My neighbor asked me this question yesterday. He mentioned that he began running again, and I have noticed him running more around the neighborhood in the past several weeks. At first this seemed like a run of the mill tendinopathy, but upon further questioning, his case became much more interesting. He has high arches and had a previous ankle sprain on that side. In the end, he still has tendinopathy. More specifically, he has peroneal tendinopathy. All the additional information helps me understand why he has it and how to keep it from returning. Read on to learn about this condition.
What is the difference between tendinopathy, tendonitis and tendinosis?
Before delving into peroneals specifically, let’s first review the basics of tendons. A tendon is the connective tissue that attaches the muscle to the bone. Tendinopathy is a term used to encompass any issue with the tendon. This is includes tendonitis and tendinosis. There is a difference between tendonitis and tendinosis. Many of the conditions that were previously thought to be tendonitis are actually tendinosis. However because we do not necessarily know if the tendon has tendonitis or tendinosis, we refer to the condition as tendinopathy.
Tendons can get inflamed with a force that is too strong or quick. This tensile force on the tendon can cause micro-tears in the tendons. This is tendonitis. It is postulated that untreated tendonitis can become tendinosis. Tendonitis is an inflammatory condition and will respond to anti-inflammatory medication. It typically has a recovery period of 1-6 weeks .
Tendinosos is a degeneration of the tendon’s collagen proteins. This is hypothesized to occur after a period of untreated tendonitis. Collagen provides the tendon with durability and strength. Tendinosis is caused by chronic overuse with no time for the tendon to rest and heal. It does not have signs of acute inflammation and is not improved with anti-inflammatory medication such as ibuprofen. Early stage tendinosis can heal within 6 to 10 weeks but chronic stage can take 3 to 6 months. Tendinosis is probably more common than tendonitis but the term tendonitis is often used to encompass both.
My neighbor could have tendonitis or tendinosis. For the purpose of this text, I am going to assume it is tendinosis. However if his pain started very recently, especially after an acute injury, it could be tendonitis.
So what is peroneal tendinopathy?
Peroneal tendinopathy is an injury to the peroneal brevis and/or peroneal longus tendon. Both muscles are located on the outside of the lower leg. These muscles perform eversion which is moving the foot in an outward direction. They also aid in plantar flexion which is pointing the foot downward. The peroneus longus and brevis work together to stabilize and balance the foot.
The peroneal longus attaches to the upper two-thirds of the outer lower leg bone called the fibula. The peroneal brevis attaches to the lower two-thirds of the fibula. Both muscles become tendons above the ankle and pass behind the boney bump, called the lateral maleolus, on the outside of the ankle. The peroneal longus tendon passes under the foot and attaches to the inside middle part of the bottom of the foot. The peroneal brevis attaches to the outside of the foot and does not pass under the foot.
How do you get peroneal tendinopathy?
Tendinopathy is an overuse injury. It often affects runners, dancers, ice skaters, basketball player, skiers, or anyone who plays a sport that requires frequent changes of direction or jumping. If the foot hits the ground in suboptimal position then the muscles and tendons have to work harder to keep the foot and ankle stable. This will eventually lead to tendons that are enlarged and possibly swollen. This causes pain on the outside of the ankle. The pain will gradually and progressively worsen over weeks or months with continued participation in the irritating sport or activity.
Tendinopathy generally occurs when participating in a sport or activity without proper training or returning after a period of extended rest. It could also be affected by shoewear, training regimen, and the training surface. Tendinopathy could also occur after an ankle sprain.
What are the symptoms of peroneal tendinopathy?
There are certain symptoms that accompany peroneal tendinopathy. These include:
- Pain along the length of the tendon
- For peroneal longus tendinopathy the pain or tenderness could extend to the bottom of the foot.
- For peroneal brevis tendinopathy the pain or tenderness could extend to the outside of the foot.
- Pain increases during or after the activity or sport
- Pain decreases with rest from the activity
- Swelling, redness or warmth around the tendon at the outside of the ankle or foot
- Thickened tendons with possible nodule that moves with the tendon
- Pain with moving the foot outward
- Pain with pushing off the ball of the foot during walking or running
Are there any risk factors for peroneal tendinopathy?
There are factors that can make one more susceptible to this condition. These include:
- Chronic ankle instability – This is instability of the ankle that occurs after a previous ankle sprain.
- Tight calf muscles
- Inappropriate training
- High arches in the feet
- Overpronation of the feet while walking or running
- Muscle weakness – This weakness includes the ankle, as well as, the knee and hip.
- Overweight or obese
- Smoking
- Systemic conditions – These conditions include diabetes, arthritis, or gout.
Could my tendon tear?
Yes, this could lead to tears in the tendon or a complete tendon rupture. With the degeneration of collagen the tendon is not as strong. With repeated stress on the tendon, the tendons could completely or partially tear. Failure to treat the tendinopathy could also lead to tendon subluxation. This causes the tendons to snap back and forth over the bone on the outside of the ankle. Subluxation could also lead to tears in the tendon.
What should I do?
- Physical therapy – This would be my first stop. Physical therapy can help decrease the pain and swelling. Abnormal joint mobility, weakness, instability, and flexibility will evaluated and addressed. Your PT will also assess and correct your walking and running form to prevent the problem from happening again.
- Orthopedic physician – An orthopedist might be necessary if a tear is suspected or if the injury is not responding to physical therapy. Your orthopedist can order imagining to determine the extent of the tendon injury.
What can I do at home?
- Relative rest – Resting the area to decrease further pain and damage from occurring is one of the best ways to treat peroneal tendinopathy. Basically stay away from the activities that are causing pain. This gives the tendons time to rest and heal. If you keep doing what is causing the injury, it is not going to get better. Swimming and biking would be good alternative activities that do not put much stress through the ankle and foot.
- Ice – Ice can help decrease the pain and swelling at the ankle. Ice the painful area for 15 to 20 minutes at a time. I would recommend using an ice pack several times per day if the pain is constant or preventing you from participating in an activity. Ice immediately after activity.
- Stretching – Stretching calf muscles can help improve the motion at the ankle. This includes stretching the gastrocnemius and the soleus. See the video below.
- Strengthening – It is important to strengthen the muscles around the ankle, knee, and hip. All of these muscles work together to stabilize the ankle while running, cutting, and jumping. Using resistance bands and loop resistance bands can increase difficulty. See the videos below.
- Bracing – Using a stability brace or ankle sleeve can be helpful to decrease pain and improve stabilization at the ankle. This might be especially useful for those that have chronic ankle instability or who have suffered from previous ankle injuries.
In review
- Peroneal tendinopathy is an overuse injury of the tendons on the outside of the ankle.
- It occurs when the foot hits the ground in an abnormal position while running or jumping.
- It mostly affects people who are very active or play sports.
- Peroneal tendinopathy is characterized by pain in the outside of the ankle that occurs during or after activity. Pain improves with rest.
- Failure to treat it can lead to tendon tears or subluxation.
- Physical therapy can treat this condition and help prevent reoccurrence.
- An orthopedist might be needed if a tear is suspected.
- There are several things you can do at home.
- Relative rest
- Ice
- Stretching
- Strengthening
- Bracing
As always, If you have questions about the content of this post or any other musculoskeletal questions, please e-mail me.
Additional resources
https://www.physio-pedia.com/Peroneal_Tendinopathy
https://www.ncbi.nlm.nih.gov/books/NBK544354/
https://www.choosept.com/guide/physical-therapy-guide-peroneal-tendinopathy