There are three peroneal muscles that run down the outside of your leg and attach into the foot. These muscles collectively work together to evert, abduct and plantarflex the foot. These muscles are called peroneus longus, peroneus brevis and peroneus tertius. Today, we will be focusing on the first of these two muscles.
You may also hear these muscles referred to as ‘fibularis’ longus, brevis or tertius. Don’t be confused! This is just another name used to describe the same muscles.
These muscles all have tendons running down into the foot and inserting into different locations. These tendons can become injured in a variety of different ways, which can be extremely debilitating.
This blog will cover all things related to peroneal tendinopathy.
What does peroneal tendinopathy feel like?
An injury to the peroneal tendons can present in a few different ways.
Sometimes, in a severe enough lateral roll of the ankle, the peroneal tendons may tear or even completely rupture.
This will present as a very sharp pain that may go down the outside of the ankle, and even continue under the foot.
Another form of injury to the peroneal tendons that will occur with a sudden injury to the area, is dislocation or subluxation of the peroneal tendon.
This may result in a ‘snapping’ sensation in the outside of the ankle and will be diagnosed by your podiatrist or doctor by moving the ankle through its range of motion and assessing the location of the peroneal tendon. If the area is too sore to assess, patients will be sent for imaging to confirm this diagnosis.
Usually, injury to the peroneals will involve a slightly slower onset, where the patient does not recall an incident where the injury occurred, but instead says it came about gradually, or they just woke up one day and the area was sore.
This often feels like a sharp pain in the same areas as discussed above, however this will often warm up as you start walking throughout the day.
Patients will often find they have trouble walking due to a painful spot on the outside of the foot. This will generally indicate that peroneus brevis tendinopathy is present. This is the injury that will be focused on for the remainder of this blog, as it is the most common form of injury related to the peroneal tendons.
In all three forms of these peroneal tendon injuries, your podiatrist or doctor should test the strength of your peroneal muscles. Weakness or pain when using this muscle is often a great diagnostic tool to identify which tissue has been affected.
Tendinopathy of the peroneals may be further divided into tendinosis, or tendinitis, and whilst this often can not be properly distinguished between without imaging. Tendinosis can be identified if there’s a palpable mass that moves with the tendon, indicating thickening of the tendon, whereas tendinitis can be identified if palpation of the tendon causes pain, but no thickening is present.
Who is usually affected by peroneal tendinopathy?
Peroneal tendinopathy tends to be more prevalent in people with a pes cavus foot type, as this foot type is more prone to lateral ankle sprains or rolled ankles.
In a pes cavus foot type, the peroneal tendons are always under a lot more tension than a normal foot type.
A pes cavus foot type is pictured below:
Peroneal tendinopathy can also be present in those with a pes planus foot type (low arches). This foot posture can place pressure on the attachments of the peroneal tendons, particularly the peroneus longus which inserts onto the medial (inside) of the foot at the arch.
Peroneal tendinopathy is typically not seen in children, as the tendons are still very elastic at this stage, thus adults are the most common population that peroneal injuries are seen in.
What causes peroneal tendinopathy?
Peroneal tendinopathy occurs when the load the tendon is placed under becomes greater than the capacity of the tendon.
The image to the right outlines what is known as the tendinopathy continuum and shows the stages of tendinopathy.
This all begins with an excessive load being applied to the tendon, and then progresses further when this load is not modified, or the tendon’s capacity is not increased.
This excessive load can come from a multitude of factors, such as an acute ankle sprain causing small tears in the tendon; overload of the tendon due to a pes cavus foot type; inappropriate footwear which causes excessive supination of the subtalar joint; or even by simply increasing levels of physical activity too quickly.
This is why a detailed history should be taken of the patient, instead of just relying on clinical tests or imaging to make the correct diagnosis.
What treatments are available for peroneal tendinopathy?
Treatments for peroneal tendinopathy follow the same model as recovering from most tendon injuries. However, it is important to identify the type of tendinopathy that is present to ensure the right interventions are put into place.
This was briefly mentioned earlier, but tendinitis and tendinosis of the peroneal tendons will be treated quite differently. This is why it is important to see a podiatrist to have this condition properly diagnosed.
The following is a list of treatment options your podiatrist may offer you for peroneal tendinopathy:
- Peroneal strengthening program: As was explained in the tendinopathy continuum, tendinopathy occurs when the load placed on a tendon exceeds its capacity. Thus, we have to strengthen the tendon to increase its capacity, so that it is strong enough to withstand higher loads. This will generally be completed with a mix of TheraBand work, and a modified calf raise program.
- Taping or wedging in the shoe: Depending on your foot type, by taping the foot into a more pronated position, or placing a wedge in the shoe that does this for us, we should be able to reduce the tension being placed on the peroneal tendons. This is particularly useful in patients with a pes cavus foot type, where the peroneals are constantly under a lot of load. By taping or wedging the foot, we are able to give the tendons a much needed break.
- Orthotics: If taping or wedging proves to be successful, orthotics are often a great solution for the long term. Orthotics can give your foot some much needed lateral support, as most runners and shoes do not cater to people with a pes cavus foot type, as they provide very little lateral stability.
- Stretching program: Tight muscles can cause problems in a variety of ways. Sometimes, it is the peroneals themselves that are too tight, and sometimes it is opposing muscles, which places more stress on the peroneals. Your podiatrist will be able to give you a range of stretches that take the load off of the peroneal muscles!
- Shockwave therapy: Extracorporeal shockwave therapy may be useful to stimulate an immune response and kickstart the healing cycle to treat peroneal tendinopathy. This treatment seems to be particularly effective in chronic cases of tendinopathy.
- Non-steroidal anti-inflammatories: In cases of peroneal tendonitis, using non-steroidal anti-inflammatories will be effective at reducing the inflammation present. This is why it is important to have your podiatrist properly assess what type of tendinopathy is present.
- Corticosteroid injections: If all conservative options have been exhausted, ultrasound guided corticosteroid injections should be trialled before going for surgery. Some patients will find this only gives a couple of weeks of pain relief, whilst others will find this fixes the problem for good. While results may vary, evidence suggests that this is worth doing before going under the knife.
- Surgery: Surgery is generally the last resort for peroneal tendinopathy, unless extremely severe tendinopathy is present, or your tendinopathy has occurred as a result of a lower limb deformity that must be altered.
Come book an appointment with us today to see which option is best for you. You can book your appointment by calling us on (03) 9432 2689 or booking online here.
