Peroneal Tendinopathy

Peroneal tendinopathy describes the damage or degeneration of the peroneal tendons, which travel down the outside of your leg and cross the outside of the ankle to attach to the bottom of the foot. Peroneal tendinopathy may also be referred to as peroneal tendonitis, depending on whether any inflammation is present and how long the pain has been present. The difference in terminology simply denotes varying characteristics of the injury, and tends to be used interchangeably by a majority of health professionals.

You have two peroneal muscles (with associated tendons) in each leg called the Peroneus Longus and Peroneus Brevis. They follow the same path down the leg and then pass behind the bony bump on the outside of your ankle (called the lateral malleolus), but attach at different sites at the base of the foot. The peroneals play an important role in our ability to walk and move our feet, helping stabilise the foot and ankle, and helping turn the foot outwards.

The symptoms of peroneal tendinopathy can range in severity depending on the extent of the damage to the peroneals, but can include:

• Pain and tenderness on the outside of the ankle
• Swelling which may be mild or severe and may be accompanied by redness or warmth on the outside of the ankle
• Pain that is exacerbated by physical activity such as walking or running. Pain will also worsen when you point your foot inwards, which stretches the peroneals on the outside of the ankle
• Feeling unstable or weak around the ankle, especially during activities that require side-to-side movement
• Stiffness or reduced range of motion in the ankle joint
• A clicking or popping sound as the peroneal tendons rub against other structures at the outside of the ankle

In severe cases, the peroneal tendons may tear or even completely rupture, resulting in sharp pain that may go down the outside of the ankle, and even continue under the foot.

Peroneal tendinopathy is often an overuse injury that is caused by overloading the peroneals past a point that they can safely handle, causing small tears and damage in the tendons. Any action that everts the foot (rolls out the ankle) will stretch and place greater strain on the peroneal tendons, and may cause them to rub against surrounding bones and become inflamed. Contributing factors to the development of peroneal tendinopathy can include:

• Ankle sprain injuries or having chronic ankle instability (weak ankles prone to rolling out). Ankle sprains are a common cause we see as they suddenly and forcefully overstretch and strain the peroneals.
• Tight calf muscles, as the foot and ankle have to compensate
• Poor foot biomechanics or alignment issues such as overpronation (flat feet), which may cause the tendons to press together
• Poor training technique - particularly going too hard, too fast and overusing the peroneals
• Sports involving high activation of the peroneals, such as jumping and side to side movements that you see in basketball, netball and volleyball
• Unsupportive footwear which may promote the foot to roll in further instead of remaining better supported
• Inflammatory ankle arthritis (such as rheumatoid arthritis) also increases the likelihood of developing peroneal tendinopathy

To help ease your ankle pain and start your path to healing and repair, you can try:

• Strapping your ankle to discourage it from rolling out and putting more strain on the peroneals, allowing them to start healing without adding to the injury
• Switching to good, supportive footwear - such as good joggers with a strong heel counter that holds your ankle in place well, and limits unwanted side-to-side movement. In this case, any light or barefoot sneakers are not suitable as they generally do not offer the required level of support. 
• Using non-steroidal anti-inflammatories (NSAIDs) as needed to help relieve pain and swelling
• Icing your ankle (through a towel or cloth to protect the skin) for no more than 15 minutes at a time, four times per day. This may help reduce your pain and inflammation. You can also keep your ankle elevated to help promote swelling reduction.

Here at Matt Raden Podiatry, our trusted and experienced podiatrists listen to the concerns, goals and needs of our patients with peroneal tendinopathy and ankle pain, and utilise a range of evidence-based treatment methods to help you get the best outcome.

Every appointment starts with a comprehensive assessment to understand the biomechanics of your ankles, feet and legs, and all of the factors that are playing a role in overloading your peroneals and contributing to your pain. We’ll then create a tailored treatment plan based on your results that focuses on helping to heal and repair the tendons, and regaining ankle strength and function so you can stay active long into the future. We may use:

• Orthotics (insoles): using custom-prescribed foot orthotics that sit inside your shoe can help provide some much needed stability and support for your ankle. Depending on the severity of your injury, your orthotics may have special features like a higher later (outer) raised side to significantly reduce any outwards ankle rolling, keeping your ankle situated in a much better position for healing and repair.
• Footwear recommendations: your footwear plays a key role in helping you recover from peroneal tendinopathy. Specifically, unsupportive shoes that let your ankles roll around will work against the recovery progress you are making by allowing further strain on the peroneals. We will assess the footwear you currently wear on a daily basis (please bring these to your appointment) and will make recommendations as needed. This may include temporarily wearing your supportive shoes inside your home.
• Temporary lateral wedges: we may also use some temporary lateral wedging in your shoe to help you get symptom relief and improve your ankle stability temporarily.
• Bracing or immobilisation: depending on the severity of the injury or if a tear in the peroneals is present, an ankle brace or other immobilisation device may be needed in the earlier stages of repair to help you get the best outcomes. This is more likely if your pain is severe, and your podiatrist will advise you of the best course of action at the time of your appointment.
• Stretching and strengthening program: after some healing has occurred, it will be time to start on a specialised stretching and strengthening program, which will be developed based on the results of your assessment with us, paired with best-practice principles in treating peroneal injuries. Your program will focus on improving ankle strength and motion, as well as overall lower limb function and stability.