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Peroneal tendon subluxation — MSRA MCQ

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ModerateAnkle and FootPeroneal tendon subluxationMSRA

A 31-year-old recreational footballer attends general practice 9 days after an inversion injury to his right ankle. He initially had lateral ankle swelling but can now walk without a limp. He reports recurrent painful snapping behind the lateral malleolus when turning sharply or walking on uneven ground. There is mild tenderness and swelling posteroinferior to the lateral malleolus. Active dorsiflexion with eversion reproducibly produces an audible snap and visible anterior displacement of a tendon over the lateral malleolus. There is no tenderness of the posterior 6 cm or tip of either malleolus, navicular or base of the fifth metatarsal. He can take four steps independently. Neurovascular examination is normal. What is the most appropriate management today?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: C — Refer routinely to a foot-and-ankle/MSK specialist pathway and provide acute soft-tissue injury measures

Explanation lettering: E = shown as B · D = shown as C · B = shown as D · C = shown as E

This presentation is most consistent with peroneal tendon subluxation following an inversion injury: the discriminating features are painful snapping and visible tendon displacement over the lateral malleolus provoked by dorsiflexion with eversion. This is not simply a resolving lateral ligament sprain. UK MSK pathways advise escalation to an advanced practitioner or foot-and-ankle service when a peroneal tendon is subluxing; acute measures such as protection, compression, elevation, analgesia and activity modification can be provided while awaiting assessment. A is initially attractive because he has had an ankle injury, but he does not meet Ottawa ankle or foot rule criteria for radiography: he can bear weight and lacks the specified bony tenderness. B is inappropriate because there are no fracture-rule criteria, deformity, neurovascular compromise or inability to weight-bear. C delays appropriate pathway referral; MRI may be considered later when imaging is required for diagnostic uncertainty or surgical planning, rather than as a prerequisite to referral. E would be appropriate for a non-subluxing peroneal tendinopathy or uncomplicated ankle sprain, but demonstrable tendon subluxation is a referral threshold.

Reference: Foot & Ankle Triage Guidance 2025 (2025) — https://eastsussexmsk.nhs.uk/wp-content/uploads/2025/10/Foot-Ankle-Triage-Guidance-2025.pdf Fractures (non-complex): assessment and management (NG38), recommendation 1.2.2 (Last reviewed June 2025) — https://www.nice.org.uk/guidance/ng38/chapter/recommendations