Do you have peroneal tendinitis? Here's how to fix it (2023)

As runners, we accept that our sport involves some risk. When we're good at oursMarathon-Trainingsplan,Addicted to trail running, or a first 5k, we hear from the high injury rates. And do you know there's a good chance we'll end up as one of many injured runners.

We anticipate that we might end up withrunner kneeorAchilles tendonitis. But what if your pain doesn't seem to fit into any of the usual categories? And when you're looking for running injuries, the sore spot and tender area just don't seem to mix.

Peroneal tendonitis, also known as peroneal tendinitis, is a rare but aggravating injury. It can cause pain on the outside of your foot. And when running on the outside of your lower leg.

What are the peroneal tendons?

While peroneal tendonitis isn't as common as the other forms of tendon pain, it doesn't make it any less frustrating. Especially when we cannot pinpoint the exact source of the pain.

There actually istwoperoneal tendons. The peroneus longus and the peroneus brevis, which run parallel to each other. Connect the outside of your foot to the peroneus longus and brevis muscles in your lower leg.

These tendons work together to evert (roll outward) your foot and also help your calf muscles plantar flex your foot. They also help stabilize your ankle during weight-bearing activities like running.

As with all cases of "tendonitis," the problem is really degeneration and damage, not inflammation. A more appropriate term would be "peroneal tendinopathy" or "peroneal tendon dysfunction".

However, since the term tendonitis is still more commonly used, this article will use that.

How common is peroneal tendinitis in runners?

Like any tendon, both peroneal tendons can be injured from overuse.

In contrast to injuries to the Achilles tendon orPatellarsehne, which are fairly common and well understood, peroneal tendon injuries are fairly rare.

A study by Taunton et al., which categorized the injuries suffered by over two thousand runners at a sports injury clinic, found only thirteen cases of peroneal tendonitis.¹This means that peroneal tendinitis accounts for only about 0.6% of all running injuries. With such a small number of cases, it is difficult to draw too many conclusions, but Taunton et al. noted that nine of the thirteen cases occurred in men.

It is difficult to say whether peroneal tendinitis is actually more common in men than in women. Or if this is just random statistical noise. However, injuries to the Achilles tendon and the patellar tendon are also more common in men. So there might be something to this trend.

What Does Peroneal Tendonitis Feel Like?

Peroneal tendonitis presents as a sharp or painful sensation along the length of the tendons or on the outside of your foot.

It can occur at the insertion point of the tendons. Along the outside edge of your fifth metatarsal. Or further up along the outside of your ankle.

Running will be painful, as will trying to flex and evert the foot, especially against resistance. Stiffness and pain can also occur when "knuckle-circling" or even passively stretching the tendon.

There should not be much pain when standing or when gently pressing on the injured area. However, if the outside of your foot feels very tender and you experience severe pain while standing or even without weight bearing, you can use insteadHave a fracture in your fifth metatarsal.

These are uncommon but can cause a lot of trouble if not addressed immediately. So if you're unsure if you have peroneal tendinitis, see your doctor as soon as possible.

Does it matter which of the two peroneal tendons you injured? The relatively sparse scientific literature on peroneal tendonitis indicates that this is not the case.

In fact, about 33% of all cases of peroneal tendinitis appear to be involvementbothtendons anyway. Therefore, any rehabilitation program must address both the peroneus longus and the peroneus brevis.²

Common causes of peroneal tendinitis in runners

Because peroneal tendinitis is so rare, there are no large studies of risk factors. The only reports that exist in the medical literature analyze a relatively small number of cases.

However, one risk factor seems to stand out.

A review of twenty-two cases of peroneal tendonitis by Clayton B. Brandes and Ronald W. Smith found that over eighty percent of these patients had a high arched foot. According to the authors, feet with higher arches put more tension on the peroneal tendons, predisposing them to injury.²

That makes sense, because with alowAn arched foot appears to be a risk factor for posterior tibial tendon injury (the tendon at thewithinof the ankle).³We've already gone into more detailHow your arch height affects your shoe choice and the type of injury you are most at risk for.

Research published in 1993 also suggests that higher running speeds may put additional stress on the peroneal tendons.

Lyle Reber, Jacquelin Perry, and Marilyn Pink of the Centinela Hospital Biomechanics Laboratory in California studied how muscle activation patterns in the muscles around the ankle changed with running speed in a group of healthy, injury-free long-distance runners.⁴

The researchers found that higher running speeds led to a significant increase in the activity of the peroneus brevis muscle. Muscle contraction intensity doubled when comparing a light jog to a running pace.

Reber, Perry, and Pink hypothesized that forces are rapidly transmitted to the midfoot when running at high speed. And the associated increase in the need for a stable ankle is responsible for the increased demands on the peroneus brevis.

As a result, faster runners and runners who engage in high-intensity interval training sessions are at greater risk of peroneal tendonitis.

Maybe it's best to stay away from thatTraditional forms of quick workif much of what we have said so far applies to you.

Some cases of peroneal tendon injuries are triggered by an ankle sprain. We have already told youHow to sprain your ankle while trail running. However, given the location of the tendons on your foot, it's easy to see how an inversion sprain can lead to tendon damage.

A 1993 report by Mark Sobel, Mark Geppert, and Russell Warren of the Hospital for Special Surgery in New York linked ankle instability from previous ankle sprains to damage to the peroneal tendons.⁵This was confirmed by a 1998 article inFoot & Ankle Internationalby researchers at the Mayo Clinic.⁶

If you have persistent pain after an ankle sprain, you may have injured one of your peroneal tendons as well. In some cases it even broke. This can be detected on an MRI.

How can I treat my peroneal tendinitis?

Even with treatment, the rarity of the injury complicates treatment. There are no controlled clinical trials that establish a rehabilitation program to be followed.

Still, we can draw some conclusions from what we know about the injury. And follow the recommendations of scientists and doctors with clinical experience.

According to Daniel S. Heckman and others at the University of North Carolina, treatment should include rest (obviously), stretching, and strengthening. And proprioceptive exercises to restore proper tendon function.⁷

From what we know about peroneal tendon function, it follows that any strengthening program should focus on eversion of the foot against resistance, probably using an elastic band.

A similar strengthening program is proposed forTendonitis of the posterior tibiavon Alvarez u.⁸

The customized program includes doing200 repetitions of the eversion exercise daily.Start with a very weak resistance band and take breaks if you must.

Over time, you should make progress to be able to do all 200 reps in a row and use a stronger resistance band.

When stretching, it's best to focus on thatStretch your calf muscles.This is because tense calves could lead to faster load transfer to the metatarsus when running, which would increase the stress on the peroneal tendons.

you can dostraight kneeAndbent kneeWade reaches outthree sets of 30 seconds each, three times a day.

One-leg balance exercises are the best wayto improve proprioception and restore proper peroneal tendon function.

As with other single leg balance programs for running injuries, you can start with simple one leg balance and then add more complex movements. For example, reach forward, left and right with your upper body. Or work on a wobble board or foam balance mat.

These balance exercises should be done in a structured and gradual manner to improve proprioception.

In the beginning, work on improving your one-leg balance until you cantwo and a half minutes of one-legged balancingconstant.

After that, you can increase the difficulty by closing your eyes, doing directed body leans, or using a wobble board.

What other possible treatment options are there?

It's possible that you have some unique biomechanical issues that are contributing to your case of peroneal tendonitis. Or you may need a different set of exercises to get back on track.

If this is one of several injuries, your running form may be to blame.

Our running form course analyzes this for youto make sure injuries become a rare occurrence rather than being healthy is rare. One of the main reasons runners get injured is because they go too far. Be sure to read oursCrossing, cadence and heel strikepost for more on that.

Both Heckman et al. and Selmani, Gjata and Gjika proposeget individual orthosesto relieve the peroneal tendons.^{7, 10}

Unlike many other injuries, ittutApparently, there should be a difference between custom orthotics and standard over-the-counter orthotics like SuperFeet or PowerStep.

Typically, the goal of an orthotic is to provide arch support, thereby transferring the load to the outside of the foot.

This can be very helpful in the event of injuries such asPlantarfasziitisorShin Splints. But in the case of peroneal tendinitis, this could be onebadThing. Keep in mind that over eighty percent of people who get peroneal tendinitis have high arches.

Building even more arch support and shifting the load to the outside of the foot (where the peroneal tendons reside) could actually be causing the problemworse!

Custom orthotics can change this equationby keeping the arch height of the insert lower and adding a "wedge" under the outside of your heel. This can take pressure off the outside of your midfoot.

If your case of peroneal tendinitis does not respond to rest and physical therapy exercise, a custom-made orthosis might be worth trying.

If conservative treatments fail, you should see an orthopedist and have an MRI done to check for a tendon tear.

Especially when a peroneal tendon injury coincides with an ankle sprain, there's a chance that what feels like tendonitis is actually a tendon rupture that needs surgical repair.

Fortunately, MRI appears to be an effective method to determine the extent of peroneal tendon damage.⁷If you tear a tendon or if there is very severe tendon damage, you may need surgery to fix it.

Outline of Treatment

conservative treatments

These are methods that are fairly easy and inexpensive and can be done even at home.

• Wadendehnung

• Everversion exercise with a resistance band

• balance exercise

Aggressive treatments

These are treatments with higher costs and less certainty of results, but they can prove useful in recalcitrant cases.

• A... seepodiatrist or orthopaedistand ask for a customized orthosis. In the case of peroneal tendinitis, standard over-the-counter orthoses are unlikely to be of much help due to the biomechanics of the injury.

• Consider dry needling. Some runners find it works very well for peroneal tendon problems. If you're desperate, it might be worth trying.

• See a physical therapist familiar with running injuries to make sure you don't have weakness, tightness, or gait abnormalities that are causing your tendon problems.

• If conservative treatments are still not working after several weeks or months, see an orthopedic surgeon you trust so you can get an MRI to check for a tendon rupture or severe tendon damage and to discuss the possibility of surgery.

When can I return to running?

Avoiding walking on the tendon while it's injured seems like the right idea.

A 1994 case study describes a 49-year-old runner who suffered an acute peroneus longus tendon tear in the middle of a 10-mile road race after running for several months with chronic tendon pain. This runner recovered and returned to training. But only after an operation and a year of rehab!¹¹

As with any injury, your return to running should be gradual and patient.

Research on Achilles tendon and patellar tendinitis suggests that mild pain upon restarting running is not a cause for concern as long as the pain does not progressively worsen.¹²

This “pain monitoring” approach (theBrad Beer spoke about it in a recent podcast interview) has not been tested on injuries to the minor tendons of the feet. However, when in doubt, use caution and wait for your tendon to heal before returning to full training.

The good news is that peroneal tendons are not known to be particularly resistant to healingPosterior Tibiasehneor the plantar fascia. With a little patience and the right rehab program, you should be able to get back into training soon.

And please do us a small favor and share this guide with others because there's a good chance it's the guide they're looking for with this frustrating injury!