import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' **Location**: Runs with lesser saphenous vein in subcutaneous tissue, 1-2cm POSTERIOR to lateral malleolus **Protection**: Identify early during superficial dissection, tag with vessel loop, retract posteriorly throughout case **Location**: Branch from sural nerve approximately 6-8cm proximal to lateral malleolus, course toward heel **Protection**: Preserve during subcutaneous dissection, gentle retraction if encountered **Location**: Deep to peroneal tendons, runs from fibular tip to lateral calcaneus at 45-degree angle **Protection**: Avoid excessive dissection anterior to tendons, preserve during SPR reconstruction and groove deepening **Location**: Lies deep to peroneal tendons in posterior compartment, approximately 2-3cm anterior to fibula at proximal exposure **Protection**: Limit deep dissection anterior to tendons, stay within tendon sheath plane **Location**: Thin posterior cortical wall of distal fibula - can be violated during aggressive groove deepening **Protection**: Deepening to 4-5mm only, avoid penetrating anterior cortex, preserve structural integrity ## Indications **Primary Indications for Peroneal Tendon Surgery** **Tendon Tears:** - Peroneal brevis longitudinal split tears with >50% tendon involvement - Complete or partial rupture of peroneal brevis or longus - Failed conservative management (3-6 months) for symptomatic tears - Acute complete ruptures in young athletic patients **Peroneal Subluxation/Dislocation:** - Symptomatic peroneal tendon subluxation/dislocation - Superior Peroneal Retinaculum (SPR) insufficiency or rupture - Shallow fibular groove (<2mm depth) with recurrent subluxation - Failed conservative management with bracing/physical therapy **Combined Pathology:** - Peroneal tendinosis with >50% tendon degeneration requiring debridement - Concurrent lateral ankle instability requiring combined reconstruction - Os peroneum fracture with peroneus longus rupture - Revision cases after failed prior repair **Contraindications:** - Active infection - Severe peripheral vascular disease - Inadequate soft tissue envelope - Medical comorbidities precluding surgery - Patient unwilling to comply with postoperative restrictions ## Preoperative Planning **Clinical Assessment:** - **History**: Lateral ankle pain, weakness, sensation of snapping/popping with activity - **Mechanism**: Acute dorsiflexion/eversion injury (subluxation) vs chronic repetitive microtrauma (tears) - **Physical exam**: Palpate tendons for subluxation (reproduce with active eversion/dorsiflexion), tenderness at fibular tip, lateral ankle stability testing (anterior drawer, talar tilt) **Imaging:** - **Radiographs**: AP, lateral, mortise views - assess for os peroneum, shallow fibular groove, ankle arthritis - **MRI**: ESSENTIAL for surgical planning - identify tear pattern (longitudinal vs rupture), degree of tendinosis, SPR status, fibular groove morphology, measure tendon quality/cross-sectional area - **Ultrasound**: Dynamic assessment of subluxation if available **Surgical Planning:** - Determine repair vs reconstruction based on MRI (>50% involvement = augmentation) - Assess for concurrent lateral ankle instability (combined procedure) - Identify tear location (fibular tip vs os peroneum vs cuboid tunnel) - Plan for FDL harvest if reconstruction likely - Consent for possible allograft if tissue inadequate **Patient Counseling:** - Success rate 85-90% for repairs, 80-85% for subluxation reconstruction - Sural nerve numbness risk 5-15% - Return to sport 4-6 months - Immobilization and restricted weight-bearing requirements ## Surgical Anatomy **Peroneal Tendons:** - **Peroneus Brevis**: Originates distal fibula, inserts base of 5th metatarsal, ANTERIOR and SUPERFICIAL in fibular groove - **Peroneus Longus**: Originates proximal fibula and lateral tibial condyle, courses plantar to cuboid in cuboid tunnel, inserts base of 1st metatarsal and medial cuneiform, POSTERIOR and DEEP in fibular groove - **Function**: Primary ankle evertors, assist with plantarflexion, dynamic lateral ankle stabilizers **Superior Peroneal Retinaculum (SPR):** - Fibrous band spanning from posterolateral fibula to lateral calcaneus - Located 2-4cm proximal to fibular tip - PRIMARY restraint preventing peroneal subluxation - Most commonly tears from fibular insertion (85%), less commonly calcaneal or midsubstance **Fibular Groove:** - Retromalleolar sulcus on posterior fibula - Normal depth >2mm (measured on axial MRI or CT) - Shallow groove <2mm predisposes to subluxation and tendon impingement - Posterolateral ridge can cause brevis impingement and longitudinal splits **Neurovascular Structures:** - **Sural nerve**: 1-2cm posterior to lateral malleolus with lesser saphenous vein, variable anatomy - **Lateral calcaneal branches**: Branch 6-8cm proximal to malleolus toward heel - **Peroneal artery**: Deep in posterior compartment, 2-3cm anterior to fibula proximally ## Patient Positioning **Position**: Lateral decubitus with affected side up - Bean bag stabilization - Axillary roll under dependent axilla - Padding for down-side leg (peroneal nerve at fibular neck) - Padding for all prominent areas - Sandbag or bump under ankle to position fibula for optimal access **Tourniquet**: Thigh tourniquet, inflate to 300mmHg after exsanguination **Preparation**: - Prep entire leg circumferentially from toes to mid-thigh - Drape to allow full access to lateral ankle, foot, and medial ankle (for FDL harvest if needed) **Preoperative Marking**: - Lateral malleolus - Course of peroneal tendons (palpate in fibular groove) - Sural nerve location (approximate based on anatomy) - Calcaneofibular ligament - Mark incision 6cm proximal to 4-6cm distal to lateral malleolus ## Surgical Approach **Incision**: - Longitudinal incision 10-12cm centered over lateral malleolus - Extends 6cm proximal to 4-6cm distal to fibular tip - Curved slightly posterior to fibular tip - Positioned directly over peroneal tendons in fibular groove - Allows exposure of entire retrofibular space, SPR, and distal tendon course **Approach Type**: Direct posterolateral approach to fibula along course of peroneal tendons **Interval**: Between subcutaneous tissue and peroneal tendon sheath (not a true internervous plane) ## Step-by-Step Operative Technique ### Step 1: Incision and Superficial Dissection **Technique**: - Make longitudinal incision 10-12cm, centered over lateral malleolus, extending 6cm proximal to 4-6cm distal - Position incision slightly posterior to fibular tip, directly over palpable peroneal tendons - Sharpen skin incision with scalpel - Careful subcutaneous dissection to identify and protect sural nerve **Critical Anatomy**: Sural nerve runs with lesser saphenous vein in subcutaneous tissue, 1-2cm posterior to lateral malleolus **Sural Nerve Protection**: The sural nerve is the MOST COMMON structure injured in this procedure (5-15% incidence). Identify it early by finding the lesser saphenous vein and dissecting carefully around it. Tag the nerve with a vessel loop and maintain gentle posterior retraction throughout the case. The nerve has variable anatomy - may be multiple branches. Lateral calcaneal branches course toward the heel and must be preserved. - Sural nerve injury causing lateral foot numbness and painful neuroma (most common complication) - Lateral calcaneal branch injury causing heel numbness - Inadequate incision length limiting exposure for tendon work - Incision too anterior (over fibula) or too posterior (missing tendons) ### Step 2: Superior Peroneal Retinaculum (SPR) Exposure **Technique**: - Identify SPR as fibrous band 2-4cm proximal to fibular tip - Assess SPR integrity: intact, attenuated (Grade 1), partial tear (Grade 2), or complete tear (Grade 3) - If torn, identify tear pattern: fibular avulsion (most common 85%), calcaneal avulsion, or midsubstance - Tag torn SPR edges with sutures for later repair - In subluxation cases, tendons may sublux anterior to fibula with ankle manipulation **SPR Tear Patterns**: The SPR is the PRIMARY restraint to peroneal subluxation. It most commonly tears from its fibular insertion (85%) due to the force vector during subluxation. Less commonly, it tears from the calcaneal insertion or in the midsubstance. Complete tears (Grade 3) require reconstruction - simple repair of attenuated tissue will fail. Remember to assess the fibular groove depth as well - shallow groove (<2mm) may require groove deepening in addition to SPR repair. - Not recognizing SPR tear pattern leading to inadequate repair selection - Iatrogenic injury to intact SPR if not carefully dissected - Missing shallow fibular groove (SPR repair alone will fail if groove inadequate) - Over-aggressive dissection damaging local tissue needed for augmentation ### Step 3: Peroneal Tendon Sheath Opening **Technique**: - Incise peroneal tendon sheath longitudinally from proximal to distal - Open sheath widely to fully expose both brevis and longus tendons - Perform synovectomy of inflamed synovium to improve visualization - Inspect tendons throughout entire exposed length - Identify both tendons: brevis is ANTERIOR and SUPERFICIAL, longus is POSTERIOR and DEEP **Tendon Identification**: Critical to correctly identify brevis vs longus. Brevis is ANTERIOR (closer to fibula) and SUPERFICIAL, inserts at base of 5th metatarsal. Longus is POSTERIOR (toward Achilles) and DEEP, courses plantar under foot. To confirm: trace distally - brevis stays superficial to 5th MT, longus dives plantar at cuboid. Proximally, brevis originates on distal fibula, longus on proximal fibula. Most tears are in brevis. - Confusing brevis and longus leading to wrong tendon being treated - Incomplete sheath opening missing proximal or distal extent of tear - Excessive synovectomy causing postoperative adhesions - Not opening sheath distally enough to assess full tear extent ### Step 4: Tendon Tear Assessment **Technique**: - Systematically inspect both tendons for tears - Identify tear pattern: - Longitudinal split (most common in brevis, appears like split book pages) - Complete rupture with gap - Partial tear with >50% cross-section involved - Assess tendon quality: good tissue (pink, firm, normal caliber) vs poor tissue (grey, friable, thin, degenerative) - Measure extent: <50% = primary repair, >50% = augmentation needed - Debride degenerative tissue back to healthy bleeding tendon edges **Decision Making - Repair vs Reconstruction**: The critical threshold is 50% tendon involvement. Less than 50% with good tissue quality can be tubularized with primary repair. More than 50% involvement, poor tissue quality, or complete rupture requires augmentation (FDL transfer preferred) or allograft. Don't attempt primary repair of >50% tears - high failure rate. FDL transfer is the GOLD STANDARD for reconstruction with 85-90% success rate. - Underestimating tear extent leading to inadequate debridement and repair failure - Over-debriding creating a larger defect than necessary - Missing tear in the second tendon (both can be injured) - Not identifying longitudinal splits that appear subtle but extend significantly ### Step 5: Primary Repair (if <50% involvement, good tissue) **Technique**: - For tears involving <50% of tendon cross-section with good tissue quality - Tubularize the longitudinal split with side-to-side repair - Use 2-0 or 3-0 absorbable suture (Vicryl or similar) - Running locked stitch technique (Krackow or baseball stitch) - Repair entire length of split, typically 4-6cm - Maintain normal tendon tension (compare to intact longus if available) - Create smooth tubular contour without bunching or gaps - Test gliding in fibular groove - should move smoothly without catching **Tubularization Technique**: Goal is to restore the normal tubular shape and tensile strength. Use a running locked stitch (Krackow provides best strength, baseball stitch easier/faster). Avoid over-tightening which restricts motion and creates a bulky repair that catches in the groove. Avoid under-tensioning which leaves gaps that fail. The repaired tendon should be slightly thinner than the original due to loss of degenerate tissue. Test gliding before proceeding - if it catches, the repair is too bulky. - Over-tightening creating a tendon that's too short and restricted motion - Under-tensioning leaving gaps that will fail under load - Repair too bulky causing impingement and pain in fibular groove - Attempting primary repair when >50% involved (will fail - need augmentation) ### Step 6: FDL Transfer for Augmentation (if >50% involvement) **Technique**: - For tears >50% cross-section, poor tissue quality, or complete rupture - Make separate 3-4cm medial incision posterior to medial malleolus - Identify neurovascular bundle (protect posterior tibial nerve and artery) - Identify FDL tendon (posterior to FHL, anterior to Achilles) - Harvest FDL with adequate length (divide distally, retrieve proximally) - Return to lateral side - Create bone tunnel in distal fibula (5mm drill, posterior to lateral malleolus) OR use 3.0-3.5mm suture anchor - Weave FDL through/around remaining peroneal tendon tissue - Pass FDL through bone tunnel or secure with anchor - Tension FDL to restore eversion strength (compare to contralateral) - Tenodese FDL to remaining peroneal tissue with multiple interrupted sutures - Test eversion strength and gliding before proceeding **FDL Transfer - Gold Standard**: FDL transfer is preferred over allograft because it's autologous, strong, and motor function is preserved (FHL compensates for FDL loss at the toes - patients don't notice functional deficit). Technique: weave FDL through remaining peroneal tissue to maximize contact surface area, then anchor to distal fibula with bone tunnel or suture anchor. Tension with ankle in neutral - too tight restricts motion, too loose weak eversion. Success rate 85-90%. Alternative: peroneus longus to brevis transfer if longus intact and brevis destroyed. - Inadequate FDL harvest length requiring excessive tension or inability to complete reconstruction - Injury to posterior tibial neurovascular bundle on medial side (devastating complication) - FDL transfer too tight causing restricted ankle motion and pain - FDL transfer too loose providing inadequate eversion strength - Anchor or bone tunnel pullout due to poor fixation or osteoporotic bone ### Step 7: Fibular Groove Deepening (if shallow groove) **Technique**: - Assess fibular groove depth (normal >2mm, shallow <2mm) - If shallow: deepen groove to improve tendon tracking and prevent impingement - Use curved osteotome or burr to remove posterolateral bony ridge - Create U-shaped groove 4-5mm deep, 8-10mm wide - Smooth all sharp edges with rongeur or burr - Avoid penetrating anterior cortex - Copiously irrigate to remove bone debris - Reassess tendon tracking in deepened groove **Groove Deepening Controversy**: Shallow fibular groove (<2mm) is a predisposing factor for both subluxation and brevis tears (impingement on posterolateral ridge). Deepening the groove removes the impingement point and improves tracking. However, aggressive deepening risks fibular fracture (rare but reported). Many surgeons prefer SPR reconstruction over groove deepening due to fracture risk. If performing groove deepening, limit depth to 4-5mm maximum and preserve anterior cortex. Alternative: use groove deepening in combination with SPR reconstruction for severe cases. - Fibular fracture from over-aggressive deepening (rare <1% but catastrophic) - Penetrating anterior fibular cortex violating ankle joint - Creating groove too wide, weakening fibula and destabilizing CFL attachment - Not removing enough bone leaving persistent shallow groove and impingement - Thermal injury from burr (use irrigation, intermittent contact) ### Step 8: Superior Peroneal Retinaculum Reconstruction **Technique**: - For Grade 3 SPR tears (complete rupture) or Grade 2 with poor tissue - **Direct Repair Technique** (most common): - Place 1-2 suture anchors (3.0mm) at posterior fibular insertion site - Pass sutures through torn SPR tissue - Tie with ankle in neutral, slight eversion - Alternatively: drill transosseous tunnels through fibula, pass sutures - **SPR Augmentation Technique** (for poor tissue quality): - Use local tissue (strip of Achilles sheath or peroneal sheath) - Weave augmentation through native SPR - Secure to fibula and calcaneus - **Bone Block Technique** (less common): - Create fibular bone flap (posterior cortex) - Elevate and rotate over tendons - Secure with screw - Test stability: tendons should remain posterior to fibula through dorsiflexion/eversion **SPR Reconstruction Technique Selection**: Direct repair with suture anchors is most common and effective for acute tears with good tissue. Transosseous sutures through drill holes are traditional alternative (cheaper, no hardware). SPR augmentation needed for chronic tears with attenuated, poor-quality tissue. Bone block technique rarely used now due to complexity and hardware issues. Key: tension the SPR with ankle in neutral and slight eversion - over-tightening restricts eversion and causes pain, under-tightening allows persistent subluxation. - SPR repair too tight restricting eversion and causing lateral pain - SPR repair too loose allowing recurrent subluxation (10-15% failure rate) - Suture anchor penetration through anterior fibular cortex - Not addressing shallow groove (SPR repair alone may fail if groove <2mm) - Anchor pullout in osteoporotic bone ### Step 9: Intraoperative Testing **Technique**: - Before closure, perform comprehensive testing: - **Gliding test**: Plantarflex and dorsiflex ankle, evert foot - tendons should glide smoothly without catching or bunching - **Stability test**: Dorsiflex and evert ankle - tendons should remain posterior to fibula, no subluxation - **Strength test**: Manually resist eversion - should have good strength, compare to contralateral - **ROM test**: Full ankle dorsiflexion, plantarflexion, inversion, eversion - no restriction or pain - If subluxation persists, revise SPR or consider groove deepening - If gliding restricted, check for repair too bulky or over-tight - If weak eversion, check FDL transfer tension **Importance of Intraoperative Testing**: Testing before closure is ESSENTIAL to identify problems that can be immediately corrected. Persistent subluxation indicates inadequate SPR reconstruction or shallow groove requiring revision. Restricted gliding suggests repair too bulky or tight requiring revision. Weak eversion suggests FDL transfer too loose or inadequate fixation. Testing under anesthesia may give false reassurance - some problems only apparent when patient awake, but major issues should be evident intraoperatively. - Missing persistent subluxation leading to early failure - Not recognizing over-constraint causing postoperative stiffness and pain - False reassurance from testing under anesthesia (muscle relaxation) - Not testing full ROM and strength adequately ### Step 10: Closure and Postoperative Immobilization **Technique**: - Close tendon sheath loosely with absorbable suture (3-0 Vicryl, simple interrupted) - Avoid tight sheath closure (causes adhesions and restricted gliding) - Close subcutaneous tissue with absorbable suture (3-0 Vicryl) - Skin closure with nylon interrupted or subcuticular absorbable - Drain placement optional (if significant bleeding risk or dead space) - Apply well-padded short leg splint with ankle in neutral, slight eversion - Compression dressing **Immobilization Position**: Position ankle in NEUTRAL with SLIGHT EVERSION to protect the repair. Excessive plantarflexion or eversion can overload repair. Excessive dorsiflexion or inversion can stress the repair. Neutral with slight eversion is optimal. NWB for 2 weeks for wound healing. Then WBAT in CAM boot for total of 6 weeks immobilization to protect tendon healing (tendon healing takes 6-8 weeks). - Tight sheath closure causing adhesions and stiffness - Inadequate skin closure leading to wound dehiscence - Splint too tight causing compartment syndrome or pressure sores - Splint in wrong position (excessive plantarflexion or dorsiflexion) stressing repair ## Management of Specific Clinical Scenarios ### Peroneus Longus Rupture at Os Peroneum **Pathoanatomy**: - Os peroneum is sesamoid bone within peroneus longus tendon at cuboid tunnel (20% population) - Fracture of os peroneum or rupture of longus at this level from acute injury or chronic stress **Surgical Approach**: - Requires separate plantar lateral incision over cuboid tunnel - Identify and protect sural nerve branches - Open cuboid tunnel sheath - Identify fractured os peroneum and ruptured longus tendon - Remove painful os fragments - If longus non-reconstructible: perform peroneus longus to brevis tenodesis - If reconstructible: repair with augmentation (FDL transfer or allograft) **Key Points**: - Different exposure than standard lateral approach - Os peroneum fracture pathognomonic for longus rupture at this level - Longus to brevis tenodesis effective salvage (brevis provides most eversion power) ### Concurrent Lateral Ankle Instability **Incidence**: 30-50% of patients with peroneal pathology have concurrent lateral ankle instability **Assessment**: - Preoperative anterior drawer and talar tilt tests - Stress radiographs if clinical exam equivocal - MRI: assess ATFL and CFL integrity **Surgical Management**: - Address both pathologies in same setting - Perform peroneal repair/reconstruction first - Then perform Modified Brostrom-Gould lateral ligament reconstruction - Can use same lateral incision, extend anteriorly for ATFL access - Immobilize in neutral (protects both repairs) **Key Points**: - Don't miss concurrent instability (leads to persistent lateral symptoms) - Combined procedures don't increase complication rate significantly - Success rate for combined procedures 80-85% ### Peroneal Tendinosis Without Frank Tear **Pathoanatomy**: - Tendon degeneration (grey, friable, swollen) without discrete tear - Often involves <50% of tendon cross-section **Surgical Management**: - Conservative debridement of degenerate tissue - Avoid creating tear by over-debriding - Synovectomy to remove inflammatory tissue - Groove deepening if shallow groove identified - SPR reconstruction if subluxation present - No tubularization needed if no discrete tear **Key Points**: - Debridement alone often sufficient if tendinosis <50% cross-section - Over-aggressive debridement creates tear requiring reconstruction - Success rate 75-85% for debridement alone ### Revision Peroneal Surgery **Indications**: - Recurrent tear after primary repair - Persistent subluxation after SPR reconstruction - Persistent pain despite prior surgery **Challenges**: - Scar tissue and adhesions - Poor tissue quality - Compromised anatomy from prior surgery - Higher complication risk **Surgical Management**: - Careful dissection protecting sural nerve (at higher risk in revision) - Allograft reconstruction if native tissue inadequate - Consider peroneus longus to brevis transfer if one tendon intact - SPR augmentation with local tissue or allograft - May need adjunctive procedures (groove deepening, lateral ligament reconstruction) **Key Points**: - Revision surgery more complex with lower success rate (70-75%) - Allograft needed more commonly in revision cases - Patient counseling essential regarding realistic expectations ## Postoperative Rehabilitation Protocol ### Phase 1: Protection (Weeks 0-2) **Immobilization**: - Well-padded short leg splint, ankle neutral with slight eversion - NWB with crutches - Leg elevation to reduce swelling - No weight bearing to allow wound healing **Goals**: - Wound healing - Control pain and swelling - Protect repair **Follow-up**: - Week 2: wound check, suture removal, transition to CAM boot ### Phase 2: Progressive Weight Bearing (Weeks 2-6) **Immobilization**: - CAM boot (controlled ankle motion walker) - WBAT (weight bearing as tolerated) in boot - Remove boot for wound care and gentle ankle pumps only **Goals**: - Protect tendon healing (requires 6-8 weeks) - Gradual return to weight bearing - Prevent stiffness **Activity**: - Ankle pumps (plantarflexion/dorsiflexion) in boot - No inversion/eversion yet - No boot removal except as directed ### Phase 3: Range of Motion (Weeks 6-8) **Immobilization**: - Discontinue boot at week 6 - Transition to ankle brace or lace-up support for 2-4 weeks **Physical Therapy**: - Begin formal PT at week 6 - Gentle ROM exercises: dorsiflexion, plantarflexion, inversion, eversion - No resistance yet - Proprioception training (balance board) **Goals**: - Restore full ROM - Prevent adhesions - Begin proprioception retraining ### Phase 4: Strengthening (Weeks 8-12) **Physical Therapy**: - Progressive strengthening with theraband - Resisted eversion (primary focus) - Resisted plantarflexion, dorsiflexion, inversion - Progress to standing exercises (heel raises, toe raises) - Continue proprioception training **Goals**: - Restore eversion strength - Improve dynamic stability - Prepare for functional activities ### Phase 5: Return to Activity (Weeks 12-24) **Week 12-16**: - Sport-specific training begins - Running program (straight line first, then cutting) - Sport-specific drills - Continue strengthening **Week 16-24**: - Return to sport gradually at 4-6 months - May use ankle brace for sport initially - Monitor for recurrent symptoms **Goals**: - Full return to preinjury activity level - Prevent re-injury ## Outcomes and Success Rates ### Primary Repair (<50% tear, good tissue) **Success Rate**: 85-90% - Pain resolution: 85-90% - Return to sport: 80-85% - Recurrent tear: 5-10% **Predictors of Success**: - Good tissue quality - Appropriate patient selection (<50% involvement) - Adequate rehabilitation compliance ### FDL Transfer Reconstruction (>50% tear, poor tissue) **Success Rate**: 85-90% - Pain resolution: 85-90% - Return to sport: 80-85% - Adequate eversion strength: 90% **Predictors of Success**: - Adequate FDL length and fixation - No concurrent pathology - Proper tensioning ### SPR Reconstruction for Subluxation **Success Rate**: 80-85% - Resolution of subluxation: 80-85% - Recurrent subluxation: 10-15% - Return to sport: 75-80% **Predictors of Success**: - Addressing shallow groove if present - Adequate SPR tissue quality - No concurrent lateral instability ### Combined Procedures **Success Rate**: 75-80% - Overall satisfaction: 75-80% - Return to sport: 70-75% **Predictors of Success**: - Addressing all pathology - Adequate rehabilitation - Realistic patient expectations ## Return to Sport Timeline **3 months**: - Light jogging, cycling, swimming - Sport-specific drills (non-contact) **4-5 months**: - Running, cutting, jumping - Contact sports practice (with brace) **6 months**: - Full return to competition - May use prophylactic ankle brace **Factors Affecting Timeline**: - Severity of injury - Type of surgery performed - Concurrent procedures - Patient age and activity level - Compliance with rehabilitation ## Complications - Comprehensive Management ## References 1. Dombek MF, Lamm BM, Saltrick K, Mendicino RW, Catanzariti AR. Peroneal tendon tears: a retrospective review. J Foot Ankle Surg. 2003;42(5):250-258. doi:10.1016/S1067-2516(03)00314-7 2. Redfern D, Myerson M. The management of concomitant tears of the peroneus longus and brevis tendons. Foot Ankle Int. 2004;25(10):695-707. doi:10.1177/107110070402501004 3. Saxena A, Cassidy A. Peroneal tendon injuries: an evaluation of 49 tears in 41 patients. J Foot Ankle Surg. 2003;42(4):215-220. doi:10.1016/S1067-2516(03)00150-1 4. 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 5. Philbin TM, Landis GS, Smith B. Peroneal tendon injuries. J Am Acad Orthop Surg. 2009;17(5):306-317. doi:10.5435/00124635-200905000-00005 6. van Dijk PA, Gianakos AL, Kerkhoffs GM, Kennedy JG. Return to sports and clinical outcomes in patients treated for peroneal tendon dislocation: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2016;24(4):1155-1164. doi:10.1007/s00167-015-3833-3 7. Demetracopoulos CA, Vineyard JC, Kiesau CD, Nunley JA 2nd. Long-term results of debridement and primary repair of peroneal tendon tears. Foot Ankle Int. 2014;35(3):252-257. doi:10.1177/1071100713514565 8. Heckman DS, Reddy S, Pedowitz D, Wapner KL, Parekh SG. Operative treatment for peroneal tendon disorders. J Bone Joint Surg Am. 2008;90(2):404-418. doi:10.2106/JBJS.G.00965 9. Roster B, Michelier P, Giza E. Peroneal tendon disorders. Clin Sports Med. 2015;34(4):625-641. doi:10.1016/j.csm.2015.06.003 10. Karlsson J, Eriksson BI, Renstrom PA. Subtalar ankle instability: a review. Sports Med. 1997;24(5):337-346. doi:10.2165/00007256-199724050-00005

Peroneal Tendon Repair/Reconstruction

Peroneal Tendon Repair/Reconstruction