The peroneal tendons are located on the outer side of your ankle. The tendons are firmly held in place in a groove behind your fibula. If the peroneal tendons slide out of the groove then you will have pain due to peroneal tendon subluxation. How do we diagnose and treat peroneal tendon subluxation. As Gareth Bale will be able to attest to, the recovery from peroneal tendon subluxation can last for months.
We have two peroneal tendons. The two tendons include the peroneus longus and the peroneus brevis. These two peroneal tendons play a critical role in balancing and controlling the motion of your foot. Injury to the peroneal tendons can occur as the result of a traumatic episode or due to chronic repetitive stress.
What Is Peroneal Tendon Subluxation?
As noticed in the diagram, the two peroneal tendons are held in place by a strong piece of tissue we call a retinaculum. If the retinaculum tears then the two peroneal tendons can subluxate or move in front of the fibula. The most common cause of peroneal tendon subluxation is an ankle sprain. During an inversion ankle sprain (the most common type) the tissues on the outside of your ankle are stretched. At the same time your tendons are pulling hard to resist that motion. That can put a lot of stress on the retinaculum holding the two tendons in place. Ultimately the retinaculum can tear or lift off the fibula and allow the peroneal tendons to subluxate or move towards the front of your ankle.
What are the symptoms of peroneal tendon subluxation?
The common symptom of peroneal tendon subluxation is a painful popping sensation on the outer side of your ankle. At the time of the injury or ankle sprain you may not notice the tendons are out of place. Especially because the entire outside of your ankle may now be swollen. As the swelling subsides, you will now notice that the tendons subluxate when you move your ankle upwards. The peroneal tendons do not stay subluxated. So they will go back into place when you move your foot downward. The tendons do not need to subluxate each and every time you move the ankle. Sometimes this will only occur with forceful motion and rotation, such as running around on a soccer field or basketball court.
How Do You Diagnose Peroneal Tendon Subluxation?
The diagnosis of peroneal tendon subluxation is generally very straightforward. Your Orthopedic Surgeon will ask you to move your ankle into certain positions. That will usually cause the peroneal tendons to subluxate which will be easy for us to feel. In situations where it isn’t clear we may need to obtain an MRI which will show us whether or not the retinaculum is torn or separated from the fibula.
How Do You Treat Peroneal Tendon Subluxation?
Gareth Bale will likely have surgery to repair his peroneal tendon dislocation. Do all cases of this require surgery? The short answer is no. If the injury is acute or fresh, then there is a chance that the retinaculum will heal if the foot is casted so the tendons stay in their normal position. If this treatment is unsuccessful then peroneal tendon subluxation is treated by fixing the retinaculum which holds the tendons in place. In many cases we are simply reattaching the retinaculum to the fibula. This is an open surgery. At the time of the surgery we also inspect the two tendons to be sure there is no evidence of a peroneal tendon tear. If a tear is noted then the tendon will be fixed at the same time that the retinaculum is repaired.
What is the Recovery From Peroneal Tendon Subluxation?
After the repair we need to give the retinaculum time to heal back to the bone. That healing process can take many months. Physical therapy will usually start within 4-6 after surgery to start to improve your motion. After months of strengthening, conditioning and sports specific training the retinaculum should have the strength and stability to allow you to return to play.
I know you won’t be able to diagnose my exact issue but I’d like your opinion anyway. I’m a 52 year old male. I was a 5 mile a day runner for 23 years. In 2012 I developed a heart condition that required a pacemaker. After recovering from that surgery a few months later I attempted to return to running. I ran 7 miles the night before my pacemaker surgery. My left ankle won’t go more than a quarter mile before giving out now. The pain sorta starts burning in the outside of the shin down to just above the ankle. At about 3/4 mile the ankle stops working all together. Other than several rollover ankle injuries on that same foot I had no significant injury. It just doesn’t work. Since then my ankle hurts at rest constantly. Driving. Sitting on a chair or couch. I’m constantly moving it to dull the pain. I’m unable to get an mri. CT scans and X-rays show nothing other than a thickening around the peroneal tendon. Long distant drives are grueling. I ride a Harley but rarely now because of the discomfort that is constant. The strangest thing is that I can ride a stationary bike till my ass is numb. 20 to 25 miles for an hour at a time. Elliptical too. But I can’t walk around the block. Also about 3 inches below my left knee there’s an indentation that travels across my shin bone from inside the knee to the outside of my calf and down toward the ankle. There’s pain and twitching in this area frequently. I have extremely poor dorsaflex in the same ankle also. Any advice before I let someone open my leg to fix something that isn’t broke. My non expert research combined with what I’m experiencing kind of makes me feel it could be some nerve entrapment somewhere in my lower leg. The discomfort and pain while at rest is extremely difficult to deal with. Thank you sir for taking the time to read this.
Howard J. Luks, MD says
Perhaps this post below might help you. This is not medical advice, but can be used to guide questions with your doctors.
J Buback says
I had surgery for this 30 years (specifically superior reticinaculum repair, I’m sure I messed that up, so sorry) and after a long recovery I have done wonderfully, until this weekend. My ankle rolled while I was doing something I do daily and I heard a pop. It has been swollen and painful, just as I remember the first time. Can an initial repair be re-injured? If so, do I treat it like a new injury? Thank you!
Howard J. Luks, MD says
HI J …
Hopefully, this was just an ankle sprain and not a retinacular tear as you had 30 years ago. some of these injuries will heal without surgery if the ankle is immobilized soon enough. I have not personally seen someone tear this twice…
Have you seen fibular subluxation at both knee and ankle before? I’m a 46yo athlete who after several meniscectomies had to have a TKR. I felt a huge shift in my bones about 6 weeks post surgery, which progressed to pain and popping upon heel strike walking, to almost constant motion and pain / burning while active. My ROM never came along as it should have either, and changed based on which direction my bone has popped (it subluxes backward / toward calf). OS hasn’t seemed to think this is an issue. I’m researching before getting a second opinion. Hoping there’s a conservative option for me.
Howard J. Luks, MD says
I have seen many cases of proximal tib-fib joint subluxations. Many people choose to live with it or have a proximal tib/fib joint fusion.