Dr Julien Lopez, a surgeon of fibular tendonitis

This is the case of Doctor Julien Lopez, practising in Nice, Monaco and Corsica to treat patients with tendonitis of the fibular tendons. This inflammation occurs most of the time in athletes, it often becomes uncomfortable to the point of stopping them in their sporting practice. Most of the time, they are athletes practicing running or even jumping. This pathology can be associated with a varus of the rear foot or related to bad practices such as a bad choice of shoes. Dr Julien Lopez will be able to perform surgery for your peroneal tendonitis if medical treatment has failed or if the cause of your tendinitis is able to be treated by surgical treatment (chronic instability of the fibular tendons, hypertrophy of the trochlea or "peroneal tuber", low muscle, lateral retromalleolar groove or a crack in the short or long peroneal tendon).

What is involved in an operation on the lateral peroneal tendonitis ?

Would you like to have an operation for tendonitis of the lateral peroneum? It is first of all essential to understand this pathology. The peroneal or peroneal tendons include 2 tendons : the short and long peroneal tendon which are located on the outer part of the ankle behind the outer malleolus. These 2 tendons have a role of stabilizing the ankle, particularly during inversion and eversion movements of the ankle. The presence of inflammation or tendonitis of these tendons causes discomfort and pain when walking or during sports (running, jumping). Running and jumping are contributing factors to this condition.

It is essential to distinguish 2 main types of pathology of the peroneal tendons :

• Tendonitis of the peroneal or peroneal tendons in the presence of inflammation
• Acute or chronic instability of the fibular tissues when they are dislocated
• It is important to note that it is possible to have a mixture of both inflammation and instability a the same time

The short fibular tendonitis surgeon will look for clinical signs that point to one or the other, in order to prescribe an appropriate treatment. The tendinitis peroneal tendons surgery is not always necessary, but is still shown in some cases to relieve the patient and contribute to healing. The surgeon's objective for fibular tendinitis of the foot will be to find the cause, determine the origin of the inflammation and then suggest medical or surgical treatment.

What are the symptoms of ankle fibular tendon surgery ?

Inflammation of the fibular tendons often occurs in young, athletic males. Overuse of the tendons leads to micro-trauma and shocks during repeated movements. The tendons are then inflammed and micro-ruptures which are characterized by swelling (swelling of the tissues). In special cases of tendon instability, the patient may experience snapping in the ankle as well as feelings of instability and pain. In most cases, it is possible to avoid the operation for tendonitis of the peroneal tendon of the foot.

The common clinical signs of fibular tendonitis is pain localized in the outer part of the ankle. Sometimes, it can sit on the medial aspect of the foot if the long fibular tendon is involved. Mild swelling is often seen in patients with this condition. Other clinical signs are possible and should be looked for by the doctor. These include :

• Limping
• Recurrent sprains
• Feeling of loose ankle or unsteadiness
• Poor stability especially on uneven terrain

Special case of instability of fibular tendons

If the tendons are not stable in their groove, we speak of sub-luxation or dislocation of the peroneal tendons. In this case, it is sometimes possible to perceive a jump or a snap when practising sports. The surgeon will perform various clinical maneuvers in order to recreate the dislocation : we can sometimes observe the dislocation of the fibular tendons under the skin.

What are the exams to be performed ?

1. X-ray : In the presence of fibular tendinopathy, the x-ray is the first examination to be performed. She will look for a cause for the bone inflammation such as sequela of sprains or a hyperthrophic peroneal tubercle. We will also look to see if any contributing factors are present such as varus of the hindfoot.
2. Ultrasound : Static or dynamic ultrasound is main method used to both to make the diagnosis and to evaluate the gravity of a serious diagnosis. It will be easy to highlight tenosynovitis, fissure, low muscle or to find the cause of tendinopathy. It allows the surgeon of tendonitis of the tendon of the fibular muscles to take the decision to operate or not.
3. MRI : MRI can also be recommended, but will be less precise than ultrasound for this type of pathology. However, another examination, to highlight the cracks of the peroneal tendons an be performed if necessary.

After the medical consultation and examinations, the surgeon for peroneal tendonitis will be able to make a diagnosis, establish the severity and suggest medical or surgical treatment. It is important to properly treat the tendonitis of the peroneal tendons as they can worsen to the point of tendon rupture.

What is the evolution of a pathology of the fibular tendons?

The course of a pathology of the fibular tendons evolves naturally regarding the aggravation of lesions and functional symptoms present. Clinically, we observe an increase in pain, swelling, limping and sometimes even a limitation of autonomy.

It is important to treat peroneal tendonitis correctly because, if left untreated, it can get worse:

• Simple tendonitis can progress to tenosynovitis (inflammation of the peri-tendon)
• A partial or total crack (tendon rupture) can happen

The treatment is much easier when action is taken early, limiting the risk of certain complications such as sprains, complete ruptures or ankle osteoarthritis.

How to treat fibular tendinopathy without operating?

A quick consultation with your fibular surgeon will allow you to quickly make the diagnosis and suggest medical treatment to avoid surgery.

The medical treatment of peroneal tendonitis is offered in early forms, it combines several measures:

• Sports rest: Sports is prohibited for 4 to 6 weeks
• Physiotherapy: Anti-inflammatory and painkillers and physiotherapy exercises
• Medicines: Painkillers and anti-inflammatory drugs
• Consultation with the podiatrist: Making insoles to correct contributing factors such as varus of the rear foot
• PRP injection or corticosteroid infiltration (to be used in specific cases because there is a risk of secondary tendon rupture)

If the medical treatment is no longer effective, that is to say that all the above measures are no longer sufficient, then surgery on the peroneal tendons should be considered. For patients who live in Corsica, it is sometimes difficult to make an appointment with a surgeon specializing in fibular tendonitis in Corsica. If you cannot get an appointment, Dr Lopez can see you in Nice.

How to prevent peroneal tendonitis?

There is no specific preventive measure because tendonitis of the peroneum is linked to repeated micro-trauma during sports. On the other hand, it is possible to correct contributing factors such as varus of the hindfoot (making insoles).

As in any sport, a good warm-up reduces the risk of injury.

How is the operation for the fibular tendon in the ankle?

Dr. Julien Lopez now explains the operation of the fibular tendon of the ankle.

The surgical indication for an operation of the fibular tendon in the ankle follows a specialist consultation with a foot surgeon. During this consultation, the surgeon will explain precisely the surgical procedure to be performed. The surgical indication can sometimes be immediate from the outset (chronic instability or large crack) or if the medical treatment fails. The goal of the surgery is to regain remove the ankle pain and return to sport without restrictions. It is important to note that fibular tendinopathy is often the result of another underlying problem: the foot surgeon will need to treat the cause AND the consequence (tendonitis).

Each clinical situation is specific and only a specialist consultation will be able to inform you about the procedures to be carried out. To know exactly the nature of the treatment to be performed, the surgeon will first have to specify certain elements in consultation. The choice of technique and the assessment of the procedures to be performed is left to the surgeon depending on the severity of the condition and the complexity of the intervention.

To achieve this result, different operating techniques are possible such as percutaneous surgery, minimally invasive surgery (arthroscopy or tendinoscopy) or more traditional techniques called "open".

Hospitalization:

The operation is usually performed on an outpatient basis, reducing the length of hospital stay to one day. However, for various reasons, it is possible to provide for 1 night of hospitalization.

Anesthesia :

You will need to perform the mandatory pre-anesthetic consultation with the anesthesiologist. During this consultation, the anesthesiologist will explain the possible modes of anesthesia to you according to your associated pathologies and the planned surgical procedure. If necessary, the anesthesiologist will adapt your treatment before and after the operation and may prescribe anticoagulants, analgesics, anti-inflammatory drugs or others.

Several types of anesthesia are possible: you may benefit from local or regional anesthesia meaning that only your leg will be desensitized: this is the most common. General anesthesia is also a solution if you prefer to be completely asleep.

The intervention:

• Before the operation for tendonitis or fibular fissure: You will be taken to the pre-anesthesia room. Local anesthesic will be performed before entering the operating room.
• Installation in the operating room: you will be installed in lateral position, that is to say on the back or slightly on the side (3/4) with a cushion under the contralateral buttock or on the side.
• The tourniquet: Throughout the operation, a tourniquet is usually placed on the calf or thigh to prevent bleeding.
• The incision: the incision measures a few millimeters using the "tendinoscopy" technique (minimally invasive or micro-invasive surgery). The technique known as “open sky” requires an incision of a few centimeters. Most operations are performed with a short 5-10cm incision. The choice of technique and the assessment of the procedures to be performed is left to the surgeon depending on the severity of the condition and the complexity of the operation.
• The surgical procedure: The first part of the tendon operation in case of fibular tendinopathy consists of repairing a crack, cleaning the tendons or removing part of the diseased tendon if it cannot be repaired. The second part of the intervention consists of treating the contributing factors or the cause: partial muscle excision, digging of the retro-malleolar groove (if groove dysplasia) or sanding of the peroneal tubercle. In the event of a rupture, a direct suture or tenodesis can be performed, that is to say a suture of the long fibular tendon on the short fibular tendon. If you have instability of the fibular tendons with episodes of dislocation, stabilization of the tendons (fixation and retention of the peroneal retinaculum) should be carried out.
• Operative time: the duration of the surgical procedure is relatively short, generally 30 to 60 minutes. The intervention may be longer in the event of associated procedures or operating difficulties.
• The material: In most cases, no implant is necessary. In some cases, screws or anchors are used to secure osteotomies or to secure structures to the bone.
• At the end of the operation: the surgeon makes a dressing and, if necessary, places the ankle in a removable boot.

It is important to note that the surgeon may face an unforeseen or unusual situation requiring different acts than those initially planned. In this case, the surgeon will explain the difficulties encountered and the actions taken as soon as you wake up or return to your room.

What are the postoperative consequences?

We explain to you the rehabilitation after an operation for long fibular tendonitis or after operation for short fibular tendonitis.

WALKING

Walking is permitted immediately or after a few days and the ankle is placed in a boot over a period of 2 to 6 weeks. After this time, you can put on regular shoes if the pain permits. Crutches can be useful for the first few days to make walking easier.

THE BANDAGE

Dressings are necessary and a prescription will be given to you by the secretary. The first dressing should be done within 72 hours of the operation by the home nurse.

SWELLING

Swelling is not a complication and is a common occurrence after such an operation. To speed up its absorption, it is recommended to regularly ice the foot and put the foot up as soon as you feel the swelling. It takes about 2 months for the swelling to go down to 80% and 6 to 9 months for the foot to deflate completely.

HOME CARE

Unless your surgeon advises otherwise, dressings should be performed every 2 days until complete healing.

MEDICINAL TREATMENTS

Painkillers will be prescribed to you by the anesthetist to reduce postoperative pain.

Depending on your history, your existing medical issues and your autonomy, the anesthesiologist may prescribe anticoagulant therapy by injection (subcutaneously) or systemically (per os). This treatment helps prevent the onset of phlebitis, i.e. the formation of a clot in the veins.

It is strongly recommended to take the painkills prescribed systematically during the 2 days following the surgery.

PHYSIOTHERAPY

Physiotherapy is not systematic; its usefulness will be assessed by the surgeon during your first postoperative consultation. In order to accelerate functional recovery and the elimination of swelling, self-rehabilitation is essential. If necessary, physiotherapy sessions will be prescribed to you during your first postoperative appointment.

WORKING

The average time off work is 30 to 60 days depending on your professional activity and the action taken.

SPORTS ACTIVITIES

For a resumption of sports activities, it will take 2 to 4 months on average. The resumption of swimming and cycling is allowed from the 1st month.

POST-OPERATIVE FOLLOW-UP

Two post-operative appointments are necessary: ​​on the 21st day and then 60 days after the operation.

IN CASE OF QUESTIONS

For any additional questions or in the event of a problem, you can email him or contact his secretariat.

In conclusion

The aim of the fibular tendonitis operation is to restore the mobility, remove the pain and stablise the ankle in order to allow the resumption of sports activities. In most cases, the surgical procedure is an outpatient hospitalization and support is authorized immediately.

What are the complications of the surgery?

The following list of complications is not exhaustive, but the most frequent complications are mentioned.

Any surgery exposes you to complications that are both common and specific to the type of intervention performed. This risk varies from one individual to another depending on their age, co-morbidities (hypertension, diabetes, poor skin condition, etc.) as well as depending on their lifestyle (tobacco, alcohol, practice of a sports activity).

Some complications can be prevented by simple measures such as:

• compliance with postoperative instructions.
• stopping smoking.

Some complications can be prevented by simple measures such as:

• compliance with postoperative instructions
• stopping smoking

Common Complications:

• Hematoma is an infrequent complication, due to certain drug treatments (anticoagulants). Some drugs can be stopped and taken over by the anesthesiologist. The hematoma rarely requires surgical intervention, it most often is resolved with ice and rest.
• These healing problems are rare thanks to the combined use of the minimally invasive and percutaneous technique. Their occurrence is increased by tobacco and a poor skin condition.
• Swelling is not a complication but a reaction of the body to surgery. In order to decrease its importance, it is useful to perform self-rehabilitation by moving your toes, to limit extreme activities for 15 days and to elevate your foot as much as possible when you are lying down.
• Thrombophlebitis is the formation of a clot in a vein, most often in the leg or foot. Its prevention is walking and possibly, depending on the anesthetic prescriptions, the administration of an anticoagulant treatment by the subcutaneous route or even systemically.
• Algodystrophy or "complex regional pain syndrome" is an overreaction of the body to the aggression of surgery. The symptoms are: redness, stiffness, swelling and pain. The evolution is always towards healing without long term consequences but the healing is long (up to 18 months). Certain simple measures minimize this risk: the pain must not be allowed to set in and the prescribed painkillers must be taken systematically during the 48 hours postoperatively.
• Infection can occur despite precautions (preoperative shower, surgical aseptic preparation). It should be considered in case of fever, scar breakdown, discharge or significant redness. It requires surgical advice.

Specific complications

• Bone necrosis is the death of bone due to damage to its vascularization.
• Recurrence and the reappearance of symptoms

FAQ

What is fibular tendonitis?

Tendonitis or fibular tendinopathy is inflammation of the short or long fibular tendon that manifests as pain and swelling in the outer part of the ankle. It often occurs as part of intense sports practice. Tendonitis can be simple or associated with more serious lesions such as a crack or a complete rupture of the tendon. It will be essential to look for contributing factors and to treat them. A special case is tendonitis with instability of the fibular tendons which requires specific surgical treatment.

Which specialist will treat peroneal tendonitis?

The course in the absence of prompt treatment can lead to a ruptured tendon, which is why a specialist foot and tendonitis surgeon should be consulted quickly.

How to treat fibular tendonitis?

Unless there is an indication for surgery from the outset, treatment is always medical. It is based on physiotherapy, soles, adaptation of the footwear and sports activity or an injection (rich plasma platelets).

How to operate on fibular tendonitis?

The operative procedure depends on the type of pathology and the type of tendonitis. It can range from simple cleaning to a tendon suture. The factors favoring the occurrence of tendonitis of the peroneal tendons must be corrected at the same time as the operation.

How long does the operation of the peroneal tendons take?

The operating time depends on the gesture to be performed. It is on average 30 minutes to 2 hours.

What anesthesia is used during the operation?

Local anesthesia is the most common meaning that only the leg is asleep. We can also use a spinal anesthesia or a general anesthesia. The mode of anesthesia is decided during the pre-anesthetic consultation according to your wishes and your state of health.

What treatment for fibular tendonitis?

When possible, treatment is always medical:

• Medicines such as painkillers and non-steroidal anti-inflammatory drugs
• Weight loss in case of overweight
• Physiotherapy: it aims to reduce pain, inflammation and swelling with techniques such as anti-inflammatory and physiotherapy exercises
• Orthopedic insoles for the correction of a possible varus of the rear foot or to better distribute the stresses
• PRP: are often tried in the presence of a small crack. However, they never provided scientific proof of their effectiveness.
• Stopping or modifying sports activities
• Corticosteroid infiltrations such as disproten are discouraged due to the risk of complete tendon rupture.

How much pain do you feel during the operation?

Pain after fibular tendon surgery is absent or moderate. The anesthesia performed in the operating room has an effectiveness of 12 to 24 hours which ensures complete numbness. When the anaesthetic wears off, postoperative pain can occur. In this instance, oral painkillers are very effective.

What is the period of mobility after an operation?

As a general rule walking is permitted upon leaving the clinic. The ankle is placed in a boot-type splint for a period of 2 to 6 weeks maximum.

Am I allowed to drive after the operation?

Yes, you have the right to drive if you have an automatic car and you have had surgery on your left foot. In all other cases, driving should be avoided as you will not be covered in the event of serious accident.

Can we operate on both feet at the same time?

No, it is not possible to operate on both feet at the same time except in rare exceptional cases.

What is the cost of a fibular tendon operation?

The price of an intervention varies depending on the clinical condition of the patient and the procedures to be performed. Social security covers the costs of the operation. The reimbursement of additional fees depends on your insurance contract. The average remaining charge after being reimbursed by your insurance company is € 300.

If you would like a consultation with a surgeon for tendonitis of the lateral peroneal short, Doctor Julien Lopez will see you in Nice or Cap d’Ail (Near Monaco). You can make an appointment directly via Doctolib or by contacting him secretary.