Lateral ankle injuries are extremely common, especially in high-torsion sports such as netball, basketball, rugby, AFL and soccer.  Peroneal tendon pathologies are a common cause of lateralising ankle pain, but are also frequently missed or underdiagnosed on medical imaging studies. 

Peroneal tendon injuries are experienced by around 20% of the population during their lifetime, and should be considered in all patients experiencing chronic lateralising ankle pain. Around 40% of patients with chronic lateral ankle pain have underlying peroneal tendon pathology. Identifying the source of chronic ankle pain can be difficult, however, due to the wide range of potential causes. 3T MRI is the gold standard for accurate diagnosis of lateralising ankle pathology, however ultrasound may have a complementary role in some patients with peroneal tendon pathology, particularly in the detection of dynamic peroneal tendon instability. Plain radiographs or low dose CT also have a complementary role in conjunction with MRI, due to their increase sensitivity for subtle avulsion fractures. However, MRI remains the most accurate investigation for investigation of lateralizing ankle pain, with its ability to accurately define injury to subtle structures such as the Superior Peroneal Retinaculum and ATFL, define the morphology of the retromalleolar groove, detection of anatomical variants of the Peroneal Tendons such as accessory Peroneus Quartus muscles, and detection of related pathology such as bone contusions and osteochondral lesions of the Talar dome. 

Peroneal tendon injuries are a commonly overlooked or underdiagnosed cause of chronic lateral ankle pain in elite and amateur athletes. Whilst less common than ATFL tears, Peroneus Brevis tendon injuries are more commonly missed or misdiagnosed. 

Below are a series of common Peroneal tendon pathologies on high resolution 3T MRI scans with Deep Resolve image enhancement, which may often be undercalled or overlooked by radiologists lacking subspecialist training and experience in musculoskeletal MRI. 

A. Peroneus Brevis longitudinal split year and prolific Peroneal tenosynovitis. 

B. Congenital accessory Peroneus Quartus muscle and developmentally shallow fibular peroneal groove which predisposes to peroneal tendon instability or ‘snapping ankle’, in a patient with an acute anterior syndesmotic rupture and posterior malleolar fracture.

C. Peroneus Brevis tenosynovitis and interstitial split tear.  

D. Superior Peroneal Retinacular tear and ruptured Anterior TaloFibular Ligament.

E. Peroneus Brevis tenosynovitis and longitudinal split tear, associated with a Fibula periosteal stripping injury at the Superior Peroneal Retinacular attachment, which may predispose to future peroneal tendon instability without appropriate treatment.

Panorama Radiology Specialists offers subspecialist musculoskeletal expertise in sports injury imaging and diagnosis (using 3T MRI and Ultrasound) and imaging-guided pain management procedures. 

Panorama’s principal radiologist, Dr Angus Watts, is a Fellowship-trained musculoskeletal and interventional radiologist with 2 decades of experience, and is always happy to discuss cases with referring clinicians including offering advice on imaging pathways and imaging-guided pain management procedures which may be beneficial in the individual patient’s circumstances.


Acute Peroneal Tendon Injuries in SportJustin M. Kane MD et Al, Operative Techniques in Sports Medicine, June 2017 

Chronic Disorders of the Peroneal Tendons: Current Concepts;  J. American Academy of Orthopedic Surgery; Van Dijk Pim A.D., Gino M., Kerkhoffs M. et al.; August 2019

Injuries of the Peroneal Tendons : Often Overlooked ; K Klos et al.; Unfallchirurg; 2017 Dec.

Peroneal Tendon Injuries; Terrence M. Philbin et al; Am Acad Orthop Surg, Vol 17, No 5; May 2009

I’m always happy to discuss individual cases with referring clinicians – if you’re a medical practitioner seeking an opinion on which imaging-guided pain management measures may be most appropriate and beneficial in an individual clinical situation, please feel free to contact me directly.

Dr Angus Watts


Diagnostic and Interventional Radiologist

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