Peroneal tendinopathy

Tendinopathy is a term that is often used interchangeably with tendinitis or tendonitis. It is a failed healing response of the tendon – a tendon (or sinew) is tough band of fibrous connective tissue that connects a muscle to a bone. Rather than the normal healing taking place to where the tendon is healthy, the repair process fails with disruption of the tendon structure leading to pain, swelling and limited function. It can occur in any tendon in the body and is typically worse with activity and movement.

What is peroneal tendinopathy?

Peroneal tendinopathy occurs in one or both of the tendons that run round the back of the outside ankle bone. The actions of the peroneus longus and brevis muscles are plantar flexion (points the foot down) and eversion of the foot (turn the foot outward). During weight bearing, the muscles act as stabilisers of the foot and ankle.

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Causes and symptoms

Causes of peroneal tendinopathy

Our tendons (which attach muscle to bone) undergo various stress and strain during our day to day activities. They adapt and recover from these on a daily basis. When the demand placed on these tendons exceeds their recovering capability they can become painful.

We understand that multiple aspects affect the demand as well as the recovery of these tendons. The common ones are age and the demand placed on the tendon. If the demand we place on the tendon is higher than its capacity to recover in the given time, the tendon can become painful. As we get older the recovery of the tendons slows down too. We also know that a lack of muscle tone, stretching and compression of the tendon can make the pain worse.

Conditions such as diabetes, hypertension, hypothyroidism, obesity, previous surgery, foot/ankle trauma and steroid use is found in up to 60% of patients with tendinopathy.

Symptoms of peroneal tendinopathy

The classic presentation is one of increasing pain at the site of the affected tendon, often with recognition that there has been an increase in inactivity. Usually the pain is use/load related.

In very early tendinopathy, pain may be present at the beginning of an activity and then disappear during activity itself, only to reappear when cooling down if the activity is prolonged, or to be more severe on subsequent attempts to be active.

The patient is usually able to localise the pain clearly and the pain is described as ‘‘severe’’ or ‘‘sharp’’ during the early stages and sometimes as a ‘‘dull ache’’ once it has been present for some weeks.

Diagnosis of peroneal tendinopathy

Examination includes inspection for muscle atrophy, asymmetry, swelling and possibly redness (erythema).
Atrophy is often present with chronic conditions and is an important clue to the duration of the tendinopathy.
Range-of-motion testing often is limited on the symptomatic side.
Physical examination must include tests that load the tendon to reproduce pain and other loading tests that load alternative structures.

Self management of peroneal tendinopathy

Initially, managing the demand that is placed on the tendon is important as it helps the tendon to recover, e.g. limiting running distance and certain exercises as well as daily activity that causes pain.

Gradually reintroducing the demand on the tendon and exercises in a graded fashion helps to increase the tendon’s capacity to deal with the demand.

To further support the theory that movement and activity assist in tendon healing, it has been shown that immobilisation of the tendons after injury often has a negative effect on healing. In chronic tendon injuries, making the tendon work (mechanical loading) has also been shown to stimulate the healing process which promotes repair and remodeling of the tendon structure back to a health state although this can take a long time. Progressive graded exercises that load the tendon at the rate it can tolerate are very important.

As tendons do not have a good blood supply they are slow to respond to treatment and make take a number of months to get better.

Exercises for peroneal tendinopathy

Exercise 1: calf stretch

Stand with your injured leg back
In a step standing position
Stretch your leg keeping your knee straight
Fell the stretch in the back of your calf
Hold for 30 seconds

Exercise 2: calf stretch (soleus)

Stand with your injured leg back with your knee slightly bent
In a step standing position
Stretch your lower calf keeping your knee bent
Feel the stretch in the lower calf
Hold for 30 seconds

Exercise 3: single leg heel raises

Put your hand on a wall or other stable surface for balance
While standing on one leg, raise up on your toes as you lift your heel off the ground
Keep your knee straight

Exercise 4: single leg balance

Stand on one leg
Hold your balance in this position
Perform this next to a table or other sturdy object

Exercise 5: step up

In standing position with a step in front of you – make sure you are supported
Slowly bring one foot up, then bring up the other
Slowly bring one foot down, then being the other down

Exercise 6: ankle eversion – exercise band

Start by lying on your back or sitting
Place a looped elastic band around both your feet
Next, turn your ankle away from the other foot and pull the band
The other foot doesn’t move, it just acts as an anchor

What next?

If you are still experiencing symptoms despite following the above advice, it is important you seek advice from your GP. Your GP may decide to refer you to the musculoskeletal clinic or to a physiotherapist.

Immobilisation for a short time in extreme cases helps the tendon to settle.

Extracorporeal shockwave therapy

US guided injection

In extreme cases that do not respond to conservative management, surgery may be appropriate.

Page updated 01/12/2020. Review date 01/01/2024

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