Peroneal Tendon Injection

The administration of corticosteroids through a peroneal tendon injection is employed for the treatment of acute or chronic tendinitis affecting the peroneal tendon at the ankle joint. This condition is identified by pain that is felt above, behind, or below the lateral malleolus, discomfort during the resisted eversion of the foot, and passive inversion.

Equipment Needed:

1. Syringe: 1 ml capacity
2. Needle: Orange, 25 gauge, 0.5 inch (13 mm)
3. Kenalog: 10 mg
4. Lidocaine: 0.75 ml, 2%
5. Total Volume: 1 ml

Related Anatomy

The peroneus longus and brevis, two tendons, travel together within a synovial sheath located behind the lateral malleolus. The longus tendon then splits off to pass beneath the foot’s arch, attaching itself at the base of the big toe. Meanwhile, the brevis tendon inserts into the base of the fifth metatarsal.

The point where these two tendons divide serves as the entry point for a needle to be inserted into the sheath. This point can be located by having the patient strongly evert their foot and feeling for the V-shaped separation of the tendons.

See Also: Peroneal Tendinopathy

Peroneal Tendon Injection Technique

Technique for Peroneal Tendon Injection with corticosteroids:

Pre-procedure preparation:

• Explain the procedure to the patient, including its purpose and potential risks.
• Obtain informed consent from the patient.
• Ensure that the patient is positioned comfortably, either sitting or lying down, with the affected leg accessible.
• Sterilize the injection site and surrounding area with an appropriate antiseptic solution.

Identify the peroneal tendon:

• Palpate the area around the lateral malleolus to locate the peroneal tendons.
• The tendons are typically found behind the bony prominence, with the peroneus brevis tendon located more posteriorly and the peroneus longus tendon located more anteriorly.

Skin preparation and local anesthesia:

• Clean the skin overlying the injection site with an antiseptic solution.
• Administer a local anesthetic (e.g., lidocaine) to numb the injection site, using a small-gauge needle and proper aseptic technique.

Needle insertion:

• Hold the syringe with the medication in one hand and a sterile needle in the other.
• Insert the needle at a 45-degree angle or perpendicular to the skin, targeting the area near the peroneal tendon.
• Advance the needle slowly and carefully, keeping it parallel to the tendon fibers to avoid injury.

Aspiration and injection:

• Once the needle is properly positioned near the peroneal tendon, gently pull back on the plunger to aspirate and confirm that the needle is not in a blood vessel.
• If no blood is aspirated, slowly inject the medication into the peroneal tendon sheath or the space adjacent to the tendon, as directed by the treating physician.
• Maintain steady pressure on the plunger while injecting to ensure even distribution of the medication.

Needle removal and post-procedure care:

• Withdraw the needle carefully and apply a sterile dressing to the injection site.
• Instruct the patient on post-procedure care, which may include avoiding strenuous activities, applying ice, or taking prescribed medications.
• Provide any necessary post-injection instructions and schedule follow-up appointments if needed.

Notes

This type of injury often coincides with acute sprains of the ankle’s lateral ligaments. A thorough examination of the joint is necessary to determine if multiple ligaments are involved, and all should be addressed if needed. If there’s any uncertainty about a tendon tear, it’s advisable to get a scan first.

Sometimes, tendinitis manifests at the attachment point of the peroneus brevis. In such cases, the same quantity of solution should be evenly distributed into the teno-osseous junction. This is achieved by inserting the needle parallel to the skin until it reaches the base of the fifth metatarsal.

A less frequent occurrence is a sprain of the flexor tendons on the foot’s medial side, where the symptoms will include pain during resisted flexion and inversion. The recommended dosage and volume of Peroneal Tendon Injection remain the same as previously mentioned.

See Also: Lateral Ankle Sprain

References & More

• Walt J, Massey P. Peroneal Tendon Syndromes. [Updated 2023 May 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK544354/
• Fram BR, Rogero R, Fuchs D, Shakked RJ, Raikin SM, Pedowitz DI. Peroneal Tendon Sheath Ultrasound Guided Corticosteroid Injection: Clinical Outcomes and Complications. Foot Ankle Orthop. 2019 Oct 28;4(4):2473011419S00175. doi: 10.1177/2473011419S00175. PMCID: PMC8696808.
• Injection Techniques in Musculoskeletal Medicine. A Practical Manual for Clinicians In Primary And Secondary Care. Fifth Edition