Question 1

I've had multiple ankle sprains over the past few years and now have chronic pain behind my outside ankle bone that's been there for 6 months. My GP has been treating me for 'chronic ankle sprain' with physiotherapy and anti-inflammatories but I'm not improving. Could this be something else?

Accepted Answer

Yes, very likely. Chronic lateral ankle pain that doesn't improve with standard ankle sprain treatment should raise suspicion for peroneal tendon pathology, which is frequently misdiagnosed. Here's why: ANKLE SPRAIN VS PERONEAL PATHOLOGY: Lateral ankle sprain: ligaments on outside of ankle torn (anterior talofibular ligament, calcaneofibular ligament). Pain and tenderness BELOW and IN FRONT of outer ankle bone (lateral malleolus). Usually improves with 4-8 weeks rest and physiotherapy. Peroneal tendon injuries: tendons running BEHIND outer ankle bone damaged. Pain and tenderness BEHIND lateral malleolus. Often doesn't improve with standard sprain treatment because tendons not being addressed. WHY MISDIAGNOSIS IS COMMON: Both cause lateral ankle pain and swelling, X-rays normal for both conditions (unless severe peroneal pathology), peroneal injuries often occur WITH ankle sprains (30-40% of severe ankle sprains have associated peroneal damage), most GPs not familiar with peroneal pathology (less common than ankle sprains). RED FLAGS SUGGESTING PERONEAL PATHOLOGY: Pain directly behind (posterior to) lateral malleolus when pressing. Clicking, popping, or snapping sensation during ankle movement (suggests peroneal subluxation). Weakness when trying to turn foot outward (eversion). Pain not improving after 3-4 months of standard ankle sprain treatment. History of multiple previous ankle sprains (chronic instability damages peroneal tendons over time). WHAT YOU SHOULD DO: See orthopedic surgeon or sports medicine doctor for assessment. Specifically ask: 'Could this be peroneal tendon pathology rather than just ankle sprain?' Request imaging: ultrasound (can see peroneal tendons in real-time, identify tears or subluxation), or MRI (gold standard—shows longitudinal splits in tendons, fluid around tendons, retinaculum tears). TREATMENT IF PERONEAL PATHOLOGY CONFIRMED: Depends on what imaging shows: Tendinitis (inflammation)—immobilization in walking boot for 4-6 weeks, peroneal-specific physiotherapy (different exercises than ankle sprain rehab), NSAIDs. Longitudinal split tears—if small (less than 50% tendon width), trial of conservative management 3-4 months. If large or failed conservative, surgical debridement and repair. Subluxation—if tendons slipping out of groove behind ankle, usually needs surgical repair of retinaculum (conservative rarely works). BOTTOM LINE: After 6 months of failed treatment, you've given conservative management adequate trial. Time for specialist assessment and imaging to identify exact pathology. Don't continue treating as 'ankle sprain' indefinitely without confirming diagnosis.

Question 2

I'm a ballet dancer and my ankle clicks and pops every time I go up on my toes (en pointe). My physiotherapist thinks I have peroneal subluxation—the tendons are slipping out of their groove. She says I might need surgery to fix it. I'm worried about downtime and whether I'll be able to dance again. What are realistic expectations?

Accepted Answer

Peroneal subluxation is relatively common in ballet dancers due to repetitive ankle plantarflexion (pointing) and eversion (turning foot out) during en pointe work. Here's what you need to know: CONFIRMATION OF DIAGNOSIS: Make sure diagnosis is confirmed with imaging (ultrasound or MRI) before committing to surgery. Ultrasound can show tendons subluxing (slipping out) in real-time during ankle movement. MRI shows torn superior peroneal retinaculum (restraining band that normally holds tendons in groove). Some clicking in dancers is normal (not all clicking is subluxation). Confirm it's truly peroneal subluxation and not: snapping hip (different location), ankle joint capsule clicking, scar tissue from previous ankle sprains. CONSERVATIVE TRIAL FIRST: Before surgery, try conservative management for 3-4 months: immobilization in walking boot or cast for 4-6 weeks (allows retinaculum to heal), complete break from dance during immobilization, physiotherapy after immobilization focusing on peroneal strengthening and ankle stability, gradual return to dance avoiding en pointe initially. Success rate conservative: only 30-40% (subluxation tends to recur once return to high-demand activities like ballet). However, worth trying before surgery if: you're young (under 18—bone still growing, may outgrow problem), first episode of subluxation, willing to modify dance activities (avoid extreme en pointe positions). SURGERY FOR RECURRENT SUBLUXATION: If conservative fails or you have recurrent subluxation episodes, surgery is reasonable: Procedure options: retinaculum repair (sewing torn band back together), groove deepening (making groove behind ankle bone deeper so tendons sit lower and can't escape), bone block (placing small bone piece to create wall preventing escape). Groove deepening has highest success rate (85-90% vs 75-80% for retinaculum repair alone). Surgery takes 60-90 minutes, day procedure. RECOVERY TIMELINE: Week 0-4: cast/boot, non-weight-bearing on crutches. Weeks 4-6: progressive weight-bearing in boot. Weeks 6-12: physiotherapy (ROM, strengthening, balance). Month 3-4: return to gentle dance classes (no en pointe). Month 4-6: progressive en pointe work under supervision. Month 6-9: full return to dance if strength and stability adequate. Total: expect 6-9 months before returning to pre-injury dance level. REALISTIC OUTCOMES: Success preventing recurrent subluxation: 80-85% with groove deepening surgery. However, even 'successful' surgery may have limitations: residual lateral ankle stiffness (10-15 degrees less plantarflexion—affects pointing), chronic pain with prolonged dancing (20-30%), subtle weakness or instability affecting balance en pointe, increased fatigue in lateral ankle during long performances. Return to pre-injury dance level: 70-75% return to same level, 20-25% dance at lower level (professional to amateur, or retire from performance), 5% cannot return to dance due to persistent pain/instability. COMPLICATIONS: Recurrent subluxation despite surgery (10-15%—most common complication). Sural nerve injury (numbness on outside of foot—10-15%). Wound complications (lateral ankle has thin skin—5-10%). Fracture of lateral malleolus from groove deepening (2-3%). Stiffness limiting plantarflexion (15-20%). BOTTOM LINE: Peroneal subluxation surgery can be successful for ballet dancers, but: expect 6-9 months before full return to dance, 70-75% return to pre-injury level, 20-30% have residual symptoms (pain, stiffness) affecting performance. Try conservative management first (3-4 months) before committing to surgery. If surgery needed, ensure surgeon experienced with dancers and peroneal pathology (not all orthopedic surgeons familiar with this specific problem). Consider second opinion from sports medicine doctor specializing in dance injuries.

Medical Disclaimer

Peroneal Tendon Tears (Outside Ankle Tendons)

📖What is Peroneal Tendon Tears (Outside Ankle Tendons)?

🔬What Causes It?

⚠️Risk Factors

You may be at higher risk if:

🛡️Prevention