Peroneal Tendonitis is a common cause of pain around the back and outer side of the foot due to inflammation, irritation or degeneration of the tendons. Tendonitis/ inflammation of peroneal tendon or tendons occurs when the tendon are over-used or placed under too much tension, usually from repetitive movements causing micro-trauma on the tendon.
There are two peroneal muscles, Peroneus Longus and Peroneus Brevis. They run down the back of the fibula through a groove on the outer side of the ankle behind the lateral malleolus. The Peroneus Brevis inserts into the base of the fifth metatarsal (little toe) and Peroneus Longus crosses the sole of the foot to attach to the outer side of the first metatarsal (great toe). The action of these muscles is to pull the foot and toes downwards, known as “plantarflexion” and to turn the foot outwards, known as “eversion”.
There are four main causes of tendonitis in the peroneal muscles:
Overuse is the most common cause of peroneal tendonitis. Sudden increases in training levels, inappropriate footwear or poor training techniques can lead to the condition. Runners, who frequently run along slopes or on uneven surfaces, causes the foot to excessively roll out into eversion are more prone to peroneal tendonitis.
Sports such as basketball, football and gymnastics, or anything requiring quick pivoting movements are also commonly associated with the disease.
Abnormal Foot biomechanics
If the hind foot is turned inwards slightly as in cases of inverted or high arch foot, the individual is at higher risk of peroneal tendonitis as this keeps the peroneal muscle tendons in a stretched position.
In recurrent ankle sprain, patients have week peroneal tendons with peroneal tendonitis/peroneal subluxation. Incomplete rehabilitation following an acute ankle injury can cause peroneal tendonitis.
Muscular imbalance due to tight calf or inverters or ankle instability can give rise to peroneal tendonitis condition.
Inadequate or unsupportive footwear
Patient complains of pain around the back and outside of the foot.
Tenderness on palpation can be elicited.
Pain increases gradually, gets worse with activity and eases with rest.
The pain often tends to be worse first thing in the morning.
Turning the foot inwards (inversion) will aggravate the pain as well as attempting to do the reverse against resistance.
The initial treatment can be abbreviated as PRICE – protection, Rest, Ice, Compression and Elevation.
The patient may have a painful limp, so the peroneal tendons need to be rested from weight-bearing activities.
Ice can be applied to reduce pain and swelling. Apply for 10-15 minutes every 3 to 4 hours during the initial inflammatory phase.
Anti-inflammatory medication may help reduce pain and swelling. Supportive Kinesio taping can support the injured soft tissue.
Other helpful physiotherapy modalities and techniques can be used to reduce pain. Once the pain settles, rehabilitation can be started on home exercise program basis to normalize range of motion, strengthen the lower limb muscles and improve balance.
Chronic tendinopathies will take longer to recover. The treatment at this stage is active rehabilitation to improve the tendon’s ability to respond to load. This includes eccentric strengthening of the peroneal muscles; as well as balance, strength and range of motion exercises of the lower limb.
The things that can be done to reduce the risk of developing peroneal tendinopathy are –
- Wear correct, supportive footwear – this is not necessarily the most expensive or newly released shoes in the market.
- Gradual increase in training load or exercise level.
- Maintain a level of activity in the “off-season”- athletes who are off sports during off season needs to maintain at least 1/3rd of strength and 2/3rd of aerobic fitness to avoid injury during high level sporting activity.
- Improve balance and proprioception
It may take a couple of months for the symptom of peroneal tendonitis to fully settle down, so, effective treatment is important.