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Foot Pain

Peroneal Tendon Subluxation

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2 months ago

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by james

Peroneal Tendon Subluxation is the displacement of the Peroneal Muscles from the deep groove behind the lateral malleolus as a result of a Superior Retinaculam tear or rupture.

The Peroneal muscles sit on the outside of the shin bone, connecting to the outer and underside of the foot via the Peroneal Tendons. Their function is to turn the foot outwards, assist with plantarflexion and help to stabilise the ankle through gait. There are 3 Peroneus muscles; Peroneus Brevis, Peroneus Tertius and Peroneus Longus. Peroneus Brevis and Peroneus Longus pass through a groove underneath the lateral ankle bone before connecting to the foot. They are held in the grove but a strong fibrous band of tissue called the Superior Peroneal Retinaculum (SPR).

Injury to the SPR can allow extra movement of the Peroneus muscles in the grove allowing them to subluxate from the grove with certain movements. When this occurs it is known as Peroneal Tendon Subluxation. 

Causes of Peroneal Tendon Subluxation

Peroneal Tendon Subluxation (PTS) is caused by repetitive lateral ankle sprains that lead to stretching of the SPR while a significant ankle sprain can lead to a complete tear of the SPR. When the SPR is stretched, then the peroneal tendons can move out of the groove behind the fibula.

In individuals who are hyper-mobile, there may not be a specific mechanism of injury but simply the SPR is not as rigid as it needs to be and with contraction of the Peroneal muscles, they push past the SPR and subluxate. In some rare cases, there is no SPR present.

Symptoms

Patients often report a loud clicking or cracking noise in their ankle when turning their foot outwards. They can feel pain on the outside of the ankle and it may be possible to visibly see the tendon popping in and out of its groove. There may be some swelling on the ankle with pain when turning the foot out, walking, running or changing direction. Ankle range of movement may be limited due to pain levels. There may be tenderness on palpation of the tendons. In some cases, where there is no retinaculum they may not feel any pain. 

Diagnosis

Peroneal Tendon Subluxation can be clinically diagnosed by a Physical Therapist or by a Sports Medicine Doctor following a clinical examination. A clinical test for Peroneal Tendon Subluxation by a foot specialist involved positioning the patient in a seated position with their knee bent. The clinician places their thumb over the SPR and asks the patient to forcibly evert and dorsiflex their foot. The clinician will feel the peroneal sublux, sometimes alongside an audible click or pop. The patient may feel pain when this occurs.

The patient may be referred for a scan to confirm the diagnosis and to see if the SPR remains intact. An x-ray is not beneficial in this instance. An MRI is useful for detecting a ruptured or torn retinaculum but they are expensive and can be difficult to attain. An ultrasound is the preferred form of scan for a Peroneal Tendon subluxation as it can provide real-time feedback and it is dynamic, allowing the patient to subluxate the tendon during the scan. 

Peroneal Tendon Subluxation Classification

The Oden Classification is used to describe the different types of subluxations of the Peroneal Tendons.

Grade 1: The Superior Retinaculum (SPR) is pulled from the lateral malleolus

Grade 2: The fibrous ring alongside the SPR is puller from the lateral malleolus

Grade 3: the SPR, fibrous ring and a bony fragment from an avulsion fracture are pulled from the lateral malleolus

Grade 4: The posterior SPR is completely torn

Picture of Peronal Tendon Subluxation

Peroneal Tendon Subluxation treatment without surgery

If a Peroneal tendon subluxation is occurring with pain then it is advised to seek conservative treatment under the guidance of a Physical Therapist. In the non-athlete population, a patient should try conservative treatment initially but be informed in advance that there is a 50% chance of reoccurrence according to a study by Ziai et al

Treatment from a Physical Therapist should consist of Peroneal strengthening exercises, foot and ankle stability, and proprioception exercises.

Peroneal tendon taping with rigid may be used to provide additional stability to the ankle joint but it’s unlikely to completely stop the subluxation. KT Tape is not beneficial for Peroneal Tendon Subluxation.

An ankle brace is an effective form of treatment for perennial tendon subluxation as it has the same effect as rigid taping and it provides better long-term support.

A reduction in exercise levels is recommended in conjunction with some non-steroidal anti-inflammatories such as ibuprofen followed by a graduated return to sport.

If these methods fail to reduce symptoms then a steroid injection may be carried out to the tendon sheath, this is usually ultrasound-guided. Generally, injections to the tendon are not recommended where possible as they can cause long-term harm to the tendon.

Peroneal Tendon Subluxation Surgery

Surgery for Peroneal Tendon Subluxation is highly successful and usually consists of a graft to replace the superior retinaculum or if it is viable a repair of the superior or posterior retinaculum may be carried out. This is normally followed by a period of time in a walker boot and 4-6 weeks of physical therapy.

A repair or a reconstruction can include deepening the groove where the Peroneal Tendons sit, to reduce the risk of their subluxation in the future.

Peroneal Tendon Subluxation Surgery Recovery Times

Post-surgery, the foot is normally placed in a short boot with the foot slightly inverted and the patient is non-weight bearing for the first 2 weeks. Following this, they are placed in a walker boot for 4 weeks with a gradual increase in weight-bearing activities. After 6 weeks the patient can wean out from the boot and commence Physical Therapy. Total recovery time from Peroneal Tendon Subluxation Surgery is 4-6 months. 

FAQ

Peroneal Tendon Subluxation with no pain

When there is a subluxation of the peroneal tendon without pain then there is no need for treatment. There may be a lax SPR or none at all but it is harmless for asymptomatic subluxation of the tendon. 

Peroneal Tendon Subluxation after Ankle Sprain

It is possible to develop a Peroneal Tendon subluxation after an ankle sprain. This occurs most often with a highgrade lateral ankle sprain as the peroneal tendon and superior retinaculum can become overstretch or tear. If this occurs it can allow the Peroneal Tendons to subluxate and can ofter be misdiagnosed as an irritable chronic ankle sprain or a Peroneal Tendonitis.

Can Peroneal Tendon Subluxation heal on its own?

If you have a Peroneal Tendon subluxation that is becoming increasingly painful, then it is unlikely to heal on it’s own. We recommend that you see a Physical Therapist for treatment. If you have a Peroneal Tendon Sublixation with no pain, then you don’t need any treatment.

Do I need surgery for Peroneal Tendon Subluxation?

If you are having pain and you have tried conservative treatment without success then you are a candidate for Peroneal Tendon Subluxation Surgery. This is a highly successful form of treatment and it is unlikely to recur. If you have no pain, then you do not need surgery.

Physiotherapy with James McCormack

This is not medical advice and we recommend a consultation with a medical professional such as James McCormack to achieve a diagnosis. He offers Online Physiotherapy Appointments for £45.

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