Even though peroneal tendinitis or tendinopathy is not as common in runners as other tendon issues such as Achilles tendon issues, it is still worth mentioning as it can be a deal breaker with running if allowed to worsen. In the literature it is not mentioned as one of the most common running injuries, but in the clinic where I work we see quite a few of these patients.
The peroneal tendons are located on the outside aspect of the ankle. They originate on the fibula and attach down at the foot. See below for an image of these tendons.
Image retrieved from the following site: http://eorthopod.com/peroneal-tendon/
You can see that the peroneus brevis attaches to the 5th metatarsal and the longus goes under the foot to the medial arch. They are primarily responsible for ankle eversion-or moving your foot in an outward direction.
Generally, tendinitis of these tendons is a result of beginning a new activity and doing too much too soon such as marathon training. Most of the time there is no known injury that has occurred, the pain just comes on and gradually increases as time goes on and the aggravating activity is continued.
The number one symptom is pain. The pain is located just posterior and lateral (on the outside) to the ankle usually. It may start out only hurting with the aggravating activity and no pain at rest but if the activity is continued the pain will eventually carry over into daily activities. You may also have weakness when trying to move the foot outward due to pain and inflammation of the tendons. It may hurt to bring the foot inward due to a stretch on the peroneals.
What causes peroneal tendonitis?
There is no definitive research that says for sure what causes it but it is usually improper training, poor shoe wear, or rapid increases in training. This information is from the American Orthopedic Foot and Ankle Society (AOFAS). I also believe that this can be caused by weaknesses in other areas of the body, especially the hips and core or the lumbo-pelvic-hip-complex (LPHC).
What should you do if you think you have peroneal tendinitis?
First, you should be sure it is not something else like a stress fracture of the fibula. A stress reaction on the fibula will hurt right on the bone rather than just posterior to the ankle bone. If you do not have symptoms of those problems then you may be able to assume you have peroneal tendonitis. Most people should stop the aggravating activity 3-7 days and see if the pain goes away. If it goes away then return to the activity (running for most of us) slowly. Not only slowly in terms of not doing speed work but slowly in terms of increasing the volume of your training.
If symptoms return then you should see someone to get properly diagnosed and be instructed in appropriate exercises. I will give basic exercises for these tendons but it would be wise to have someone evaluate you to be sure it is not stemming from a weakness somewhere else in the body that needs to be corrected. If this is the case then even though you do peroneal exercises, your problem will return/persist because you did not correct the root of the problem.
The best treatment is prevention! If you keep the appropriate strength and flexibility and do not have training errors then it is unlikely you will get this issue.
Most of the time rest from the activity is the best treatment for this issue followed by corrective exercises. You will also need to correct any training errors in your program and possibly your shoes.
Sometimes you can continue running with this issue if it is mild and if you reduce your training load and begin the appropriate exercises immediately. It would be wise to incorporate cross-training as well to keep your cardio condition while you reduce your running. Also, cross-training has frequently been cited as a method of decreasing injury risk. You may have to use ice after each run as well. If the pain progresses from being mild to moderate then you should stop running and seek help from a professional.
If the pain is severe and just resting from the activity did not relieve the symptoms then more significant rest might be warranted such as wearing a CAM boot that doesn’t allow the ankle to move with walking so the tendons get rest. This usually takes care of the pain but unfortunately may have to be done for 2-8 weeks and no running would be allowed during that time. When you are allowed to return to running you must do so in a slow manner progressing distance and intensity appropriately. You may need the help of a professional to help you transition safely back into running so the problem does not recur.
In the most severe cases surgery is needed. Surgery is usually only needed if you tear the tendon. The tendon can be torn by continuing to run when symptoms are significant. This is why it is important to be diagnosed correctly, perform the corrective exercises, and reduce your training as needed so that you do not tear the tendons. If you need surgery you will not be able to return to running for a long time. So, don’t tear it!!!
Keep in mind that if the reason you have peroneal issues is due to a weakness or muscle imbalance somewhere else then you need to correct that issue as well. Also, just so you know, sometimes single leg balance exercises cause the peroneal tendons to really fire up and can sometimes aggravate them at the beginning of rehab if you do too much and if you do not have some strength in the peroneal tendons. If you are having more pain with the balance exercises then wait two weeks to try them after you have been performing the targeted tendon strengthening exercises first.
If you need targeted exercises for this issue you should seek out an orthopedic physical therapist.
I hope no one gets this issue. I have had it in the past and it is a real bummer! Prevention, prevention, prevention!!