Peroneal tendon surgery

The peroneal tendons lie on the outside (lateral side) of the ankle joint. They play an important role in stabilising the ankle joint, contribute to power when pushing off the ankle/ foot and also enable the ankle to be turned outwards (eversion).

There are three peroneal muscle-tendons, called peroneus brevis, peroneus longus and peroneus tertius. The lattermost is rarely injured. The other two tendons can be injured as part of a severe ankle sprain. More often the tendons are inflamed as a result of over-use or a training error. In active middle-age and elderly patients, the tendon can become degenerate and be prone to rupture. If the patient has a high-arched foot-ankle (per cavo-varus) this may predispose the patient to peroneal problems. In severe cases the cavovarus foot has to be corrected in order to solve the problem. In less severe case the use of orthotics may be sufficient.

Patients will present with acute or chronic onset of pain and swelling along the peroneal tendons. The tendons are often tender to palpation and there is pain with weight bearing activities. In those patients with instability of the tendons, part of a torn tendon, or the entire tendons is moving out place and is described as a painful snapping sensation as the tendon moves out of place (with eversion and dorsiflexion) and back in again. Peroneal tendon instability usually develops acutely as a result of a twisting injury to the ankle. In order for the tendon to move out of place, the peroneal retinaculum has to be torn. This is a ligament that hold the tendons in place behind the lateral malleolus (lower end the fibula).

The operation is performed a sterile operating theatre with the patient under a general anesthetic.

The operation is an open procedure, that is not a key-hole procedure. An incision is made over the peroneal tendons, and the tendons assessed for damage.

If the tendon is torn then it can be repaired with sutures. If the cause is degeneration and swelling then the the pathological tissue is simply excised. If the tendon is unstable then in most cases the problem can be rectified by repairing the superior peroneal retinaculum, or SPR. On rare occasions the groove behind the lateral malleolus, in which the peroneal tendons (brevis and longus) sit, has to be made deeper to prevent the tendons from subluxing (moving out of place). Some patients will have both a tear and instability of the tendon.

Immediately post-surgery

• You will wake up in recovery with your leg in a “below knee cast” or boot. This is to immobilize the operative site and helps to control pain. This should be left intact until you see the surgeon for your first post-operative visit in around 2 weeks. In some cases it will positioned with your foot plantar flexed and everted slightly (“down and out”).
• The wound will be closed with dissolving sutures and these do not have to be removed.
• You will be allowed to mobilize with the assistance of crutches as soon as feeling up to it.
• You are not allowed to place any weight through the operated leg
• You will be discharged home later that day when you have recovered from the
  surgery.

Discharge until first post-operative review (usually 2 weeks)

• Keep the leg elevated (above your heart if possible) whenever you are not mobilizing
• Keep moving the knee and hip on the operated side regularly, at least 4 times each day for 10-15 minutes
• The local anesthetic injected at the time of surgery will start to wear off a few hours post surgery, and therefore some increase in pain is to be expected after you get home. However, you will have been given adequate analgesics to control this pain
• Leave the dressings and cast intact until reviewed by your surgeon at 2 weeks.
• Do not be alarmed if bruising appears in the toes a few days following surgery, this is blood that has tracked down the foot under the influence of gravity and the bandage.
• The surgeon will see you 2 weeks following surgery (unless there are any problems before this
• The surgeon will remove your cast, check the wound, and place you in a cast, or a removable boot, depending upon the precise pathology and surgery performed.

2-6 weeks post surgery

• Most patients will be allowed to begin partial weight bearing when 2-3 weeks post-surgery and progress to full weight-bearing when 4 weeks post surgery
• The boot is only allowed to be removed for cleaning purposes only

Second post-operative review (6 weeks)

• At this appointment, the cast will be removed and healing of the tendons and/or other structures will be checked
• The surgeon will communicate with your physiotherapist with regard to the progression of your rehabilitation. Most patients will be allowed to wean themselves off the use of the boot, over 2 weeks.
• The physiotherapist will supervise a progress strengthening and balance work, with final emphasis on the strength and control of the peroneal muscles.
• The patient will be allowed to swim and cycle for fitness, while running should not be attempted until strength and muscle balance have all been restored completely.

Third post operative review (3 months)

• At this review the surgeon will be checking of healing is sufficient to allow the patient to return to all sports activities.

Return to sports activities

Return to swimming and cycling – usually possible within 6 weeks of surgery
Return to running – this is usually possible within 8-12 weeks of surgery, as long as on an well-lit even surface
Return to unrestricted sport – this is usually possible at 3-4 months post surgery.

Patients will be referred back to their usual physiotherapist.

Up to 4 months of physiotherapy is usually required to return patients back to competitive sports.

Dr. Porter will review patients intermittently during this period and at any stage if there are problems with recovery.