Your ankles are the unsung heroes of every step you take. They power your dash to the front door, support you as you squeeze into your jeans, and absorb the impact of every single stride on your morning jog. We take these tireless joints for granted—until a sharp, debilitating pain on your outer ankle stops you in our tracks. This is often the calling card of peroneal tendonitis, nowadays more commonly known as peroneal tendinopathy. Now the inflammation and dysfunction of the tendons on the outside of your ankle turn the simplest movements into a painful chore.
If a sharp pain and instability on the outside of your ankle are making every step a challenge, you might have Peroneal Tendonitis.
What is the peroneal tendon?
A tendon attaches muscle to bone. The two peroneal muscles fill the lateral, or outside, compartment of your lower leg. These two muscles are mainly responsible for moving the sole of your foot outwards, in other words away from the other foot. The peroneal tendon is actually two tendons, namely the peroneus longus and peroneus brevis tendons. The peroneus longus tendon and muscle belly is longer than that of peroneus brevis. Both peroneal muscles attach to the fibula, the outer bone of your lower leg. The peroneus longus and brevis tendons run in a special groove behind the outer ankle bone, or lateral malleolus. The peroneus brevis tendon inserts at the base of the 5th metatarsal on the outside of your foot, whereas the peroneus longus tendon passes underneath your foot to insert on the base of your big toe.
What have you lost?
As we discussed in the previous section, your peroneal tendons cross the outside of your ankle joint to anchor the peroneal muscles to the bones of your foot. This anchor creates a leverage system that enables movement when the muscle contracts. When your foot is not bearing weight, the peroneal muscles work together to plantarflex your ankle, like a ballerina. These muscles also evert your ankle, in other words turn the foot outwards. When your foot is weight bearing, like when you’re standing or walking, the peroneus longus tendon also supports the transverse arch of your foot and provide stability. This means that the peroneal muscles and tendons are important for dynamic ankle stability, i.e. stability with movement.
I have peroneal tendonitis – How did it happen?
Tendons are infamous for their poor blood supply. This means that tendons take longer to heal than a muscles. If there is excessive load at this muscle anchor site, some of the tendon fibers may fray and cause inflammation. Some causes of excessive load may be starting a new activity, like boot camp, or increasing your exercise intensity, like running faster or often. Runners are especially susceptible to peroneal tendon pain, especially if they have muscle imbalances. Most of us have “muscle imbalances” because none of us move 100% symmetrically. If you favor one 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. As the peroneal tendons become painful and weak, their ability to stabilize the ankle is compromised. This peroneal weakness contributes to the functional instability of you ankle, increasing the likelihood of subsequent sprains and placing even more stress on the already damaged tendons.
While often a chronic, overuse condition, the onset of peroneal tendinopathy can also be traced back to an acute injury. The most common cause is an inversion ankle sprain, where you roll you ankle inwards. This injury damages your peroneal tendons as they are stretched or compressed. Another acute injury could be a sudden, powerful contraction of the peroneal muscles, for instance, while trying to prevent a fall or during a rapid cutting maneuver in sports.
Causes of peroneal tendonitis
- Previous ankle injuries
- Training errors
- Improper techniques
- Barefoot walking
- Change in running style
- New or unaccustomed exercise
- Increase distance or speed of runs
- Running on the same side of the road or track every time
- New routine (exercise or dance)
- Sustained positions, like sitting with your foot at an awkward angle
- High foot arches
- Flat feet
- Muscle imbalances
How severe is my peroneal tendonitis?
At first you will feel sharp, acute pain when your tendon is pressurized by movement, like climbing stairs or changing direction. You will have pain and stiffness when you start to move, especially first thing in the morning, but the pain settles as your warm up. The pain also goes away completely with rest. Standing on one leg might be challenging, almost as if your balance isn’t what it should be. This phase is of short duration and your tendon still has potential to heal completely.
If you don’t take note of your stiff, painful ankle tendons, the tendon tissue begins to change to adapt to the overload. Unfortunately, it doesn’t adapt in a good way. New blood vessels and nerve endings form in the tendon. Your pain will be a constant, nagging discomfort and stiffness. It might settle a bit after your warmup, but activity usually makes it worse until the pain forces you to stop moving. Your ankle will feel less flexible now and you will be more susceptible to injury, like rolling your ankle.
In the late stage of peroneal tendinopathy, the tendons become thickened and these changes have become irreversible. You’ll have pain with your normal, everyday activities, like shopping, and constant stiffness around your ankle. Any extra activity like walking uphill of climbing stairs will be excruciating, with the pain taking a couple of days to settle.
Diagnosis
Physiotherapy diagnosis
Physiotherapists are experts in diagnosing musculoskeletal conditions, like peroneal tendinopathy. We perform a thorough physical assessment, using skilled hands-on techniques to pinpoint the exact source of your problem. Through specific strength and movement tests, we determine the health of your peroneal tendons and rule out other potential causes of your ankle pain, such as ligament sprains or joint issues. This comprehensive, hands-on approach allows us to make an accurate diagnosis and create a personalized recovery plan tailored specifically to you.
X-rays
The bones of your lower leg and ankle will be visible with X-ray imaging, but not the muscles and tendons. Therefore, this is not a useful test to diagnose peroneal tendinitis or tendinopathy.
MRI
Magnetic resonance imaging is costly and unnecessary to confirm peroneal tendonitis. It can only be ordered by a specialist and enables a view of all the structures surrounding the ankle joint.
Why is my peroneal tendon pain not going away?
- Chronic Ankle Instability
This is the most common complication and is inextricably linked to peroneal tendinopathy in a self-perpetuating cycle. As the tendons become weak and painful, their ability to provide dynamic support to the lateral ankle diminishes. This results in a functionally unstable ankle, characterized by recurrent inversion sprains and a persistent sensation of the ankle “giving way” during activity.2 Chronic ankle instability is both a primary cause and a principal consequence of peroneal tendon dysfunction.
- Peroneal Tendon Tears (Partial/Longitudinal)
As the degenerative process of tendinopathy continues unabated, the weakened and disorganized collagen fibers of the tendon can begin to fail structurally. This typically manifests as longitudinal “split” tears, where the tendon frays and separates along its length, similar to a rope unraveling.4 Tears of the peroneus brevis tendon are significantly more common than those of the peroneus longus.2 These tears represent a more advanced stage of tendon degeneration.
- Peroneal Tendon Subluxation or Dislocation
This complication occurs when one or both peroneal tendons slip out of their normal position within the retromalleolar groove behind the fibula. This is often caused by an acute injury that tears the superior peroneal retinaculum (SPR), the ligamentous band that holds the tendons in place.2 Patients may report a distinct and often painful popping or snapping sensation on the outside of their ankle during certain movements.8 Chronic, recurrent subluxation creates ongoing friction and mechanical irritation, which can severely exacerbate the underlying tendinopathy and lead to further tearing.
- Complete Tendon Rupture
Although less common than partial, longitudinal tears, a severely degenerated and neglected tendon can eventually rupture completely. This is a traumatic event that results in a sudden loss of tendon function, accompanied by acute pain, swelling, and pronounced weakness in the ability to evert the foot.8
- Sural Nerve Irritation or Neuroma
The sural nerve, which provides sensation to the outer border of the foot, runs in very close proximity to the peroneal tendons. Chronic inflammation, swelling, and scar tissue associated with advanced tendinopathy (or following surgery in the area) can compress or irritate this nerve.19 This can lead to symptoms of burning pain (neuritis), numbness, or tingling (paresthesia) in the nerve’s distribution, a condition known as a neuroma if the nerve becomes entrapped in scar tissue.14
A big problem we see with peroneal tendon treatment
If peroneal tendinopathy is ignored and left untreated, it rarely resolves on its own. The initial pain, which may have been intermittent and activity-dependent, will likely evolve into a chronic and more severe pain state, eventually becoming present even during periods of rest and disrupting daily life. The underlying degenerative process within the tendon will continue unchecked, causing further structural breakdown and weakening of the tendon fibers. This makes the tendon highly vulnerable to more severe structural failure, such as extensive partial tearing or a complete rupture, which can occur with minimal trauma. This failure of the tendon’s structural integrity results in profound functional ankle instability, a markedly altered and inefficient gait pattern, and a significantly increased risk of recurrent, debilitating ankle sprains. Over the long term, this chronic instability and the resulting abnormal joint loading mechanics place excessive wear and tear on the ankle joint itself. This can lead to secondary damage to the articular cartilage, culminating in the development of premature and painful degenerative ankle arthritis. Ultimately, neglecting the condition can result in permanent limitations to mobility, an inability to participate in work, recreational, or social activities, and a substantially diminished quality of life. This often forces the individual to consider more invasive and complex surgical interventions to address the extensive accumulated damage, which could have been avoided with earlier treatment.
A longstanding problem cannot be magically relieved in a single session or with a magic machine. 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.
Ignoring the problem
Inaccurate Diagnosis
Immobilisation
Too much rest
Too little rest
Medication use
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?
Physiotherapy treatment
Physiotherapists 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
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.
Final Phase: Concentric muscle strength, Global stability, Speed and Power
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.
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.
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.
Healing time for peroneal tendon pain
Tendons are infamous because of the long time it takes to heal, compared to other injuries like muscle tears. Full recovery and return to sport will take longer and should not be confused with the healing period. Each case is unique, but be patient. Peroneal tendonitis can take anything from 6 weeks to 6 months to heal completely.
In the first stage, we will need to see you twice a week for treatment. Once pain starts to improve and we can start adding loading to your rehabilitation program, we will see your for treatment once a week for the next 2-3 sessions. Thereafter, you will start to return to light activities, while continuing your home specific loading program. We will still see you once in two to three weeks to monitor progress and adapt your loading accordingly. Once you’ve returned to training or normal activities, we will see you once a month or every 6 weeks to monitor tissue adaptation and response to the increase in loading. The last thing you want is to go through the hard work of treatment, only to quit too soon and start all over again in a year or two.
Other forms of treatment
- 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 Biokineticist.
- Cortisone 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.
Is surgery an option?
Surgery will only be considered after 3 months of non-surgical 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 it be?
- Lateral ankle sprain
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. - Referral pain from the lumbar spine
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.
Also known as
- Peroneal tendinopathy
- Peroneus brevis tendon pain
- Lateral ankle pain
- Peroneus longus tendon pain
- Ankle tendon pain
- Peroneal tendon pain
