Acute Peroneus Brevis Tendon Rupture

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Acute Peroneus Brevis Tendon Rupture

A patient guide by Mr Matthew Welck, Consultant Orthopaedic Foot & Ankle Surgeon, London and North London

An acute peroneus brevis rupture is when one of the two tendons on the outside of your ankle suddenly tears all the way through. These tendons run behind the bony bump on the outer side of your ankle. The tear usually happens in a single injury, such as a bad ankle roll during sport, and it is often mistaken for a bad sprain. Over time the torn ends of the tendon pull apart, so it is important to get it checked early. For most active people, the best treatment is an operation to repair the tendon soon after the injury. This guide explains the injury, how it is diagnosed and the treatment options available in London and North London.

At a Glance: Acute Peroneus Brevis Rupture

Key factAcute peroneus brevis rupture
What it isA sudden, complete tear of the peroneus brevis tendon, either behind the bony bump on the outside of the ankle (the fibula) or where it joins the outer edge of the foot (the fifth metatarsal)
Who it affectsMostly active adults playing sport. It is more likely if the tendon is already weak from an earlier injury, steroid injections or some medicines
Main symptomsA pop or tearing feeling, quick swelling and bruising on the outside of the ankle, and weakness when turning the foot outwards
Key testsAn examination by a specialist, X-rays, an ultrasound scan and an MRI scan
First-line treatmentFor most active people, an operation to repair the tendon, ideally within the first few weeks
SurgeryStitching the tendon back together or fixing it back to the bone. If the gap is too big, joining it to the other peroneal tendon (tenodesis) or using a graft. Any other damage, such as torn ligaments, is repaired at the same time
RecoveryAbout 6 weeks in a boot after surgery; most people return to sport after 4–6 months
EvidenceA rare injury, so the evidence comes from reports of individual patients, small studies and expert agreement (ESSKA-AFAS 2018); there are no large trials

01

What Is an Acute Peroneus Brevis Rupture?

You have two peroneal tendons. They run down the outside of your lower leg and curve tightly behind the bony bump on the outside of your ankle (the fibula). The peroneus brevis tendon attaches to the outer edge of your foot, at a bone called the fifth metatarsal. Its main job is to turn your foot outwards, and it helps stop your ankle rolling over.

An acute rupture means the tendon has torn all the way through in a single injury. It can tear in three main places: behind the ankle bone, where the tendon is under the most pressure; higher up the leg, where the tendon joins its muscle; or where it attaches to the foot. In the last case the tendon can pull away from the bone, sometimes taking a small piece of bone with it. This is called an avulsion.

Sometimes a tendon has already been weakened by a long-standing problem and then finally tears during an injury. Doctors call this an “acute-on-chronic” rupture. It is important to know if this has happened, because it can change the type of repair you need.

02

How Common Is It?

Acute rupture of the peroneus brevis is rare. Peroneal tendon injuries are much less common than ankle sprains, and a complete tear from a single injury makes up only a small share of them. This means most of what we know comes from reports of individual patients and small groups of patients.

Because it is rare and feels like a bad sprain, this injury is easily missed. In one study, only 60% of peroneal tendon problems were correctly diagnosed at the first visit. Ruptures are often found only later, once the ankle has become weak or unstable. They are most common in sports with jumping, sudden turns and changes of direction, such as football, basketball, netball, rugby and racquet sports.

03

What Causes an Acute Rupture?

The tendon tears when it is suddenly put under more strain than it can take. This usually happens when your foot is forced inwards while the muscles on the outside of your leg are working hard to stop it.

  • Rolling your ankle: a bad ankle roll is the most common cause, for example landing on another player’s foot or on uneven ground.
  • A sudden, powerful push: pushing off or changing direction quickly can overload the tendon, especially where it attaches to the foot.
  • The tendons slipping out of place: a band of tissue called the retinaculum holds the tendons behind the ankle bone. If it tears, the tendons can flick forwards over the bone, and the brevis tendon may tear at the same time.
  • A tendon that is already weak: an old split in the tendon, earlier ankle sprains or a high-arched foot with the heel tilted inwards (called cavovarus) can make the tendon more likely to tear.
  • Medicines and health conditions: steroid injections, some antibiotics (called fluoroquinolones), inflammatory arthritis, diabetes and kidney disease can all weaken tendons.

04

What Are the Symptoms?

Symptoms usually start suddenly, at the moment you are injured.

  • A pop, snap or tearing feeling on the outside of your ankle or foot
  • Sudden pain behind or below the bony bump on the outside of your ankle, or along the outer edge of your foot
  • Swelling and bruising on the outside of your ankle that come on quickly
  • A foot that feels weak, or that you cannot turn outwards when pushing against pressure
  • Tenderness along the tendon; you may be able to feel a gap, or a sore lump on the outer edge of your foot
  • Difficulty walking, and an ankle that feels wobbly or gives way

Is it just a bad sprain?

This injury can feel just like a bad ankle sprain. If you felt a pop, your ankle is very swollen and bruised, or you cannot push your foot outwards, see a foot and ankle specialist early, ideally within two weeks.

05

How Is It Diagnosed?

Your surgeon will start by asking how the injury happened and examining your ankle. They will test the tendon by asking you to push your foot outwards against their hand. They will also feel along the tendon for tenderness or a gap, and check your ankle ligaments and the position of your heel.

  • X-rays of your foot and ankle to look for broken bones. These include a small piece of bone pulled off the outer edge of the foot, or a flake of bone from the back of the ankle bone, which suggests the retinaculum has torn
  • An ultrasound scan, which can quickly confirm a rupture and show the gap between the torn ends. Scanning while you move your ankle can also show if the tendons are slipping out of place
  • An MRI scan, which shows exactly where the tendon has torn, how far apart the ends have pulled, whether the tendon was already weak, and any damage to the other peroneal tendon (peroneus longus), the retinaculum or the ankle ligaments
  • A Weight-Bearing CT scan in some cases. This is taken while you stand and shows the position of your heel, in case a high-arched foot or tilted heel played a part

It is important to have scans early. In the first few weeks, the torn ends can usually be stitched back together. If the injury is found later, a more complex operation may be needed.

06

Non-Surgical Treatment

Treatment without surgery works less well for a complete rupture than for other peroneal tendon problems. This is because the torn ends do not always heal back together at the right length. But it may still be the right choice for:

  • Partial tears, where most of the tendon is still intact
  • People who are less active and do not put much strain on their ankle day to day
  • People with health problems that make surgery more risky

Treatment usually means wearing a walking boot for about six weeks, using crutches at first if needed. This is followed by physiotherapy to rebuild your strength, balance and sense of where your foot is (proprioception). You may also wear an ankle brace for sport or uneven ground. Steroid injections are avoided, because they can weaken the tendon further.

Some people treated without surgery are left with a weak foot or an ankle that feels unstable. If problems continue, an operation to rebuild the tendon can still be done later.

07

Surgical Treatment

For most active people, an operation is recommended to make the ankle strong and stable again. The aim is to join the tendon back together at the right tension and repair anything else damaged in the same injury. The right operation for you depends on where the tendon has torn, how healthy the torn ends are, how long ago you were injured, and whether the other peroneal tendon (peroneus longus) is also damaged. Surgeons often use guidance from a 2018 international expert group (ESSKA-AFAS) to help make these decisions.

Timing of Surgery

The best results come from repairing the tendon early, ideally within the first two to three weeks. After that, the torn ends pull back and soften, and the muscle shortens. This makes it harder to stitch the ends together, and more likely that you will need a graft or tenodesis (see below).

Direct Repair

If the tear is in the middle of the tendon and the ends are healthy, they are tidied up and stitched straight back together. This restores the tendon’s normal length and strength. It is the usual operation for a rupture that is found early.

Reattachment to the Fifth Metatarsal

If the tendon has pulled away from the outer edge of the foot, it is fixed back to the bone using small anchors with stitches attached (suture anchors). If a larger piece of bone has come away with the tendon, that piece of bone is fixed back in place, usually with a screw.

Joining to the Other Tendon (Tenodesis) or Using a Graft

Sometimes the torn ends cannot be brought together without pulling too tight, or the tendon is in poor condition, for example if it was already weak before the injury. In this case the brevis tendon can be stitched to the healthy peroneus longus tendon next to it, so that one tendon does the job of both. This is called a tenodesis. Another option is to bridge the gap with a piece of tendon from elsewhere (a graft), usually a hamstring tendon from the back of the thigh. Expert guidance prefers a graft to a tenodesis if the muscle is still working. If both peroneal tendons are torn, or the muscle no longer works, a tendon from elsewhere can sometimes be moved to take over (a tendon transfer).

Treating Associated Injuries

An acute rupture often comes with other damage. If the retinaculum is torn, it is repaired to stop the tendons slipping out of place, and sometimes the groove behind the ankle bone is made deeper. Torn ankle ligaments are repaired in the same operation. If a high-arched foot or tilted heel played a part, your surgeon may suggest an operation to reposition the heel bone (a calcaneal osteotomy) to protect the repair.

Comparing the Main Surgical Options

OptionWhen it is usedWhat to expect
Direct repairTear in the middle of the tendon, healthy ends, found earlyRestores the tendon’s normal length and strength
Reattachment to boneTendon pulled off the outer edge of the foot, with or without a piece of boneTendon fixed back with small anchors, or the piece of bone fixed with a screw
Joining to the longus (tenodesis)Gap too big or tendon in poor condition; other tendon healthySimple and reliable; one tendon does the job of two
Graft reconstructionLarge gap or injury found late; muscle still workingRestores length and tension using a hamstring tendon or a donor tendon
Associated repairsTorn retinaculum or ligaments, or a high-arched footAdded to any of the above to protect the repair

Recovery After Surgery

After surgery you will usually wear a splint for about two weeks and must not put weight on your foot. You will then wear a walking boot until about six weeks, slowly putting more weight through your foot. After this, physiotherapy helps you get back movement, strength, balance and control. Most people can start running again from about three months and return to sport after four to six months, depending on the type of repair and the sport they play.

Reports of patients who had an early repair show that most get back good strength and use of their foot. But because this injury is rare, there are no large studies. Recovery can take longer if the repair was done late or needed a graft or tenodesis. Some people have ongoing discomfort or weakness, so it helps to have realistic expectations.

08

Why Choose Mr Welck?

Mr Matthew Welck is a Consultant Orthopaedic Foot & Ankle Surgeon at the Royal National Orthopaedic Hospital (RNOH), Stanmore, and Honorary Associate Clinical Professor at University College London (UCL).

He works only on the foot and ankle, with clinics in Central and North London. The RNOH is one of the UK’s leading specialist orthopaedic hospitals, and other surgeons often refer complex cases to him there. He regularly sees patients with peroneal tendon ruptures and other tendon injuries, ankles that keep giving way, and high-arched feet.

Sports injuries are a large part of his work. Where helpful, he uses a Weight-Bearing CT scan, taken while you stand, to show how your foot works under load and find out why a tendon has failed. He also performs total ankle replacement, complex reconstruction and revision surgery, so if your injury has caused wider damage to your ankle, all of your care can be managed in one place.

Mr Welck is active in research, with more than 50 published scientific papers. He sits on the BOFAS Education Committee and teaches senior trainee surgeons about tendon rupture. He will always talk through your options with you, so that you can decide on your treatment together.

09

Frequently Asked Questions

Can an acute peroneus brevis rupture heal on its own?

A complete tear rarely heals back together at the right length without surgery, and the torn ends tend to pull further apart over time. Partial tears, and people who are less active, may do well with a boot and then physiotherapy. Most active people are advised to have an early repair.

How do I know if I have ruptured my peroneus brevis or sprained my ankle?

Both cause pain, swelling and bruising on the outside of the ankle. A rupture is more likely if you felt a pop, the pain is behind the bony bump on the outside of your ankle or on the outer edge of your foot, and you cannot push your foot outwards against pressure. If you are not sure, see a foot and ankle specialist within two weeks.

How soon should a ruptured peroneus brevis be repaired?

Ideally within the first two to three weeks. After that, the torn ends pull back and the muscle shortens. This can make it harder to stitch the ends together, and more likely that you will need a graft or tenodesis.

Do I need an MRI scan?

Not always. An ultrasound scan can often confirm a rupture quickly, and X-rays show any broken bone. An MRI scan helps plan surgery, because it shows exactly where the tendon has torn, how far apart the ends are and whether anything else is damaged.

How long will I be in a boot after surgery?

Usually about six weeks in total: around two weeks in a splint without putting weight on your foot, then a walking boot. Physiotherapy then helps you rebuild strength and balance.

When can I return to sport?

Most people can start running at about three months and return to sport after four to six months. This depends on the type of repair, your sport and how your rehabilitation goes.

What are the risks of surgery?

Risks include problems with wound healing, irritation of a nerve on the outside of the foot (the sural nerve) causing numbness along the outer edge of the foot, stiffness, ongoing discomfort, blood clots and, rarely, the tendon tearing again. Your surgeon will explain how these risks apply to you.

Where can I see a foot and ankle surgeon in London for a peroneal tendon rupture?

Mr Matthew Welck sees patients with peroneal tendon ruptures and other sports injuries at HCA The Princess Grace Hospital in Central London, and at Spire Bushey, HCA The Wellington Hospital Elstree and the RNOH Private Patients Unit in North London.

10

Book a Consultation

If you think you may have ruptured a peroneal tendon, or your ankle is very swollen, bruised or weak after an injury, see a specialist early. This gives you the widest choice of treatment. Mr Welck sees private patients (insured and self-funding) and NHS patients at the following locations:

  • HCA The Princess Grace Hospital, Central London (outpatients at Nottingham Place, W1U 5NY and 30 Devonshire Street, W1G 6PU)
  • HCA The Wellington Hospital Elstree, North London
  • Spire Bushey, North London (0203 733 5665)
  • RNOH Private Patients Unit, Stanmore, North London

Telephone 07547 395 270, email secretary@matthewwelck.com or book a consultation online. Patients are seen from across London, Hertfordshire, the UK and overseas.

Written and medically reviewed by Mr Matthew Welck

MBChB FRCS (Tr&Orth), Consultant Orthopaedic Foot & Ankle Surgeon, RNOH Stanmore; Honorary Associate Clinical Professor, UCL. GMC 6074385.

Last reviewed: October 2026. Next review due: October 2027.

References

  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;26:3096–107. doi:10.1007/s00167-018-4971-x
  2. Davda K, Malhotra K, O’Donnell P, Singh D, Cullen N. Peroneal tendon disorders. EFORT Open Rev 2017;2:281–92. doi:10.1302/2058-5241.2.160047
  3. Redfern D, Myerson M. The management of concomitant tears of the peroneus longus and brevis tendons. Foot Ankle Int 2004;25:695–707.
  4. Pelet S, Saglini M, Garofalo R, Wettstein M, Mouhsine E. Traumatic rupture of both peroneal longus and brevis tendons. Foot Ankle Int 2003;24(9). doi:10.1177/107110070302400912
  5. van Dijk PA, Lubberts B, Verheul C, et al. Rehabilitation after surgical treatment of peroneal tendon tears and ruptures. Knee Surg Sports Traumatol Arthrosc 2016;24:1165–74.

This guide is for general information and does not replace an individual consultation. Treatment decisions should be made with a clinician who has examined you.

Written by: Matthew Welck | Consultant Orthopaedic Foot & Ankle Surgeon London — last updated 22 October 2026

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