Ankles are taken for granted until injured. Actually our ankles work much harder than our wrists. Each and every step you take from your desk to the door, hopping up and down to squeeze into your jeans or each stride of freedom you take during your jog can only happen with smooth functioning, well oiled ankle joints. Ask anyone who has ever been sentenced in a moon boot. Peroneal tendonitis is inflammation around the peroneus longus tendon and the peroneal brevis tendon causing peroneal tendon pain. Peroneal tendonitis leads to instability and pain of the outer ankle and makes moving around difficult.
What is the peroneal tendon?
Tendon attaches muscle to bone. The two peroneal muscles fill the lateral, or outside, compartment of the lower leg. The peroneus longus tendon is the insertion of the peroneus longus muscle, while the peroneus brevis tendon is the insertion of the peroneus brevis muscle. The peroneus longus tendon and muscle belly is longer than the peroneus brevis tendon and muscle belly. Both peroneal muscles attach to the fibula, the thinner of the two bones in the lower leg. The peroneal longus and brevis tendon run behind the outer ankle bone, malleoli, in a special groove to prevent them from bouncing over the ankle. The peroneus brevis tendon inserts at the base of the 5th metatarsal on the outside of the foot. The peroneus longus tendon passes underneath the foot to insert on the base of the big toe.
What do the peroneal tendons do?
The peroneal tendons anchor the peroneal muscles into the bone. This anchor creates a leverage system that enables movement on muscle contraction. When the foot is not bearing weight the peroneal muscles work together to plantarflex the ankle, like a ballerina, and evert, or move the foot outwards. When the foot is weight bearing, the peroneus longus tendon supports the transverse arch of the and provide stability. This is important for weight distribution when you are balancing on one leg and moving from the heel to the toes when you take a step or run.
How does peroneal tendonitis happen?
Tendons are infamous for their poor blood supply. On dissection, they appear white, compared to a muscle belly that is pink. This means that a tendon will take longer to healing than a muscle. If there is excessive pulling at this muscle anchor site some of the tendon fibres may fray and cause inflammation. Excessive pulling may be due to a new activity, like boot camp, or increasing your exercise intensity, like running further, faster more often. Runner’s are especially susceptible to peroneal tendon pain, especially if they have any muscle imbalances. Most of us have “muscle imbalances” because none of us move 100% symmetrical through our days. If you favour a side to carry your laptop bag it may cause imbalance from left to right. If you always run on the same side of the road the camber may cause muscle imbalance too.
Causes of peroneal tendonitis
Flattened foot arches cause a lot of different issues, in the foot, ankle and even higher “upstairs” in the knee and hip. If the ankle joint roll inwards, and flatten even more, with every stride you take, your risk for peroneal tendonitis is higher. This decreases the transverse arch height, pulling at the peroneus longus tendon. Continous pulling can elicit an inflammatory response. If you rest you feel better and when you start exercising you reignite the inflammatory response, creating a vicious cycle and a lot of frustration. Chronic peroneal tendon pain changes the physiology around the tendon leading to tendinopathy which may not heal at all.
Trail running or hiking on uneven surfaces increases the risk for sustaining peroneus brevis tendonitis. The peroneal muscles are working overtime to maintain stability and balance and can become inflamed.
- new shoes
- barefoot walking
- change in running style
- unaccustomed exercise
- increase distance or speed of runs
- running on the same side of the road or track every time
- trail run
- new routine (exercise or dance)
Symptoms of peroneal tendonitis
How bad is my peroneal tendonitis?
Peroneal tendinopathy is an umbrella term used to cover any and all types of the pathology of the peroneal longus tendon, as well as the peroneus brevis tendon. The pain experienced may come and go and fluctuate in intensity, as your tendon transitions through the different phases of tendinopathy. The three different stages are:
Phase 1
Reactive peroneal tendinopathy is the first phase and happens when the tendon responds to acute compressive or tensile overload. The cells adapt and cause the tendon to thicken by producing more protein, while the collagen integrity is maintained. This is like an “organised peaceful protest” within the tissue. Tendon thickening is not necessarily a bad thing, it shows that the body can alter as demand changes. You will feel acute pain when the tendon is pressurised by movement, like a sharp sudden pain when your ankle rolls. This phase is of short duration and the potential of the peroneal tendon to heal completely is high.
Phase 2
Peroneal tendon disrepair happens when the tendon is not offloaded and allowed adequate rest to complete the healing process. The increase in protein production persists and leads to collagen separation and disorganisation. The “peaceful protest” escalates to a “strike”. Vascularization and neural growth, where capillaries and nerve ending are formed within the tissue take place. The pain may become more constant and intense because of this. This phase tends to happen with repeat peroneal tendon injuries. Your ankle will feel less flexible now and more susceptible to injury.
Phase 3
Degenerative peroneal tendinopathy is the final phase in the tendon continuum and unfortunately has a poor prognosis as the changes within the tendon are now irreversible. Let’s say the “strike” took a wrong turn and there were fatalities. Cell death has been found in this phase and grossly thickened tendon, where most fibres are disappeared and only a small amount are normal. This happens when you neglect your peroneal tendonitis for a long time. The pain will follow even the smallest of exertion and felt chronic.
Diagnosis of peroneal tendonitis
We are skilled at clinical examination to diagnose the structures responsible and contributing to your peroneal tendonitis. You can trust us to get to the bottom of your problem, like the CSI team.
Sonar
Diagnostic ultrasound is the image of choice for peroneal tendonitis. A sonar will show the soft tissue structures around the outside of the ankle, the integrity of the peroneus longus tendon and peroneus brevis tendons and the groove wherein they travel. Inflammation, tears or rupture of the peroneal tendon will be visible on sonar.
Xray
The bones of the lower leg and ankle will be visible on Xray, but not the peroneus longus tendon or peroneus brevis tendon. Fractures caused by trauma can be diagnosed with Xray imaging. Peroneal tendon pain can not be confirmed with Xray and is therefor not needed.
Why is my peroneal tendon pain not going away?
Mismanaged or misdiagnosis of peroneus longus tendon pain can lead to chronicity. You do not want to get stuck in a cycle of pain, rest to relieve symptoms, back to training and then your peroneal tendonitis returns. Rather get to the root cause of your particular problem and sort it out once and for all.
You cannot only address the site of injury, you need to bring about change to all the contributing factors. Hip and knee stability need to be addressed if they are contributing to your pain. Endurance of the calf muscles, as well as ankle and toe mobility. Lack of movement in one area can cause more load to be transferred through another structure and lead to injury. Address the whole issue holistically and get the right peroneus tendon treatment.
A big problem we see with peroneal tendon treatment
A longstanding problem cannot be magically relieved in a single session or with a magic machine. Shockwave therapy can change the physiology around your peroneal tendon, but if you do not address the other contributing factors the pain is bound to return. You will need to commit to the work to heal your peroneal tendon pain. Patience and persistence are needed to sort out the problem once and for all. The biggest problem we see with peroneus longus tendon pain is insufficient rest that leads to recurrence as soon as the activity is resumed. Excessive load with insufficient stability can cause peroneus brevis tendon pain.
Arch support, insoles and braces should be considered and used responsibly. If you won’t jog on crutches, why would you be ok to train with either of these?
Peroneal tendonitis treatment
You can trust us to get to the bottom of your peroneal tendonitis treatment. We are skilled to determine the severity of the injury of your peroneal tendon and any contributing factors of your pain. Addressing the root cause of your symptoms is crucial to prevent recurrence of your injury. We will do active and passive tests to determine muscle length and strength, not only of the peroneus longus tendon, but also peroneus brevis tendon. Our physiotherapists can determine local contributing factors in the area as well as an imbalance or poor movement patterns further away, especially from the hips.
Phases of rehabilitation for peroneal tendonitis treatment
1st Phase: Protection and initial healing
Peroneal tendonitis treatment starts at home. You can follow these easy steps to put your mind and peroneal tendonitis symptoms some PEACE.
Protect
Many people tend to push through their pain during exercise or even walking with a limp. The peroneal muscles contribute to ankle stability and will be strained with every step you take, especially on uneven surfaces. Rest and use crutches to keep the load off of your ankle. You want to prevent a cycle of continuous inflammation and pain.
Elevation
Swelling can be relieved by elevating your ankle. That means getting your ankle higher than your heart. So lie down and prop your foot on a few pillows or the couch’s backrest.
Avoid anti-inflammatory medication
Avoid using anti-inflammatory medication, especially in the first 48 hours as it delays healing by delaying inflammation. Inflammation is needed to get the healing process going.
Compression
By using strapping, elastic bandages or tight socks swelling can be relieved. It gives support and stability, which also helps with your pain.
Education
Make sure that you get the right information from the person that is treating you. It’s important to understand what you should and shouldn’t do. You can make better decisions if you are informed. Your body knows best, so trust your gut feeling regarding movements. It can be confusing to get different opinions from friends, family and google, so avoid too many types of treatments at once.
2nd Phase: Establish pain free range of movement
During your examination, we will be able to tell you what is safe and what you should avoid. We identify factors that contribute to your pain, specific to your case and will address these factors as your peroneal tendonitis treatment progresses. When moving your ankle, like taking a step, you will be able to move to a certain point, before your pain starts. This is your pain-free range of movement. You are safe to move in this range and our exercises will be targeted between these boundaries. With time, your pain-free range of movement becomes bigger and your exercises will be adjusted accordingly as you progress through your peroneal tendonitis treatment. Trust your body and let the intensity of your pain be your guide. You will need to find the balance between rest and loading to keep muscles and joints moving, without overdoing it.
3d Phase: Tissue healing
We monitor the healing of your peroneal tendon. On a cellular level, we are able to accelerate tissue healing by using electrotherapy modalities, like laser and ultrasound, during your peroneal tendonitis treatment. These modalities and cardiovascular exercise increase bloodvessel formation and oxygen delivery to the site of the injury. Choose cardio options which are not painful, like a stationary bike or swimming. As healing takes place, we want to see not only improvement of your pain, but also improvement in the peroneal muscles’ ability to contract and provide stability around your ankle joint on movement.
4th Phase: Tendon loading
During each session, we will re-evaluate to see if you are achieving the necessary targets for the peroneal muscles to handle tensile, elastic and compression forces. We start with small movements and minimal load, like non-weight bearing movements, then and resistance with therabands and gradually get you to bear weight on the ankle while moving. We use isometric muscle contractions to start with. These are muscle contractions without any movement. This keeps the muscle bulk and increase circulation, without causing flare-ups of inflammation, during your peroneal tendonitis treatment.
5th Phase: Full range of movement
Regaining full range of motion of your ankle is a very important component of your peroneal tendonitis treatment. You need this to have a good stride and placement during the gait or running cycle. To get the full range of movement we use massage, dry needling, stretches, joint and neurodynamic mobilisations. At the end of this phase of rehabilitation, you should be able to comfortably point and flex your ankle and toes as well invert and evert your ankle.
6th Phase: Eccentric muscle strength
During this phase of your peroneal tendonitis treatment, you will work on strengthening all muscles that are responsible for the ankle’s stability. Stronger muscles have the capacity to work harder and all team members can do their part, so we can avoid overload because of muscle imbalance. Eccentric movement refers to the muscle belly lengthening on contraction. This enables controlled return from a movement, like landing from a jump. This type of contraction is especially beneficial for peroneal tendonitis, as it lessens the pull on the tendon. We will progress your exercises more and more, adding resistance, doing more repetitions and building your overall strength. Now, you should be able to walk, climb stairs and balance on your ankle with ease.
7th Phase: Concentric muscle strength
Concentric muscle contraction is the shortening of the muscle belly with movement. During this phase of your peroneal tendonitis treatment, you will do calf raises, resisted eversion and balancing drills.
8th Phase: Global stability
The ankle is at the bottom of the food chain, so to speak, so any imbalance, weakness or poor movement pattern from above can influence the way your ankle moves and the type of load it needs to carry. We will address your hip and knee stability during your peroneal tendonitis treatment to ensure that the problem doesn’t recur.
9th Phase: Balance, high speed and power
Now that you’ve worked through the different phases of your rehabilitation, we want to improve the power, speed and control of your ankle joint movements. You need to be able to do activities with precise balance, high load, and speed to ensure that your ankle keeps up with the demand of your sport.
Your physiotherapist will guide you to return to normal activities but will also challenge you past your normal boundaries to determine how your body reacts to different forces. Ultimately we prepare you to return to participating in your sport.
Whatever must be done – we’ll get you there, running, sprinting, jumping or dancing.
10th Phase: Sport specific training
This is the final stage of your peroneal tendonitis treatment. Depending on your sport, your physiotherapist will tailor specific exercises to further improve your strength and endurance. A successful outcome is when you understand your condition, know how to prevent flare-ups and can participate at full power and speed, not to mention the benefits of minimizing your chance of future injury. You can expect hops, jumps, landing and direction changing drills.
Healing time for peroneal tendonitis
Tendons are infamous because of the relatively long time it takes to heal. Each case is unique, but be patient. Peroneal tendonitis can take anything from 6 weeks to 6 months to heal completely. You can trust us to diagnose and treat any and all the contributing factors to get to the bottom of your peroneal tendon pain once and for all.
Other medical treatment for peroneal tendonitis
Your GP may prescribe anti-inflammatories or analgesics. It is not advised to take medication to enable you to participate in your sport or train. Medication should be us used responsibly.
A brace will be of minimal benefit. Long term use of a brace may lead to muscle weakness and instability. If strapping is used to alter your running pattern it should be done with a rehabilitation professional.
Your rehabilitation program can be done in collaboration with a Biokiniticist.
Cortizone injections can decrease symptoms, but also influence the integrity of all the tissues around the ankle joint and cause other injuries over time. There is a reason why cortisone injections are restricted to three applications within a 12 month period.
Surgery for peroneal tendonitis
Surgery will only be considered after 3 months of conservative treatment. It is not a quick fix and will require extensive rehabilitation to get you back to what you love doing, be it dancing, running or hiking.
A synovectomy can be done if the sheath around the peroneal tendons is damaged or inflamed.
The peroneal tendons may be repaired (smoothed) or replaced by a part of the Achilles tendon.
If you have peroneal tendon subluxation the groove on the fibula where the tendon runs can be deepened.
After the surgery you will be in a moon boot for at least 4 weeks to ensure tissue recovery before you can start gaining range of movement, strength, endurance and finally get back to participating in your sport of choice.
What else could the pain be?
An inversion injury, where you roll over your ankle can cause an ankle sprain. This usually causes immediate pain, some swelling and even bruising.
- Tarsal tunnel syndrome
If the posterior tibial nerve gets impinged in the tarsal tunnel it can cause tingling, numbness and pain into the foot.
- Sinus tarsi syndrome
Repeated ankle sprains and poor biomechanics can cause inflammation of the structures around the ankle which leads to stiffness, difficulty walking on uneven ground and chronic pain on the outside of the ankle.
Nerve root compression from the lower back can cause pain, pins and needles, numbness and weakness down the leg and into the ankle.
- Superior tibiofibular joint
Knee injuries can influence the joint which can lead to pain at the outside of the ankle.
- Stress fracture
Excessive training can cause stress fracture of the talus, which will cause a gradual onset of pain on the outside of the ankle that is worsened by weight bearing and running.
- Complex Regional Pain Syndrome (CRPS)
Repeat injuries with chronic ankle pain may cause a change in the nerves, central sensitization. This will cause symptoms of temperature change, flaky skin, swelling without reason and stiffness.
- Avulsion fracture of the base of the 5th metatarsal
If not responsibly treated your peroneus tendonitis may lead to an avulsion fracture, which means the tendon pull is too strong for the attachment site and a muscle contraction causes the bone to break away with the tendon.
When a small piece of bone breaks away, together with the peroneus brevis tendon, from the 5th metatarsal you will have swelling, pain and bruising along the outside of the foot. You may limp when walking due to the pain.
