Peroneal Tendonitis/Tendon Subluxation?

Hi everyone.  Follow up: I had surgery in April.  I'm almost 5 weeks post op.  Have 2 more weeks in a boot.

Questions for those who've had this surgery/post-surgery:

Did you have spasms in your tendon?  Any zinging? Electrical feelings?  Any burning?  I've experienced all of those and Dr says it's normal. .but they tested the tendons to make sure everything in place 10 days post op and everything looked felt great

Hi Everyone, I (29M) just discovered this forum and will add my case in for anyone’s reference. I had the injury while performing a relatively simple down-climbing move on a 45 degree wall at the gym. I felt the snap and “shock” feeling of my tendon snapping over the bone. Within the next 2 hours I had two more subluxations. I spent 2 weeks in a boot followed by 6 weeks of physical therapy; this didn’t help - as soon as I started returning to activity I was provoking more subluxations. I scheduled surgery 2 weeks later (June 6, 2023). My procedure was groove deepening and reattachment of the retinaculum plus a graft. I’m 2.5 weeks post surgery, got the cast off at 2 weeks, had my first PT appointment 2 days later (4 days ago). I never had pain more than about a 3/10, and now I’m already semi-to-full weight bearing in the boot, not sure if I should really be doing it but my PT said “let pain be your guide” so maybe I’m OK. I’ll be keeping up with PT/mobility work and hoping to be close to normal within the next 2-3 months depending on the activity.

Hey guys, I have some questions for you! Almost two weeks ago now I had a bad climbing fall and overflexed my foot towards the wall. I had all the symptoms people have described above, the popping of the peroneal tendons, etc.. On Thursday I went to the doctor to review MRI results and I have torn the retinaculum and partially town the peroneal longus tendon, in addition to moderate to severe tears of the anterior talofibular ligament and the calcaneofibular ligament. Luckily, my peroneal tendons are still in their groove. My doctor wants me in a boot for 6 weeks so the retinaculum can heal with scar tissue and we can try to give the non-surgical option a chance. However, I have read online non-surgical approaches are usually unsuccessful. Additionally, everything is horrible timing because I have a climbing trip coming up in two weeks. Thus I have some questions. Did anyone go the non-surgery route, and did it work? How long did it take? And lastly, I am wondering if I can return to climbing earlier than I should and just try to avoid moves that might make my tendons pop out of place. Any experience with this? 

Thanks for any help!

@Kim

Scroll back and read my posts on this from before. If you have insurance and no other conditions that would discourage you from having a surgery ASAP, I would get a second opinion and get operated on. All the medical opinions I consulted were confident that this type of injury does not heal on its own. As far as a climbing trip on a busted retinaculum goes, oh my. Maybe your predictive powers of when the tendons pop are better than mine, or your pain tolerance is higher but I felt like I han no idea when would it happen and then I'd have to sit for 10 minutes to get myself back together. Typical scenario - walking on eggshells to drag the trash to the curb while minding the foot and ankle with all my attention, I see the rabbit on the front lawn. "Oh hey, little fella", * barely turn the body 10 degrees  to the left* - POP!. Something like this would happen several times a day and it conditioned me mentally so that I had a had time trusting any movement even after it was surgically repaired and I was back to normal. I can't imagine climbing on this and having much fun. 

@Kim

After seeing the videos taken during my surgery, I can’t imagine it is something that could heal on its own enough to prevent it from happening again. As far as I can tell, the surgical outcomes are the best option. I had mine done 6 weeks ago and I will be back climbing within the next month or so, if I had to guess.

It sure would suck to be in a boot for SIX WEEKS, then still have to get surgery. Also, make sure you go to sports orthopedic docs and PT because I’ve heard other stories of people being in casts and boots for much much longer than I was in my experience. I got into PT 2.5 weeks after surgery and started making a very rapid recovery compared to other stories I’ve read.

Best of luck to you

Hi Friends,

I am 2.5 months through recovery from groove deepening and retinaculum repair surgery; just getting back into climbing again. I wondered if anyone here has any cases of this injury occurring in both ankles? I’ve become hyper aware of the tendon movements in both ankles and have started to notice some slipping occurring in my “good” ankle. It’s not fully subluxing, but definitely sliding up and sometimes visibly out to the edge of my ankle bone. I am nearly certain that if I was under the same pressure as I was during the initial injury, and at the right angle, that the same injury would occur in my “good” ankle.

I’m hoping for some confidence that this isn’t likely to happen again just as easily to my other ankle, and if anyone has any preventative measures they’ve taken to help insure this I would appreciate it greatly because as I see it, I’m not sure I will ever be able to climb “hard” again without leaving myself extremely prone to this injury…

This thread seems to have more information about peroneal subluxation than anywhere so here's my contribution, hopefully someone can benefit.

I have been researching alternatives to surgery. Here's the most interesting things I've found:

First this link. This doctor says peroneal subluxation and dislocation is related to fibular position and rotation, more specifically, she sees it in individuals who are over-pronating when they walk or run. Pronating means walking with toes pointed outwards, also known as duck-footed. When the "fibular is externally rotated (as in the case of pronation and TFER), this causes a relaxation of the superior peroneal retinaculum and allows the peroneal tendons to roll on each other and possibly sublux over the lateral malleolus." Basically she claims if you are subluxing, the reason is you are over-pronating and that is triggering the problem, and you need to take the necessary steps to correct for that.

This rings true in my case because one of my legs over-pronates badly, and that leg now has a problem with peroneal subluxation. So this made me think that maybe this podiatrist's theory *might* actually be correct. I've also found I'm able to reduce the frequency of subluxations if I follow her suggestions and am very careful to not over-pronate when I walk. If you try this, be aware that it's not enough just to make sure that your foot isn't pronated when it lands in front of you. You also need to be sure it's straight when it's behind you "pushing off" which takes a lot more focus to modify. This is important because it's when you push off with a pronated foot that your tendons sublux. This seems to exactly fit my own experience. Many pronate without being aware of it. To check yourself, take a video of your walking from foot level, and then play it in slow motion to see if your subluxing foot is turning outward even slightly when it's pushing off.

A related piece of information comes from the podiatrist Dr. Christopher Segler who writes on his website here that if you are suffering from peroneal subluxations to "Try to run in a way that supinates the foot. Try shoe inserts that hold your foot in a supinated position." Supinate is the opposite of pronate, so he's essentially echoing what Splichal is saying, although Splichal goes into greater depth in her explanation and recommendations for recovery.

Lastly, there's various videos on Youtube about how to stretch peroneals and/or reduce "snapping" and "popping" of the ankle, so maybe it's possible to further reduce subluxations just by loosening the peroneal muscles.

So could subluxations be stopped just by doing all of the above? 

And another consideration is that in the weeks immediately after the injury, you may sublux easily, but over time many say the subluxations seem to become less frequent and less painful. In my case, it seems like subluxations are decreasing and stability is increasing slowly. So when orthopedic surgeons say it's risky to walk on a subluxing peroneal tendon because you can damage the tendon, that may be true if you try to go out and immediately run on it post injury, but I also wonder how much of it is surgeons just trying to push people into the operating room. Not claiming that's the case, but it's a factor to consider. Surgeons typically advise surgery as the only solution to chronic peroneal subluxation, but there are a sizable number of people reporting their problem resolved without surgery.

Bottom line, I'm not sure. This information might be helpful with people who aren't that badly injured or are young and can recover quickly. What's not clear is, if your case is chronic, and you have trouble walking and have pain upon subluxation as a result of this injury, is it really possible to avoid surgery and solve the problem just by modifying gait and stretching, or is it not worth the hassle and we should all just rush and get surgery asap? Would love to hear from anyone else who can help test this theory. Specifically, if you have this injury:

1. Are you an over-pronator?
2. If your answer to #1 is yes, after reading this, try to modify your gait to stop over-pronating and see if you sublux less or not-at-all.
3. Has anyone found that stretching the peroneal muscles helped?

EDIT: FWIW, in case anyone was considering using her services, it seems that Dr. Splichal is not accepting patients. Which is unfortunate, because when I first posted this message I thought she might be a resource for people with this injury. I have not tried contacting Dr. Segler so no idea about him.

One more thing I wanted to add. Since mechanically, this problem is the peroneal tendons subluxing over the ankle bone, and this is happening in plain sight, why isn't it possible to take a 3d scan of the person's foot, and 3d print a device that fits over the ankle bone (lateral malleolus) with something like rubber claws that clamp around the perimeter of the lateral malleolus that remove any gap for the peroneal tendons to move over the bone. 

It seems like it should be possible to come up with some external device that would stop this tendon movement without resorting to surgury.

I work with CAD and 3d printing so I'm working now to design something for my own foot. If it works, I'll post results here. Good luck everyone.

Just an update in my case. No subluxing for about 10 days now. The main adjustment I've made is focusing on not pronating my foot when I move around, and that alone seems to have played a major role in stopping the subluxing.

I've started walking a few kilometers a day to build strength back that I lost while trying to "rest" the leg over a period of about 6 weeks that allowed mainly my calf muscles to atrophy.

Created a 3d printed brace which pushes down at 3 points around the ankle to prevent subluxation. See picture. The circle indicates the location of the center of the ankle bone, and visible are 3 points around the ankle that are depressed by the brace. Can't be 100% sure if the brace is helping or not but it's not painful to wear and psychologically at least it helps me feel more secure about not subluxing.

Hey friends! Not to revive an old thread, but I figured I'd give everyone an update on my situation. *Scroll to the bottom to read my recommendation and not read the story*

About 7 years ago, I tore my tendons and they were subluxing. Went to many many different doctors and orthopaedic surgeons. Most all of them came back with the same treatment- throw me in a cast/boot, wait like 3-4 months and see if it heals on its own. 

It did. All said and done, I was back to running, climbing, lifting etc. within 7-8 months of initial injury. Obviously took some PT but recovered quick.

Update from November 2022, I was running an ultra outside of Vegas when I hit a rock, hyperflexed my foot, tendons tore and ripped out again. Wasn't even that bad of a fall. I finished the race, but they were subluxing. 

Went into an orthopedic surgeon in Utah and an MRI concluded peroneal longus was longitudinally torn (half was in front half behind malleolus) and brevis had a good tear in it. Scheduled surgery in December, I was out of a boot and hiked angels landing in the snow the end of March. (Was still super unstable and weak). Ran a 100 miler in June, July and a 200 mile race in August. Very stiff, gets swollen easily, and tightened up the opposite side of my ankle. A lot of my form is messed up from it, but at least it's rock solid. 

BOTTOM LINE: if you are any sort of an athlete (which I assume you are, being on MP) DO NOT go the conservative route. Get the surgery. It will happen again, unless it's a very very slight tear and you believe in miracles. 

DM with any questions :)

@Master Beta

So to summarize, after surgery, you say the surgery was the right choice because you're not subluxing any more, but in your own words, the ankle where you had surgery is (I assume chronically) very stiff, gets swollen easily, and the surgery also tightened up the opposite side of your ankle, and your running form is messed up from the surgery?

This is essentially what "Doc on the Run" Dr. Christopher Segler says, that if runners get this surgery, it can potentially do damage to the foot that is not fixable, and that seems to have happened to you. It sounds like it was the right choice for you, but you've also traded 1 problem for 3 or 4 others. Above I'm citing a couple podiatrists (who also happen to be surgeons) that claim that by changing gait, some with this injury are able to avoid re-injury and surgery. This has actually worked for some, including myself. 

Prior to your surgery, were you pronating when you walk/run? If so, did you try correcting that prior to your surgery? Prior to your surgery, did you try the 3d printed brace which seems to be working for me? Prior to receiving surgery, did you try supinating your foot when you run, as Dr. Segler recommends, and that didn't work for you and you injured your foot again? I'm guessing not. So your personal experience doesn't refute or disprove what these other doctors have to say. And you don't need to feel threatened by these ideas, although I can imagine it would be maddening for you and others on this forum who've undergone surgery for this injury to hear someone propose other possible routes to recovery. That would imply the possibility that the surgery you endured and the associated complications might have been avoidable. Not pleasant to contemplate that, I understand.

You say you injured yourself in a race, and then went on to ignore the injury and complete the race. Is it surprising that your MRI showed considerable damage after doing that? I think the general consensus in the medical community is if you abuse your body, you should expect that it will take extreme measures, up to and including surgery, to recover. So maybe what you did to yourself in that race made surgery the only option for you.

You are claiming that surgery is always the best choice for everyone, or that all athletes should get surgery, based on your personal experience, sample size N=1. That's essentially making a medical claim without the scientific evidence required to make medical claims. Even if the experience of the majority on this forum supports your claim, it's still overstepping. You're also claiming everyone here should avoid the conservative route, which is normally the first course of action recommended by orthopedic surgeons, who are both "pro-surgery" and presumably know more about how to treat this injury than you do. And you're making the claim that everyone who's had this injury that hasn't had surgery WILL re-injure themselves. Your proof for this claim is what? That you re-injured yourself, therefore everyone else will? Your case doesn't represent the whole population who've had this injury. The fact is that some people re-injure, some fully recover without surgery and do not re-injure.

That said, surgery may be the best choice for athletes who are in a hurry to get back to their sport and are willing to live with the likely consequences of surgery, like you are doing now. It may also depend on the sport. For example, ballet dancers, in particular, who are prone to this injury, go to great efforts to avoid the surgery because the surgery can potentially damage feet in ways that make it impossible for many of them to return to ballet dancing. So what applies to runners or climbers may not apply to ballet dancers, for example.

Many on this thread have had surgery and seem satisfied with their choice, including the previous poster. That's fine.  My mind is open. At some point I may reverse course and get surgery if I start having problems again.

Bottom line is this: 

I recommend that anyone reading this forum who hasn't yet had surgery first try the solutions from the podiatrists (who also happen to be surgeons) above, which have so far worked for me and others. Even most surgeons, which have zero training in other potentially relevant modalities and do have financial incentives to recommend surgery, agree that if you can avoid surgery, that is the better choice, and that is why many recommend conservative treatment first. 

Also, before making any rash decisions, understand that there are risks associated with surgery, that some (although they are in the minority) people regret their decision to get surgery, and according to medical surveys, the majority who've had it report lasting negative consequences as a result, just as @Master Beta above reports, such as stiffness, a more limited range of motion, etc. Don't expect surgery to return your foot to the perfect state it was in prior to your injury, because most are not reporting results that good.

As for an update to my condition, it's been a full month and I haven't had another subluxation since I changed my gait in the way I described in a previous post, and the 3d printed brace I made may also be helping. 

My foot is totally pain-free. I don't suffer from loss of motion, problems with nerve pain, persistent scar tissue, stiffness, the other side of my ankle doesn't stiffen up, and my running/walking form isn't messed up. Note that I didn't opt for surgery, and those are common side effects from the surgery. In my own case, spending time in a boot or a brace was a complete waste of time, it didn't work at all, whereas changing my gait, namely, stopping over-pronating, worked from day 1.

And I just want to remind people, having peroneal subluxations is not necessarily, by itself, a permanent/debilitating injury. Lots of people walk and run pain-free with subluxations, for some it's even congenital. So that alone is not an issue for which surgery is always necessary. OTOH, surgery can cause problems which are permanent. I can't remember exactly which study it was, but I've seen results from a study of about 30-40 people who have had the surgery, and only 3 or 4 out of about 40, about 10%, rated their foot condition as "Excellent" after having surgery. The majority rated the outcome from the surgery as just "good," and another minority reported either subluxing again, needing surgery again, or major pain/problems caused by the surgery. So about 90% of those surveyed did not find surgery to be a panacea for this particular injury.

Good luck to everyone with this injury, it's a challenging problem to deal with, far more complex than a simple broken bone.

Great thread - I appreciate all the input and recovery stories! Here's mine, and I have a couple questions. 

On 11/11 I fell 10-15 feet lead climbing and must have hit the wall with my foot dorsiflexed. Had frequent subluxing of the peroneal tendon(s). Initially saw a podiatrist - xray was negative for fracture. Started in an Airboot 2 days post injury, but I would still sublux in the boot. Improved a little with max padding and pumping with more air than it seemed I should need to use. After a few days I went to an ortho urgent care and was put in an ankle brace. At that point I already had an appointment scheduled with a foot/ankle ortho. MRI was ordered but I didn't get it done which is good because the ortho said it was unnecessary (that surgery would be recommended regardless of the findings, since it was clear that the retinaculum had at least a partial tear). Ankle now feels very stable in the brace with leucotaping (friend who is an athletic trainer sent video instructions; in addition to her recommendation I added tape from the bottom of the foot up over the achilles in order to prevent dorsiflexion). I wear an ace wrap at night in addition to keeping the tape on. I've been able to swim and do circuit training with the brace, without subluxing. About a week ago I started a bit of elliptical with caution. Not sure if it was that or just that my gait has been off (stiff due to avoiding dorsiflexion) but I ended up with sciatica which is very unpleasant when you can't do the normal back care you'd do with 2 normal feet/ankles. I'm planning surgery next week (repair SPR, likely deepening bone groove). I was told 2wk NWB, 4wk in Airboot (I think full WB but not sure if this is partial at first), then PT. Was told 5mo to return to my usual activities (mtb, snowboarding, etc). 

Wondering whether others ended up having back pain/sciatica or other musculoskeletal issues due to using crutches/knee scooter/gait being off once in a boot and recommendations for minimizing/managing this? I'm using a foam roller, got a myofascial release massage (may have helped but many other factors could have led to improvement), and have been sitting on a heating pad. 

Also, I was planning on returning to work 6 days postop with a knee scooter. Supposed to have a 12 hour shift that first day (Monday), then work 8 hours Weds and Fri. I'm in the medical field so will be up and down to patient rooms. Does this seem reasonable?

Thx in advance!

@not-alex honnold

Lots to respond to there. I'll do my best. 

When I first had the injury, I tore the retinaculum. With a shallow groove, athletes statistically almost always have a re-ocurring injury, there's nothing holding the tendons in. And anything but a partial retinaculum tear has no way of magically healing. Most of the medical research out there includes the huge amount of folks who live relatively sedentary lives. Without getting too anecdotal, I was told this repeatedly by many Ortho surgeons and folks I trust in the field. By all means, roll your own dice. I'd rather have a bombproof ankle than not. 

I do not regret the surgery whatsoever. Probably could've done better research on a surgeon instead of someone who hasn't had a ton of experience with this, but relatively speaking it's a simple operation. 

Yes, I finished the race, you're right it wasn't the greatest idea but it didn't make a bit of difference in the long run. It was an acute injury. 

I could've worded my advice better, maybe a better approach is to weigh your options instead of a blanket approach. I'm just trying to look out for people who would be in the same position. To be clear, the surgery has fixed a problem that wouldn't have occurred in the first place if I had gotten the surgery 7 years ago. 

My form is messed up in the sense that I'm still not quite as confident on trails and uneven terrain. I'm sure that'll change with time. It is 1,000x better than fear of subluxing. We all have our different journeys. I very much regret not getting the surgery when I first injured it. 

I'm happy that you could avoid surgery! I was not as lucky. Hope it holds up for the rest of your life!

@Kaeli C

>Wondering whether others ended up having back pain/sciatica or other musculoskeletal issues due to using crutches/knee scooter/gait being off once in a boot and recommendations for minimizing/managing this?

Yes, I had terrible back and hip musculoskeletal pain from limping and my gait being completely off by compensating for the injury. My whole body was in pain. Practically any movement could cause a subluxation, even at night while sleeping.

However, I wasn't aware that I was walking with toes pointed out, essentially duck-footed, and that was the main contributor to having subluxations. As soon as I became aware of that, I started making a conscious effort to stop, and instead started to try and keep my foot straight, or if anything, exaggerate and walk slightly pigeon-toed. Upon making that change, I found to my amazement that I was able to walk without subluxing, and I found that I could stop limping and walk normally, and that eventually resolved my musculoskeletal pain.

The reason this works is that by turning your toes inward (slightly pigeon-toed), you activate and put tension on your peroneal tendons, forcing them into the groove where they should lie naturally. These tendons can only sublux when you start to turn your foot outwards, and the more outwards you turn your feet, the more easily they can sublux. This is also why nearly everyone who has this injury got it when their foot was in an extreme over-rotated position.

Here's a link that discusses the mechanics.

Hope this is helpful and good luck!

@Master Beta,

>I very much regret not getting the surgery when I first injured it.

I really do sympathize with that, and I may eventually have the same regrets if I re-injure. At that point I'll be sure to check in here and you can oblige me with "I told you so!"   

Glad that ultimately you had a successful outcome. Being secure in the fact that the tendons are stabilized and cannot sublux definitely has value, and I agree that peace of mind only comes with surgery.

@not-alex honnold 

How's it been? Any updates?

I was skiing early season conditions over Christmas 2023, and re- injured the same ankle. Took me outta yet another ski season. Sort of complicated injury, however. Not a whole lot to do with the original injury, moreso a freak accident with the ski binding and the fact my bone got grooved in surgery. .

Basically, they found my binding was a DIN of like 12 on that foot. I hit some subsurface rocks and it took extra long to release, so (same mechanism as before) hyperflexion and weighted the ankle. The tendons stayed put, but since there was Soo much pressure, something had to give- and it wound up fracturing off a chunk of lateral malleolus. 

I'm still doing PT for it, but I'm back to full activity.. At least it's all under workers comp

Hello @Master_Beta

Really sorry to hear of your injury. Glad to hear you're back to full activity.

In my case, the good news is I have never subluxed again after I started correcting my gait, meaning, I stopped walking with my toes pointed outwards.

However, there are times when I'm working outside putting a lot of pressure on my ankle or torquing my ankle and I feel a twinge of pain, like it's going to sublux, but so far it hasn't gotten to the point of actual subluxation.

One potential reason is I never did any PT or strengthening after the injury. I sit in front of my PC all day for work. I'm not an athlete, I'm not trying to scale mountains and run marathons. Seems like a lot of people who get surgery have a little bit of ongoing chronic pain or numbness from the surgery, and I have experienced nothing like that. Zero pain on normal days. However my ankle is not as strong as it was before the injury, again, possibly because I didn't do any PT. Or it's also possible that no matter how much PT I do, I'll still have issues if I overstress that ankle.

I spent a couple months trying to recover from the injury where I wasn't putting a lot of weight on my achillies so that's why my ankle is weakened vs the strength I had before the injury.

I went back for an ultrasound at the surgeon's office and mentioned my recovery, the surgeon was very unhappy that I had recovered without doing the $30,000 surgery he recommended. The ultrasound was apparently inconclusive. Not 100% sure but he either couldn't tell me or refused to tell me if the injury had fully healed or not.

Basically, I'd rate my recovery without surgery as 90%, and it might be at 100% if I ever get around to doing PT. Oh another thing is I developed my own 3d printed brace which seems to help keep those tendons from subluxing and would potentially be helpful for anyone who's suffered the injury, but seems like nobody is interested in a brace like this. I should add that normally I don't wear the brace, but occasionally I do when I'm working outside and it gives added stability and sense of security.

Feel free to message further or PM me anytime and best of luck for your 100% recovery!

Hi folks, 

I’m now beyond the 1-year mark since my (severe) peroneal tendon injury/surgery. This thread helped me when I was researching treatment options and setting expectations for recovery. Hopefully my story will do the same for others. It’s a bit long, but I recall always wanting more information during this experience :) 

Injury

In late March 2023, I was bouldering in the gym and I did a move requiring a high step and rock over on one foot. My right ankle was in max dorsiflexion and slightly inverted for better contact with the hold. As I went for the next hand, my foot slipped and I began to fall. Unfortunately, my foot caught again a few inches lower on the same hold (bolt hole). This hyper-inverted and shock-loaded my ankle, which caused a sharp pop/pain around my lateral malleolus. I then fell a measly 4ft to the mat and landed safely on my back. I tried to stand up and weight my foot, and I immediately collapsed due to pain and a feeling of severe instability. I could see (and feel) that both peroneal tendons were completely dislocated anterior to the fibula, so I knew best case I’d completely torn whatever was holding them in place. The swelling was immediate but only moderate and fairly localized.

Diagnosis

I had someone drive me straight to the ER, where they did x-rays and put me in a boot. Initially the doctor told me there was no sign of a fracture. I asked them to look closer around the lateral malleolus, and after some searching they were able to locate a tiny sliver of detached bone called a “fleck” sign. It turns out that a fleck sign is a highly accurate (basically 100%) indicator of a torn superior peroneal retinaculum. So at that point I had a diagnosis before even seeing an orthopedist, but I didn’t know the full extent of the damage.

About a week after the injury, I managed to schedule appointments with both a surgical podiatrist and orthopedic surgeon. The podiatrist told me it would take a month to get an MRI. Fortunately, the orthopedist was able to fast-track my imagining just 3 days later. The MRI confirmed the retinaculum tear and showed additional longitudinal (split) tearing of both peroneal tendons. It also showed that I had tendonosis and no fibular groove, just a flat to slightly convex posterior fibula. Both the podiatrist and orthopedist (and every other study I found in the medical literature) assured me that this type of injury - especially with my level of damage - requires surgery in 99% of cases. I didn’t feel like testing those statistics in the hope I was an extreme outlier, so I scheduled surgery for the following week. The decision was also easy because there was a high likelihood I’d never walk normally again let alone climb.

Surgery

I had surgery 3 weeks after the injury. It took about 1.5 hours and included 1) relocating and reconstructing (retubularizing) both peroneal tendons, 2) fibular groove deepening, 3) removal of an extra tendon and excess distal brevis muscle, and 3) reattachment of the retinaculum via bone tunnels and sutures. The surgeon said everything went well, but they did use the words “carnage” and “shredded” more than once. I was told that there was zero chance the bouldering injury had caused all the damage they found. Instead, much of it was likely caused by a combination of “rare anatomical variations” and years of ankle abuse from crack climbing. Apparently it was a minor miracle I was (mostly) asymptomatic before the injury. My ankle was basically a ticking time bomb that would have exploded and needed surgery eventually.

Recovery

I was told from the start that full recovery would take at least a year. This was more conservative than estimates I found online from various case studies, and it also seemed long compared to some reports in this thread. Regardless of the timeline, it’s important to note that with severe injuries/surgeries, “full recovery” never means “the same as before the surgery.” What it means is “full (or acceptable) function in the context of sport activities”. Climbers, like many athletes, require an extremely high level of function from their ankles. So whatever I (or someone reading this) consider “recovered” will be different than a completely sedentary person who only wants to walk normally again or do the occasional hike. Given my own experience, I believe a year was the right mark for managing expectations.

Starting 2-3 weeks after surgery, I adopted a super disciplined physical therapy routine. I probably spent 4-6 hours per day in the first ~6 months doing mobility and strength exercises - far more than the prescribed program but with constant care to not makes things worse. In order to retrain my gate, I walked over 500 miles back and forth on the one-block sidewalk in front of my apartment. I did shockwave therapy to help with post-op scaring. I started a rather extreme supplement regimen, which included high dose collagen, pro-resolving mediators, various natural anti-inflammatories - too many to list here. I realize that might have given me nothing more than expensive urine, but I figured it was worth the chance of even 10% faster/better recovery. (My PT did say at one point my surgical scars healed about as fast as he’d ever seen, but that could just be an artifact of my skin genetics). Below is a brief recovery timeline for the first ~4 months, which are generally the most critical:

• Weeks [1,2): 23.5 hours per day in a recliner with my legs elevated above my head. I was in a plaster surgical splint. I discovered I'm largely immune to the analgesic effects of Oxycodone, so it was a rough first 2-3 days. 
• Weeks [2,6): Stitches removed after 2 weeks and I was put in a boot. I began daily mobility (forward and backward) movement. No weight bearing. Still keeping my ankle elevated most of the day.
• Weeks [6,8): Partial weight bearing in the boot. Waking with crutches several times a day.
• Weeks [8,10): Transitioning out of the boot and into regular shoes. Full weight bearing by about week 9 but still using crutches on occasion for balance. 
• Weeks [10,12): Walking slowly with no crutches. I took a trip that required navigating a few airports, which was slow but manageable. This is when I began more aggressive mobility exercises to regain plantar and dorsiflexion.
• Weeks [12,16): Started driving again at 3 months, and slowly ramped up the PT program with much longer walks and daily strength exercises.

Climbing

I began climbing again at ~6 months post-op. I started with short sessions and focused on control and safe/comfortable ankle positions. By 9 months I was limit bouldering and lead climbing in the gym, but I was still fairly apprehensive about my ankle. By 12 months I was pretty much climbing as well as before the surgery. I could take large bouldering falls, but I definitely avoided (and still do) anything that might result in an awkward fall from high. At 15 months, I climbed 100 boulders in a single gym session, and I never even noticed my ankle. So I can say with some confidence that I’ve achieved a “full recovery” by any reasonable definition. There are still some positions I avoid - most notably aggressive, inverted smearing on insecure slabs. I can do it, but my brain doesn't like that position for obvious reasons.

I waited over a year to even try crack climbing. I probably could have started sooner, but given the stress toe/foot jams put on the ankles, I wanted to be absolutely sure the tissues were healed and no longer inflamed/swelling after activity. Crack climbing has been by far the hardest and scariest part of my recovery. It was especially hard because, prior to the injury/surgery, cracks were my top skill/style. So I had to be really careful not to jump in too fast. I began with 1-2 gym cracks once per week. Now 16 months post-op, I just returned from a trip to climb 30+ pitches of .10/+ outdoor cracks. This was extremely demanding of my ankle, and it performed roughly as well as before my surgery. I plan to try harder cracks outside pretty soon. 

Also, I recently did my first big alpine climbing trip since surgery. This involved the entire package of ankle-stressing activities: long approach with heavy pack, lots of talus hopping, hundreds of feet of snow climbing with crampons, lots of technical rock with endless foot jams, etc. Overall I barely noticed my ankle, which I think qualifies as a success.

Learnings

For anyone in a similar injury situation who’s considering surgery, here’s a short list of learnings/advice I believe helped most in my recovery:

1. Set realistic expectations. Surgery is major trauma, and healing is both non-linear and recovery varies widely between individuals. A full year is a reasonable estimate, so just accept it and plan accordingly. You will have good days and bad, good weeks and bad, but over long time intervals you will/should see steady improvements.
2. Do everything you can to maximize comfort and convenience while recovering, especially during the first 6 weeks. I took 3 weeks off from work, which I know was critical. Take at least the first 2 weeks off if at all possible. Also avoid excessive swelling as much as possible, and eat a high-calorie, high-protein diet to promote healing.
3. Physical therapy will make or break your recovery. Remember that you’re playing a long game, and in that discipline and consistency are everything. Don’t settle for the nominal PT protocol. I still do 30m of ankle strength/mobility work every single day, and I probably will for years (or life). Learn to discern between good and bad pain and embrace the former (within reason) during PT. You simply will not recover without some pain.
4. Do everything you can to stay healthy and maintain the functional parts of your mind and body. I did countless pull-ups/push-ups, hangboard sessions, breath work and meditation, core workouts, etc. throughout the entire year post-op. When I did come back to climbing after 6 months off, I basically hadn’t lost any strength or endurance. That was a huge advantage.

Nolan

Hi everyone. This has been one of the most useful threads on the subject, and I told myself last year that if I could climb again I would write my story here to add to the discussion.

My right peroneal tendon subluxed last July 18, 2023 due to a bad rock over. I knew something had blown; I heard the pop, which turned out to be the retinaculum coming off. I was careful not to put any weight on the injury and immediately went to the ER. They weren't sure what it was, but there was a climber ortho in my hospital that I was able to see the day after. I took the conservative route on his advice based on my profile (am not a serious climber, did not need to return to climbing right away, and am a little fearful of surgery even when it was offered to me) and was in a fiberglass cast for 6 weeks, boot for about 4. It is true that an MRI is of limited use (though can still be useful depending on the kind of tear) - I had one, and because it wasn't dynamic imaging, of course it showed everything in place - I was in a cast, after all!

I used the iWalk hands-free crutch the whole time I was unable to walk. After PT in the hospital, I then worked with a personal trainer. So many things were wrong with me: my knees, my whole right side, etc. My left had had to compensate for my right. My trainer has been very patient with me.

I was able to climb (rather pathetically, but still) rainbow on top-rope by February 2024. Late March I started carefully bouldering again.

It has been a year and a month since the injury and I would say I am recovered. The programming for my recovery went as follows:

• Bands in the hospital for the whole ROM of a foot. For about 2 months, I did not have full range of motion. (Frankly, hospital stuff is not enough. The number one thing that boosted my recovery was working with my personal trainer, who stressed the importance of loading carefully.)
• Lots of loading once I was in the hands of my physical trainer. Every week, we'd assess and add weight if I could progress.
  • Single-leg calf raises, double-leg calf raises, all barefoot. I do these raises using a smith machine, where the bar rests behind me, atop my shoulders. The last parts to heal were the outer edge of my foot, and the movements involving my toes. For those, the tib bar helped immensely. You can also use a cable machine to replace the band when performing other ROM exercises.
  • For my knees - ATG split squats. I did this on a bench. Eventually added dumbbells for weight.

I can climb a v3 now, which is only one grade lower than my previous. I believe I can hit a v4 given some time. I am a casual climber and consider that acceptable. Mostly I am focusing on upper strength training now so that I need not put so much strain on my right foot when I execute rock overs. I am still very careful not to lift my right foot too high or put too much strain on it when it's too high a step for me to make use of the leverage. Lesson learned. I will never forget how it felt like my world was ending if I couldn't climb.

Thank you to everyone for writing their experiences - I reread this thread so many times when I was in rehab!