Peroneal tendinosis refers to the enlargement, thickening, and swelling of the peroneal tendons located on the outside of the ankle, just behind the fibula. This condition is commonly caused by overuse, such as repetitive activities that irritate the tendons over extended periods of time. Overuse injuries, such as marathon running or sports involving frequent ankle movement, can increase the likelihood of developing peroneal tendinosis.
How Common It Is and Who Gets It? (Epidemiology)
Peroneal tendinosis is common in athletes who participate in activities that require repetitive use of the ankle, such as running or sports like soccer. It can also affect individuals who significantly increase their training intensity without proper adjustment. Patients with high arches may be more prone to developing this condition, as their foot structure requires the tendons to work harder to stabilize the ankle.
Why It Happens – Causes (Etiology and Pathophysiology)
Peroneal tendinosis occurs when there is excessive strain on the peroneal tendons, which connect the muscles to the bones of the foot. This overuse leads to the enlargement and thickening of the tendons. Rapid increases in training intensity or poorly fitting shoes can contribute to this condition. Additionally, individuals with high arches may experience more strain on the tendons due to the inward position of the heel, which requires the tendons to work harder.
How the Body Part Normally Works? (Relevant Anatomy)
The peroneal tendons, peroneus longus and peroneus brevis, run along the back of the fibula and are responsible for turning the ankle outward. The peroneus longus tendon starts higher up the leg and runs beneath the foot to attach to the first metatarsal, while the peroneus brevis tendon connects to the base of the fifth metatarsal. Both tendons play a crucial role in stabilizing the ankle and enabling movement during walking and running.
What You Might Feel – Symptoms (Clinical Presentation)
Patients with peroneal tendinosis typically experience pain around the back and outside of the ankle, especially during activities that require repetitive ankle use. Symptoms may worsen with activities like running, jumping, or standing for long periods. The pain often has no specific history of injury, but patients may notice increased discomfort after starting new exercise routines or intensifying their activity levels.
How Doctors Find the Problem? (Diagnosis and Imaging)
Diagnosis of peroneal tendinosis is based on the patient’s history and physical exam. The doctor may notice pain when pressing along the peroneal tendons or when turning the foot inward (inversion) and outward (eversion). While X-rays are typically normal for tendinosis, they may help rule out fractures. Ultrasound can effectively assess tendon thickening or tears, and an MRI may show tendon damage or inflammation.
Classification
Peroneal tendinosis can be classified based on the severity of the condition, including mild cases with minimal tendon damage to more severe cases involving complete tendon tears.
Other Problems That Can Feel Similar (Differential Diagnosis)
Conditions that can mimic peroneal tendinosis include:
- Ankle sprains: Often present with similar pain but usually associated with a specific injury.
- Peroneal tendon tears: Tears can cause more severe pain and dysfunction.
- Chronic ankle instability: Weakness in the ankle may cause similar symptoms, especially after a sprain.
Imaging and a physical exam are key in distinguishing these conditions from peroneal tendinosis.
Treatment Options
Non-Surgical Care
The majority of peroneal tendinosis cases can be treated conservatively:
- Rest and activity modification: Limiting high-impact activities to reduce strain on the tendons.
- Ice and compression: To alleviate pain and swelling.
- NSAIDs: Anti-inflammatory medications can help control pain.
- Ankle bracing or taping: To support the joint and limit excessive motion.
- Physical therapy: A key treatment option focusing on strengthening the tendons and improving flexibility.
- Orthotics: Custom foot inserts can address biomechanical misalignments, especially for patients with high arches.
Surgical Care
Surgery may be recommended if conservative treatments fail or if there is tendon damage. Surgical options include:
- Excision of the damaged tendon or tissue.
- Tendon repair: If there is a tear, surgical repair can restore tendon function.
- Groove deepening: In some cases, the groove in the fibula may need to be deepened to relieve pressure on the tendon.
Recovery and What to Expect After Treatment
Non-surgical recovery typically involves a period of rest and physical therapy. It may take 4–6 weeks for symptoms to improve. Post-surgical recovery can be more extensive, requiring 6–8 weeks of immobilization, followed by rehabilitation. Full recovery, particularly after surgery, can take several months.
Possible Risks or Side Effects (Complications)
- Recurrence of pain: If the underlying cause, such as improper footwear or overuse, is not addressed.
- Tendon instability: Particularly if the tendon is not properly repaired.
- Chronic discomfort: Due to inadequate rehabilitation or incorrect biomechanical treatment.
Long-Term Outlook (Prognosis)
The prognosis for peroneal tendinosis is generally excellent with early diagnosis and proper treatment. Most patients recover fully with conservative care, while surgery offers good outcomes in more severe cases. Rehabilitation plays a crucial role in preventing recurrence.
Out-of-Pocket Costs
Medicare
CPT Code 27659 – Tendon or Ligament Repair (Foot and Ankle): $110.22
Medicare Part B generally covers 80% of the approved cost for this procedure once your annual deductible has been met, leaving you responsible for the remaining 20%. Supplemental Insurance plans such as Medigap, AARP, or Blue Cross Blue Shield typically cover the remaining 20%, resulting in little or no out-of-pocket expense for Medicare-approved procedures. These plans work with Medicare to fill the coverage gap and reduce the patient’s financial responsibility.
If you have Secondary Insurance through TRICARE, an Employer-Based Plan, or Veterans Health Administration coverage, it will act as a secondary payer. These plans usually cover the remaining coinsurance or deductibles, which generally range from $100 to $300 depending on your plan and provider network.
Workers’ Compensation
If your tendon or ligament repair is due to a work-related injury, Workers’ Compensation will cover all medical expenses, including surgery and rehabilitation. You will not have any out-of-pocket costs, as payments are made directly by your employer’s insurance carrier.
No-Fault Insurance
If your tendon or ligament injury resulted from an automobile accident, No-Fault Insurance will typically cover the full cost of your treatment, including surgery and postoperative care. The only potential out-of-pocket cost may be a small deductible or co-payment based on your policy.
Example
Megan Brooks sustained a tendon injury in her foot that required repair (CPT 27659). Her estimated Medicare out-of-pocket cost was $110.22. Since Megan had supplemental coverage through Blue Cross Blue Shield, her remaining balance was fully covered, leaving her with no out-of-pocket expenses for the procedure.
Frequently Asked Questions (FAQ)
Q. What is peroneal tendonitis?
A. Peroneal tendonitis is an underdiagnosed condition that causes lateral ankle pain, particularly in athletes or individuals engaged in repetitive physical activities. It involves injuries to the peroneus longus and peroneus brevis tendons on the outer side of the ankle.
Q. What are the peroneal tendons?
A. The peroneal tendons, comprising the peroneus longus and peroneus brevis, are located in the lateral compartment of the lower leg. They are responsible for eversion (turning the foot outward) and stabilizing the ankle during walking and running.
Q. What causes peroneal tendonitis?
A. Peroneal tendonitis often arises from overuse or repeated strain on the tendons, such as during sports that involve sudden changes in direction or excessive running. Chronic ankle instability, typically due to previous sprains, can also increase the risk of developing tendonitis. Additionally, foot deformities such as a high-arched foot (pes cavus) or a varus (inward turning) hindfoot can place additional strain on the peroneal tendons.
Q. What are the symptoms of peroneal tendonitis?
A. The primary symptoms include lateral ankle pain, especially during physical activity; swelling or a palpable mass along the tendons; pain when the foot is moved outward (eversion) against resistance; and tenderness when palpating the area behind the lateral malleolus.
Q. How is peroneal tendonitis diagnosed?
A. Diagnosis involves a thorough clinical examination and imaging studies. The doctor will check for tenderness along the tendon and assess foot alignment. Specific maneuvers like resisted eversion or plantarflexion can help localize the pain. Imaging techniques such as ankle X-rays, ultrasound, and magnetic resonance imaging (MRI) are essential for confirming the diagnosis and ruling out other conditions.
Q. What are the treatment options for peroneal tendonitis?
A. Treatment typically begins with conservative measures: rest and activity modification, ice and compression to reduce swelling, non-steroidal anti-inflammatory drugs (NSAIDs) to manage pain, and physical therapy to strengthen the ankle and improve flexibility. For severe cases, surgical interventions like tenosynovectomy, tendon repair, or groove deepening may be necessary.
Q. What is the recovery process for peroneal tendonitis?
A. Post-surgery, the patient typically needs to wear a cast or boot for several weeks to immobilize the ankle. After the initial healing phase, rehabilitation begins with gentle range-of-motion exercises, followed by strengthening exercises as the tendon heals. Most patients can return to their normal activities within 3 to 6 months, depending on the severity of the injury and the treatment method.
Q. Can peroneal tendonitis recur after treatment?
A. Yes, peroneal tendonitis can recur if the underlying causes, such as improper footwear, biomechanical issues, or overuse, are not addressed. Rehabilitation and corrective measures, such as strengthening exercises, proper footwear, and activity modification, are important to prevent re-injury.
Q. Is surgery always required for peroneal tendonitis?
A. Surgery is generally considered a last resort when conservative treatments, including rest, physical therapy, and medications, fail to provide relief. Surgical options are typically reserved for severe cases where there is significant tendon damage, or other treatments have not been effective in alleviating symptoms.
Q. How can I prevent peroneal tendonitis?
A. Prevention involves strengthening the muscles around the ankle, avoiding overuse during physical activity, wearing supportive footwear, and addressing any underlying foot or ankle issues, such as flat feet or high arches. Regular stretching and warm-up routines before exercise can also help prevent strain on the tendons.
Q. Can peroneal tendonitis lead to long-term complications?
A. If untreated, peroneal tendonitis can lead to chronic pain, tendon degeneration, and weakness in the affected ankle. Over time, it can cause instability in the ankle, increasing the risk of additional injuries or sprains. Early diagnosis and treatment are crucial to prevent these long-term complications.
Q. How long does it take to recover from peroneal tendonitis?
A. Recovery time varies depending on the severity of the tendonitis and the treatment approach. For mild cases, recovery may take a few weeks with rest and physical therapy. More severe cases may require several months for full recovery, especially if surgery is necessary. The patient’s commitment to rehabilitation plays a key role in recovery time.
Q: What causes peroneal tendinosis?
A: It is caused by overuse, especially in athletes who engage in repetitive ankle movements.
Q: How is it treated?
A: Treatment usually involves rest, physical therapy, and possibly orthotics or bracing. Surgery is considered if conservative methods fail.
Summary and Takeaway
Peroneal tendinosis is a condition caused by the repetitive overuse of the peroneal tendons, leading to pain and swelling around the ankle. Early diagnosis and treatment are key to preventing further damage. Conservative treatments, including rest and physical therapy, are often effective, with surgery reserved for more severe cases. Most patients recover fully with the right care.
Clinical Insight & Recent Findings
A 2024 study by Maffulli et al. highlighted the efficacy of eccentric strengthening exercises for treating early-stage peroneal tendonitis. The study also found that groove-deepening procedures combined with retinacular repair provided better long-term stability compared to isolated procedures.
Who Performs This Treatment? (Specialists and Team Involved)
Treatment is typically managed by orthopedic foot and ankle surgeons, podiatrists, and physical therapists.
When to See a Specialist?
See a specialist if you experience persistent ankle pain or weakness, especially if symptoms don’t improve with rest.
When to Go to the Emergency Room?
Seek emergency care if you experience severe pain, swelling, or the inability to move the ankle, particularly after an injury.
What Recovery Really Looks Like?
Recovery can take 4–6 weeks with physical therapy. After surgery, full recovery may take several months, depending on the procedure.
What Happens If You Ignore It?
Ignoring peroneal tendinosis can lead to tendon tears, chronic pain, and ankle instability.
How to Prevent It?
- Strengthen the ankle muscles and improve flexibility.
- Use proper footwear during physical activity.
- Avoid rapid increases in training intensity.
Nutrition and Bone or Joint Health
A diet rich in calcium, vitamin D, and omega-3 fatty acids supports tendon health and healing.
Activity and Lifestyle Modifications
After treatment, focus on strengthening exercises and gradually return to low-impact activities while avoiding repetitive strain on the ankle.
Dr. Mo Athar
