Surgical Overview
The peroneal tendons are two tendons located on the outside of the leg near the fibula. They connect the muscles in the lateral leg to an insertion point on the metatarsals in the midfoot. They allow people to push off while walking, running and jumping and assist with cutting and pivoting activities. Problems with the peroneal tendons can be either acute or chronic. Chronic, long-lasting tendon disorders can range from overuse injuries to attritional rupture of the tendon. Acute injuries usually involve a tear of one of the tendons or the retinaculum (covering over the tendons).
Chronic inflammation of either tendon that can occur anywhere along the tendon (pictures A & B below). This may occur in the midportion of the tendon or at the insertion on the metatarsal. This is commonly associated with overuse injuries and may be associated with bone spur formation. In some cases, an accessory tendon may be the cause of symptoms.
These usually occur with an acute injury and can sometimes be mistaken for an ankle sprain. This condition involves pain over the lateral ankle behind the fibula. The tendon sheath can become inflamed or thickened and also stick to the tendon (called stenosis). Chronic tears are more common in certain patient populations.
Involves an injury (pictures C & D below) to the superior peroneal retinaculum (covering over the tendons). This is most commonly due to an inversion injury in younger patients. However, aging may play a part in this process and repetitive minor trauma, such as playing sports that involve running or jumping, without proper healing can also play a role. Tendon tears or tendinopathy may also develop because of this chronic subluxation or dislocation.
The main symptoms usually associated with peroneal tendinopathy are pain and swelling. In the early stages of disease, pain is present with movement or activity (walking, running, sports, stairs, prolonged standing). As the tendinopathy progresses, the pain can be present even at rest or with minimal pressure on the area. Other common symptoms of peroneal tendinopathy include joint stiffness, loss of ankle motion, posterior ankle swelling, changes in foot shape and difficulty walking (or walking with a limp).
Treatment for peroneal tendon pathology is focused on controlling pain, limiting motion and activities that cause pain, and assisting in increasing walking tolerance. Non-surgical treatment approaches are usually tried first. Non-surgical treatment options include: medications (nonsteroidal anti-inflammatory medications (NSAIDs)), ankle-foot orthosis (AFO) or other ankle braces to decrease ankle motion, physical therapy, CBD cream and/or platelet-rich plasma (PRP) injections into or around the tendon.
Once conservative treatment options have been exhausted or the degree of pathology is very severe, surgical intervention is usually necessary. Early surgical intervention is indicated in some cases of acute tendon rupture or dislocation in younger patients. There are three main surgical options to treat the majority of peroneal tendon pathology:
The peroneal tendons can be assessed, and the damaged tendon is excised. This can also be performed to remove inflammatory or scar tissue from within the tendon sheath. This procedure also assists with identification of accessory tendons within the tendon sheath.
The damaged tendon is excised, and the healthy tendon is then repaired. This also includes removal of any tenosynovitis or scar tissue present near the peroneal tendons. The retinaculum is also assessed and repaired, as necessary. In most cases, regenerative stem cells are obtained from the iliac crest to encourage further healing of the peroneal tendon after repair.
In some cases, a tendon transfer between the peroneal tendons or from the foot may be necessary to further strengthen the peroneal tendon and prevent further foot deformity. In most cases, regenerative stem cells are obtained from the iliac crest to encourage further healing of the peroneal tendon after repair. This procedure is usually reserved for more severe cases of peroneal tendon pathology.
Peroneal Tendon
Your surgery takes place at the New England Baptist Outpatient Center as a day surgery.
The procedure generally takes about 1-1.5 hours.
General anesthesia is usually used, but occasionally a light sedation is possible for some patients. All patients will have a preoperative nerve block performed to the back of the knee immediately before the surgery. This will decrease intra-operative anesthesia requirements as well as post-operative pain medication requirements. It is very effective in greatly reducing pain.
Benefits of these surgeries include decreased pain, improved function and maintenance of ankle joint motion.
Conservative treatments as discussed above including long-term bracing.
In general, most patients are able to return to their previous level of function including recreational activities.
Like any surgery, complications can develop. Fortunately, they are rare for most patients, but not zero. These include infection, bleeding, numbness, blood clots, delayed wound healing, bone fracture, chronic pain and/or swelling. Appropriate recognition and medical treatment of these complications generally will allow for a satisfactory outcome. Many of the risks are mitigated using the minimally invasive surgical techniques.
You will get a dose of antibiotics just before surgery. All patients are started on one 325 mg aspirin once a day for 4 weeks after the surgery to reduce the risk of blood clots.
Read carefully the “What to Expect and How to Prepare for Surgery” handouts.
No. Bleeding is minimal with use of a tourniquet during the surgery.
Discuss the surgery with your rheumatologist, but it is generally recommended that immunosuppressive modulator medications (e.g. Methotrexate, Enbrel, Humira) are stopped for 2 weeks before and 2 weeks after surgery.
Focus for the first 2 weeks post-surgery is to rest, get plenty of sleep, eat well and drink plenty of water. Your body will have greater metabolic demands on it to heal. Keep your surgical foot elevated at the level of your heart when you are not moving around the house. You should take the pain medication as directed, as necessary. You should take the blood thinning medication for reducing the chance of blood clots as well. Keep the dressing clean and dry. In some cases, you are able to weight bear as tolerated in the boot once your nerve block has worn off. This will be further discussed at the time of surgery.
Small spots may appear on the bandage. You may reinforce the dressing with an ace wrap obtained from a pharmacy. While highly unlikely, excessive bleeding through the bandage is of concern and you should call the office to be seen.
If the surgery was on the LEFT side, many patients drive by two weeks when they are off the pain medication. If surgery was on the RIGHT side, driving can resume around the 6-8 week mark, at which time the boot can be removed to drive and then placed back on when getting out of the car. You will also be given a handicap parking placard, as necessary.
That depends on what you do. Sedentary desk workers may return as soon as 2 weeks. On the other end of the spectrum, professions that are a bit more demanding may be out of work for 3 months. You will be provided out of work notes or restricted duty notes as necessary during the recovery phase. Family leave paperwork can also be submitted.
Download the Peroneal Tendon Post-Operative Guidelines for full details.
