging to differentiate peroneal splits from other peroneal disorders. AJR Am J Roentgenol. 1997;168(1):129–33.PubMedCrossRefGoogle Scholar
  47. 47.
    Wang XT, et al. Normal variants and diseases of the peroneal tendons and superior peroneal retinaculum: MR imaging features. Radiographics. 2005;25(3):587–602.PubMedCrossRefGoogle Scholar
  48. 48.
    Rosenberg ZS, et al. Normal variants and pitfalls in magnetic resonance imaging of the ankle and foot. Topics Magnet Reson Imaging. 1998;9(5):262–72.Google Scholar
  49. 49.
    Kennedy JG, et al. Functional outcomes after peroneal tendoscopy in the treatment of peroneal tendon disorders. Knee Surg Sports Traumatol Arthrosc. 2016;24:1148–54. Scholar
  50. 50.
    van Dijk CN, et al. A 2-portal endoscopic approach for diagnosis and treatment of posterior ankle pathology. Arthroscopy. 2000;16(8):871–6. Scholar
  51. 51.
    De Leeuw PAJ, et al. A 3-portal endoscopic groove deepening technique for recurrent peroneal tendon dislocation. Tech Foot Ankle Surg. 2008;7(4):250–6.CrossRefGoogle Scholar
  52. 52.
    Lui TH, Tse LF. Peroneal tendoscopy. Foot Ankle Clin. 2015;20(1):15–25.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Pim A. D. van Dijk
    • 1
    • 2
    • 3
  • Cornelis Nicolaas van Dijk
    • 1
    • 2
    • 3
    • 4
    Email author
  1. 1.Department of Orthopedic SurgeryAcademic Medical CenterAmsterdamThe Netherlands
  2. 2.Academic Center for Evidence Based Sports Medicine (ACES)AmsterdamThe Netherlands
  3. 3.Amsterdam Collaboration for Health and Safety in Sports (ACHSS)AmsterdamThe Netherlands
  4. 4.FIFA Medical Center of ExcellenceRipoll De Prado & van Dijk Sport ClinicMadridSpain

Personalised recommendations