Peroneal tendonitis and what to do about it
By Sue Reive
As runners train for road races this fall, one of the most common injuries that some will suffer is peroneal tendonitis. It is an inflammation of one or both of the tendons that connect your lower leg to your foot.
The peroneal tendons can be strained, leading to pain and inflammation. The strain can occur with an acute injury, such as an ankle sprain where the tendon is stretched when you roll the ankle, or it can come on gradually, usually from overtraining. Sports such as football and soccer place a lot of stress on the tendons due to the cutting actions while running. Other factors contributing to peroneal tendonitis include poor footwear that doesn’t provide enough support, running on uneven ground, increasing the intensity of training and poor flexibility in the calf and peroneal muscles. Symptoms include pain just below the ankle bone, swelling, increased pain when walking and running and pain and weakness when turning the foot out or rising on the toes.
The peroneal muscles include the peroneus longus (PL) and the peroneus brevis (PB) which originate from the outside of the lower leg on the fibula. The PL arises from the upper two-thirds of the fibula while the PB arises from the lower two-thirds. Together the peroneal tendons continue to course down the outside of the fibula and travel in a groove around the outside of the ankle bone. Here the tendons are encased in a synovial sheath and secured in place by a ligament-like structure called the superior retinaculum. The PB inserts onto the base of the fifth metatarsal on the outside of the midfoot while the PL curves and runs under the sole of the foot to insert onto the medial cuneiform bone and first metatarsal bone in the midfoot.
When non weight bearing, the tendons work together to turn the foot outward (eversion) and point the foot down (plantar flexion). When weight bearing, the peroneal tendons function to stabilize the foot and ankle on the ground and maintain proper alignment such that the foot doesn’t roll in (pronate) or roll out (supinate) too much.
Treatment for peroneal tendonitis initially includes rest, ice and compression with a brace. Physiotherapy helps guide the healing process by introducing the correct exercises for stretching and strengthening depending on the stage of healing and the extent of the injury. The goal is to allow the tendons to heal, improve flexibility and strength so the patient can return to sport without pain. Indeed, when the tendons are sufficiently healed, most of the strengthening exercises are done in weight bearing to ensure adequate function.
Ultrasound and electrotherapy can help with the healing process by reducing swelling and improving blood flow. Soft tissue massage techniques can also help improve flexibility if the muscle is tight. Manual therapy can help mobilize any stiff joints, especially in patients who have had the injury for months which is considered chronic tendinopathy. Balance training is extremely important to regain function and stability in weight bearing. Finally, a gradual return to sport is introduced.
Peroneal tendonitis and even small peroneal tendon tears most often heal with physiotherapy. Larger tendon tears – greater than 50 per cent of the tendon – will often require surgery followed by extensive physiotherapy and rehabilitation.
Sue Reive is a physiotherapist at Ottawa Physiotherapy & Sport Clinics in the Glebe and former owner of Kilborn Physiotherapy Clinic.