Peroneal tendon pathology can range from mild synovitis/inflammation, to subluxation/snapping, to tearing/degeneration of the tendon. The surgical treatment is tailored to the conditions for the patient as in many cases, the problem is not isolated to the tendons. There can be associated damage to the ankle joint, loose ankle ligaments, and issues with the alignment of the foot.
In cases where the advanced imaging shows inflammation of the tendons (tenosynovitis) and nonoperative management has not provided relief, surgery can be considered. The surgery does require an incision on the outside of the ankle to identify the tendons and remove the inflamed tissue surrounding the tendons and causing the pain. If there is an accessory muscle - called the peroneus quartus, this is removed to minimize the risk of recurrent pain.
If there is a tendon tear - most commonly this is not a tear where the tendon is torn in half. The tears of the peroneal tendon most commonly are degenerative and an analogy we use is that it is akin to a rope that is unraveling/frayed. If this condition is encountered during surgery (MRI/US does not always accurately show a tear) then the unhealthy tissue is removed and the remaining tendon is repaired with suture.
If the quality of the tendon is so poor that it cannot be repaired, then there are two alternatives. One is called a tenodesis - where the damaged portion of the tendon is removed and the remaining portion is sewn to the healthy one. Given that the tendons work together for most of their function, this can be a good solution for many. In some patients, this may not be ideal and a graft can be used to reconstruct the damaged tendon so that you can maintain the independent function of both tendons. This requires more surgical dissection and requires the use of cadaveric tendon and is considered in very active / athletic patients.
In some cases, the tendons are snapping out of the back of the bone called the fibula (subluxation). In this situation, after the tendons are cleaned and repaired, the groove that the tendons are supposed to be sitting in is deepened (made more concave) so that the tendons do not continue to pop. The lining of the tendon is then tightened to ensure the tendons can still slide but do not snap/subluxate out of place.
If additional problems are noted such as ankle instability, cartilage injury (OCLT) or alignment issues of the foot, these may need to be addressed at the same time in order to provide a long-lasting solution. Many conditions of the foot and ankle have underlying biomechanical issues that are the cause of the problem and may need to be treated in order to maximize your functional outcome.
