Peroneal tendonitis can lead to tendon rupture

Dividing tendons into four zones can aid in diagnosis and surgical treatment.

Peroneal tendonitis and tendon ruptures can cause severe pain and immobility if left untreated, while early treatment can help patients avoid ruptures. But expect patients to require surgery when they have full ruptures or fail to respond to conservative treatment.

“Peroneal tendonitis is a common cause of lateral ankle pain. It occurs in a system of fiberosseous tunnels at the lateral aspect of the foot and ankle. Commonly it is an overuse condition that responds to conservative treatment, but if it is left untreated it can progress to a complete tendon rupture,” said G. James Sammarco, MD, of the Center for Orthopaedic Care in Cincinnati. He discussed management of peroneal tendon ruptures at the American Orthopaedic Foot and Ankle Society Specialty Day meeting at the American Academy of Orthopaedic Surgeons 72nd Annual Meeting in Washington.

Predisposing factors

Predisposing factors for peroneal tendonitis and rupture include varus alignment of the hindfoot and peroneal subluxation and dislocation. Participation in certain sports, including downhill skiing, skating, ballet, running and soccer creates higher risk for peroneal tendon tears. “Poorly fitting footwear, particularly ski boots and hockey skates, are often the inciting factors,” Sammarco wrote in his abstract.

If caught early, surgeons can treat peroneal tendonitis or instability conservatively with NSAIDs, immobilization and avoidance of exacerbating activities. Once secondary changes in the tendon occur, however, surgical treatment often becomes necessary. Sammarco recommended dividing the course of the tendons into four anatomic zones as follows:

Zone A includes the superior peroneal retinaculum and distal fibula;
Zone B is the inferior peroneal retinaculum at the level of the peroneal tubercle of the calcaneus;
Zone C involves the cuboid notch at the point the peroneus longus tendon enters the osseous groove; and
Zone D involves avulsion of the tendons from their insertion at the metatarsal base.

“Zone A tears usually involve the peroneus brevis, although both tendons can be involved at this level," Sammarco said. "The treatment is to ... do a side-to-side repair.” He noted the need to address nearby muscles and that sometimes accompanying muscles must be excised.

Surgical procedures

Surgical procedures for the other zones are similar in the need for a side-to-side repair, but some aspects differ. For Zone B tears, surgeons should remove the peroneal tubercle and take care not to close the peroneal retinaculum too tight over the tendon tear. Generally speaking, surgical treatment in all zones “involves decompression of stenosis, debridement, and side-to-side repair of attritional tears and tendon repair for all cases of complete rupture,” according to the abstract.

Varus heel deformity, Sammarco noted, may require a calcaneal osteotomy, because when left untreated it can lead to further tendon problems and ankle instability. “Delayed diagnosis or chronic rupture may require [a] tendon transfer,” he wrote. “Neglected rupture may result in secondary varus foot deformity or first metatarsal elavatus.” Early and comprehensive treatment of any peroneal tendonitis or rupture is key for ensuring a good result and full recovery.

For more information:
Sammarco GJ. Surgical technique tip I: managing complete peroneal tendon ruptures. Presented at the American Orthopaedic Foot and Ankle Society Specialty Day Meeting. Feb. 26, 2005. Washington.