The peroneal tendons are a pair of fat-filled tunnels situated behind a bony lump on the outside of the ankle. They house two muscles; the peroneus longus, a longer muscle that runs along the outside of the lower leg and the peroneus brevis, a shorter muscle that sits immediately under the longus. Both muscles play important roles in movement of the foot and provide support during activities such as walking, running and jumping.
The peroneal tendons course distally down the lateral aspect of the ankle hindfoot, posterior to the lateral malleolus before crossing over to the medial aspect of the hindfoot and continuing into the foot where they attach to various bones. The peroneus longus tendon attaches to the base of first metatarsal and medial cuneiform. The peroneus brevis tendon attaches to the base of the fifth metarsal. These tendons play a significant role in positioning the foot and provide stability during activities such as walking on uneven terrain. According to Hallinan et al. ( 2019), “anatomical and biomechanical studies demonstrate that both peroneal tendons play a critical role in ankle stabilisation”.
The peroneal tendons in the ankle joint perform the function of eversion, meaning that they help turn the bottom of the foot outward. This is an important function for people who need to be balanced and agile for sports or other activities. For example, runners use their peroneal tendons to prevent their feet from inverting, or rolling in, as they run. Morgan, R. L., Chen, C. Y., Sangeorzan, B. J., Akutsu, J. H., Heier, T. G., Mann, R. A. ( 2020).
The peroneal tendons surround two muscles which help support structures in the foot that play a significant role in enabling people to walk and run. While they are integral to many movements, injuries such as tendonitis or tendon tears can occur, leading to pain, swelling and disability of the foot. The clinical presentation of these injuries is well recognised. Understanding their pathology and effects is therefore important in terms of diagnosis and management, in order to prevent lasting defect or impaired mobility. In recent years various rehabilitative strategies have been used in the management of injuries affecting the peroneal tendons. Those targeting the peroneal tendons have been shown to enhance rehabilitation and aid in the prophylaxis of future injury.
This paper reviews the current literature pertaining to the anatomy of the peroneal tendons, common peroneal tendon injuries, rehabilitation following injury, factors influencing outcome and advice for integration of peroneal tendon rehabilitation into clinical practice. An empirical study assessing physical activity levels of a group of runners is also reported in order to gain insight into potential mechanisms to facilitate return to exercise for participants within rehabilitation for peroneal tendon injuries.
Philbin T, Cherian S, Keller Tsai K, Ranwala G, Alton M ( 2009 ) Anatomy of the peroneal tendons. Journal of Foot and Ankle Surgery; 48(4): 439–444.
Roster B, Korff T, Stevens A ( 2015 ) Exercise for ankle hindfoot, midfoot and forefoot conditions (except Plantar fasciitis). Cochrane Database of Systematic Reviews . http://dx.doi.org/10.1002/14651858.CD010279.pub3 .
The peroneal tendons are important for facilitating foot eversion and allowing for adaptation to uneven surfaces during activities of daily living such as walking on a sidewalk or trail running. When the foot needs to jump up off a hard surface or land on a soft surface during activities of sports or recreation, the peroneal tendons play a critical role in stabilizing the foot and ankle. Doral et al. ( 2010) noted that the peroneal tendons provide substantial support to the foot and ankle during these types of activities, and are critical in helping to prevent injuries to the foot and ankle.
Injuries and pathologies affecting the peroneal tendons can significantly affect foot mobility and function. The most common peroneal tendon injuries include tendonitis, subluxation, and tears of the peroneal tendons. Tendonitis occurs when the tendons become inflamed or irritated and is typically occurs in athletes involved in running or jumping activities. The tendons can subluxate or become displaced out of their normal position, resulting in pain and instability. In severe cases, the tendons can suffer tears, including partial or complete ruptures of the tendon fibers. Treatment of these injuries typically involves rest and ice, and in severe cases, surgical intervention (Raikin et al., 2008; Davda et al., 2017).
The epidemiology of lateral ankle ligament sprains is also important in the context of peroneal tendon injuries since commonly sprained ankle ligaments can suffer secondary injury to the peroneal tendons. This occurs as the peroneal tendons function to support the ankle and help bring the foot up to compensate for an ankle that has rolled outward. The motion and stress of an ankle sprain can put considerable additional stress on the peroneal tendons, causing injury. Sprains of the lateral ankle ligaments are among the most common sports injuries, particularly those involving contact and quick changes of direction (Ferran & Maffulli, 2006, Chen et al., 2009).
In order to return to safe and effective participation in sports following a peroneal tendon disorder it is very important that accurate diagnosis and effective treatment occurs as early as possible to prevent unnecessary prolonged pain and disability. Initially a physical examination is performed by a medical doctor and imaging studies such as an ultrasound or MRI. A differential diagnosis of ankle pathology may also be performed. Initial treatment consists of physical therapy exercises aimed at strengthening the muscles around the ankle that help support the tendons. Patients are also provided with a safe return to activity programme based on the individual’s specific tendon disorder and their unique circumstances (Benjamin PJ, Al-Fahham RA, Denahan TJ, Maree VE, Naique SS, Casals E. (2008) The contribution of muscles to joints: muscle, joint action, and joint muscle origin. Arthritis Rheum, 59 (6): 808–818).
The functional anatomy of the peroneal tendons is also an important aspect to understand their significance in foot mechanics. The peroneus longus and peroneus brevis muscles, alongside the associated tendons, act together to provide lateral support to the ankle and assist in movements of the foot such as everting the heel. Further research into the functional anatomy of the peroneal tendons will help clinicians and sports medicine professionals better understand the causes of common injuries to the tendons, and provide patients with the best possible clinical outcomes. By developing more advanced imaging and surgical techniques clinicians will be able to more effectively treat a range of peroneal tendon pathologies. Enhanced understanding by healthcare professionals of the anatomy and function of the peroneal tendons will lead to more effective diagnosis, management and rehabilitation of patients with peroneal tendon injuries.
Peroneal tendon inhibition problems are increasingly common and many occur in athletes. Being aware of the issues that can occur, the potential for degeneration and the importance of prevention will help athletes and active people alike to look after their feet and engage in sports and other activities more safely. Many athletes do not know the importance of the peroneal tendons inhibition or recognise when they have suffered a injury to the structures (Roster et al., 2015, Philbin et al., 2009).
Citations:
Philbin, T.M., Landis, G.S. and Smith, B., 2009. Peroneal tendon injuries. JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 17(5), pp.306-317. https://journals.lww.com/jaaos/fulltext/2009/05000/peroneal_tendon_injuries.5.aspx
Hallinan, J.T.P.D., Wang, W., Pathria, M.N., Smitaman, E. and Huang, B.K., 2019. The peroneus longus muscle and tendon: a review of its anatomy and pathology. Skeletal Radiology, 48(9), pp.1329-1344. https://link.springer.com/article/10.1007/S00256-019-3168-9
Roster, B., Michelier, P. and Giza, E., 2015. Peroneal tendon disorders. Clinics in sports medicine, 34(4), pp.625-641. https://www.sportsmed.theclinics.com/article/S0278-5919(15)00046-0/abstract
Davda, K., Malhotra, K., O’Donnell, P., Singh, D. and Cullen, N., 2017. Peroneal tendon disorders. EFORT open reviews, 2(6), pp.281-292. https://eor.bioscientifica.com/view/journals/eor/2/6/2058-5241.2.160047.xml
Morgan, O., Song, J., Hillstrom, R., Sobel, M. and Hillstrom, H.J., 2020. Biomechanics of the peroneal tendons. In The peroneal tendons: a clinical guide to evaluation and management (pp. 23-40). Cham: Springer International Publishing. https://link.springer.com/chapter/10.1007/978-3-030-46646-6_2
Raikin, S.M., Elias, I. and Nazarian, L.N., 2008. Intrasheath subluxation of the peroneal tendons. JBJS, 90(5), pp.992-999. https://journals.lww.com/jbjsjournal/fulltext/2008/05000/Intrasheath_Subluxation_of_the_Peroneal_Tendons.7.aspx
Chen, T.M., Rozen, W.M., Pan, W.R., Ashton, M.W., Richardson, M.D. and Taylor, G.I., 2009. The arterial anatomy of the Achilles tendon: anatomical study and clinical implications. Clinical Anatomy: The Official Journal of the American Association of Clinical Anatomists and the British Association of Clinical Anatomists, 22(3), pp.377-385. https://onlinelibrary.wiley.com/doi/abs/10.1002/ca.20758
Doral, M.N., Alam, M., Bozkurt, M., Turhan, E., Atay, O.A., Dönmez, G. and Maffulli, N., 2010. Functional anatomy of the Achilles tendon. Knee Surgery, Sports Traumatology, Arthroscopy, 18(5), pp.638-643. https://link.springer.com/article/10.1007/s00167-010-1083-7
Ferran, N.A. and Maffulli, N., 2006. Epidemiology of sprains of the lateral ankle ligament complex. Foot and ankle clinics, 11(3), pp.659-662. https://www.foot.theclinics.com/article/S1083-7515(06)00063-5/abstract
Benjamin, M., Kaiser, E. and Milz, S., 2008. Structure‐function relationships in tendons: a review. Journal of anatomy, 212(3), pp.211-228. https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1469-7580.2008.00864.x
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