What is the recommended treatment for a patient with chronic foot pain and MRI findings of a chronic split tear of the peroneal tendon, a chronic complete tear of the anterior talofibular ligament (ATFL), and a chronic high‑grade partial tear of the deltoid ligament complex?

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Last updated: September 28, 2026 • View editorial policy

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Treatment Approach for Chronic Peroneal Split Tear with Complete ATFL and High-Grade Deltoid Tears

This patient requires surgical intervention addressing all three pathologies simultaneously: peroneal tendon debridement/repair, lateral ligament reconstruction, and deltoid ligament repair, as conservative management has failed and the combination of chronic complete ligament tears with peroneal tendon pathology necessitates operative treatment.

Surgical Management Algorithm

Primary Surgical Objectives

The presence of chronic complete ATFL tear combined with peroneal tendon split tear indicates that the lateral ankle instability is both contributing to and perpetuating the peroneal pathology 1, 2. These concomitant lesions must be addressed together, as treating only one component leads to suboptimal outcomes.

Operative sequence should include:

  1. Peroneal Tendon Management

    • Debride the split/torn peroneus brevis segment
    • If viable tissue remains: perform side-to-side tubularization repair 3
    • If >50% tendon loss or irreparable: perform peroneus longus-to-brevis transfer 4, 5
    • Consider synthetic graft augmentation (TeKBrace) if tissue quality is poor 6
    • Flatten the sharp posterior fibular edge to prevent recurrent injury 1

  2. Superior Peroneal Retinaculum Reconstruction

    • Reconstruct the SPR to prevent recurrent subluxation 2, 3
    • This is critical as SPR laxity allows the peroneus brevis to ride over the fibular edge, perpetuating the split 1

  3. Lateral Ligament Reconstruction

    • Perform anatomical reconstruction of the ATFL (and CFL if involved) 7
    • Options include modified Brostrom-Gould or autologous peroneus brevis tendon reconstruction with double bone tunnel technique 7
    • Important caveat: If using peroneus brevis for ligament reconstruction, ensure sufficient remaining peroneal function or plan concurrent longus-to-brevis transfer 4

  4. Deltoid Ligament Complex

    • Address the high-grade partial deltoid tear with direct repair or imbrication
    • This medial instability component must be corrected to restore overall ankle stability

Why Surgery Over Conservative Management

The 2018 British Journal of Sports Medicine guideline establishes that while functional treatment is preferred for acute ankle sprains, chronic complete ligament tears with persistent instability and concomitant tendon pathology represent a different clinical scenario 8. Surgery is indicated when:

  • Conservative treatment has failed (implied by "chronic" presentation)
  • Complete ligament rupture exists (not just sprain)
  • Concomitant structural pathology (peroneal tear) is present
  • Functional demands require restoration of stability

The guideline specifically notes surgery prevents recurrent sprains and is appropriate for "patients whose complaints are not resolved by conservative treatment" 8.

Critical Pitfalls to Avoid

Do not address only the ligaments while ignoring the peroneal pathology - Studies consistently show that overlooking concomitant peroneal tears leads to persistent posterolateral pain despite successful ligament reconstruction 1, 2. The injury mechanisms are similar (inversion), and chronic lateral instability directly contributes to peroneal tendon damage through repetitive subluxation over the fibular edge.

Do not perform isolated peroneal repair without addressing ankle instability - The underlying mechanical instability will perpetuate tendon injury 1, 4.

Do not overlook the deltoid component - Bilateral ligament insufficiency creates global ankle instability that compromises outcomes.

Postoperative Protocol

  • Non-weight-bearing in posterior splint: 1 week
  • Short leg cast: 2 weeks
  • Transition to walking boot with progressive weight-bearing: week 3
  • Supervised exercise therapy focusing on proprioception, strength, and coordination 8
  • Expected timeline: 3-6 months to full activity 7, 3

Expected Outcomes

Studies report AOFAS scores improving from 65 preoperatively to 84+ postoperatively, with 85-90% achieving good-to-excellent results when all pathologies are addressed comprehensively 7, 4, 3. Failure to address concomitant lesions results in persistent pain and dysfunction despite technically successful individual repairs.

References

1
Research

Chronic ankle instability as a cause of peroneal tendon injury.

Clinical orthopaedics and related research, 1993

3
Research

Split Peroneus Brevis: An Overlooked Cause of Ankle Dysfunction.

Journal of orthopaedic case reports, 2026

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.