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What is a peroneal tear?
Causes
Symptoms
Diagnosis
Treatment
Surgery
Prevention
FAQs

Developing a tear in one of the peroneal tendons can leave the ankle feeling weak and unstable. This makes walking difficult, and puts you at risk of further ankle injuries like sprains.

What Is A Peroneal Tear?

You have two peroneal tendons that run across the outer ankle called the peroneus longus and peroneus brevis. These tendons play a crucial role in stabilising the ankle, as well as assisting in various movements such as everting the foot (rotating it outwards) and plantarflexion (pointing the foot downward). When a tear occurs in either of the peroneal tendons, it can lead to pain, swelling, instability, and limited mobility in the ankle and foot.

Peroneal tears can vary greatly in their severity, depending on the size of the tear, the direction of the tear (whether it goes across the tendon or through the tendon in the direction of the tendon fibres) and the location of the tear. In mild cases, there may be discomfort and difficulty with certain activities, such as walking or climbing stairs. In more severe cases, where there is significant damage to the tendons or associated structures, mobility can be greatly impaired, making it challenging to bear weight on the foot and ankle, or engage in routine daily tasks.

Causes Of Peroneal Tears

Peroneal tears can result from a variety of factors, including a traumatic injury, overuse, and biomechanical issues. While peroneal tears are often thought of occurring after a single event, much like an ankle sprain where you suddenly and forcefully roll your ankle, research shows that 40% to 80% of peroneal tears occur gradually over time, until it reaches a level where the painful symptoms become significant and professional help is sought. As such, common causes of peroneal tears include:

• Activities that involve repetitive movements of the foot and ankle, such as running, jumping, or dancing, due to the excessive stress that they can place on the peroneal tendons. This repetitive stress can weaken the tendons and make them more susceptible to tears, especially without adequate rest and recovery protocols.
  

• Your foot biomechanics. Having anatomical variations or abnormalities in foot structure can contribute to the development of peroneal tears by placing additional stress on the peroneal tendons. For example, in those with high arches or excessive pronation (flat feet).
  

• Ankle sprains are one of the most common causes of peroneal tears, particularly sprains where  the ankle rolls outward (eversion sprain). This is because during an ankle sprain, the peroneal tendons can be stretched or torn as a result of the sudden twisting motion.
  

• Wearing unsupportive footwear or shoes that do not provide adequate stability and cushioning can exacerbate your existing biomechanical issues and increase the likelihood of peroneal tears. 
  

• Having a history of ankle injuries or previous tears may make you more prone to experiencing recurrent tears. Weakness or scar tissue in the affected tendons can compromise their integrity and predispose them to further injury.
  

Symptoms Of Peroneal Tears

Symptoms of a peroneal tear can vary depending on the severity of the injury and may include:

• Pain along the outer edge of the ankle and foot which may be sharp or stabbing, especially during activities that involve ankle movement or weight-bearing. In milder cases, the pain may be intermittent or only present during specific movements (like those that twist the foot in and the ankle outwards), while in more severe tears, the pain may be constant and more intense.
  

• Swelling around the ankle and lower leg, that may be localised to the area over the injured tendon or may extend along the entire outer aspect of the ankle.
  

• Instability, or a feeling of "giving way" in the ankle. This happens because the damaged tendon(s) may no longer provide adequate support and stability to the ankle joint, leading to a sensation of instability, particularly during weight-bearing activities or changes in direction.
  

• Weakness in the ankle and foot muscles, particularly those involved moving the foot to face in and out at the ankle. The weakened muscles can contribute to decreased proprioception (awareness of joint position) and functional impairment, making it challenging to perform activities that require balance and coordination.
  

• In more severe cases of peroneal tears, bruising may develop around the ankle and foot due to bleeding within the tissues.
  

The severity of symptoms can vary depending on the extent of the tear and whether it involves partial or complete disruption of the tendon. In mild cases, you may experience relatively minor pain and swelling, with minimal impact on your mobility. In severe tears or complete ruptures of the tendon, symptoms may be more pronounced, with intense pain, significant swelling, and marked instability in the ankle.

Diagnosing A Peroneal Tear

Injuries to the peroneals are fairly straightforward to identify and diagnose after a clinical assessment and testing with our podiatrists during your appointment. As peroneal injuries can come in a range of forms (peroneal tendinopathy, an acute tendinitis, a peroneal tear of varying severities, and a peroneal tendon rupture), if we suspect that you have a peroneal tear specifically, then we may refer you for medical imaging to be able to get a complete picture of what is happening at your outer ankle. 

It is not uncommon for ultrasounds to reveal that alongside a partial tear, injury to the ankle stabilising ligaments has also occurred. This will confirm your diagnosis, and the information uncovered in your imaging will serve as a confident basis for your management plan, as well as a baseline to compare your progress and recovery against.

Treatment For Peroneal Tears

The home care for a peroneal tear is similar to that of peroneal tendinopathy, though you may wish to have more time resting and off your feet as the symptoms of a peroneal tear tends to be more severe and limiting to your daily life and ability to walk comfortably.

Start by following the PRICE principles: protection, rest, ice, compression and elevation. This will help you get some much needed relief from symptoms, while reducing the likelihood of worsening the tear - as it can grow larger, and even lead to a rupture.

Once you start working with a podiatrist, your treatment will then focus on ensuring you have everything you need for adequate healing and repair while the tear is present and the tendon is in its most vulnerable state. This will be followed by addressing the reasons that your tendons are being overloaded so that they can continue to recover and you don’t have to worry about this problem recurring again in the future. Your treatment with us will be tailored to your injury severity, symptoms and goals, and may involve:

• A moon boot or walker: if you have a significant tear or tendon rupture, a moon boot may be recommended to best support, add stability and importantly immobilise and restrict the movement at the ankle, so that the tendon can heal efficiently while no further undue stress is placed on it that may otherwise slow progress - or even do further damage. Moon boots have additional benefits in terms of the rigid outer acting as a protective barrier from external forces, reducing swelling, allowing you to stay somewhat mobile on your feet, and improving your overall comfort throughout your recovery. Our podiatrists can recommend the best boot for you, if clinically indicated.
  

• Custom foot orthotics: once you have achieved significant healing and repair (or if you only had a minor tear), then you may be prescribed custom foot orthotics to help reduce the strain on peroneal tendons while optimising your stability with every step. Your podiatrist will prescribe your orthotics to match the unique demands of your feet - whether that’s through greater shock absorption, higher sides at the heel for greater ankle stability, or a range of other features. This means your orthotics will actively be working to help prevent excess stress on the peroneals even after you have recovered from your tear.
  

• Footwear assessment to ensure that your shoes are providing adequate stability and support to the foot and ankle, and minimise any unwanted movement that may be increasing the stress through the peroneals.
  

• Footwear modifications: in some cases, we may opt to make modifications to your existing footwear to best support your foot and ankle and ensure your shoes are doing an adequate job of keeping your feet and ankles secure and stable as you move throughout your day.
  

• MLS laser: MLS is an effective form of pain relief that works in many ways - from helping minimise your pain levels, to supporting the repair and regeneration process, to optimising your recovery. With a peroneal tear, it can help make your recovery more comfortable while facilitating optimal healing and repair.
  
• Physical therapy: as you progress throughout your recovery and the tear has sufficiently healed, stretching and strengthening exercises will be prescribed appropriately to help address any muscle imbalances that may have contributed to your tear developing. This also helps with preventing future recurrence.
  

• Activity modifications: we may recommend some activity modifications throughout your recovery until there has been sufficient healing and repair, and your peroneals have regained sufficient strength. Examples of activities that may need to be temporarily modified include high impact interval training and sports with rapid changes in direction or side-to-side movements such as basketball, netball or tennis.
  

Surgery For Peroneal Tears

In severe cases of peroneal tears, such as complete ruptures or failed conservative treatment, surgical treatment may be necessary. Operative options may include tendon repair, reconstruction, or debridement, depending on the extent of the injury and your specific needs. 

Peroneal tear surgeries aim to repair or reconstruct the damaged peroneal tendons, restore ankle stability, and alleviate symptoms associated with the tear. Following peroneal tear surgery, the postoperative recovery and rehabilitation process typically involves promoting healing, restoring function, and optimising long-term outcomes. Initially, you’ll be instructed to rest and elevate the affected ankle to minimise swelling and discomfort. Physical therapy begins shortly after surgery, focusing on gentle range of motion exercises, strengthening of the surrounding muscles, and gradual reintroduction of weight-bearing activities. As the healing progresses, therapy advances to more challenging exercises to improve balance, proprioception, and functional mobility. Where clinically indicated, we can refer you to a trusted orthopaedic surgeon for further evaluation and assessment.

How To Prevent Peroneal Tendinopathy

When it comes to peroneal tendinopathy, prevention is always better than cure. If you know you’re at risk, such as if you play sports such as netball, basketball or tennis, we recommend:

• Regularly stretching the calf muscles, Achilles tendon, and plantar fascia to maintain flexibility and reduce tension on the peroneal tendons.
  

• Actively working to strengthen the muscles of the lower leg and foot, including the peroneals, anterior tibialis, and intrinsic foot muscles, to support ankle stability and proper foot biomechanics.
  

• Incorporating balance and proprioception training into your workout regimen, as having improved balance, proprioception, and coordination will go a long way in helping prevent ankle injuries, including peroneal tears.
  

• Taking a slow and steady approach to increasing your exercise or training intensity. Gradually increase the intensity, duration, and frequency of physical activity to avoid overloading the peroneal tendons and reduce the risk of overuse injuries.
  

• Wearing supportive footwear that provides adequate stability surrounding the ankle, as well as cushioning and arch support. If you’re not sure about whether your shoes are right or best suited to your feet and activity levels, see your podiatrist.
  

• Wearing your custom foot orthotics, if they have been prescribed to you by your podiatrist, any time you’re active on your feet. This includes walking to and from work.
  

• Always warming up before exercising to increase blood flow to the muscles and prepare them for activity. Similarly, cool down afterwards to promote muscle relaxation and reduce the risk of stiffness.
  

• Prioritising proper form and technique during physical activities, particularly those involving repetitive movements or changes in direction, to minimise the risk of injury to the peroneal tendons.
  

• Allowing adequate time for rest and recovery between workouts to prevent overuse injuries and give the peroneal tendons time to heal and adapt to training stress.
  

• Listening to your body - the best time to manage peroneal damage is in its earliest stages, before it has progressed to a tear. Stay mindful of your body and any early signs of discomfort or pain around your outer ankle. This will be the best time to protect your ankle and start your repair and recovery process, long before it has a chance to progress to a tear.
  

Frequently Asked Questions (FAQs)

How long does it take to recover from a peroneal tear?

The recovery time for a peroneal tear varies depending on factors such as the severity and location of the tear, your injury history and ankle strength, your overall health, and your adherence to your treatment and rehabilitation. In mild cases, recovery may take several weeks to a few months with conservative (non-surgical) management, including rest, physical therapy, and gradual return to activities. More severe tears or those requiring surgery may have a longer recovery period, lasting several months or more.

Can peroneal tears heal without surgery?

Yes, peroneal tears can sometimes heal without surgery, especially if they are mild or partial tears. Conservative treatments such as rest, immobilisation, custom foot orthotics, ankle braces, physical therapy, and activity modification may be sufficient to promote healing and alleviate symptoms. However, in cases of severe tears or complete ruptures, more aggressive treatment (including surgical intervention) may be necessary to repair or reconstruct the damaged tendons and restore ankle stability.

What are the long-term effects of untreated peroneal tears?

Untreated peroneal tears can lead to chronic pain, instability, weakness, and functional limitations in the ankle and foot. Untreated tears may also result in degenerative changes within the tendons and surrounding structures, increasing the risk of recurrent injuries and long-term complications such as tendonitis, arthritis, and ankle instability.

Are there specific exercises to prevent peroneal tears?

Yes, there is a range of exercises that can help strengthen the muscles surrounding the ankle and foot, improve balance and proprioception, and reduce the risk of peroneal tears. These exercises may include calf raises, ankle circles, resistance band exercises for ankle inversion and eversion, single-leg balance exercises, and proprioceptive drills such as standing on uneven surfaces. Your podiatrist can provide guidance on appropriate exercises based on your individual needs and risk factors.

How can I differentiate between a sprained ankle and a peroneal tear?

Remember that while a sprained ankle typically results from ligamentous injury due to sudden twisting or rolling of the ankle, a peroneal tear involves damage to the peroneal tendons that can occur in a range of ways, including gradual damage over time. As such, ankle sprains tend to be very noticeable and sudden as the foot is twisted in (and the ankle rolls out). This process may both sprain the ankle and damage the peroneals. With peroneal tears, similar outer ankle symptoms may come on gradually without a distinct causal ‘event’, and present symptoms including pain along the outer edge of the foot and ankle, weakness during eversion and dorsiflexion, and a feeling of "giving way" in the ankle.