Peroneal tendonitis – Symptoms, Treatment & Exercises

Peroneal tendonitis is an inflammation of peroneal tendon & one of the common cause for the pain on outside of foot.

Tendons are anatomical structures that attach muscles to bones, and are a fundamental part of the human locomotor system.

Tendons are responsible for transmitting the force of muscle contractions to the bone (rigid structures), generating active movement.

Mechanical imbalances in any follow-up of the muscle-tendon-joint-bone complex (Musculoskeletal System) generate excessive tensions or compressions and potentially affecting the associated structures.

Tendinopathy or tendonitis is defined as an overload injury generated by the imbalance of forces of the musculoskeletal complex that can affect one or more tendons, generating the classic inflammatory process: pain, edema and increased vascularization.

Role of Tendons in Ankle Joint

The feet are essential elements for the postural stabilization of the body.

The ankle joint interacts dynamically with the other lower limb joints to sustain and stabilize body weight and impacts during the static and dynamic balance of the body. Therefore, ankle injuries can be extremely limiting. 

Peroneal tendinitis is poorly understood by the population and often receives the generic diagnosis of ankle torsion.

Only 60% of this tendinopathy is diagnosed precisely during the first medical visit.

The inability to accurately diagnose this tendonitis may prolong the recovery time of this lesion and even increase its severity

Peroneal Tendonitis - Things You Should Know

Peroneal tendinosis is a relatively frequent problem in the general population, but is usually more frequently observed in runners and old adults.

The fibular tendons are structures that attach the musculature of the lateral portion of the calf to the foot.

There are two peroneal tendons that running along the fibula bone:

  1. Peroneous brevis (Short)
  2. Peroneous longus (Long).

The tendons have the primarily function of perform ankle eversion (turning the foot outside) and to stabilize the lateral portion of the joint during the gait, helping to prevent ankle sprains.

Peroneal tendinopathy is an injury in these tendons, causing an inflammatory or a degenerative process.

Acute ankle inversion injury is a typical trigger for this injury but ankle instability, overuse, tendon subluxation and anatomic abnormalities are also associated to the development of microtraumas.

What Causes Peroneal Tendonitis?

The peroneal tendinitis presents a multifactorial etiology.

Failures in foot mechanics caused by improper footwear, acute tendon trauma due to over-training, and overload injury are the most commonly associated causes of this injury.

1. Excessive Overload & Repetitive Movements

The peroneal tendons are surrounded by a ligamentous-type tissue called "retinacullum", with structures there are responsible for the secretion of a fluid (synovial) that allows the tendons to slide with low friction during the movements of the ankle and foot. 

Excessive overload and repetitive movements of the region decreases the effectiveness of the synovial fluid and can cause microtraumas in the tendons, triggering an inflammatory process characterized by pain, edema and increased local vascularization.

Although the inflammatory condition is a natural and beneficial process of the body's process of healing, the weakening of the tendons caused by the microtraumas makes the joint less stable, creating a vicious cycle of repetitive stress in the region, which can later progress to more severe conditions (e.g.: tearing of the tendon).

2. Lateral Ankle Sprain

Lateral ankle sprains are in the top common acute musculoskeletal injuries and the most described traumatic etiology associated with peroneal tendonitis.

According to the literature, 38-40% of ankle sprains can lead to peroneus brevis tendon tears.

3. Imbalance of Muscles

Actively young populations, such as runners, are a considerable risk group for this type of injury, especially when training is carried out on irregular grounds.

4. Aging Factors 

As mentioned before, the elderly are also a risk group but, unlike the young group, the causes are associated with a decrease in tendon elasticity common to the aging process.

Peroneal Tendonitis Symptoms: What Does it Feel

  1. Pain in the lateral and inferior (and sometimes back) region of the ankle;
  2. Pain during foot inversion;
  3. Edema (swelling) in the same area;
  4. Redness and heat (increased blood flow) in the same area;
  5. Prolonged discomfort after a simple sprain.

Diagnosis: How will You Find Out?

A good clinical evaluation, with questions about the symptoms, the cause of the injury and an examination, of the tendon are usually sufficient for the diagnosis.

The patient will present pain on a palpation of the peroneal tendons.

As mentioned before, sometimes an ankle sprain erroneously mistakes these injuries, and an ultrasound or MRI may be helpful if the diagnosis is not clear.

Peroneal Tendonitis Treatment: What Should You Do?

As mentioned, injury of the peroneal tendons can be very debilitating for patients.

Usually the treatment for this injury is conservative, but depending on the level of the injury, surgery may be required.

At an early stage conservative treatment may include:

  • Anti-inflammatory drugs to reduce the inflammatory response of tendons;
  • Use of an ankle brace or CAM walker boot to decrease the inversion movement;
  • Limiting walking and avoid excessive weight on the foot;
  • check-square-o
    Use ice packs on the affected area every 10-20 minutes to get rid of the acute symptoms.
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    Physiotherapeutic resources to reduce the inflammatory picture (eg: Ultrasound, TENS, Kinesiology Taping).

In a more advanced phase, in which the inflammatory signs are practically nonexistent, the most used techniques are:

  • Ankle brace for stabilization;
  • Strengthening and stretching exercises can help rehabilitate the tendon and muscle after immobilization.
  • Orthopedic or orthoses. To give the necessary support to the plantar arch and the heel.
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    Shoe adaptation and use of insoles. The use of insoles designed by an orthopedic surgeon may be advised.

Peroneal Tendonitis Exercises: How you Would Do It?

The following exercises are usually prescribed during the rehabilitation of a peroneal tendinosis:

Calf Stretching Exercises

Calf Stretching

Calf stretching (passive in an early stage and active when the pain is less present) - 2 to 3 sets of 30 seconds, 3 times per day.

Balance Exercises

In order to increase proprioception, single leg balance exercises. The complexity of the exercise increases with time, and other resources can be added (e.g.: catching ball in single-leg).

Strengthen Exercises

(Flexion, extension, controlled inversion and eversion) - The progression should be inversely proportional to the level of pain.

It can start with free foot movements, without resistance, and evolve to resistance applications with elastics.

Check out this video that will guide you on peroneal tendonitis exercises -

References +

1. Van Dijk PAD, Lubberts B, Verheul C, DiGiovanni CW, Kerkhoffs GMMJ. Rehabilitation after surgical treatment of peroneal tendon tears and ruptures. Knee Surgery, Sports Traumatology, Arthroscopy. 2016;24:1165-1174. doi:10.1007/s00167-015-3944-6.

2. Dombek MF, Lamm BM, Saltrick K, Mendicino RW, Catanzariti AR. Peroneal tendon tears: a retrospective review. J Foot Ankle Surg. 2003; 42(5):250-8.

3. Davda K, Malhotra K, O’Donnell P, Singh D, Cullen N. Peroneal tendon disorders. EFORT Open Reviews. 2017;2(6):281-292. doi:10.1302/2058-5241.2.160047.

Dr. Sachin

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