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1 · SNAPSHOT

Peroneal Tendon Disorders body chart — Illustrative, not diagnostic. Canva body chart for Peroneal Tendon Disorders.

Who: Anyone who sprained an ankle and kept complaining. Cavovarus feet. Court and field sports.
What: Posterolateral pain, behind and below the fibula. Sometimes a snap.
How it behaves: Load-related, worse on uneven ground and push-off.

The one thing to take from this page:

It co-occurs with chronic ankle instability rather than competing with it.

Finding	Figure
Peroneal tenosynovitis at surgery for chronic ankle instability	47/61 = 77%
Attenuated peroneal retinaculum, same series	33/61 = 54%
Peroneus brevis tear, same series	15/61 = 25%
Patients with an ISOLATED lateral ligament injury	0 of 61
Peroneal pathology found intra-operatively in a second instability series	76/82 = 92.7% — but seen on MRI in only 40/82 = 48.8%

([1], peroneal sheath opened routinely in every case [2].)

The chronic ankle instability page names peroneal disorders as its key differential. This page is the other half of that conversation — and the honest answer is that the relationship is AND, not OR.

⚠️ No Australian guideline exists. Anchored to the ESSKA-AFAS consensus [3] — 16 specialists, 9 countries, Level of evidence V. Its own field states that treatment recommendations rest on case series and expert opinion.

Pattern > Label. Three entities share one location and one screening examination, and telling them apart is the whole job.

2 · SE — THE SUBJECTIVE PATTERN (the 70%)

Five stages, in your course's order.

MAIN PROBLEM

"The outside of my ankle still isn't right." Often months after a sprain that was "successfully managed".

BODY CHART

Posterolateral — behind and below the lateral malleolus, tracking toward the base of the fifth metatarsal.
Plantar-lateral midfoot instead? That is a different entity — see §3.
Lateral ligament pain sits more anteriorly. Both can be true.

HISTORY — the mechanism fork

This is a history question and it separates two of the three entities:

	Mechanism
Tendinopathy / tenosynovitis	Overuse. Insidious, load-related
Subluxation / dislocation	A single event — forceful peroneal contraction during sudden dorsiflexion while landing or abruptly stopping

[4]

And ask about the index sprain. "Patients usually give a history of previous ankle injury, which may have been misdiagnosed as a sprain" [5].

BEHAVIOUR

Aggs: uneven ground, push-off, cutting, running on cambered surfaces, prolonged walking.
Eases: flat ground, supportive footwear, offloading.
Severity: VAS 0–10 at best / at worst / right now.
Snapping, clicking or a sense the tendon moves — ask directly. See §3.
Irritability: resting symptoms, vigour, time to settle.

SPECIAL / SCREENING QUESTIONS

Previous ankle fracture — especially calcaneal or talar. See §4. Plus systemic features and inflammatory history.

The patient who "finished rehab" and didn't get better

Eight athletes over seventeen years, all with plantarflexion-inversion sprains, all successfully managed non-operatively, all with clinically stable ankles and no tendon instability — who kept complaining of lateral swelling, popping and retrofibular pain after rehabilitation. All eight had longitudinal tears of 1–3 cm; radiographs were normal [6].

That is the patient. Not the acute sprain — the one who came back.

Assessing this region? Download the Ankle & Foot assessment template →

3 · HYPOTHESIS RANKING

Competing pattern	The one discriminating feature
Chronic ankle instability	Giving way, and the CAIT — see that page. And it co-occurs 77–93% of the time
Lateral ankle sprain, acute	Anterior to the malleolus, acute mechanism
Painful os peroneum syndrome	Plantar-lateral midfoot, not retromalleolar. Resisted plantarflexion of the first ray, single-stance heel rise
Fifth metatarsal base avulsion	Focal bone tenderness at the base
Sural nerve	Burning, numbness, a different distribution
Osteochondral lesion	Deep joint pain, catching

Three ways a tendon snaps — and only one is visible

This is the page, and students have never heard of two of the three.

Entity	The discriminator	Visible?
Subluxation / dislocation	Displacement over the fibula, often on circumduction or plantarflexion-eversion. Traumatic — a retinacular failure	Yes
Intrasheath type A	The two tendons swap position inside the groove. Atraumatic	No
Intrasheath type B	Peroneus longus subluxates through a peroneus brevis split, still inside the groove. Atraumatic	No
Longitudinal split	Popping on active foot rotation in a clinically stable ankle with no tendon instability	No

"Both types can be missed on a physical examination" — Draghi et al. 2018 [7], of intrasheath instability. By definition, since nothing leaves the groove.

So: snapping tells you something is moving that shouldn't. It does not tell you which thing. Retinaculum, an intrasheath switch, or a split — all three snap, and only the first is visible.

Dynamic ultrasound is the only test that separates them [8]. Anterior instability follows traumatic retinacular injury; intrasheath subluxation is atraumatic.

Jones' hypothesis categories that change your plan: sources of symptoms — and accepting that the ligament and the tendon are usually both involved — plus contributing factors, which here means the foot.

A negative circumduction test does not clear the peroneals. Two of the three snapping entities are invisible.

4 · RED FLAGS — DON'T MISS THIS

This section is free, on every pattern, forever.

Signs / symptoms	Implication
Previous calcaneal fracture	Peroneal tendon dislocation in 24%, missed at presentation in 10 of 19
Previous talus fracture	Dislocation in 21.1% — and 39% of lateral process fractures
Acute dislocation after a single forceful event	Often misdiagnosed as a sprain. Conservative care fails often — §6
Plantar-lateral midfoot pain with resisted first-ray plantarflexion	Painful os peroneum syndrome — look for the sesamoid on radiograph
Focal tenderness at the fifth metatarsal base	Avulsion fracture
Complete loss of eversion strength	Complete tear

The fracture association is the flag worth knowing

Peroneal tendon dislocation hides inside a hindfoot fracture, and it is routinely missed.


Calcaneal fractures — 79 consecutive	Dislocation in 19 (24%), and initially missed in 10 of those 19
Pooled across 9 studies, 1,027 patients, 1,050 fractures	Overall 29.3% — Sanders I 5.4%, II 19%, III 39.4%, IV 49.5%
With a fleck sign present	54.7%
Talus fractures — 126 patients	21.1%; isolated talus fractures 16.7%; 39% of lateral process fractures

([9] [10]; and a talus series with avascular necrosis 30.4% vs 12.7% with versus without dislocation.)

A real denominator, and the same clinical lesson as the unsourced "40%" this page refuses to print.

Painful os peroneum syndrome — the named subset

A five-condition spectrum, from acute os peroneum fracture through chronic fracture with callus, attrition and partial rupture, to frank peroneus longus rupture and gigantic tubercle entrapment [11].

Tests named: single-stance heel rise, varus inversion stress, resisted plantarflexion of the first ray. No accuracy data for any of them.

Ask about previous hindfoot fractures. A quarter of calcaneal fractures have a dislocated peroneal tendon and half of those were missed.
Plantar-lateral midfoot pain is not retromalleolar pain. Different entity, different tests.
Complete loss of eversion strength is a tear until proven otherwise.

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Guideline anchor

No Australian guideline for this presentation.

Anchored to ESSKA-AFAS consensus on peroneal tendon disorders (van Dijk et al.)

PubMed

No Australian guideline or clinical care standard exists for peroneal tendon disorders.

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The evidence summary is for members

Verified diagnostic accuracy, where the evidence stands and what it doesn't settle. Free with an account.

Sources · 27

Show

Every source on this page resolves and title-verifies against PubMed. Newest first.

2000DIGiovanni et al. (2000). Associated injuries found in chronic lateral ankle instability. Foot & ankle international, 21(10), 809-15. https://doi.org/10.1177/107110070002101003
2022Clair et al. (2022). Open Evaluation of the Peroneal Tendons Should Be Considered in Patients With Chronic Lateral Ankle Instability Undergoing Ankle Arthroscopy With Lateral Ankle Stabilization. The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons, 61(6), 1177-1181. https://doi.org/10.1053/j.jfas.2021.10.020
2018van Dijk et al. (2018). The ESSKA-AFAS international consensus statement on peroneal tendon pathologies. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA, 26(10), 3096-3107. https://doi.org/10.1007/s00167-018-4971-x
2020Lugo-Pico et al. (2020). Peroneal Tendinosis and Subluxation. Clinics in sports medicine, 39(4), 845-858. https://doi.org/10.1016/j.csm.2020.07.005
2006Ferran et al. (2006). Recurrent subluxation of the peroneal tendons. Sports medicine (Auckland, N.Z.), 36(10), 839-46. https://doi.org/10.2165/00007256-200636100-00003
1993Bassett FH 3rd & Speer (1993). Longitudinal rupture of the peroneal tendons. The American journal of sports medicine, 21(3), 354-7. https://doi.org/10.1177/036354659302100305
2018Draghi et al. (2018). Intrasheath Instability of the Peroneal Tendons: Dynamic Ultrasound Imaging. Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine, 37(12), 2753-2758. https://doi.org/10.1002/jum.14633
2016Pesquer et al. (2016). Dynamic ultrasound of peroneal tendon instability. The British journal of radiology, 89(1063), 20150958. https://doi.org/10.1259/bjr.20150958
2015Wong-Chung et al. (2015). Incidence and recognition of peroneal tendon dislocation associated with calcaneal fractures. Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons, 21(4), 254-9. https://doi.org/10.1016/j.fas.2015.01.013
2018Mahmoud et al. (2018). Prevalence of Peroneal Tendon Instability in Calcaneus Fractures: A Systematic Review and Meta-Analysis. The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons, 57(3), 572-578. https://doi.org/10.1053/j.jfas.2017.11.032
1994Sobel et al. (1994). Painful os peroneum syndrome: a spectrum of conditions responsible for plantar lateral foot pain. Foot & ankle international, 15(3), 112-24. https://doi.org/10.1177/107110079401500306
2021Taniguchi et al. (2021). Association of Cavovarus Foot Alignment With Peroneal Tendon Tears. Foot & ankle international, 42(6), 750-756. https://doi.org/10.1177/1071100721990348
2013Giza et al. (2013). A clinical and radiological study of peroneal tendon pathology. Foot & ankle specialist, 6(6), 417-21. https://doi.org/10.1177/1938640013501544
2022Deu et al. (2022). Tendinopathies of the Foot and Ankle. American family physician, 105(5), 479-486. PubMed 35559641
2020Bakker et al. (2020). Non-operative treatment of peroneal tendon dislocations: A systematic review. Journal of orthopaedics, 18, 255-260. https://doi.org/10.1016/j.jor.2019.08.031
2019Fram et al. (2019). Clinical Outcomes and Complications of Peroneal Tendon Sheath Ultrasound-Guided Corticosteroid Injection. Foot & ankle international, 40(8), 888-894. https://doi.org/10.1177/1071100719847629
2019van Dijk et al. (2019). Chronic Disorders of the Peroneal Tendons: Current Concepts Review of the Literature. The Journal of the American Academy of Orthopaedic Surgeons, 27(16), 590-598. https://doi.org/10.5435/JAAOS-D-18-00623
2017Davda et al. (2017). Peroneal tendon disorders. EFORT open reviews, 2(6), 281-292. https://doi.org/10.1302/2058-5241.2.160047
2010O'Neill et al. (2010). Is MRI adequate to detect lesions in patients with ankle instability?. Clinical orthopaedics and related research, 468(4), 1115-9. https://doi.org/10.1007/s11999-009-1131-0
2010Park et al. (2010). Reliability of MRI findings of peroneal tendinopathy in patients with lateral chronic ankle instability. Clinics in orthopedic surgery, 2(4), 237-43. https://doi.org/10.4055/cios.2010.2.4.237
2019Hudson et al. (2019). Preoperative Assessment of the Peroneal Tendons in Lateral Ankle Instability: Examining Clinical Factors, Magnetic Resonance Imaging Sensitivity, and Their Relationship. The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons, 58(2), 208-212. https://doi.org/10.1053/j.jfas.2018.07.008
2015Mirmiran et al. (2015). Prevalence and Role of a Low-Lying Peroneus Brevis Muscle Belly in Patients With Peroneal Tendon Pathologic Features: A Potential Source of Tendon Subluxation. The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons, 54(5), 872-5. https://doi.org/10.1053/j.jfas.2015.02.012
2011Saxena et al. (2011). Magnetic resonance imaging and incidental findings of lateral ankle pathologic features with asymptomatic ankles. The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons, 50(4), 413-5. https://doi.org/10.1053/j.jfas.2011.03.011
2015Galli et al. (2015). An examination of anatomic variants and incidental peroneal tendon pathologic features: a comprehensive MRI review of asymptomatic lateral ankles. The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons, 54(2), 164-72. https://doi.org/10.1053/j.jfas.2014.11.005
2026Gür et al. (2026). Double-Convex Peroneal Tubercle Morphology and MRI-Detected Peroneal Tendon Abnormality in a Non-Lateral Referral Cohort. Diagnostics (Basel, Switzerland), 16(8). https://doi.org/10.3390/diagnostics16081184
2015Yammine (2015). The accessory peroneal (fibular) muscles: peroneus quartus and peroneus digiti quinti. A systematic review and meta-analysis. Surgical and radiologic anatomy : SRA, 37(6), 617-27. https://doi.org/10.1007/s00276-015-1438-3
2026Tham et al. (2026). Peroneal tendoscopy for peroneal tendon disorders: A systematic review of indications, diagnostic utility, and clinical outcomes. Journal of orthopaedics, 74, 24-32. https://doi.org/10.1016/j.jor.2025.12.057

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