Indications for Peroneal Tendon Surgery

Peroneal tendon tears that fail to respond to a dedicated 3–6 month course of conservative management — structured physical therapy with eccentric peroneal strengthening, custom orthotics controlling hindfoot valgus, and relative rest from provocative activity — are appropriate candidates for surgical intervention. Additional indications include: peroneal tendon subluxation or dislocation (which reliably fails conservative management), complete peroneal tendon rupture producing weakness and instability, and symptomatic peroneal tendon tears in the context of chronic lateral ankle instability requiring concurrent ligament reconstruction.

The specific surgical procedure performed depends on the nature, severity, and extent of tendon pathology identified intraoperatively after full inspection, as well as the presence of associated anatomical factors (shallow fibular groove, loose retinaculum, low-lying peroneus brevis muscle belly) that require concurrent treatment.

Preoperative Planning

Surgical planning begins with thorough preoperative imaging. MRI characterizes the extent of longitudinal split tears — the percentage of the tendon cross-section involved — guides the decision between primary tubularization repair (for tears less than 50% cross-sectional) and tenodesis (for tears greater than 50%). Ultrasound dynamic assessment confirms subluxation and characterizes retinacular integrity. Standing X-rays identify associated hindfoot valgus that may require concurrent calcaneal osteotomy for comprehensive correction, preventing rapid retear from biomechanical overload after tendon repair.

Surgical Approach

Peroneal tendon surgery is performed through a curvilinear incision posterior and inferior to the lateral malleolus, centering over the fibular groove where the tendons run in their shared sheath. The incision length varies from 4–8 cm depending on the extent of exploration needed. The sural nerve runs in the vicinity of this incision and must be identified and protected throughout the procedure to prevent iatrogenic sural neuritis — a recognized complication of peroneal tendon surgery.

The peroneal sheath is opened longitudinally along its inferior border. Both tendons are systematically inspected from proximal to distal through their retinacular tunnel, assessing for longitudinal tears, degenerative nodularity, areas of constriction, and subluxation from the groove.

Tubularization: Repairing Split Tears

For peroneus brevis split tears involving less than 50% of the cross-section with viable margins:

The split tear edges are carefully debrided using sharp scissors to remove degenerative tissue until only healthy tendon collagen remains at the tear margins. The debridement must be thorough but conservative — excessive debridement reduces the amount of viable tissue available for repair. The debrided split edges are then approximated with running or interrupted absorbable sutures (typically 3-0 PDS or Vicryl), closing the split and reconstituting the tendon’s tubular cross-section. A smooth, uniform tendon diameter is confirmed visually and by passing the tendon through the groove under direct vision to ensure no constriction remains.

Tenodesis: Managing Extensive Tears

When peroneus brevis tears exceed 50% cross-sectional involvement, or when the damaged segment is so extensive or irregular that primary tubularization would leave an inadequate tendon cross-section, tenodesis is performed:

The damaged brevis segment — often a central or distal portion of the tendon — is excised using scissors and scalpel. The proximal brevis stump (from the musculotendinous junction down to the excision site) and the distal brevis stump (from the excision site to the fifth metatarsal insertion) are each sutured directly to the adjacent peroneus longus tendon using Pulvertaft weave technique — a fish-mouth interlocking suture configuration that provides secure fixation. This ‘siameses’ the brevis remnants to the longus, transferring mechanical load to the intact longus while eliminating the damaged brevis segment. Peroneal function is maintained through the longus, with modest reduction in pure eversion strength.

Retinaculum Repair and Groove Deepening

The superior peroneal retinaculum — torn in subluxation or subluxation-associated tears — is repaired by plicating the remaining retinacular tissue with non-absorbable sutures, creating a tight fibrous restraint against re-subluxation. If the fibular groove is anatomically shallow (a predisposing factor for both subluxation and attritional tearing), groove deepening is performed with a burr, creating a deeper trough that mechanically contains the tendons more securely. The combination of tendon repair, groove deepening, and retinacular plication addresses all contributors to the pathology in a single procedure.

Concurrent Procedures

Peroneal tendon surgery is frequently combined with ancillary procedures addressing associated conditions:

• Lateral ligament reconstruction (modified Broström-Gould) for concurrent chronic ankle instability — a very common association, as ankle instability increases peroneal tendon shear stress and predisposes to tears
• Calcaneal osteotomy for hindfoot valgus — corrects the biomechanical alignment that overloads the lateral ankle structures
• Peroneal groove deepening when shallow groove morphology is the primary predisposing factor

Postoperative Recovery

Non-weight-bearing for 2 weeks post-operatively is followed by transition to a walking boot at 2–6 weeks (timing depends on the procedure performed). Physical therapy begins at 6–8 weeks and focuses on progressive peroneal strengthening, proprioceptive retraining, and functional return. Return to sport typically requires 4–6 months following isolated tendon repair, and 5–8 months when concurrent ligament reconstruction or osteotomy is performed. Outcomes are generally good to excellent for appropriately selected patients with well-executed technique — 80–90% report significant improvement in pain and function, with most returning to pre-injury activity levels.

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Dr. Tom Biernacki, DPM is a double board-certified podiatrist and foot & ankle surgeon at Balance Foot & Ankle Specialists in Southeast Michigan. With over a decade of clinical experience, he specializes in heel pain, bunions, diabetic foot care, sports injuries, and minimally invasive surgery. Dr. Biernacki is a member of the APMA and ACFAS, and his patient education content on MichiganFootDoctors.com and YouTube has reached over one million views.