Peroneal Tendon Subluxation and Dislocation

with Rehab

 The two peroneal tendons are located on the outer side of the back of the ankle, and connect the muscles that allow you to stand on your tip toes. These tendons are susceptible to two similar injuries known as a dislocation or a subluxation. A dislocation occurs when one or both of the tendons is out of alignment and slips completely out of the groove where they normally rest. A subluxation is a lesser but similar injury in which one or both of the tendons slide in and out of normal alignment. The tendons are normally held into place by a ligament-like structure (retinaculum); however, when this structure is injured dislocations and subluxations are common.

SYMPTOMS

  • A "pop" or "snap" heard or felt at the time of injury.

  • Pain, swelling, tenderness, and bruising (contusion) at the injury site, behind the outer ankle, that initially is worsened by standing or walking.

  • Pain and weakness when trying to push the foot toward the injured side.

  • Often no problems (asymptomatic) when walking, but symptomatic when trying to cut or pivot on the injured leg, moving toward the side of injury.

  • A crackling sound (crepitation ) when the tendon is moved or touched.

  • Numbness or paralysis below the dislocation from pinching, cutting, or pressure on the blood vessels or nerves (uncommon).

CAUSES

Peroneal tendon dislocations and subluxations are caused by a force placed on the tendon(s) that is strong enough to displace one or both of them from their normal alignment. Common mechanisms of injury include:

  • A sudden stressful incident, such as forceful bend to an ankle (most often outwardly turned) against resistance by the peroneal muscles.

  • Severe ankle sprain.

  • You are born with it (congenital abnormality), such as a shallow or malformed groove for the tendons.

RISK INCREASES WITH:

  • Snow skiing or ice skating.

  • Jumping sports (basketball, gymnastics, or volleyball).

  • Sports in which pivoting is important (football, soccer, or lacrosse).

  • Exercise on uneven terrain or surfaces.

  • Previous foot or ankle injury.

  • Poor strength and flexibility.

PREVENTION

  • Warm up and stretch properly before activity.

  • Maintain physical fitness:

  • Strength, flexibility, and endurance.

  • Cardiovascular fitness.

  • Protect the vulnerable ankle with supportive devices, such as wrapped elastic bandages, tape, braces, or high-top athletic shoes.

  • Avoid irregular surfaces for running or other activities.

  • Complete the full rehabilitation course after an ankle injury before return to practice or competition.

PROGNOSIS

If treated properly, then peroneal dislocations and subluxations can be expected to heal.

RELATED COMPLICATIONS

  • Chronic pain and disability and recurrent dislocation if activity is resumed too soon.

  • Rupture of the tendon due to recurrent subluxation or dislocation.

  • Unstable or arthritic joint following repeated injury or delayed treatment.

TREATMENT

  • Acute dislocations and subluxations: Treatment initially involves the use of ice and medication to help reduce pain and inflammation. The use of compression bandages and elevating the foot above the level of the heart will also help reduce inflammation. A controversy exists about whether to treat these injuries with surgery or non-surgical (conservative) measures. The conservative method is to immobilize the foot and ankle for up to 6 weeks. Surgical treatment requires early intervention to repair the injured retinaculum, followed by immobilization. After immobilization it is important to perform strengthening and stretching exercises to help regain strength and a full range of motion. These exercises may be completed at home or with a therapist.

  • Chronic dislocations and subluxations: Treatment initially involves the use of ice and medication to help reduce pain and inflammation. Surgery is recommended to hold the peroneal tendons in the groove where they are suppose to be located. Surgery is followed by immobilization of the foot and ankle. After immobilization it is important to perform strengthening and stretching exercises to help regain strength and a full range of motion. These exercises may be completed at home or with a therapist.

MEDICATION

  • If pain medication is necessary, then nonsteroidal anti-inflammatory medications, such as aspirin and ibuprofen, or other minor pain relievers, such as acetaminophen, are often recommended.

  • Do not take pain medication for 7 days before surgery.

  • Prescription pain relievers may be given if deemed necessary by your caregiver. Use only as directed and only as much as you need.

COLD THERAPY

Cold treatment (icing) relieves pain and reduces inflammation. Cold treatment should be applied for 10 to 15 minutes every 2 to 3 hours for inflammation and pain and immediately after any activity that aggravates your symptoms. Use ice packs or massage the area with a piece of ice (ice massage).

SEEK MEDICAL CARE IF:

  • Pain, tenderness, or swelling worsens despite treatment.

  • You experience pain, numbness, or coldness or a blue, gray or dark color appears in the toenails.

  • Any of the following occur after surgery: signs of infection, including fever, increased pain, swelling, redness, drainage, or bleeding in the surgical area.

  • New, unexplained symptoms develop (drugs used in treatment may produce side effects).

EXERCISES

RANGE OF MOTION (ROM) AND STRETCHING EXERCISES - Peroneal Tendon Subluxation and Dislocation

These exercises may help you when beginning to rehabilitate your injury. Your symptoms may resolve with or without further involvement from your physician, physical therapist or athletic trainer. While completing these exercises, remember:

  • Restoring tissue flexibility helps normal motion to return to the joints. This allows healthier, less painful movement and activity.

  • An effective stretch should be held for at least 30 seconds.

  • A stretch should never be painful. You should only feel a gentle lengthening or release in the stretched tissue.

RANGE OF MOTION - Ankle Eversion

  • Sit with your right / left ankle crossed over your opposite knee.

  • Grip your foot with your opposite hand, placing your thumb on the top of your foot and your fingers across the bottom of your foot.

  • Gently push your foot downward with a slight rotation so your littlest toes rise slightly

  • You should feel a gentle stretch on the inside of your ankle. Hold the stretch for __________ seconds.

Repeat __________ times. Complete this exercise __________ times per day.

RANGE OF MOTION - Ankle Inversion

  • Sit with your right / left ankle crossed over your opposite knee.

  • Grip your foot with your opposite hand, placing your thumb on the bottom of your foot and your fingers across the top of your foot.

  • Gently pull your foot so the smallest toe comes toward you and your thumb pushes the inside of the ball of your foot away from you.

  • You should feel a gentle stretch on the outside of your ankle. Hold the stretch for __________ seconds.

Repeat __________ times. Complete this exercise __________ times per day.

RANGE OF MOTION - Ankle Plantar Flexion

  • Sit with your right / left leg crossed over your opposite knee.

  • Use your opposite hand to pull the top of your foot and toes toward you.

  • You should feel a gentle stretch on the top of your foot/ankle. Hold this position for __________ seconds.

Repeat __________ times. Complete __________ times per day.

STRETCH – Gastroc, Standing

  • Place hands on wall.

  • Extend right / left leg, keeping the front knee somewhat bent.

  • Slightly point your toes inward on your back foot.

  • Keeping your right / left heel on the floor and your knee straight, shift your weight toward the wall, not allowing your back to arch.

  • You should feel a gentle stretch in the right / left calf. Hold this position for __________ seconds.

Repeat __________ times. Complete this stretch __________ times per day.

STRETCH – Soleus, Standing

  • Place hands on wall.

  • Extend right / left leg, keeping the other knee somewhat bent.

  • Slightly point your toes inward on your back foot.

  • Keep your right / left heel on the floor, bend your back knee, and slightly shift your weight over the back leg so that you feel a gentle stretch deep in your back calf.

  • Hold this position for __________ seconds.

Repeat __________ times. Complete this stretch __________ times per day.

STRETCH – Gastrocsoleus, Standing

Note: This exercise can place a lot of stress on your foot and ankle. Please complete this exercise only if specifically instructed by your caregiver.

  • Place the ball of your right / left foot on a step, keeping your other foot firmly on the same step.

  • Hold on to the wall or a rail for balance.

  • Slowly lift your other foot, allowing your body weight to press your heel down over the edge of the step.

  • You should feel a stretch in your right / left calf.

  • Hold this position for __________ seconds.

  • Repeat this exercise with a slight bend in your right / left knee.

Repeat __________ times. Complete this stretch __________ times per day.

STRENGTHENING EXERCISES - Peroneal Tendon Subluxation and Dislocation

These exercises may help you when beginning to rehabilitate your injury. They may resolve your symptoms with or without further involvement from your physician, physical therapist or athletic trainer. While completing these exercises, remember:

  • Muscles can gain both the endurance and the strength needed for everyday activities through controlled exercises.

  • Complete these exercises as instructed by your physician, physical therapist or athletic trainer. Progress the resistance and repetitions only as guided.

STRENGTH - Ankle Eversion

  • Secure one end of a rubber exercise band/tubing to a fixed object (table, pole). Loop the other end around your foot just before your toes.

  • Place your fists between your knees. This will focus your strengthening at your ankle.

  • Drawing the band/tubing across your opposite foot, slowly, pull your little toe out and up. Make sure the band/tubing is positioned to resist the entire motion.

  • Hold this position for __________ seconds.

  • Have your muscles resist the band/tubing as it slowly pulls your foot back to the starting position.

Repeat __________ times. Complete this exercise __________ times per day.

STRENGTH - Ankle Inversion

  • Secure one end of a rubber exercise band/tubing to a fixed object (table, pole). Loop the other end around your foot just before your toes.

  • Place your fists between your knees. This will focus your strengthening at your ankle.

  • Slowly, pull your big toe up and in, making sure the band/tubing is positioned to resist the entire motion.

  • Hold this position for __________ seconds.

  • Have your muscles resist the band/tubing as it slowly pulls your foot back to the starting position.

Repeat __________ times. Complete this exercises __________ times per day.

STRENGTH - Towel Curls

  • Sit in a chair positioned on a non-carpeted surface.

  • Place your foot on a towel, keeping your heel on the floor.

  • Pull the towel toward your heel by only curling your toes. Keep your heel on the floor.

  • If instructed by your physician, physical therapist or athletic trainer, add ____________________ at the end of the towel.

Repeat __________ times. Complete this exercise __________ times per day.