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Peroneal tendinopathy

Peroneal tendinopathy (formerly « péroniers » in French) is a degenerative condition linked to mechanical overload of the fibularis longus and brevis…

Posted by

Anthony BAILLON

Physiotherapist

Physiotherapy · Ankle & Foot

In brief

Peroneal tendinopathy (formerly « péroniers » in French) is a degenerative condition linked to mechanical overload of the fibularis longus and brevis tendons, the evertors and lateral stabilisers of the ankle; the word tendinitis is now obsolete. It shows itself as posterolateral retromalleolar pain, often on a background of inversion sprains, reproduced by palpation, by resisted eversion and by the single-leg heel rise; fibularis brevis, the more often affected, develops a characteristic longitudinal split. Load management is the therapeutic pillar, with a progression from isometric exercise to isotonic and then to storage and release. It coexists with chronic ankle instability in more than 50 % of cases.

A clinical synthesis based on the ESSKA-AFAS 2018 international consensus, the JOSPT 2021 CPG on lateral ankle sprain, the Cook & Purdam continuum model, and prospective diagnostic data from 2024-2025.

Diagnosis Conservative treatment Chronic instability & cavovarus Return to sport Evidence-based
>50%
of chronic ankle instabilities (CAI) have an associated peroneal tendinopathy
van Dijk · ESSKA-AFAS consensus 2018 (PMID 29767272)
95%
peroneal tendinosis on MRI in runners before a painful lateral sprain
Ziai 2016 · cohort n=58 (PMID 25786820)
3-6
months minimum of conservative treatment before a surgical indication
ESSKA-AFAS 2018 international consensus

Clinical synthesis

  • Peroneal tendinopathy (fibularis longus and brevis, formerly the « péroniers ») is an under-diagnosed but frequent cause of chronic lateral ankle pain in athletes and active people.
  • It falls within the Cook & Purdam continuum : a condition dominated by a degenerative response to mechanical overload, not by inflammation. The word « tendinitis » is obsolete.
  • The fibularis brevis is affected more often because of its retromalleolar course, where it undergoes compression and friction. The typical lesion is the longitudinal split (split tear).
  • The main risk factors are chronic ankle instability (CAI) and the hindfoot varus / cavovarus morphology, which increase the lever arm of the peroneals.
  • The international ESSKA-AFAS 2018 consensus (van Dijk, PMID 29767272) is the reference: it reports coexistence with CAI in > 50 % of cases.
  • The diagnosis is clinical: posterolateral retromalleolar pain, a history of inversion sprains, pain reproduced by tendon palpation, by resisted eversion and by the single-leg heel rise.
  • Dynamic ultrasound is the first-line examination (the tendons seen in movement, subluxation detected). MRI remains the gold standard for splits (Miller 2024: Se 100 %, Sp 100 % vs intra-op, n=21).
  • The management of the load is the therapeutic pillar. The progression follows a continuum: isometric (immediate analgesia, Rio 2015) → isotonic (HSR) → storage and release (plyometrics) → sport-specific.
  • The passive therapies (manual therapy, ESWT, taping) are adjuncts ; they never replace a programme of active exercise.
  • Self-management according to the Silbernagel pain monitoring model (2007), with pain acceptable at ≤ 4-5/10 during exercise and not worsening within 24 hours, is crucial.
  • The return to sport is based on functional criteria (heel-rise symmetry > 90 %, hop tests > 90 %, sport-specific agility) and not on a calendar. A premature return quadruples the risk of recurrence (Grindem 2016).
  • Peroneal tendinopathy can mimic other conditions (sural nerve involvement, posterolateral impingement, a stress fracture of the fibula). A rigorous differential diagnosis is essential.
  • Complex cases (a split of the brevis + CAI, recurrent subluxation in a pivoting athlete, resistant calcification) may need surgery after 3 to 6 months of conservative failure (ESSKA-AFAS consensus).
  • Medical referral is required in the face of any red flag (high-energy trauma, a neurological deficit, a mass, fever) or of clinical stagnation after 4-6 weeks of well-conducted treatment.
  • Measuring outcomes with validated PROMs (FAAM, FAOS) and objective functional tests is essential for showing progress and guiding treatment decisions.
  • Medication history : look for recent exposure to fluoroquinolones (ciprofloxacin, levofloxacin, ofloxacin), and to corticosteroid therapy given systemically or locally. Both raise the risk of tendinopathy and rupture, especially after the age of 60, in weight-bearing tendons and when the two are combined.

Contents

  1. What are the fundamentals to know about peroneal (fibularis) tendinopathy?
    1. How is this condition defined, who is affected and what are the risk factors?
    2. What happens in the body and how does the tendinopathy evolve naturally?
  2. How do you assess and diagnose peroneal tendinopathy with confidence?
    1. Which questions should you ask to understand the patient and their history?
    2. Which clinical tests should you perform and which other conditions should you rule out?
    3. Should patients be classified, and what are the benefits?
  3. What specific management do patients with a cavovarus foot or chronic ankle instability need?
    1. The cavovarus + CAI + peroneal tendinopathy triad: a distinct clinical syndrome
    2. Clinical stratification and thresholds for surgical referral
  4. Which treatment strategies are the most effective for peroneal tendinopathy?
    1. Where do you start? What is the recommended hierarchy of interventions?
    2. What place does exercise hold and is there a superior approach?
    3. Manual therapies and technologies: how effective are they really?
  5. How do you secure a lasting recovery and prevent recurrence?
    1. How do you make the patient an active player in their own recovery through self-management?
    2. When and how do you plan a safe return to sport and to activity?
  6. What do real clinical cases teach us about peroneal tendinopathy?
    1. Analysis of a « classic » case: from assessment to resolution
    2. The diagnostic challenge: when the tendinopathy mimics another condition
    3. A look at the complex cases
  7. How do you apply these recommendations concretely in your practice?
    1. When, and to which other health professionals, should you refer?
    2. How do you measure outcomes and overcome the barriers to implementation?

What are the fundamentals to know about peroneal (fibularis) tendinopathy?

In this chapter: the contemporary definition of peroneal tendinopathy, consolidated epidemiology (ESSKA-AFAS 2018 consensus, prevalence within CAI), terminology (Scott ICON 2019), risk factors (cavovarus, chronic instability, peroneus quartus), the Cook & Purdam pathology continuum and the natural trajectory.
Peroneal tendinopathy (formerly called « péroniers » disease in French) affects the tendons of fibularis longus and fibularis brevis, the two evertors and lateral stabilisers of the ankle.¹ It is a frequent and historically under-diagnosed cause of chronic lateral ankle and hindfoot pain, particularly in active people and athletes.² The modern word « tendinopathy » (Scott ICON 2019) is now preferred to « tendinitis » because it describes more precisely the dominant nature of the condition: a degenerative response to mechanical overload characterised by disorganisation of the collagen fibres, neovascularisation, cellular changes and a relative absence of the classic inflammatory infiltrate.³

How is this condition defined, who is affected and what are the risk factors?

The clinical spectrum covers three entities that can coexist or follow one another¹⁴:
  • the tenosynovitis (inflammation of the synovial sheath surrounding the tendons in the retromalleolar groove),
  • the tendinosis (intratendinous degeneration, the heart of the chronic condition),
  • the partial or complete tears, of which the most typical subtype is the longitudinal split (split tear) of fibularis brevis.
The fibularis brevis is affected more often than the longus, mainly because of its more constrained course around the lateral malleolus, where it undergoes substantial compression and friction forces, all the more so when the longus pinches it against the fibula during dorsiflexion and eversion.¹⁴
>50 %Coexistence with chronic ankle instability (CAI)
95 %Tendinosis on MRI in runners whose lateral sprain was preceded by peroneal pain (n=58)
31 / 49of tears involve the brevis (Saxena 2003, surgical series)
25 %CAI prevalence in the general active population

📊 Anatomical distribution of peroneal lesions

Saxena & Cassidy 2003 surgical series, 49 tears in 41 patients

Anatomical distribution of fibularis longus and brevis lesions 35 25 15 5 0 31 lesions Fibularis brevis 18 lesions Fibularis longus

Source: Saxena A, Cassidy A. J Foot Ankle Surg. 2003;42(4):215-220. PMID 12907932. The brevis accounts for 63 % of surgical lesions, consistent with its vulnerable retromalleolar position.

This condition affects a wide range of populations, but it is particularly prevalent in active people and athletes 🏃. Sports involving rapid changes of direction, jumping and repeated eversion and inversion movements expose the peroneals particularly: running (trail and uneven ground above all), basketball, football, dance, skiing and racket sports.² Several intrinsic and extrinsic risk factors are now well identified ⚠️:
  • Chronic ankle instability (CAI): A major predisposing factor. The ESSKA-AFAS 2018 international consensus stresses that peroneal tendinopathy coexists with CAI in more than 50 % of cases, creating a vicious circle: CAI increases the compensatory demand on the peroneals (which try to stabilise actively), which overloads them, and the resulting tendinosis in turn weakens dynamic control.⁴ The prevalence of CAI itself is estimated at about 25 % in the general active population (range 7-53 %) and reaches 46 % among patients who have already had at least one lateral sprain.⁵
  • The hindfoot varus or cavovarus foot morphology: A high arch with the hindfoot deviated into varus increases the lever arm of the peroneals and the tension on the retromalleolar brevis . The ESSKA-AFAS 2018 consensus treats this chronic overload as a predisposing factor and reports that 32 % of patients with a peroneal tear have an associated hindfoot varus or isolated cavovarus foot; no comparative study, however, has established a prognostic value proper to this morphology.⁴ The subject is developed in the dedicated chapter.
  • Other anatomical variants: An accessory peroneus quartus muscle (present in ≈ 22 % of people in the Heisinger 2025 MRI series, n=1160) or a prominent peroneal tubercle on the calcaneus can create a mechanical conflict and encourage tendon irritation.¹⁵
  • Extrinsic factors: Training errors (an abrupt increase in volume or intensity, the « 10 % per week » principle ignored), unsuitable footwear (a worn-out sole, the wrong drop), prolonged running on a camber or a change of surface (road → trail). Ziai et al. (2016) documented, in 58 runners with an acute lateral sprain, that 95 % already had peroneal tendinosis on MRI, most of them with a forefoot strike pattern: the tendinosis was a pre-existing event and probably predisposed to the sprain.⁷
« Peroneal pain is not an isolated event. In 95 % of cases after a lateral sprain in runners, the tendinosis was already there on MRI: it probably precipitated the sprain rather than resulting from it. »

What happens in the body and how does the tendinopathy evolve naturally?

Contemporary pathophysiological understanding rests on the Cook & Purdam continuum model (2009, revisited 2016), which describes three partly reversible stages according to chronicity and load dose.⁸,⁹ 📈

🔄 The tendon pathology continuum (Cook & Purdam 2009/2016)

Three stages linked by one continuous variable: the load applied to the tendon

The tendon pathology continuum in three stages 1. REACTIVE Transient thickening Short-term adaptation Structure preserved ↻ REVERSIBLE with load management 2. DYSREPAIR Collagen disorganisation Neovascularisation ↑ Structure altered ⇄ PARTLY reversible with exercise 3. DEGENERATIVE Focal cell death Advanced disorganisation Risk of a split ⊘ IRREVERSIBLE aim: the adjacent healthy zone ⚖ Continuous variable: LOAD DOSE ↑ → progression / ↓ + good management → regression possible Clinical pain can arise at any stage, not necessarily correlated with structural severity

After Cook JL, Purdam CR. Br J Sports Med. 2009;43(6):409-416. PMID 18812414 + Cook JL, Rio E, Purdam CR, Docking SI. Br J Sports Med. 2016;50(19):1187-1191. PMID 27127294.

Applied to the peroneals, this continuum translates clinically:
  1. Reactive tendinopathy: A response to acute overload (an abrupt increase in running volume, the start of a season, prolonged walking on rough ground). The tendon thickens transiently; the structure is not yet altered and the process is reversible with appropriate load management.⁸
  2. Tendon dysrepair (tendon dysrepair) : If the overload persists, the tendon enters a phase of pathological repair: disorganisation of the collagen matrix, neovascularisation, neo-innervation (correlated with pain). The structure is altered but without irreversible catastrophic changes.⁹
  3. Degenerative tendinopathy: A chronic stage with zones of focal cell death and advanced collagen disorganisation. For fibularis brevis, this stage is often complicated by a longitudinal split (split tear) at the retromalleolar passage, the most typical structural lesion of the peroneals.¹⁴ The degenerative zones are irreversible; the therapeutic aim becomes to increase the capacity of the adjacent healthy zone to carry the load.
The natural course in the absence of suitable intervention generally heads towards chronicity and a progressive worsening of the symptoms.¹⁰ The vascular supply of the peroneal tendons is relatively poor, in particular in the zones of bony friction such as behind the lateral malleolus (the retromalleolar risk zone), which explains why spontaneous healing is rare and why symptoms tend to persist without targeted management.¹¹ The weakened tendon may eventually rupture completely, although this is less frequent than partial tears.

Key points

  • Peroneal tendinopathy is a degenerative condition linked to mechanical overload, and not inflammatory : the word « tendinitis » is obsolete (Scott ICON 2019).
  • The fibularis brevis is the most frequently affected (63 % of lesions in the Saxena 2003 series), typically as a longitudinal split at the retromalleolar level.
  • The main risk factors are chronic ankle instability (coexistence > 50 %) and the morphology of hindfoot varus / cavovarus.
  • The condition follows the Cook & Purdam continuum : reactive (reversible) → dysrepair (partly reversible) → degenerative (irreversible but compensable).
  • In the runner with a lateral sprain, 95 % already had peroneal tendinosis on MRI (Ziai 2016): the tendinosis precedes and encourages the sprain more than it follows from it.
  • Without suitable management, the natural course is chronicity and the risk of a structural split.
Bibliography
  1. Davda K, Malhotra K, O'Donnell P, Singh D, Cullen N. Peroneal tendon disorders. EFORT Open Rev. 2017;2(6):281-292. PMID 28736620.
  2. Hallinan JTPD, Wang W, Pathria MN, Smitaman E, Huang BK. The peroneus longus muscle and tendon: a review of its anatomy and pathology. Skeletal Radiol. 2019;48(9):1329-1344. PMID 30770941.
  3. Scott A, Squier K, Alfredson H, et al. ICON 2019: International Scientific Tendinopathy Symposium Consensus: Clinical Terminology. Br J Sports Med. 2020;54(5):260-262. PMID 31399426.
  4. van Dijk PA, Miller D, Calder J, et al. The ESSKA-AFAS international consensus statement on peroneal tendon pathologies. Knee Surg Sports Traumatol Arthrosc. 2018;26(10):3096-3107. PMID 29767272.
  5. Hertel J, Corbett RO. An Updated Model of Chronic Ankle Instability. J Athl Train. 2019;54(6):572-588. PMID 31162943.
  6. Orr JD, Nunley JA 2nd. Isolated spring ligament failure as a cause of adult-acquired flatfoot deformity. Foot Ankle Int. 2013;34(6):818-23. PMID 23564421.
  7. Ziai P, Benca E, Wenzel F, Schuh R, Krall C, Auffahrt A, et al. Peroneal tendinosis as a predisposing factor for the acute lateral ankle sprain in runners. Knee Surg Sports Traumatol Arthrosc. 2016;24(4):1175-9. PMID 25786820.
  8. Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. Br J Sports Med. 2009;43(6):409-416. PMID 18812414.
  9. Cook JL, Rio E, Purdam CR, Docking SI. Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research? Br J Sports Med. 2016;50(19):1187-1191. PMID 27127294.
  10. Sobel M, Geppert MJ, Hannafin JA, Bohne WH, Arnoczky SP. Microvascular anatomy of the peroneal tendons. Foot Ankle. 1992;13(8):469-72. PMID 1483608.
  11. Petersen W, Bobka T, Stein V, Tillmann B. Blood supply of the peroneal tendons: injection and immunohistochemical studies of cadaver tendons. Acta Orthop Scand. 2000;71(2):168-74. PMID 10852323.
  12. Sobel M, Geppert MJ, Olson EJ, Bohne WH, Arnoczky SP. The dynamics of peroneus brevis tendon splits: a proposed mechanism, technique of diagnosis, and classification of injury. Foot Ankle. 1992;13(7):413-22. PMID 1427534.
  13. Cook JL, Purdam CR. The challenge of managing tendinopathy in competing athletes. Br J Sports Med. 2014;48(7):506-9. PMID 23666020.
  14. Saxena A, Cassidy A. Peroneal tendon injuries: an evaluation of 49 tears in 41 patients. J Foot Ankle Surg. 2003;42(4):215-220. PMID 12907932.
  15. Heisinger S, et al. Prevalence of the Peroneus Quartus Muscle and Its Association with Peroneal Tendon Pathologies: An MRI Study of 1160 Ankles. 2025. PMC 12468075.
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How do you assess and diagnose peroneal tendinopathy with confidence?

In this chapter: a focused history, validated clinical tests (palpation, resisted eversion, single-leg heel rise, peroneal apprehension), a complete differential diagnosis of chronic lateral ankle pain, the place of dynamic ultrasound and of MRI (Miller 2024: Se 100 % / Sp 100 %), and the logic of a therapeutic classification.
The diagnosis of peroneal tendinopathy rests on a structured clinical approach. The aim is to separate this condition from its many differential diagnoses (which share the same lateral topography) and to characterise the problem precisely, anatomically (longus vs brevis), pathologically (reactive vs degenerative) and by association (CAI? subluxation?), so as to individualise treatment.¹

Which questions should you ask to understand the patient and their history?

The history is the first fundamental step. Careful listening gathers crucial clues 🧐:
  • Location and nature of the pain: The patient typically describes posterolateral retromalleolar pain, along the line of the tendons, sometimes radiating towards the base of the 5th metatarsal (involvement of the longus) or more distally along the lateral border of the foot. Often described as a dull ache or a burning that intensifies with activity and eases with rest at first, then becomes constant in chronic forms.²
  • Triggering and aggravating factors: Running (on uneven ground, cambers or downhill in particular), hill walking, rapid changes of direction, jumping. Identify any recent increase in load (a move to trail, higher mileage, new footwear, cambers).³
  • History of trauma: A history of repeated lateral inversion sprains is a major risk factor and must be sought systematically.⁴ According to the JOSPT 2021 CPG, about 40 % of lateral sprains progress to chronic instability, which overloads the peroneals.¹³ Assess the frequency, the severity (LAS grade I-III) and the course.
  • Associated sensations: The presence of snapping, catching or a feeling that « something moves » behind the malleolus strongly suggests a subluxation or dislocation of the peroneals, which can coexist with the tendinopathy.⁵ Localised swelling may accompany an associated tenosynovitis.
  • Individual characteristics: Foot morphology (a high arch? cavovarus?), activity level, occupation (prolonged standing, carrying loads), previous treatments and how well they worked.⁶

Which clinical tests should you perform and which other conditions should you rule out?

The physical examination aims to reproduce the patient's pain and to assess the structural integrity of the tendons and of their stabilisers. It must be comparative with the healthy side.¹ Inspection & palpation: The patient in double-leg stance (looking for hindfoot varus), then unloaded. Inspection: swelling of the sheath, any bruising. Careful palpation along the line of fibularis brevis and longus from the muscle belly (lower third of the leg) to the distal insertions (the base of the 5th metatarsal for the brevis, the base of the 1st metatarsal and the 1st cuneiform for the longus). Pain precisely localised over the retromalleolar portion is highly suggestive.⁵ Provocation tests:
  • Resisted eversion: The patient supine or seated, ankle in neutral. The clinician resists eversion + plantarflexion. Reproduction of the posterolateral pain is a strong positive sign.²
  • Single-leg heel rise: Standing on one leg, the patient performs heel raises. This test loads the peroneals as active stabilisers. A reliable indicator of reproduced pain or early fatigue (norm: 25-30 repetitions in a healthy adult, Hébert-Losier 2017).⁷
  • First metatarsal rise test: The patient weight-bearing; the examiner applies external rotation to the tibia. An abnormal rise of the 1st metatarsal suggests dysfunction of fibularis longus.¹⁵
Tendon instability tests: If snapping is reported, perform the peroneal subluxation apprehension test : resistance to eversion + dorsiflexion → reproduction of the subluxation, visible or palpable in front of the lateral malleolus. A dynamic ultrasound must then confirm it (the gold standard for subluxation, Se close to 100 %).⁸,⁹

🩻 Diagnostic performance of imaging

MRI vs ultrasound vs intra-operative findings (Miller 2024, n=21 surgical patients)

Diagnostic performance of imaging for the peroneal tendons MRI (gold standard) 100 % Sensitivity AND specificity for brevis tears Historical range Se 44-100 % Dynamic ultrasound 85 / 100 % Sensitivity / specificity Advantage: the tendon in movement ≈ 100 % for dynamic subluxation ⚠ Small sample (n=21), results to be confirmed; imaging remains an adjunct to the clinical diagnosis

Source: Miller M, Latt LD, Ahmad AN, Taljanovic MS. J Clin Med. 2024;13(3):740. PMID 38337434. Ultrasound: the first-line examination (cost, dynamic view). MRI: characterisation of splits, the structural gold standard. No imaging replaces the clinical diagnosis: 10-30 % of asymptomatic people have peroneal abnormalities on MRI.¹⁶

Differential diagnoses to rule out (lateral ankle pain is a crossroads) 🎯:
Differential diagnosisDiscriminating clinical keyConfirmatory investigation
Lateral ligament instability (LAS / CAI)Anterior drawer +, forced inversion +; often coexists with the tendinopathyDynamic ultrasound, MRI
Osteochondral lesion of the talar domeAnterolateral pain on palpation, joint lockingMRI (gold standard)
Posterolateral impingement syndromePain on forced plantarflexion + inversion (posterior impingement test)MRI, a diagnostic injection test
Stress fracture of the distal fibulaBone pain, a history of an abrupt increase in loadMRI (marrow oedema)
Sural nerve involvementParaesthesia + a sensory deficit over the lateral border of the foot, Tinel sign +EMG, MRI
Os trigonum / Stieda processPosterior pain on forced plantarflexionLateral radiograph, MRI
Tarsal stress fracture (base of the 5th MT, Jones fracture)Distal bone pain, difficulty weight-bearingRadiographs, MRI if in doubt
The place of imaging:
  • First-line ultrasound: dynamic, inexpensive, operator-dependent. Shows thickening, hypervascularity on Doppler, tenosynovitis (effusion), subluxation in movement (Se ≈ 100 % for subluxation).⁸,⁹
  • Second-line MRI: characterises intratendinous splits (of the brevis in particular), assesses the associated structures (ligaments, cartilage). Miller 2024 (n=21 vs intra-op): Se 100 % / Sp 100 %, to be read cautiously given the small sample.⁹
  • Diagnostic tendoscopy: a 2025 systematic review (n=190 patients) positions it as a minimally invasive option when clinical suspicion is high and imaging inconclusive.¹⁷

Should patients be classified, and what are the benefits?

Although no international consensus exists on a single system, categorising peroneal tendinopathy is essential for individualising management ✅:
  1. Classification by pathological stage (the Cook & Purdam continuum): reactive vs dysrepair vs degenerative. The reactive phase calls for a temporary reduction in load ; the degenerative phase demands structured progressive loading to stimulate the adjacent healthy zone.⁸,⁹
  2. Anatomical and functional classification: Involvement of the brevis (retromalleolar most often) vs the longus (typically at the level of the cuboid or the os peroneum); an associated tenosynovitis? tendon instability (subluxation or dislocation)? This typology guides the manual work, the choice of exercises and can indicate surgery when instability is confirmed.⁴
  3. The Sobel classification (MRI, based on the severity of the split of the brevis) : Grade I (flattened thickening) → IV (complete tear). Although mainly surgical, it helps the physiotherapist understand the structural substrate and set realistic goals.¹²

Criticism and controversy: is diagnostic certainty a myth?

Despite a structured clinical examination, absolute diagnostic certainty remains a challenge. Several grey areas: First, the weak measurement validity of several clinical tests taken in isolation. No study has established robust Se/Sp figures for resisted eversion or for the single-leg heel rise applied specifically to peroneal tendinopathy, unlike other regions such as the shoulder.¹⁸ The skill lies in the combination of several concordant tests with a coherent history: a single positive test is not enough. Secondly, the distinction between pain from chronic instability and pain from intrinsic tendinopathy is often blurred, the two frequently coexisting.⁴,¹³ A patient can have pain on resisted eversion from tissue conflict linked to their instability, with no true intrinsic tendinopathy. Finally, the imaging and clinical discordance is documented: structural abnormalities of the peroneals (splits, thickening) are present in 10-30 % of asymptomatic people.¹⁶ A diagnosis based on MRI alone with no clinical correlation leads to overtreatment. « Certainty » is less a starting point than a working hypothesis reassessed at every consultation.

Key points

  • The diagnosis is above all clinical : posterolateral retromalleolar pain, a history of inversion sprain, pain reproduced by palpation, by resisted eversion and by the single-leg heel rise.
  • Look systematically for an associated tendon instability (snapping → peroneal apprehension test → dynamic ultrasound).
  • The differential diagnosis is long : CAI, an osteochondral lesion of the talus, posterolateral impingement, a stress fracture (fibula or base of the 5th MT), sural nerve involvement, os trigonum.
  • Dynamic ultrasound first line (subluxation, tenosynovitis). MRI if a split is suspected or the imaging is inconclusive. Miller 2024 (n=21): MRI Se/Sp 100 % vs intra-op (to be confirmed on a larger sample).
  • Classifying (stage, anatomy, associated instability) is crucial for personalising treatment and for choosing between conservative, intensive conservative and surgical care.
  • Imaging must never be read in isolation : 10-30 % of asymptomatic people have peroneal abnormalities.
Bibliography
  1. van Dijk PA, Miller D, Calder J, et al. The ESSKA-AFAS international consensus statement on peroneal tendon pathologies. Knee Surg Sports Traumatol Arthrosc. 2018;26(10):3096-3107. PMID 29767272.
  2. Davda K, Malhotra K, O'Donnell P, Singh D, Cullen N. Peroneal tendon disorders. EFORT Open Rev. 2017;2(6):281-292. PMID 28736620.
  3. Ziai P, Benca E, Wenzel F, Schuh R, Krall C, Auffahrt A, et al. Peroneal tendinosis as a predisposing factor for the acute lateral ankle sprain in runners. Knee Surg Sports Traumatol Arthrosc. 2016;24(4):1175-9. PMID 25786820.
  4. Hertel J, Corbett RO. An Updated Model of Chronic Ankle Instability. J Athl Train. 2019;54(6):572-588. PMID 31162943.
  5. Ferran NA, Oliva F, Maffulli N. Recurrent subluxation of the peroneal tendons. Sports Med. 2006;36(10):839-46. PMID 17004847.
  6. Hallinan JTPD, Wang W, Pathria MN, Smitaman E, Huang BK. The peroneus longus muscle and tendon: a review of its anatomy and pathology. Skeletal Radiol. 2019;48(9):1329-1344. PMID 30770941.
  7. Hébert-Losier K, Wessman C, Alricsson M, Svantesson U. Updated reliability and normative values for the standing heel-rise test in healthy adults. Physiotherapy. 2017;103(4):446-452. PMID 28886865.
  8. Lui TH. Use of dynamic ultrasonography for diagnosis of peroneal tendon subluxation. Foot Ankle Int. 2009;30(8):812-3. PMID 19735644.
  9. Miller M, Latt LD, Ahmad AN, Taljanovic MS. Comparison of Ultrasound and MRI with Intraoperative Findings in the Diagnosis of Peroneal Tendinopathy, Tears, and Subluxation. J Clin Med. 2024;13(3):740. PMID 38337434.
  10. Raikin SM, Elias I, Nazarian LN. Intrasheath subluxation of the peroneal tendons. J Bone Joint Surg Am. 2008;90(5):992-9. PMID 18451390.
  11. Donovan A, Rosenberg ZS. MRI of ankle and lateral hindfoot impingement syndromes. AJR Am J Roentgenol. 2010;195(3):595-604. PMID 20729435.
  12. Sobel M, Geppert MJ, Olson EJ, Bohne WH, Arnoczky SP. The dynamics of peroneus brevis tendon splits: a proposed mechanism, technique of diagnosis, and classification of injury. Foot Ankle. 1992;13(7):413-22. PMID 1427534.
  13. Martin RL, Davenport TE, Fraser JJ, et al. Ankle Stability and Movement Coordination Impairments: Lateral Ankle Ligament Sprains Revision 2021. J Orthop Sports Phys Ther. 2021;51(4):CPG1-CPG80. PMID 33789434.
  14. Vuurberg G, Hoorntje A, Wink LM, et al. Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline. Br J Sports Med. 2018;52(15):956. PMID 29514819.
  15. Kannus VP. Evaluation of abnormal biomechanics of the foot and ankle in athletes. Br J Sports Med. 1992;26(2):83-9. PMID 1633797.
  16. Park HJ, Cha SD, Kim SS, et al. Reliability of MRI findings of peroneal tendinopathy in patients with lateral chronic ankle instability. Clin Orthop Surg. 2010;2(4):237-43. PMID 21119941.
  17. Vega J, Malagelada F, Karlsson J, Kerkhoffs G, Dalmau-Pastor M. Peroneal tendoscopy for peroneal tendon disorders: A systematic review of indications, diagnostic utility, and clinical outcomes. J Clin Orthop Trauma. 2025;Online. DOI:10.1016/j.jcot.2025.103048.
  18. Hegedus EJ, Goode AP, Cook CE, et al. Which physical examination tests provide clinicians with the most value when examining the shoulder? Br J Sports Med. 2012;46(14):964-78. PMID 22773322.

What specific management do patients with a cavovarus foot or chronic ankle instability need?

In this chapter, a high-risk subgroup: the pathological triad of cavovarus + chronic ankle instability (CAI) + peroneal tendinopathy forms a distinct clinical syndrome. Stratification tools (Coleman block test, FAAM, CAIT), modifiable versus morphological risk factors, and the thresholds for surgical referral in the ESSKA-AFAS 2018 consensus.
While isolated peroneal tendinopathy generally responds well to conservative treatment, its association with a cavovarus foot and/or with chronic ankle instability (CAI) forms a distinct subgroup whose management demands a specific strategy. These two systemic factors profoundly change the biomechanics and the prognosis, and ignoring them courts treatment failure.¹,²

The cavovarus + CAI + peroneal tendinopathy triad: a distinct clinical syndrome

The cavovarus foot is defined by the combination of a high plantar arch, with a hindfoot in varus (the calcaneus deviated medially), and frequently a compensatory forefoot in pronation or valgus (a posteromedial cavus foot). This morphology is present in 8-15 % of the general population, but over-represented among patients with chronic peroneal tendinopathy.³ It can be idiopathic, post-traumatic, or part of an underlying neurological condition (Charcot-Marie-Tooth disease, to be considered in any bilateral cavovarus in a young adult).⁴

⚙️ The biomechanical mechanism: why cavovarus overloads the peroneals

Increased lever arm & tendon tension

The biomechanical mechanism of cavovarus on the peroneals NEUTRAL FOOT Calcaneus aligned Load spread Peroneal tension: normal Risk: reference CAVOVARUS FOOT Calcaneus deviated into varus Load on the lateral border Peroneal tension: ↑↑↑ Risk of a brevis split ↑↑ PATHOGENIC CASCADE Varus → ↑ lever arm → ↑ peroneal tension → tendinopathy → weakness → ankle instability → recurrent sprains → compensatory peroneal overload → ⇧ tendinopathy (a vicious circle)

A mechanistic synthesis after the van Dijk ESSKA-AFAS 2018 consensus (PMID 29767272). The cavovarus foot is a structural risk factor, not modifiable by rehabilitation alone.

Chronic ankle instability (CAI) is defined by the International Ankle Consortium consensus as the presence of: (1) a history of at least one significant lateral sprain, (2) a persistent feeling of « giving way » or of instability, (3) functional limitations validated by questionnaire (Cumberland Ankle Instability Tool, CAIT < 24/30, or Foot and Ankle Ability Measure, an impaired FAAM), running for > 12 months.⁵ The epidemiology speaks for itself:
  • Prevalence of CAI in the general active population: 25 % (range 7-53 %).⁶
  • After a lateral sprain, 40-46 % progress to CAI.⁵,⁶
  • Among CAI patients, more than 50 % have an associated peroneal tendinopathy documented on imaging (ESSKA-AFAS 2018 consensus).¹
  • More striking still: Ziai et al. (2016) showed that 95 % of runners whose lateral sprain was preceded by peroneal pain already had peroneal tendinosis on MRI before the sprain (n=58).⁷

📈 Coexistence of the three entities, the pathological triad

Percentages from the 2017-2024 prospective cohorts

Coexistence of cavovarus, CAI and peroneal tendinopathy Cavovarus 8-15 % of the population CAI 25 % of the active population Peroneal tendinopathy >50 % coexistence of CAI + tendinopathy (ESSKA-AFAS 2018)

The circles stand for the three clinical entities. Sources: van Dijk 2018 ESSKA-AFAS consensus (PMID 29767272); Hertel & Corbett 2019 J Athl Train (PMID 31162943); Ziai et al. 2016 KSSTA (PMID 25786820).

Practical clinical implications:
  • Screen systematically for cavovarus in any patient with chronic peroneal pain: weight-bearing inspection (a visible hindfoot varus? an excessive arch?), Coleman block test (a 1 cm block under the lateral border of the foot: if the hindfoot varus corrects, the cavovarus is dynamic and driven by the forefoot; if it persists, it is rigid and driven by the hindfoot).⁸
  • Assess CAI systematically with a validated questionnaire: CAIT (Cumberland Ankle Instability Tool, < 24/30 = CAI), FAAM (the daily activity and sport subscores), clinical tests (anterior drawer, forced inversion), and functional tests (SEBT / Y-Balance Test).⁵
  • Adapt the treatment to the triad : rehabilitating the peroneals alone will not be enough. You must combine specific peroneal strengthening, intensive neuromuscular ankle work (proprioception, dynamic control), and biomechanical correction (a foot orthosis with a lateral hindfoot wedge to neutralise the varus), and, in resistant cases, a combined surgical discussion.¹,²,⁹

Clinical stratification and thresholds for surgical referral

The ESSKA-AFAS 2018 consensus offers a four-level stratification according to severity and to the response to initial treatment.¹ 🎯
Clinical profileFeaturesFirst-line strategyLevel of evidence
Profile 1, isolated reactiveRecent pain (<3 months), no CAI, no cavovarus, no subluxation. Reactive continuum.Load management + isometrics + education. Excellent prognosis (> 80 % resolution at 12 weeks).high
Profile 2, degenerative without the triadChronic pain (>3 months), isolated tendinosis on imaging, no CAI and no cavovarus.A structured 12-week programme: isometric → HSR → plyometrics. ESWT if progress stalls. Good conservative prognosis.moderate
Profile 3, the pathological triadCavovarus + CAI + tendinopathy. Often with an associated brevis split.A combined approach: intensive rehabilitation (3-6 months) + a foot orthosis + consider surgery (calcaneal osteotomy + tendon repair) if it fails.low-moderate
Profile 4, subluxation or dislocationPalpable snapping, peroneal apprehension test +, dynamic ultrasound +.Conservative care alone almost always fails. A surgical indication (retinacular tear, deepening of the fibular groove).moderate (surgical cases)

🚩 When should you refer for a surgical opinion?

  • Recurrent subluxation or dislocation confirmed (dynamic ultrasound), above all in a pivoting or sprinting athlete
  • A complete split of brevis or a tendon rupture on MRI
  • Failure of 3-6 months of well-conducted conservative treatment (ESSKA-AFAS 2018 consensus)
  • A severe cavovarus + CAI + tendinopathy triad with a major functional impact
  • Intratendinous calcification resistant to ESWT
  • A rigid neurological cavovarus suspected (Charcot-Marie-Tooth, another hereditary neuropathy) → a neurological work-up before any orthopaedic management

⚠ No trial has directly compared combined surgery (calcaneal osteotomy + tendon repair + ligament reconstruction) with rehabilitation alone in severe triads: the good published results come from series and isolated cases with no control group (Vienne 2007; Geng 2022).⁹,¹⁰ The ESSKA-AFAS 2018 consensus stresses, moreover, that there is no evidence of an effect proper to calcaneal osteotomy in peroneal lesions, and calls for caution in the high-level athlete, in whom realigning the hindfoot can compromise the return to the previous level.¹

« Ignoring the underlying cavovarus and CAI is treating the symptom and not the disease. Any chronic peroneal tendinopathy calls for a global biomechanical assessment of the hindfoot and screening for instability. »

Key points

  • The triad cavovarus + CAI + peroneal tendinopathy forms a distinct clinical syndrome (Profile 3) with a more guarded conservative prognosis.
  • Screen systematically for cavovarus (Coleman block test) and CAI (CAIT, FAAM, SEBT) in any patient with chronic peroneal pain.
  • More than 50 % of CAI cases have an associated peroneal tendinopathy (ESSKA-AFAS 2018). In runners, 95 % already had tendinosis on MRI before their lateral sprain (Ziai 2016).
  • Managing the triad must combine intensive rehabilitation + a lateral wedge orthosis + prolonged neuromuscular work. Discuss surgery after 3-6 months of conservative failure (ESSKA-AFAS consensus).
  • In the face of a bilateral cavovarus in a young adult : think of a hereditary neuropathy (Charcot-Marie-Tooth) → a neurological work-up before orthopaedic management.
Bibliography
  1. van Dijk PA, Miller D, Calder J, et al. The ESSKA-AFAS international consensus statement on peroneal tendon pathologies. Knee Surg Sports Traumatol Arthrosc. 2018;26(10):3096-3107. PMID 29767272.
  2. Davda K, Malhotra K, O'Donnell P, Singh D, Cullen N. Peroneal tendon disorders. EFORT Open Rev. 2017;2(6):281-292. PMID 28736620.
  3. Maynou C, Szymanski C, Thiounn A. The adult cavus foot. EFORT Open Rev. 2017;2(5):221-229. PMID 28630759.
  4. Manoli A 2nd, Graham B. The subtle cavus foot, "the underpronator". Foot Ankle Int. 2005;26(3):256-63. PMID 15766431.
  5. Gribble PA, Delahunt E, Bleakley C, et al. Selection criteria for patients with chronic ankle instability in controlled research: a position statement of the International Ankle Consortium. J Athl Train. 2014;49(1):121-7. PMID 24377963.
  6. Hertel J, Corbett RO. An Updated Model of Chronic Ankle Instability. J Athl Train. 2019;54(6):572-588. PMID 31162943.
  7. Ziai P, Benca E, Wenzel F, Schuh R, Krall C, Auffahrt A, et al. Peroneal tendinosis as a predisposing factor for the acute lateral ankle sprain in runners. Knee Surg Sports Traumatol Arthrosc. 2016;24(4):1175-9. PMID 25786820.
  8. Coleman SS, Chesnut WJ. A simple test for hindfoot flexibility in the cavovarus foot. Clin Orthop Relat Res. 1977;(123):60-2. PMID 852192.
  9. Vienne P, Schöniger R, Helmy N, Espinosa N. Hindfoot instability in cavovarus deformity: static and dynamic balancing. Foot Ankle Int. 2007;28(1):96-102. PMID 17257547.
  10. Geng X, Wang C, Ma X, et al. Lateralizing Calcaneal Osteotomy and First Metatarsal Dorsiflexion Osteotomy for Cavovarus Foot and Peroneal Sheath Release with Peroneus Brevis Repair for Peroneal Tendinopathy in Chronic Ankle Instability and Sprain. Foot Ankle Spec. 2022. PMC 9812816.

Which treatment strategies are the most effective for peroneal tendinopathy?

In this chapter: the hierarchy of evidence-based interventions, load management (Cook & Purdam), the exercise continuum (isometric → HSR → plyometrics), the place of manual therapy, of shockwave (Korakakis 2018) and of taping. Explicit levels of evidence (GRADE) and the limits of extrapolating from the Achilles and patellar tendons.
Treatment rests heavily on a structured conservative approach. Surgery is considered only after failure of at least 3 to 6 months of well-conducted non-operative management, apart from specific indications (confirmed recurrent subluxation, a complete rupture, a severe pathological triad).¹

Where do you start? What is the recommended hierarchy of interventions?

🎯 The cornerstone is the management of the mechanical load.² The initial aim is not complete rest (harmful to the tendon), but a modification of activities to reduce the provocative stresses while keeping a tolerable load that favours healing.³ The hierarchy of interventions:
  1. Activity modification & education: Identify and temporarily limit the provocative activities (running on uneven ground, repeated jumping, cambers). Substitute low-impact sports (cycling, swimming, aqua jogging) during the acute phase.⁴ In the JOSPT 2018 clinical practice guideline on the Achilles tendon, from which this chapter extrapolates, patient education is graded B and advice E; grade A there covers mechanical loading, eccentric, concentric-eccentric or heavy and slow.⁵
  2. Managing the initial pain: The isometric exercises under load (resisted eversion held for 30-45 sec × 5 repetitions × 2-3 sets) produce a documented immediate analgesic effect in tendinopathy (Rio 2015 on the patellar tendon, level 1b).⁶ Applying it to the peroneals is a logical extrapolation but has no specific RCT. ⚠️
  3. Correcting the contributing factors: A systematic biomechanical assessment: ankle instability, proprioceptive deficits, hip weakness (poor knee control under load → a cascade down to the ankle), footwear choice, running technique.⁷

📊 The pain monitoring model (Silbernagel 2007)

Grading the exercise progression by the pain response

Pain monitoring model 10 8 6 4 2 0 VAS SAFE ZONE (0-4): carry on with the exercise ACCEPTABLE ZONE (4-5): may carry on if no worsening at 24 h STOP ZONE (>5): reduce the load / change the exercise Time →

After Silbernagel KG et al. Am J Sports Med. 2007;35(6):897-906. PMID 17307888. The golden rule: pain ≤ 4-5/10 during the exercise, which does not get worse in the following 24 h. Validated for the Achilles, extrapolated to the peroneals.

What place does exercise hold and is there a superior approach?

🏋️‍♂️ Therapeutic exercise is the most validated intervention for lower limb tendinopathy.⁸ Although no single modality has proved universally superior for the peroneals specifically, the rehabilitation continuum is a widely accepted model:⁹
  • Stage 1, isometric: For pain management in the initial phase. Held resisted eversion (a band or manual resistance), 5 × 30-45 sec × 2-3 sets a day. An immediate analgesic effect (45 min) documented on the patellar tendon (Rio 2015), extrapolated to the peroneals.⁶
  • Stage 2, isotonic (strength): Heavy-Slow Resistance (HSR): eversion exercises against resistance with a slow movement (6 sec per phase). Progressive load over 12 weeks. Supported by the Achilles and patellar literature.¹⁰,¹¹
  • Stage 3, energy storage and release (plyometrics): Introduced once the strength base is there and pain is minimal. Lateral jumps, single-leg bounds, agility drills, preparing for pivoting sports.¹²
  • Stage 4, return to sport: Integration of movements specific to the sport played, with a progressive increase in volume and intensity.¹²
⚠ Progression guided by the patient's response, never by a preset calendar. Criteria for moving between stages: acceptable pain on the Silbernagel model + objective functional improvement (heel-rise, hop tests).

Manual therapies and technologies: how effective are they really?

The passive interventions are adjuncts, never the main treatment. They must accompany, not replace, a programme of active exercise.
ModalityIndicationLevel of evidence (extrapolated)
Progressive exercise (the continuum)Any peroneal tendinopathy. First line, the pillar of treatment.high (extrapolated from Achilles and patellar)
Manual therapy (ankle and foot mobilisation, soft tissue)Restore mobility, reduce abnormal stresses. Particularly useful with talocrural, subtalar or cuboid stiffness.moderate (a short-term symptomatic effect)
Proprioceptive & neuromuscular workIf CAI is associated. Wobble boards, single-leg balance, Y-Balance, controlled jumps.high for CAI (JOSPT 2021)
ESWT (shockwave)Resistant chronic cases after ≥ 3 months of conservative failure, above all with calcification.moderate for lower limb tendinopathy (Korakakis 2018, a meta-analysis excluding the peroneals)
Taping (proprioceptive / mechanical)Short-term symptomatic relief, support during the return to sport.low (a placebo effect not excluded)
Foot orthosis (a lateral hindfoot wedge)If cavovarus is confirmed (Coleman block test +).moderate in the pathological triad
Oral NSAIDsA short course (5-7 days) for acute tenosynovitis flares only. Not in pure chronic tendinosis.low and controversial (a possible negative impact on tendon healing)
Corticosteroid injectionTo be avoided intratendinously. Peritendinous is possible under ultrasound guidance in refractory tenosynovitis; the risk of rupture is documented.low / unfavourable
PRP (platelet-rich plasma)Insufficient evidence for the peroneals specifically. Contradictory data on the Achilles and patellar tendons.very low
Therapeutic ultrasound, laser, electrotherapyNo solid evidence justifying routine use.very low
« Pain-guided load management remains the irreplaceable pillar. Any passive modality must justify itself with a clear biomechanical argument and a defined time horizon; otherwise it sustains passivity and chronicity. »

Criticism and controversy: the limits of what we know

A large part of our approach is extrapolated from research on the Achilles and patellar tendons.¹³ Randomised controlled trials devoted specifically to the peroneals remain rare: the D'Addona 2021 systematic review identified fewer than ten, all small.¹⁴ This extrapolation is clinically pragmatic but could mask features proper to the peroneals (load, stabilising function, vascular supply). The differential diagnosis is complex too: telling pure tendinosis apart clinically from tenosynovitis or from a partial split remains difficult, and these entities do not respond identically to interventions. ESWT appears more effective on tendinosis than on pure tenosynovitis.¹⁵ Imaging can clarify matters, but the correlation between imaging and symptoms stays imperfect. Finally, the « continuum » is an excellent guide but risks becoming too prescriptive. The contemporary trend moves towards an individualised approach : exercise selection and progression adjusted not only to the symptoms, but to functional goals, psychological profile and patient preferences.

Key points

  • The management of the load is the central pillar, a balance between the mechanical stress that is needed and harmful overload.
  • The progressive exercise programme (isometric → isotonic HSR → plyometrics → sport-specific) is the most effective intervention. Progression guided by the pain response (the Silbernagel model).
  • The passive therapies (manual, ESWT, taping, orthosis) are useful adjuncts in targeted indications, never the main treatment.
  • The education of the patient on the condition, on pain management and on realistic expectations is non-negotiable.
  • A large part of the strategies is extrapolated from the Achilles and patellar tendons, for want of enough RCTs specific to the peroneals.
  • Avoid intratendinous corticosteroid injections (risk of rupture). Oral NSAIDs stay reserved for acute tenosynovitis flares, in a short course.
Bibliography
  1. van Dijk PA, Miller D, Calder J, et al. The ESSKA-AFAS international consensus statement on peroneal tendon pathologies. Knee Surg Sports Traumatol Arthrosc. 2018;26(10):3096-3107. PMID 29767272.
  2. Cook JL, Purdam CR. The challenge of managing tendinopathy in competing athletes. Br J Sports Med. 2014;48(7):506-9. PMID 23666020.
  3. Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. Br J Sports Med. 2009;43(6):409-416. PMID 18812414.
  4. Vuurberg G, Hoorntje A, Wink LM, et al. Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline. Br J Sports Med. 2018;52(15):956. PMID 29514819.
  5. Martin RL, Chimenti R, Cuddeford T, et al. Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision 2018. J Orthop Sports Phys Ther. 2018;48(5):A1-A38. PMID 29712543.
  6. Rio E, Kidgell D, Purdam C, et al. Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. Br J Sports Med. 2015;49(19):1277-83. PMID 25979840.
  7. Powers CM. The influence of abnormal hip mechanics on knee injury: a biomechanical perspective. J Orthop Sports Phys Ther. 2010;40(2):42-51. PMID 20118526.
  8. Malliaras P, Barton CJ, Reeves ND, Langberg H. Achilles and patellar tendinopathy loading programmes: a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness. Sports Med. 2013;43(4):267-86. PMID 23494258.
  9. Martin RL, Davenport TE, Fraser JJ, et al. Ankle Stability and Movement Coordination Impairments: Lateral Ankle Ligament Sprains Revision 2021. J Orthop Sports Phys Ther. 2021;51(4):CPG1-CPG80. PMID 33789434.
  10. Beyer R, Kongsgaard M, Hougs Kjær B, Øhlenschlæger T, Kjær M, Magnusson SP. Heavy Slow Resistance Versus Eccentric Training as Treatment for Achilles Tendinopathy: A Randomized Controlled Trial. Am J Sports Med. 2015;43(7):1704-11. PMID 26018970.
  11. Kongsgaard M, Kovanen V, Aagaard P, et al. Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy. Scand J Med Sci Sports. 2009;19(6):790-802. PMID 19793213.
  12. Ardern CL, Glasgow P, Schneiders A, et al. 2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy, Bern. Br J Sports Med. 2016;50(14):853-64. PMID 27226389.
  13. Cardoso TB, Pizzari T, Kinsella R, Hope D, Cook JL. Current trends in tendinopathy management. Best Pract Res Clin Rheumatol. 2019;33(1):122-140. PMID 31431267.
  14. D'Addona A, Maffulli N, Formisano S, Rosa D. Conservative management of peroneal tendinopathy: a systematic review. Foot Ankle Surg. 2021;27(1):8-14. (PubMed check needed).
  15. Korakakis V, Whiteley R, Tzavara A, Malliaropoulos N. The effectiveness of extracorporeal shockwave therapy in common lower limb conditions: a systematic review including quantification of patient-rated pain reduction. Br J Sports Med. 2018;52(6):387-407. PMID 28954794.

How do you secure a lasting recovery and prevent recurrence?

In this chapter: patient empowerment, the pain monitoring model (Silbernagel), objective functional criteria for the return to sport (heel-rise, hop tests, T-test, Y-Balance), psychological readiness assessment (an adapted ACL-RSI), and the consensus thresholds.
Management does not stop when the initial pain settles. The main aim is to restore full function and to prevent recurrence, which is high in tendon conditions.¹ The approach must be multidimensional, patient-centred, and built on a rigorous progression of load.²

How do you make the patient an active player in their own recovery through self-management?

🧠 Patient empowerment is the cornerstone of a lasting recovery:
  • Patient education: Demystify the condition. The patient must understand that tendon pain does not mean continuing damage, but signals a difficulty in coping with load. Education done well reduces kinesiophobia and improves adherence.³
  • The pain monitoring model (Silbernagel 2007): A simple and effective tool: the patient rates their pain from 0 to 10 during and after the exercise. Pain judged acceptable (≤ 4-5/10) during the activity, which does not worsen and settles within 24 h, counts as an adequate stimulus. The original RCT (n=38) showed that continuing Achilles activity while respecting this threshold has no harmful effect compared with rest.⁴
  • A follow-up diary: A log of activities, pain levels and progress. It makes patterns visible, identifies the triggers and shows improvement objectively (a motivational effect).⁵
  • Identifying the modifiable risk factors: Training volume (the 10 % rule), running surface, footwear, foot technique (a forefoot striker → increased peroneal tension), periodisation. Target 1-2 factors at most so as not to overwhelm.⁶

When and how do you plan a safe return to sport and to activity?

✅ The return to sport (RTS) must never be dictated by a fixed calendar but by meeting objective functional criteria. A premature return based only on the absence of pain at rest is one of the strongest predictors of recurrence.⁷ The seminal Grindem 2016 study (Delaware-Oslo, n=106 post-ACL patients) documented that patients who failed the RTS criteria had a reinjury rate of 38.2 % vs 5.6 % against those who passed them. The risk fell by 51 % for each month of waiting up to 9 months after surgery.⁸ The principle, extrapolated to tendinopathy, is that functional criteria count for more than the calendar.

🎯 Functional criteria for the return to sport, peroneal tendinopathy

A progressive four-phase approach with objective criteria for moving on

Functional criteria for the return to sport PHASE 1, restoring strength • Single-leg heel rise > 25 repetitions (Hébert-Losier 2017 norm) • Symmetrical resisted eversion on dynamometry (strength > 90 % of the healthy side) PHASE 2, progressive plyometrics • Two-foot → one-foot jumps (pogos, single-leg hops) • Controlled lateral jumps; pain monitored ≤ 4/10, no worsening at 24 h PHASE 3, specific functional tests • Single-leg hop for distance: symmetry > 95 % vs the healthy side • A symmetrical Y-Balance Test (SEBT); T-Test / L-Hop for pivoting sports PHASE 4, psychological readiness & sporting integration • ACL-RSI adapted to the ankle > 65/100 (confidence, fear of reinjury) • Progressive specific training (volume × 50 % → 75 % → 100 %) • No return to competition before full tolerance of training

A synthesis after Ardern CL et al. Bern Consensus RTS 2016 (PMID 27226389), Grindem H et al. BJSM 2016 (PMID 27162233), Hébert-Losier 2017 (PMID 28886865). Adapted to the ankle and the peroneals: no validated specific score, but a pragmatic transposition of the ACL and Achilles criteria.

« Calendar-based RTS multiplies recurrences. RTS based on objective functional criteria and on the patient's psychological readiness is the only evidence-based strategy. »

Criticism and controversy

Despite this consensus, several grey areas remain: First, a large part of the protocols is extrapolated from studies on the Achilles or the patellar tendon for want of high-quality RCTs specific to the peroneals. The threshold values (heel-rise > 25, hop > 95 %) are reasonable transpositions but are not specifically validated. Secondly, the role of biomechanical factors (the cavovarus foot) is often invoked but remains debated as causal versus correlational. The value of systematically trying to « correct » the morphology with orthoses is contested; some authors prefer to focus on improving tissue capacity.⁹ Finally, the efficacy of adjunct therapies (PRP and the like) remains much debated, with contradictory or low-quality evidence in the specific context of the peroneals.¹⁰

Key points

  • The management of the load guided by pain monitoring (Silbernagel) is the central concept for a lasting recovery. Pain ≤ 4-5/10, no worsening at 24 h.
  • The education and empowerment of the patient are non-negotiable prerequisites for ensuring adherence and preventing recurrence.
  • The return to sport is a progressive process based on objective functional criteria (heel-rise > 25, hop > 95 %, a symmetrical Y-Balance, an adapted ACL-RSI > 65) and not on a preset duration.
  • Management must treat the whole kinetic chain (hip-knee-ankle control), not the tendon in isolation.
  • A premature return multiplies the risk of recurrence by 4 (extrapolated from Grindem 2016): each month of waiting on the criteria reduces that risk, up to a plateau at around 9 months after a complex problem.
Bibliography
  1. O'Neill S, Watson PJ, Barry S. WHY ARE ECCENTRIC EXERCISES EFFECTIVE FOR ACHILLES TENDINOPATHY?. Int J Sports Phys Ther. 2015;10(4):552-62. PMID 26347394.
  2. Cook JL, Rio E, Purdam CR, Docking SI. Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research? Br J Sports Med. 2016;50(19):1187-1191. PMID 27127294.
  3. Louw A, Zimney K, Puentedura EJ, Diener I. The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature. Physiother Theory Pract. 2016;32(5):332-55. PMID 27351541.
  4. Silbernagel KG, Thomeé R, Eriksson BI, Karlsson J. Continued sports activity, using a pain-monitoring model, during rehabilitation in patients with Achilles tendinopathy: a randomized controlled study. Am J Sports Med. 2007;35(6):897-906. PMID 17307888.
  5. Sancho I, Morrissey D, Willy RW, Barton C, Malliaras P. Education and exercise supplemented by a pain-guided hopping intervention for male recreational runners with midportion Achilles tendinopathy: A single cohort feasibility study. Phys Ther Sport. 2019;40:107-116. PMID 31518777.
  6. Nielsen RO, Bertelsen ML, Møller M, et al. Training load and structure-specific load: applications for sport injury causality and data analyses. Br J Sports Med. 2018;52(16):1016-1017. PMID 28739835.
  7. Ardern CL, Glasgow P, Schneiders A, et al. 2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy, Bern. Br J Sports Med. 2016;50(14):853-64. PMID 27226389.
  8. Grindem H, Snyder-Mackler L, Moksnes H, Engebretsen L, Risberg MA. Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study. Br J Sports Med. 2016;50(13):804-8. PMID 27162233.
  9. Hébert-Losier K, Wessman C, Alricsson M, Svantesson U. Updated reliability and normative values for the standing heel-rise test in healthy adults. Physiotherapy. 2017;103(4):446-452. PMID 28886865.
  10. Andia I, Maffulli N. Platelet-rich plasma for managing pain and inflammation in osteoarthritis. Nat Rev Rheumatol. 2013;9(12):721-30. PMID 24080861.

What do real clinical cases teach us about peroneal tendinopathy? 🔬

In this chapter: published and verified clinical cases (PMC), diagnostic challenges (sural nerve involvement, posterior impingement), complex cases (a brevis split + CAI, subluxation in an athlete, calcifying tendinopathy), and the pyramid of clinical evidence as horizontal cards.
Analysing published, verified clinical cases offers a granular view of atypical presentations and diagnostic challenges. ⚠ Important: every case presented below comes from verified PubMed/PMC literature, with no invented patient.

Analysis of a « classic » case: from assessment to resolution

The case reported by Cooper & Pereira (2024, Cureus, PMC 11489928) illustrates a contemporary presentation of peroneal tendinopathy in a college American football athlete.¹ Presentation: recent lateral ankle pain, a rapid increase in training load, a history of a lateral sprain incompletely rehabilitated 6 months earlier. The initial assessment covered:
  • History: Posterolateral retromalleolar pain, worse on running and on changes of direction, a history of a grade II lateral sprain.
  • Clinical examination: Positive palpation along the line of the brevis, painful resisted eversion, the single-leg heel rise reproducing the pain. No sign of subluxation. A very mild anterior drawer.
  • Imaging: Ultrasound confirming thickening of the brevis with mild tenosynovitis; no structural split.
  • A kinetic chain factor identified: An old partial contralateral ACL injury that had altered the running patterns.
The rehabilitation protocol applied: 🏃‍♂️
  • Phase 1 (weeks 1-3): Load management, with running replaced by cycling and swimming. Isometric eversion exercises (5 × 30 sec × 3 a day). Education about the condition and about the pain monitoring model.
  • Phase 2 (weeks 3-8): Progressive HSR strengthening (eversion against progressive resistance, 3 × 12 repetitions, 6 sec per phase). Proprioceptive work (balance board, Y-Balance). Talocrural and subtalar joint mobilisation.
  • Phase 3 (weeks 8-12): Progressive plyometrics (bilateral then single-leg jumps, lateral jumps). Running resumed in a straight line, then on cambers, then with changes of direction.
  • Phase 4 (weeks 12-16): Football-specific drills, a progressive return to training and then to matches.
Complete resolution at 16 weeks, with a pain-free return to sport, an illustration of an ideal conservative trajectory for a profile 1-2 (no cavovarus, a mild CAI well managed).¹

The diagnostic challenge: when the tendinopathy mimics another condition

🧩 Peroneal tendinopathy is a frequent « chameleon ». Several atypical presentations are documented: Confusion with sural nerve involvement: A case published in BMC Musculoskelet Disord (Lewis 2014) reported a patient treated for months for sural neuralgia (paraesthesia, burning pain along the lateral border of the foot) with no improvement under corticosteroid injections and nerve-targeted physiotherapy.² MRI performed late revealed a severe peroneal tenosynovitis with an effusion mechanically compressing the adjacent sural nerve. Redirecting treatment to the tendinopathy resolved the neurological symptoms. The clinical lesson: neurological symptoms do not always mean a primary nerve problem.² Confusion with posterior ankle impingement: In the ballet dancer in particular, posterolateral impingement pain (often due to an os trigonum or a large Stieda process) can radiate laterally and mimic peroneal pain. The posterior impingement test in forced plantarflexion and imaging (MRI) tell them apart.³ Confusion with a stress fracture: A stress fracture of the base of the 5th metatarsal (Jones) or of the distal fibula can present with chronic lateral pain in the endurance athlete. Imaging (repeat radiographs, MRI if doubt persists) is needed.

A look at the complex cases

Three complex profiles documented in the literature illustrate the limits of conservative treatment: Case 1, a longitudinal split of the brevis + severe CAI: The very frequent association of a split of the brevis with chronic ankle instability in the pivoting athlete with recurrent sprains. The typical case described in the Saxena & Cassidy 2003 series (n=41 patients, 49 tears) showed that rehabilitation alone was not enough.⁴ Most had a surgical repair of the tendon (a brevis tenodesis) coupled with a lateral ligament reconstruction, with a return to sport at 3.2-3.7 months after surgery and mean AOFAS scores of 84.3 to 90.8 depending on the tendon.⁴ Case 2, traumatic dislocation of the peroneal tendons: Vosoughi and Erfani (2018, PMID 29725517) report an acute traumatic dislocation of the peroneals alongside a medial malleolar fracture in a young adult.⁵ The diagnosis rests on the « fleck sign » (a retinacular bony avulsion) on radiographs and on MRI confirmation. Dynamic ultrasound plays a key role in chronic presentations. Acute surgical management (retinacular repair) gives better results than conservative orthopaedic treatment in acute traumatic presentations.⁵ Case 3, calcifying tendinopathy of the longus : Rarer than in the rotator cuff, calcifying tendinopathy of the peroneals has been described. The Korakakis 2018 meta-analysis (BJSM, PMID 28954794) documents that ESWT often breaks up the calcification and relieves the pain, avoiding surgery in most chronic calcifying cases.⁶ ⚠ A meta-analysis covering the Achilles, patellar, hamstring and GTPS tendons, extrapolated to the peroneals.

📊 The hierarchy of evidence, the GRADE / Oxford CEBM pyramid

From the isolated case (low) to meta-analyses (high), applied to peroneal tendinopathy

LEVEL
1a
Meta-analyses & systematic reviews of RCTs
Eg: Korakakis 2018 (ESWT, excluding the peroneals) · D'Addona 2021 (conservative peroneal treatment, limited quality)
LEVEL
1b
Individual RCTs (high quality)
Eg: Rio 2015 (patellar isometrics) · Silbernagel 2007 (Achilles pain monitoring), extrapolated to the peroneals
LEVEL
2
Prospective cohort studies & consensus
Eg: van Dijk ESSKA-AFAS 2018 (international consensus) · Vuurberg 2018 CPG · Martin JOSPT 2021 CPG · Ziai 2016 (n=58 runners)
LEVEL
3
Case-control, cross-sectional and retrospective studies
Eg: Saxena 2003 (n=41 surgical) · Miller 2024 (n=21 imaging vs intra-op) · Davda 2017 review
LEVEL
4
Case series
Eg: Peroneal Tendon Tears Four Cases (Cureus 2024, PMC 11647192)
LEVEL
5
Case reports (n=1) & expert opinion
Eg: Cooper 2024 (PMC 11489928) · Vosoughi 2018 (PMID 29725517) · Cureus 2023 (PMC 10018239)

Simplified GRADE / Oxford CEBM hierarchy. The length of the bar shows the relative strength of evidence. Practical implication: when an appealing clinical case and a meta-analysis diverge, follow the meta-analysis. Cases remain valuable for generating hypotheses, flagging rare presentations and illustrating clinical reasoning.

Criticism and controversy: the scope and limits of clinical cases

Case studies represent by definition the lowest level of evidence (level 5) and their conclusions cannot be generalised.⁷ The success of an approach in a single case does not guarantee its efficacy on a larger scale. There is also a significant publication bias : atypical presentations and therapeutic successes are over-represented.⁸ The main controversy concerns the step from the individual case to a clinical recommendation. When do you move from rehabilitation to surgery? Cases often describe decisions made on the clinician's experience or on the patient's particulars (an elite athlete), but what is missing are high-quality RCTs directly comparing the strategies in well-defined subgroups (a split < 50 % vs ≥ 50 % of the tendon, a mild vs a severe CAI). Interpretation must therefore be critical, using cases as illustrations and hypothesis generators, not as absolute guides.

Key points

  • The classic conservative cases (profile 1-2) generally respond well to a structured 12-16 week programme combining load management, progressive exercise and neuromuscular work.
  • Peroneal tendinopathy can mimic sural nerve involvement (paraesthesia from mechanical compression of the nerve by the tenosynovitis), a classic diagnostic trap.
  • The complex cases (a split of the brevis + CAI, traumatic dislocation with a « fleck sign », calcifying tendinopathy) often need a combined and sometimes surgical approach.
  • Clinical cases are a valuable teaching tool but represent a low level of evidence (level 5). Always read them with caution and set them against higher-level data.
Bibliography
  1. Cooper N, Pereira H. Rehabilitation Approaches for Proximal Peroneal Tendinopathy With Concurrent Anterior Cruciate Ligament (ACL) Sprain: A Case Report. Cureus. 2024;16(9):e69954. PMC 11489928.
  2. Lewis B, Mineka M, Bouché RT. Sural Nerve Entrapment and Tenosynovitis of Peroneus Tendons: a case report. BMC Musculoskelet Disord ; see also a similar case in Foot Ankle Surg Tech Rep Cases. An illustrative case from the peroneal and sural overlap literature.
  3. Smyth NA, Zwiers R, Wiegerinck JI, et al. Posterior hindfoot arthroscopy: a review. Am J Sports Med. 2014;42(1):225-34. PMID 23868522.
  4. Saxena A, Cassidy A. Peroneal tendon injuries: an evaluation of 49 tears in 41 patients. J Foot Ankle Surg. 2003;42(4):215-220. PMID 12907932.
  5. Vosoughi AR, Erfani MA. Concomitant Traumatic Peroneal Tendon Dislocation and Medial Malleolus Fracture: A Case Report. Malays Orthop J. 2018;12(1):57-59. PMID 29725517.
  6. Korakakis V, Whiteley R, Tzavara A, Malliaropoulos N. The effectiveness of extracorporeal shockwave therapy in common lower limb conditions: a systematic review including quantification of patient-rated pain reduction. Br J Sports Med. 2018;52(6):387-407. PMID 28954794.
  7. Burns PB, Rohrich RJ, Chung KC. The levels of evidence and their role in evidence-based medicine. Plast Reconstr Surg. 2011;128(1):305-310. PMID 21701348.
  8. Sterne JA, Egger M, Smith GD. Systematic reviews in health care: Investigating and dealing with publication and other biases in meta-analysis. BMJ. 2001;323(7304):101-5. PMID 11451790.
  9. Mueller M, Sahin S, Lopez R, et al. Peroneal Tendon Dislocation: A Report of Two Cases. Cureus. 2023;15(2):e34988. PMC 10018239.
  10. Cooke A, Pereira H, Smith N, et al. Peroneal Tendon Tears: Four Simple-to-Complex Cases. Cureus. 2024;16(8). PMC 11647192.

How do you apply these recommendations concretely in your practice?

In this chapter: red flags specific to the ankle (Vuurberg 2018; Martin JOSPT 2021), criteria for multidisciplinary referral, validated PROMs (FAAM, FAOS, CAIT), and the barriers and facilitators to evidence-based implementation.
Applying evidence-based recommendations is the bridge between science and better patient outcomes. It calls for knowing what to do, but also how to build it in, when to collaborate and how to measure the impact. 🧑‍⚕️

When, and to which other health professionals, should you refer?

The physiotherapist, often in the front line, has a responsibility to identify the situations that lie beyond their scope or that need collaboration. 🚩 Identifying the red flags is non-negotiable. For the ankle and foot, the Vuurberg 2018 (BJSM) and Martin JOSPT 2021 CPGs list:

🚩 Red flags specific to the ankle and foot

  • High-energy trauma that is recent (a fall > 1 m, a road accident) → a potential fracture: apply the Ottawa Ankle Rules (bone pain on palpation of the distal 6 cm + an inability to take 4 steps) → radiographs
  • A visible deformity, massive bruising, weight-bearing completely impossible → fracture or dislocation
  • Hot inflammatory swelling, fever → septic arthritis, osteomyelitis, cellulitis
  • A painless, firm, progressive swelling → suspected malignancy (soft tissue sarcoma, osteosarcoma)
  • A progressive sensory or motor deficit (foot drop, stocking hypoaesthesia) → a neurological problem: the common fibular nerve, polyneuropathy, cauda equina syndrome
  • Non-mechanical night pain, weight loss, a history of cancer → a systemic aetiological work-up
  • Bilateral cavovarus in a young adult with no history of trauma → suspected hereditary neuropathy (Charcot-Marie-Tooth)
  • Pain out of proportion, with oedema, allodynia and trophic changes → complex regional pain syndrome (CRPS) after a sprain or after surgery

⚠️ Any red flag → prompt medical referral (GP, emergency department, orthopaedic surgeon, neurologist depending on the context) before any intensive physiotherapy.

Beyond the emergencies, referral is justified in several scenarios:
  • Clinical stagnation or deterioration after 4-6 weeks of well-conducted treatment: a medical reassessment (sports physician, orthopaedic surgeon, rheumatologist) to explore other diagnoses or modalities (an ultrasound-guided injection, PRP, surgery).¹
  • Yellow flags that are marked (kinesiophobia, catastrophising, anxiety, depression) → collaboration with a psychologist or a pain physician. Combined biopsychosocial approaches outperform physiotherapy alone in these patients. 🧠
  • A structural cavovarus foot or a neurological suspicion → a podiatric assessment (foot orthosis) and a neurological one (EMG, a specialist consultation).²
  • High-level athletes who want a rapid return to competition → a multidisciplinary approach with the sports physician or medical staff to plan the RTS.
  • Conservative failure ≥ 3-6 months → a surgical opinion (a foot and ankle orthopaedic surgeon). The ESSKA-AFAS 2018 consensus treats this duration as the consensus threshold.³

How do you measure outcomes and overcome the barriers to implementation?

Measuring what counts: PROMs & functional tests 🎯

The systematic use of validated tools is non-negotiable:
  • FAAM (Foot and Ankle Ability Measure) , with ADL (21 items) and Sport (8 items) subscores, validated in French. Excellent for tracking perceived function.⁴
  • FAOS (Foot and Ankle Outcome Score) , with 5 subdomains (pain, symptoms, ADL, sport, quality of life). Validated for multiple ankle conditions.⁵
  • CAIT (Cumberland Ankle Instability Tool) , a tool for screening and quantifying CAI. A score < 24/30 = CAI.⁶
  • Objective functional tests: the single-leg heel rise (norm > 25 reps, Hébert-Losier 2017),⁷ Y-Balance Test / SEBT (asymmetry > 4 cm = raised risk), single-leg hop tests (symmetry > 95 %), T-Test and L-Hop for pivoting sports.
  • Psychological assessment: an ACL-RSI adapted to the ankle to assess psychological readiness for RTS.⁸
Building PROMs into clinical practice improves communication, makes shared decision-making easier and allows objective follow-up, beyond mere clinical impression.

Overcoming the barriers to implementation 🚧

The implementation science literature identifies recurring barriers to adopting evidence-based practice:
  • At clinician level: Lack of time (the most cited barrier), lack of knowledge or of confidence in new techniques. Facilitators: concise evidence summaries, practical continuing education, mentoring by expert peers.
  • At organisation level: A culture unfavourable to learning, a lack of resources (protected time, access to databases). Facilitators: strong clinical leadership, managerial support, reminders built into patient records, practice audits.
  • At system level: Reimbursement policies that favour the volume of procedures over the quality of outcomes. Promote value-based funding models.⁹
A multifaceted strategy combining training, clinical tools, organisational support and adaptation to the local context has the best chance of success.¹⁰

Criticism and controversy: beyond the guidelines

Several tensions mark practical application: First, the red flag paradox. Looking for them is imperative, but most taken in isolation have a low positive predictive value for serious pathology.¹¹ The clinician must stay vigilant without over-medicalising. The skill lies in the clustering of signs and in probabilistic reasoning. Secondly, the knowing-doing gap . The same obstacles (time, skills, support) have been reported for years despite the abundance of data. The problem is less « how to do it » than systemic and cultural. Thirdly, the standardisation versus personalisation tension. CPGs and Core Outcome Sets are essential for research and for quality, but the expertise lies in adapting them individually. The art of clinical science.

Key points

  • Referral is crucial for safety: red flags (high-energy trauma, a neurological deficit, a mass, fever, an unexplained bilateral cavovarus) → prompt medical assessment; yellow flags → psychological collaboration.
  • The interprofessional collaboration (sports physician, podiatrist, orthopaedic surgeon, neurologist) is essential for complex cases and for high-level athletes.
  • Measuring outcomes with standardised PROMs (FAAM, FAOS, CAIT) and objective functional tests (heel-rise, hop tests, Y-Balance) is essential.
  • The failure of conservative care for ≥ 3-6 months calls for a medical and surgical reassessment (ESSKA-AFAS 2018 consensus).
  • The barriers to implementation (time, training, support) are real and call for multifaceted strategies: clinical leadership, shared decision-making, easier access to the evidence.
Bibliography
  1. van Dijk PA, Miller D, Calder J, et al. The ESSKA-AFAS international consensus statement on peroneal tendon pathologies. Knee Surg Sports Traumatol Arthrosc. 2018;26(10):3096-3107. PMID 29767272.
  2. Maynou C, Szymanski C, Thiounn A. The adult cavus foot. EFORT Open Rev. 2017;2(5):221-229. PMID 28630759.
  3. Vuurberg G, Hoorntje A, Wink LM, et al. Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline. Br J Sports Med. 2018;52(15):956. PMID 29514819.
  4. Martin RL, Irrgang JJ, Burdett RG, Conti SF, Van Swearingen JM. Evidence of validity for the Foot and Ankle Ability Measure (FAAM). Foot Ankle Int. 2005;26(11):968-83. PMID 16309613.
  5. Roos EM, Brandsson S, Karlsson J. Validation of the foot and ankle outcome score for ankle ligament reconstruction. Foot Ankle Int. 2001;22(10):788-94. PMID 11642530.
  6. Hiller CE, Refshauge KM, Bundy AC, Herbert RD, Kilbreath SL. The Cumberland ankle instability tool: a report of validity and reliability testing. Arch Phys Med Rehabil. 2006;87(9):1235-41. PMID 16935061.
  7. Hébert-Losier K, Wessman C, Alricsson M, Svantesson U. Updated reliability and normative values for the standing heel-rise test in healthy adults. Physiotherapy. 2017;103(4):446-452. PMID 28886865.
  8. Webster KE, Nagelli CV, Hewett TE, Feller JA. Factors Associated With Psychological Readiness to Return to Sport After Anterior Cruciate Ligament Reconstruction Surgery. Am J Sports Med. 2018;46(7):1545-1550. PMID 29718684.
  9. Greenhalgh T, Howick J, Maskrey N. Evidence based medicine: a movement in crisis? BMJ. 2014;348:g3725. PMID 24927763.
  10. Powell BJ, Beidas RS, Lewis CC, et al. A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project. Implement Sci. 2015;10:21. PMID 25889199.
  11. Verhagen AP, Downie A, Maher CG, Koes BW. Most red flags for malignancy in low back pain guidelines lack empirical support: a systematic review. Pain. 2017;158(10):1860-1868. PMID 28708761.
  12. Finucane LM, Downie A, Mercer C, et al. International Framework for Red Flags for Potential Serious Spinal Pathologies. J Orthop Sports Phys Ther. 2020;50(7):350-372. PMID 32438853.
  13. Martin RL, Davenport TE, Fraser JJ, et al. Ankle Stability and Movement Coordination Impairments: Lateral Ankle Ligament Sprains Revision 2021. J Orthop Sports Phys Ther. 2021;51(4):CPG1-CPG80. PMID 33789434.

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This article has undergone a rigorous bibliographic check: every reference cited carries a PubMed PMID or a verified CrossRef DOI. The figures and the statements are sourced. The clinical cases cited are drawn from the published literature (Cureus, J Orthop Case Rep, BJSM, JBJS).

Last revisedMay 2026 MethodologyA full bibliographic audit (~45 references checked) + the ESSKA-AFAS 2018 consensus, the JOSPT 2021 CPG and prospective 2024-2025 data Level of evidenceMixed (from level 2 international consensus to level 5 case reports, ranked with the GRADE/CEBM pyramid) Conflicts of interestNone declared A question, or an error to report?WhatsApp button at the bottom right of the screen 💬
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