What is peroneal tendonitis? Peroneal tendonitis is an inflammatory condition of the peroneal tendon, which runs along the outside of the lower leg, behind
the ankle and under the foot. This condition is commonly seen in runners as an "overuse" condition. The Peroneal Muscles originate On the outer (lateral)
side of the lower leg just below the head of the fibula (smaller, outer bone of the lower leg). Pass under the outer ankle bone (lateral malleolus) over
the side of the foot bone (cuboid) under the foot and attach to the base of the big toe.
The peroneal tendon is encased in, or surrounded by, a synovial sheath that secretes fluid. This fluid allows the tendon to slide up and down without friction
as the foot pronates and supinates (moves outward and inward).
How does peroneal tendonitis occur? Excessive pronation of the foot places stress on the peroneal tendon by causing the tendon to have to work to hard to
provide foot stability. Foot stability occurs when the mid foot is "locked up" during the push-off phase of gait. The cuboid and other midfoot bones will
be "unlocked" if pronation of the foot continues as the foot is pushing off. As the foot over-pronates, the tendon is over-stretched, resulting in inflammation
and localized sharp pain.
What are the signs and symptoms of peroneal tendonitis? Typically, patients complain of pain and swelling located in one or two of three areas:
Base of the 5th metatarsal - the prominent long bone on the outer side of the foot.
In the cuboid tunnel (groove for the peroneus longus tendon) - location is proximal to the prominence of the 5th metatarsal.
Behind the outer ankle bone (lateral malleoli).
Progressive increase in intensity of pain with weight bearing.
Pain with inward movement of the foot (inversion).
Pain with resistance to outward movement of the foot (ankle eversion).
How is peroneal tendonitis diagnosed? Your physician will ask you many questions about the pain in your foot. For example when it began, does the pain increase
with activities, does anything seem to relieve the pain. The doctor will also examine your leg and probably take X-rays. X-rays can help rule out a stress
fracture, a condition that can mimic the symptoms of peroneal tendonitis. Lastly, your physician may observe you walk so that your gait (low back, hips,
knees and feet) may be observed for any unusual characteristics.
How is peroneal tendonitis treated? Your immediate goal is to control pain, reduce inflammation and swelling, and protect the injured leg.
REST: Rest is critical to recovering from peroneal tendonitis. It is important that you restrict or limit your activity. Decrease both the frequency and
duration of your exercise routine. Increase the amount of time between workouts. Do not confuse this: some individuals have taken a few weeks off and then
gone right back to the same routine. This will not provide your body the kind of rest it needs in order to recover.
ICE: While resting, apply ice or cold therapy to limit the swelling and reduce the pain. This may be accomplished by using a cold pack, cold therapy device
or ice massage. To massage, fill a paper cup with water. After freezing, tear back the top portion of the paper exposing the ice. Massage firmly over the
injured area in a circular fashion. Repeat this for 15 minutes 3 or 4 times per day, especially before workouts or competition. Be careful not to overexpose
NSAID: Your physician may prescribe an NSAID (non-steroidal anti-inflammatory medication) such as Advil or ibuprofen to help reduce the pain and inflammation.
STRETCHING: Gradual progressive stretching increases flexibility and can prevent the injury from returning. Be sure to stretch both before and after all
activities. Calf, Achilles, and peroneal stretching exercises may be performed 3-4 times per day. Consult your physician or physical therapist.
CORRECTION OF FOOT PROBLEMS: If you have any abnormal biomechanical problems of the lower extremity, they must be addressed or the problem will recur. The
type of running shoe you wear, arch supports and a foot strap should all be considered based on your individual gait evaluation. Consult a qualified therapist
for a professional evaluation.
The goal of rehabilitation is to return to your sport or activity as soon as medically possible. Everyone, especially athletes, is anxious to return to
activity. Returning too soon can cause permanent damage. Follow your physician's advice regarding your activity level and date of return. Length of recovery
will vary from person to person.
There are three peroneal muscles in the lower leg. These muscles attach to the tibia and fibula bones on the outside of the lower leg. The tendons of these
muscles pass around the outside of the ankle and attach into the foot. These tendons are a part of the "stirrup muscles" that work to support the arch
of the foot. They also function to move the foot in an outward direction. One of these tendons attach into the base of the fifth metatarsal. The fifth
metatarsal is the long bone behind the fifth toe.
Pain on the outside of the foot can be the result of inflammation of the peroneal tendons. In children this can cause tenderness at the base of the fifth
metatarsal, which is located in the middle of the outside of the foot. Peroneal tendonitis can also cause pain along the outside of the foot and outside
of the ankle.
The causes of peroneal tendonitis are excessive calf muscle tightness, twisting of the foot or ankle and chronic abnormal foot function. In many instances
the cause of the tendon inflammation is not evident.
In mild cases of peroneal tendonitis rest and an oral inflammatory medication is sufficient. In more acute cases cast immobilization may be necessary. Long-term
treatment includes regular
calf muscle stretching
and an insert for the shoes called
On occasion the peroneal tendon may sublux over the outside of the ankle. This condition is called
subluxing peroneal tendon.
This condition often requires surgical correction.
If you have any further questions make an appointment with a podiatrist in your area.
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Peroneal tendonitis may present as a chronic ankle sprain that does not get better. Patients may also say there is pain, there is swelling and on occasion
when they put their foot in different positions, they get popping in the posterior lateral corner of their ankle peroneal tendonitis, ankle pain, perineal
tendonitis peroneal tendonitis, ankle pain, perineal tendonitis. They may also have some limitation in plantar flexion in the extreme case.
So these peroneal tendons, let me orient you to this slide, this line right here showing you the fibula, here is the front of the ankle, here is the calcaneus
and here is the lateral border of the foot extending out this way. So there are those peroneal tendons as they turn the corner around the fibula to travel
down the lateral border of the foot to the base of the fifth metatarsal, they have all this inflammation here in the tenosynovium, that's painful and that
hurts, and they are going to present with swelling in that region that just doesn't seem to go away, and they thought it was an ankle sprain. What is the
source of that chronic inflammation that they have in that region? There is over-use or over-pull of the peroneal tendons.
Those peroneal tendons are supposed to sit in the groove behind the fibula. If you have a very shallow groove to begin with anatomically, then the soft
tissue structures, namely the retinaculum, that acts as a band to keep those peroneal tendons behind the fibula, if that gets stretched out in an ankle
sprain or in a mechanism that might be consistent with an ankle sprain, those tendons are popping out of their groove, they are riding up on the lateral
side of the fibula and just like a frayed rope running over the side of a building, it pops up, it pops down, it pops up it pops down, you start to get
tearing and fraying of that and you get tendonitis. So some of the secondary manifestations can be associated with a pes cavus foot or hind foot varus.
Another possibility is posterior lateral impingement. Some of them may have had a calcaneus fracture, for example. When you fracture a calcaneus, the calcaneus
tends to get wider, so that space between the lateral wall of the calcaneus and the tip of the fibula is lost and the peroneal tendons are getting pinched
between those two bony surfaces. I apologize for this slide, when I reproduced it, it came out very wide, but what I am trying to point out here to you
is one sign that may be very indicative of peroneal tendon subluxation or an injury to that retinacular band that helps keep the peroneal tendons behind
You see this, this helps make that diagnosis of subluxated peroneal tendons.
Again, our treatment is, we need to reduce the inflammation. We need to also put this foot at rest, which could again be immobilization, that over-use,
over-pull syndrome that may be driving this inflammation. Eventually, we need to work on their eversion strengthening or turning that foot out to the side
so they can do that more effectively so they don't overwork the tendon, and there may be a roll.
Orthotics, the main thing that helps here, if your hind foot is in varus or if it's tipped toward the midline, you need to put a strutter, a post on the
lateral border of the heel, you need to try and rotate that calcaneus from being tipped in to being tipped out, so they don't have t overwork their peroneal
tendons to do that. Sometimes in severe cases in very rigid deformities, you need to brace them from their foot onto their leg to help stabilize the ankle.
When I look at someone who presents to me with a foot complaint, I try to break it up into what the primary pathology is, and what are the secondary manifestations
that they are coming to me to complain about? The foot is a complex weight bearing surface. There re 28 bones and nearly 60 articulating surfaces, so there
are a lot of inter-relationships going on between the different segments of the foot, the hind foot, mid foot and forefoot, and problems in one region
can have manifestations elsewhere. So it is very important to recognize what the root cause of the problem is, as well as identifying all the secondary
manifestations. So when I think of the problems, I start to look at the structural malalignments that might be present in the patient's foot, is the arch
too high, is it too low? Is there some imbalance of the muscle forces that is causing that problem; or imbalance of those muscle balance forces driving
the secondary manifestations.
There could be a problem in the hindfoot, but the patient comes in to see you because there is a forefoot problem. That is where it hurts them, that is
where it's difficult for them to wear their shoes. So by way of the anatomy, the osteology of the foot.
There are the seven tarsal bones in the hindfoot region, we have that defined as the calcaneus, and the talus, that separates the hindfoot from the midfoot
through the transverse tarsal joint. The remaining five tarsal bones are the middle, medial and lateral cuneiform, the cuboid bone, and the navicular.
Then you enter into the forefoot which has the five metatarsal bones and the 14 phalanges. As you know, in the hallux, there are only two phalanges, whereas
in the lesser toes, there are three, and then the two sesamoids that are under the first metatarsal head. Ligaments are important for static stabilization
of the arch of the foot, both it's longitudinal arch and the transverse arch.
Another concept that I use frequently when I am looking at foot problems, is that the foot should have an axis of balance. That axis of balance runs along
the sagittal plane. It goes from the center of the calcaneus, to the center of the midfoot, and runs between the second and third metatarsals in the forefoot.
Weight bearing forces are balanced across that access medially and laterally, in fact, minimal muscle activity is required for quiet standing. The muscle
forces, or the dynamic forces during the phases of gait are also balanced across this access for dorsiflexion, plantar flexion, but mostly for inversion
and eversion of the foot.
It needs to be rigid when you're standing on it, and it needs to be flexible as it strikes to the ground, so it can absorb the shock forces and the weight
bearing forces as it strikes the ground. These static restraints such as the ligaments, as they start to weaken and the foot starts to collapse, you start
to overwork or atrophy some of the dynamic restraints.
You can imagine structures over here become lax, both the tendons and the ligaments, structures over here become contracted. So now, you have the axis of
balance disrupted and now you have further forces that are acting to contribute to worsening of the deformity. Foot posture - it is very important to get
weight bearing x-rays, nonweight bearing x-rays of the foot.
(Note: more to article, but subscription was required, and I didn't know if I wanted to pay $10.)
Tendonitis is inflammation of a tendon (the cord-like structure that connects muscle to bone). Tendonitis (also spelled tendinitis) can occur in the
foot and ankle. Causes are usually overuse of the muscle with increased, repetitive or excessive exercising. It also can be caused by weight gain or
inactivity, shoes that are worn out to one side or foot deformities like flatfeet or rigid high arched feet.
Tendons under excessive strain will begin to cause the outer covering of the tendon to swell or develop small tears. Tendonitis can start out with episodic
pain, but with continued use of the part, the tendon will be painful whenever it is used.
There are four major tendons in the foot and ankle that commonly are involved. Each will be discussed briefly.
This affects the large tendon that connects the calf muscles to the back of the heel. Pain will usually occur as you lift your heel off the ground while
walking or when going up steps. This condition may be associated with bursitis (inflammation of the soft tissue in the back of the heel) or a "pump bump"
(an enlargement of bone that rubs against the back of your shoe).
Posterior Tibial Tendonitis:
This affects the tendon that inserts under the arch and helps hold it up. Pain under the arch will be felt when you push off to take
a step. People with flatfeet are affected the most. Overweight women are prone to this tendonitis as well. It is not uncommon for an injury to partially
tear this tendon sheath which easily becomes a chronic problem.
Anterior Tibial Tendonitis:
This affects the main tendon on the front of the ankle that lifts your foot during gait. Pain is felt in the instep when going down stairs or downhill.
This tendonitis is also associated with stop and start sports like tennis.
This affects the tendon on the outer portion of your ankle and foot.
Pain will be felt with standing or when pushing off to take a step. This condition is almost always created by injury.
When presenting to the podiatrist's office the doctor may question you about your shoes, what type of activities are painful, and your general health.
During the exam the doctor may take x rays to look for a stress fracture or other problems of the bones. In certain cases the doctor may order an MRI (magnetic
resonance image) to evaluate the tendon for tears or tenosynovitis (inflammation of the tendon sheath).
Tendonitis is readily treatable with rest or change of activity to a non-impact sport like swimming or bicycling. Ice should be used when symptoms begin.
Heat may be used after a few days. Your doctor will usually prescribe an anti-inflammatory medicine that should be taken exactly as prescribed. In some
cases the doctor may inject the tendon sheath with medicine (cortisone) to reduce inflammation except in the case of Achilles tendonitis where injections
are to be avoided.
The doctor may prescribe a heel lift or orthotic to optimally position your foot to reduce tendon strain (see previous topic of the month). Your doctor
may also refer you to a physical therapist for treatment. Some severe cases of tendonitis will require immobilization with a below the knee cast for a
period of 2-4 weeks. Finally, surgery may be performed to repair partial or complete tears in the tendon or to address severe tenosynovitis.