Peroneal tendon surgery is often considered after months or years of persistent ankle pain and instability. The peroneus longus and peroneus brevis tendons run along the outer side of the ankle, acting as dynamic stabilizers. Injuries range from simple inflammation (tendinosis) to severe issues like longitudinal tears and instability, where the tendon snaps out of its groove (subluxation). When conservative care fails to resolve these high-grade injuries, surgery requires a careful look at the procedures, recovery, and expected functional return.
Understanding Peroneal Tendon Injuries and Non-Surgical Options
Peroneal tendon disorders commonly cause chronic lateral ankle pain, often stemming from ankle sprains, repetitive motion, or specific foot structures like a high arch. Injuries are classified by severity, ranging from simple inflammation to complete rupture or chronic subluxation. Subluxation occurs when the superior peroneal retinaculum, the fibrous band holding the tendons in place, is torn, allowing the tendons to snap out of position behind the ankle bone.
Initial treatment begins with conservative, non-surgical methods. These protocols include rest, anti-inflammatory medications, physical therapy, and temporary immobilization with a boot or brace. While a non-weight-bearing cast may treat acute subluxation, failure rates for non-operative therapy can be as high as 50–76% for dislocation. Surgery is considered necessary when symptoms persist despite a minimum of 4 to 6 months of dedicated conservative treatment, especially for high-grade tears or chronic instability that impairs walking and sports performance.
Surgical Approaches for Peroneal Tendon Repair
The specific surgical technique depends on the type and extent of the injury, aiming to restore normal tendon function and stability.
Repairing Tendon Tears
For small tears, the surgeon performs a debridement to remove frayed tissue, followed by tubularization, stitching the remaining tendon into a strong cylinder. If a tear involves more than 50% of the tendon’s cross-sectional area, the damaged segment is excised. The remaining tendon ends may then be connected to a neighboring tendon (tenodesis), or a graft may be used for reconstruction.
Addressing Instability
When the primary issue is instability or subluxation, the focus shifts to the restraining structures and bony anatomy. Procedures involve repairing the superior peroneal retinaculum (SPR) to stabilize the tendons, often using anchors to reattach it to the fibula. If a shallow bone groove contributes to subluxation, a groove deepening procedure may be performed simultaneously to create a more secure pathway. Associated issues, such as a low-lying muscle belly, may also require debridement.
Navigating the Post-Surgical Recovery Process
The commitment to a prolonged and structured recovery is a significant factor when considering surgery. Directly following the procedure, the ankle is immobilized in a splint or cast. The patient must remain non-weight-bearing for two to six weeks to protect the repair. During this initial phase, the focus is on pain control, managing swelling through elevation, and maintaining strength in the hip and knee. Suture removal typically occurs 10 to 14 days after the operation.
The transition to weight-bearing is gradual, often beginning with protected weight-bearing in a walking boot around four to six weeks post-surgery. A full return to walking without the boot is anticipated around week eight. Formal physical therapy is mandatory, starting a few weeks after surgery and focusing on regaining ankle range of motion, strength, and balance. Patients must adhere strictly to therapy protocols, especially avoiding active eversion if the retinaculum was repaired. Full athletic activity and maximum recovery often take between six and twelve months.
Weighing the Outcomes: Factors Determining Success
Surgical intervention for peroneal tendon pathology provides positive clinical outcomes and high satisfaction rates for many patients. Studies show significant improvement in functional scores post-surgery; for example, the mean weighted American Orthopaedic Foot and Ankle Society (AOFAS) score improves from about 70 to nearly 89. For instability cases, the redislocation rate following surgery is low, often less than 1.5% at long-term follow-up.
Success depends on several patient-specific factors, including injury severity, the presence of other ankle issues, and the patient’s overall health. Adherence to the intensive rehabilitation program is the most significant modifiable factor influencing a successful outcome. While outcomes are positive, the average overall complication rate is approximately 38.7%, with persistent ankle pain being the most common minor complication. The decision balances the risk of lengthy recovery and potential complications against the high probability of restoring ankle stability and reducing chronic pain.