Injury of an ankle tendon can be debilitating. What is a tendon? What are the peroneal tendons? What is ankle tendon surgery? How long does it take to recover from ankle tendon surgery?
There are multiple tendons in the ankle and this post will focus exclusively on the peroneal brevis and longus ankle tendons.
What is a Tendon?
A strong band of connective tissue that connects muscle to bone.
What are the Peroneal Tendons?
The peroneal longus and the peroneal brevis tendons are important stabilizers in the ankle. The peroneal longus tendon travels around the outside ankle bone, dives underneath the base of the foot, and attaches to the first metatarsal (1). The peroneal brevis is a shorter and smaller tendon that lies underneath the peroneal longus. It too travels on the outside of the ankle bone but attaches to the base of the small bone on the outside of the foot (5th metatarsal) (2). The peroneal longus and brevis muscles and tendons are critical to the flexion of the foot and lateral stabilization of the ankle. The peroneal longus also provides important support of the arch.
Lateral ankle sprains are common acute musculoskeletal injuries and can result in injuries to the ankle tendons. The peroneal tendons are especially vulnerable (3). Ankle sprains can cause instability of the ankle joint. Instability of the ankle joint can lead to inflammation of the ankle tendons termed tendinitis. If chronic, additional degeneration and small tears in the ankle tendon can occur called tendinosis. If left untreated, tendinosis can lead to partial or full-thickness tears in the ankle tendon. Symptoms vary depending upon the severity of the injury but may include ankle pain, swelling, and instability.
Ankle Tendon Surgery
Depending on the severity of the tendon injury, different surgical treatment options are used (4). If the tear involves less than 50% of the tendon, a cleanout and suture repair are recommended. If more than 50% of the tendon is torn, the tendon is typically re-attached to the adjacent peroneal tendon. In the case of a complete rupture, the two ends of the tendon are sutured together.
How Long Does It Take to Recover from ankle tendon surgery?
The short answer is months. Immobilization of the ankle is required after surgery and varies with the type of surgery. The mean duration of immobilization after clean up and suture repair is 6.0 weeks whereas the transfer of the tendon to an adjacent tendon requires 7.0 weeks. 8 weeks is required with tendon rupture repair (5). Patients are non-weight bearing for 4 weeks on average requiring the use of crutches or a walker. Rehabilitation is extensive and takes time.
Return to work is important. Results vary with the severity of injury and type of surgery. In a recent study of 41 patients who underwent ankle tendon surgery for peroneal tears, the mean return to work time was 3.6 months (6). Return to sports is also important. In a different study that followed thirty patients who underwent ankle tendon surgery, nearly all patients were able to return to work, but only 46% were able to successfully return to sports at an average of 31 months after surgery (7). Residual symptoms were common as 58% had scar tenderness and 54% had lateral ankle swelling.
The Current Patient Dilemma
Most patients are led to believe that they have a massive tendon tear that requires surgery which unfortunately is not always the case. The type of tendon tear is important as there are three different types: partial thickness, full-thickness, and full-thickness tear with retractions. A partial-thickness tear is a tear that involves only a portion of the tendon whereas a full-thickness tear extends across the entire tendon. A retraction occurs when the tear extends across the entire tendon and the two ends are physically pulled apart. MRI reports oftentimes do not differentiate the type or the extent of the ankle tendon tear. Some surgeons do not look at the actual MRI but rely upon the formal report by the radiologist. Regrettably, this does not serve the patient or their ability to determine the best treatment plan. What is a patient to do? Make an appointment with an Interventional Orthopedic physician who will perform an ankle ultrasound. The ultrasound will determine the type of tendon tear, the extent of the tear, and the stability of the ankle joint. The latter is achieved by a stress ultrasound examination which is critical. Recall that ankle sprains can lead to instability, tendinitis and if left untreated tendon tears. To learn more about the use of ultrasound in ankle injuries please click on the video below.
Non-Surgical Treatment Options
Not all ankle tendons tears require surgery. PRP injections are effective in the treatment of tendon injuries (8). Both laboratory and clinical studies suggest stem cells can contribute to accelerate and improve the quality of tendon healing (9). At the Centeno-Schultz Clinic, we have extensive experience in the treatment of ankle tendon injuries with both PRP and bone marrow-derived stem cells. All injections are performed under ultrasound to ensure the best clinical outcome. The procedures are demanding and require extensive training. To better understand please watch the video below that highlights the use of PRP in the treatment of an ankle ligament and tendon injury.
In Conclusion
Ankle tendon injuries can be debilitating. A tendon is a connective tissue that connects muscle to bone. The peroneal brevis and longus are important ankle tendons that are responsible for foot flexion and ankle stability. Lateral ankle sprains are common injuries that can predispose the ankle tendons to inflammation and tears. Ankle tendon surgery requires immobilization and rehabilitation both of which are extensive. Return to sports is not possible for all. Understanding the exact type of tendon tear along with the stability of the ankle joint is critical. Precise ultrasound-guided PRP and stem cell and stem cell injections are effective non-surgical options.
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2. Dombek MF, Orsini R, Mendicino RW, Saltrick K. Peroneus brevis tendon tears. Clin Podiatr Med Surg. 2001;18(3):409-27.
3. Boruta PM, Bishop JO, Braly WG, Tullos HS. Acute lateral ankle ligament injuries: a literature review. Foot Ankle. 1990;11(2):107-13.DOI: 10.1177/107110079001100210
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5. van Dijk PA, Lubberts B, Verheul C, DiGiovanni CW, Kerkhoffs GM. Rehabilitation after surgical treatment of peroneal tendon tears and ruptures. Knee Surg Sports Traumatol Arthrosc. 2016;24(4):1165-74. DOI: 10.1007/s00167-015-3944-6
6. Saxena A, Cassidy A. Peroneal tendon injuries: an evaluation of 49 tears in 41 patients. J Foot Ankle Surg. 2003;42(4):215-20. DOI: 10.1053/jfas.2003.50028
7. Steel MW, DeOrio JK. Peroneal tendon tears: return to sports after operative treatment. Foot Ankle Int. 2007;28(1):49-54. DOI: 10.3113/FAI.2007.0009
8. Di Matteo B, Filardo G, Kon E, Marcacci M. Platelet-rich plasma: evidence for the treatment of patellar and Achilles tendinopathy–a systematic review. Musculoskelet Surg. 2015;99(1):1-9. DOI: 10.1007/s12306-014-0340-1
9. Costa-Almeida R, Calejo I, Gomes ME. Mesenchymal Stem Cells Empowering Tendon Regenerative Therapies. Int J Mol Sci. 2019;20(12):E3002. DOI: 10.3390/ijms20123002
