We dive into all things Peroneal Tendon pain which is found on the outside of the ankle. Brodie has sifted through the available literature to bring you a comprehensive analysis and best current advice. First, Brodie dives into the anatomy and potential causes for this particular injury. Once the aetiology is understood, we dive deeper into the other potential diagnosis, treatment options and strength training progressions. Whether you have this injury or not, understanding its components is handy to understanding other injuries and reducing injury risk. Become a patron! Receive Run Smarter Emails Book a FREE Injury chat with Brodie Run Smarter App IOS or Android Podcast Facebook group Run Smarter Course with code 'PODCAST' for 3-day free trial.
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on today's episode, Peroneal Tendinopathy, Management and Prevention. Welcome to the Run Smarter podcast, the podcast helping you overcome your current and future running injuries by educating and transforming you into a healthier, stronger, smarter runner. If you're like me, running is life, but more often than not, injuries disrupt this lifestyle. And once you are injured, you're looking for answers. and met with bad advice and conflicting messages circulating the running community. The world shouldn't be like this. You deserve to run injury free and have access to the right information. That's why I've made it my mission, to bring clarity and control to every runner. My name is Brodie Sharp, I am a physiotherapist, a former chronic injury sufferer and your podcast host. I am excited that you have found this podcast and by default, become the Run Smarter Scholar. So let's work together to overcome your injury, restore your confidence, and start spreading the right information back into your running community. So let's begin today's lesson. I have accelerated the release of this episode because in the last maybe two weeks, or at the time of recording anyway, two people have reached out to me to say, Brody, do you have any episodes on peroneal tendinopathy or peroneal tendon pain? And I have had nowhere for them to go to. I've given them the Tidpost episode, which is kind of similar, but I feel bad. Like I've got almost 160 episodes now. And the Yeah, I just don't have that condition to point people in that direction. So, um, the last day or so I've put together, uh, what evidence is available, compiled it into this episode. And there's not a lot of evidence, maybe just, especially for runners, but, um, maybe just cause it isn't that common, but needs to be done. If I've done all the other running related injuries, um, I will, I do have, um, on my to-do list, meniscus. Um, knee injuries as well, because that's something that I also get a lot of people requesting. Even though it's not a running related injury, there are people with a lot of knee meniscal injuries that are also runners and wanting to know what to do about it. And so I'm working on it. I'm trying to find a guest and that episode will come out shortly when I can put together something. So what I've tried to do for this episode is see what the available evidence is like. and then kind of just all compile it together and put it into this document and then let you know, because I haven't had much experience with, um, managing peroneal tendinopathy. I haven't had it myself and only a very select few runners come in with peroneal tendon issues. It's not like, you know, a hamstring or a knee or an Achilles where they're very, very common. But, uh, let's start with the anatomy. So if you're not familiar, first of all, I'm not going to go into too much detail with the anatomy because one. Either you're a health professional listening to this and you know the anatomy anyway, or, and two, if you're a runner or like a running coach, you're not familiar with the anatomy. Um, if I talk too much in detail about like the tubercles or like where it moves and use all this like really highly, um, scientific landmarks, this is going to go straight over your head anyway. But what you need to know is there's kind of two muscles and two tendons that we need to worry about the peroneus longus and the peroneus brevis. So the brevis being a little bit brief, so it's quite shorter, the longest, the longest, obviously being the longest. And it's on the foot. If you can imagine the outside of your ankle, we can almost trace it. So if you can see the outside of your ankle, you'll see there's that bone sticking out. Both of those tendons pass behind that bony landmark. And so the brevis, I've kind of got, what have I got here with our in? written things down. There's the Brevis that goes and attaches onto the base of the 5th metatarsal, so almost on the outside of the foot where your little toe is on that side, it's almost halfway between your little toe and your heel. You might see there's a little bony prominence there. That's where the Brevis attaches, but the peroneus longus does something a little bit different. It passes behind that bony ridge, like we said at the start, that's on the outside of your ankle bone, and it goes underneath your foot. And so it takes a few twists and turns, goes on the planter side of your foot, underneath your foot, and attaches almost, it almost attaches on the other side of your foot. So on your big toe side, it's what we call the fifth metatarsal base. And so it's almost inserting itself behind the big toe. And when it comes to its function and that sort of thing, it becomes quite important. And so, good to know and good to know where those two little bits kind of match up. So hopefully that made sense. So the function of both of these, so the, I guess the pronial muscles in combination with each other, they in function wise, they do a few things. So they, I found a study that said that it provides 63% of the total eversion power. And so most people will know if they've sprained their ankles, they'll know the difference between inversion and eversion. But if you roll your ankle and roll your ankle inwards, that's inversion. But if you have your foot swinging in free air and you try and rotate it outwards in that opposite direction, that's what we call eversion. And so when you ever your foot, the peroneal tendons and the peroneal muscles are contributing 63% of that power and that strength. So key to know for treatment when we move further into this episode. The longus acts to plant effect, plantaflex the first ray, the big toe and evert the foot. So because it inserts behind that big toe, if you were to almost curl your big toe or what we call plantar flex your big toe. This has a bit of a contributing factor with that. Also, the tendon acts as a secondary plantar flexer of the ankle. So plantar flex are being safe, you'll do a calf raise because of where they're attached. Obviously when you do a calf raise, your calf, achilles, all these big muscles, they're gonna take on the primary role of doing that calf raise. But these muscles, they assist a little bit in that movement. And they also help with stabilizing the medial column in stance. So acting as a stabilizer in mid stance. Those sorts of things we'll review in a second, but it's good to know. Um, yeah, for this part of the episode. Diagnosis wise, um, I found a couple of studies. There was one done back in 2003 and they say that when it comes to a diagnosis, physical signs such as tenderness on palpation of the fibula groove. So we're kind of feeling. around that big bony ridge that kind of sticks out of the ankle on the outside. We're sort of feeling behind that where those tendons are following up, following down and seeing if there's any tenderness there. There's edema or swelling along the tendon sheath, which if you just follow the tendons through that groove, there might be some swelling there. And there may also be some, what we call sublake subluxation present. And if there is a subluxation present, then it can be. an accurate indicator of this diagnosis. And another thing I'll probably should say about the anatomy is you're probably thinking, if these tendons run behind this bony ridge and they kind of bend and arc their way around, what's to stop them if we activate those tendons quite forcefully or with a really awkward foot movement? What's to stop those tendons from activating and actually slipping out of that groove and kind of moving over to the other side of that bone? Well, we have this retinaculum which sits or almost anchors those tendons down to the bone so they can't go anywhere. And so anchoring them down assures that they stay behind that bony ridge and when someone talks about a tendon sheath, it's just like an extra layering on top of the tendons that allows the lubrication and less friction if there was an anchor holding them down. They need some sort of lubrication to make sure that there's not a bunch of friction that develops when you activate and move those tendons. So when it comes to subluxation, sometimes that anchor can, um, detach or just not function as well. And, and the tendons themselves can kind of subluxate or move out of that groove and then back in. And if that's present, then you're probably more likely to develop this sort of injury. Still on the diagnosis. I also found a study by Pym van Dyck in 2019 and colleagues. And the title of the study was called Chronic Disorders for the Peroneal Tendons, Current Concepts Review of the Literature 2019. And they said that although a tendinopathy can arise anywhere along the course of that tendon, it is most often found within areas of the greatest stress and angular change. And so, like I said with particularly with the longus, there's a lot of bending and arcing and kind of changes directions a couple of times as it passes under the foot and behind the ankle and they're more susceptible in those areas to developing this sort of tendinopathy or pain. And so they said for the brevis, it's usually around that lateral malleolus, so the outside of that ankle as it passes behind that bone. And also for the longus, within the while the cuboid groove, which is underneath the foot and more where it attaches as well. So diagnosis wise, obviously we're not gonna diagnose anything via a podcast. If you are suspecting something like this, best to get a health professional to check it out and assess it. Moving on, so the causes, like how this could happen in the first place, I can fall back on a couple of resources that I did find. So that Van Dyke paper said that recurrent ankle sprains. So if you currently sprain that ankle or just generic overuse may exacerbate these loads, the loads of the tendon, predisposing the tendons to a tendinopathy and potentially tearing. Um, and that these, there's several anatomical, um, abnormalities that may be present in these tendons. Um, which I didn't really want to go into too much detail with. this but I did find in the research there was a couple of what we call anatomical variations so in a certain amount of the population like 6 to 10 percent there may be an extra muscle, there may be an accessory muscle that leads to more overloading in this particular area but I thought I'd skip it for now. But they do say that the tendons do develop, are more likely to develop this pathology if it includes. hind foot malalignment, so like your heel in relation to the rest of your um calf and the rest of your leg if there's a malalignment there that might put extra strain on these tendons, accessory muscles like I explained with the anatomical variants, uh and also a low lying muscle belly. So higher up in the leg there's the peroneal muscles and as they come down closer to the ankle they turn into a tendon and sometimes that muscle is present further down and it becomes tendon later on in its course as it goes further down towards the ankle. So a low lying muscle belly may predispose people to these sort of causes. Also, I looked on physiopedia, which is just a website blog and they had an article on peroneal tendinopathy and they said when it comes to the causes of this particular pathology, that chronic lateral ankle instability, so if you're constantly rolling your ankle, and also excessive subtalar rotation. So again, talking about like if there's more mobility within the heel part of your ankle joint and more rotation there that may cause damage to the peroneal tendons and be, and all their associated structures that surround there. And they mentioned that some factors that may contribute to the development of this tendinopathy are tight calf muscle, inappropriate footwear or inappropriate training. So this is where we go back to our basics, our universal principles. It talks about training errors and making sure that if you change your footwear or you have a drastic, if your changing footwear is too abrupt, that might lead to like tendons being overused if they haven't been used that way in a long period of time. They did mention poor foot biomechanics in here and also muscle weakness. They didn't say which muscle weakness, but if I would suspect if the calf, Achilles and those major ankle stabilizing muscles, if they're not operating appropriately, then the peroneal ones who usually act as a secondary, they're usually just supporting roles. If the others aren't functioning too well, then they might have to take on a primary role or more demand than what's required. So that being tight calf muscles, inappropriate training, inappropriate footwear, poor foot biomechanics and also weak muscles is what Physiopedia had as the causes for these particular tendinopathies. I want to add in my two cents because we're talking about abrupt changes. So changes in foot position, particularly for runners, I thought I might include something here. If you have say, I've got a couple of maybe rare scenarios, but they do happen. If you're running and like your sock bunches up or you've got like a stone or a pebble or something inside your shoe or if you've got a pebble on the outside of your shoe and you're wearing quite minimalist shoes and it's disrupting your pattern. A lot of people change their step for a while. They might say, oh, it's a bit annoying. Let's see if I can move that around or maybe they're in a race and they just put up with it without addressing it immediately. that gets to a certain point, you're changing your foot position. You'll, you're maybe putting more pressure on the outside of your foot or more pressure on the inside of your foot, just to, um, make it more comfortable for you in that moment. That is a classic sign of a very abrupt change in the demands for the tendon and the foot to stabilize. And that could be a sure fire way, not only for peroneal tendinopathy, but for other stuff, um, it's just changing the demands. really quickly because we know that running has such a high demand every single step that you take on the foot that if you have like a rolled up sock or something's in there and you decide to change how you contact the ground it's going to be a huge change. But trails also if you're not used to trails and the stabilizers of the foot have to work harder so if there's a training error with the shift to dealing with trails then that could be a cause as well. This episode is sponsored by the Run Smarter app. This includes all my free and paid content, along with housing the patron exclusive podcast episodes. You can download this free app by searching Run Smarter app in your app directory and start scrolling through past podcast episodes, blogs and videos. You'll find categories like injury prevention, running misconceptions, strengthen performance, and of course, injury specific information. You've already learned a lot listening to the podcast. Why not kick it up one more gear? through the Run Smarter app. Okay, moving on from causes, so I'll do a bit of a recap at the end to summarize, but the next category I thought I'd put in a differential diagnosis, and because people are going to listen to this and say, oh my god, this is me, I have this condition, it's very, very common for that to happen, or I have had this in the past, but there are a couple of things here that I wanted to highlight. One being just a generic. lateral ligament injury like your lat your very common ankle sprain it could just be an ankle sprain it could just be damaged to the ligaments on the outside of the ankle which is the most common thing to happen when you roll your ankle on the out on the outside so either these two things could be coexisting you could be you could roll your ankle and damage the ligaments but also damage this tendon that could form a pathology down the track like a tendinopathy. Um, but so they could co-exist together or you could think you have this peroneal tendinopathy when it's just a generic ankle sprain or if you do have an ankle sprain that isn't getting better with treatment, it's just not, um, subsiding, then maybe it could be this peroneal tendon issue. So keep that in mind, um, because we know that the mechanics and we know that the symptoms are very common or very closely related. Sometimes the cause can be chronic ankle instability when it comes to this peroneal tendinopathy. We know that there's tenderness on the outside of the ankle to help diagnose this. And we know that it's very close to, the tenderness is very close to those ligaments if you were to sprain an ankle. So keep that in mind, very closely linked, but treatment would be slightly different. The other differential diagnosis that I found in the literature was this syndrome called os perineum syndrome. And going back to our anatomy, when we're talking about the brevis, how it passes behind that ankle bone and then attaches on the outside of the foot halfway in between the little toe and the heel, where that there's a little bony ridge there. Sometimes it could be extra bone that grows where that tendon attaches. And it's called where the fifth metatarsal head is. And extra bone grows here. I saw in the literature around about 20% of the population have extra bone here. And when people do have extra bone here and it gets a bit grumbly, some people can refer to the feeling of stepping on a pebble when they're walking and they feel like they're stepping on a pebble. That could be, um, this particular syndrome. And, um, if the brevis attaches onto that area and the brevis gets overloaded and pulls on that bone a little bit too much. the bone becomes irritated and you've got this osperinium syndrome. So those two things I thought I'd mention when it comes to differential diagnoses. Hopefully it helps those health professionals out there, but obviously it might help some runners who are looking for answers. Other studies that I found, like I said, there wasn't a lot. And some of the studies that I found were more on the severe side of things. We're talking like, the peroneal tendon tears rather than a tendinopathy. So all the recommendations, they're always talking about surgery as the most common treatment, but it's because the population that they studied were disease very severe things. I looked at, one study looked at, I think about 22 patients with peroneal tendinopathy and only two or three had a grade one tendon issue, and all the rest were two, three, four. So like, um, very significant tears, um, almost complete ruptures in some cases. So yeah, it was very hard for me to be like, well, this isn't going to be the running population, but, um, so it was hard, but I did come across some that I thought I'd illustrate here. One study was called, um, oh, it's this Dombac 2003, which I mentioned above. Um, the title was peroneal tendon tears, a retrospective review. And they said that this is the largest retrospective study, um, reviewing peroneal tendon tears of its kind. And they had 40 patients with a surgically confirmed, um, tear of the peroneus brevis or longus. So they've actually been operated on and saw that there was a tear there. So it was confirmed via that. And they said that, um, 53% of the patients presented, uh, with chronic, uh, sorry, presented with a complaint of pain on the outside of the ankle. 45% had pain with activity and difficulty walking. The majority of the patients had pain on palpation of those tendons. So 75% of those people included in the study had that tenderness and 60% had edema, so swelling or warmth around that area. So very common with the lateral ankle sprain as well. But that's what they presented with. And strangely enough, the pain with eversion inversion, those two movements I was talking about before, was found to be quite a low percentage, only 33% of the people in this study of those 40, only 33% had pain with eversion inversion. They didn't say whether that was with weight bearing or non-weight bearing, but thought I'd add it in anyway. Okay, the good stuff, let's get to a treatment. What can we do for treatment with this tendon? So, um... When I just put one of the studies said if left untreated, the peroneal tendon disorders can lead to persistent lateral ankle pain and substantial functional problems. The Van Dyck paper, they said that non-surgical treatment should always be the first step in the management of peroneal tendinopathy. A short period of rest and immobilization can be helpful in cases of a flexible hind foot. really flexible heel joint, you could call it. If there's more mobility there, then corrective orthotic can be considered, and several weeks of rest, physical therapy, and trying to initiate some form of strengthening of the tendons and the surrounding muscles. And so I thought I would add in my strengthening exercises in here based on the function of the tendon, and Yeah, just made sense in my mind. So with rehab, we're talking about strengthening. Um, now if we remember back to our function of the tendons at the start of the episode, we knew that E version of the foot, these tendons contribute to 63% of the total E version power. And so this could be done with some simple band exercises. So if you were to, um, say sit on the floor, legs out straight, and you were to put a, Thera-band, a resistance band around both of your feet, usually around the base of the little toe. So not too high up on the foot that it's hugging the toes, but not too far down on the foot that it's not really gonna do much. So the base of the toes, and then you get that affected side and you just try and roll the, just the foot or just the ankle outwards. If you try and roll it outwards and then back to the start, roll it outwards again and back to the start, what you're doing is averting the foot. and strengthening up those tendons through eversion. It's only a very small movement. I'll say that because people think that they need to go through a large range and they end up either externally rotating the entire leg or abducting the foot, the whole entire leg away from the body. And so I do wanna illustrate, it's a very small, subtle movement. So make sure we're not doing any trick movements to try and get more range. We also know through the function of the foot that, or the function of these tendons, that it assists in plantar flexion. So that calf raise component. And we also know that the perineus longus acts as the plantar flexor for the big toe. And so I found a really nice exercise here because we want to do that calf raise action, but we also want to, um, force that big toe down into the ground. And so. I looked up on YouTube and found a really nice video where someone put a coin underneath their big toe and they were to come up into a double leg calf raise in standing and they just wanted to squeeze the coin with the pad of the big toe. So we're flexing that big toe as we're coming up into a calf raise and then we're still constantly trying to press down on that coin as we come down into the back to the start of our calf raise. And I found that a really, I thought that'd be really nice, really nice feedback for someone if they had a coin under their toe to really focus on pressing down that pad as it come up and down. If that becomes too easy, we can do it in a single leg and just work the way up our progressions there as we normally would with our calf raises. So maybe on a step, maybe with some weights, holding onto a dumbbell, those sort of things. The other thing technique wise with this particular exercise, is a lot of people, they kind of, when they come up into the top of their calf raise, they kind of even their foot or roll their ankles out. They think that's a more stable, more safe position. But when you come up and down into these calf raises, you want to make completely straight. You want the ankle to be completely straight as you come up and as you come down, that's going to allow for the best activation of these tendons. And then also we know with the function of this tendon that it acts as a stabilizer. of the foot. So we just do various balance exercises, making sure we're challenging. We could be say single leg, trying to balance on one leg, maybe on carpet, maybe with your eyes closed and you just have the intrinsic muscles of the foot being challenged. You could use a wobble board, trying to stay two feet on that wobble board, trying to keep all sides of the board off the floor. Then you can progress to single leg, trying to tap the wobble board back and forth in a really nice controlled fashion. all these different variations. Treat still on the treatment side of things, but away from strengthening appropriate footwear, particularly if it's still in this really sore phase, ankle bracing, like getting an ankle brace or taping, those sort of things. Short term orthotics, which I mentioned above, but thought I mentioned here as well. It can help with the stability of the foot, but also help with activation of the muscles within the foot if we have the foot in a correct position. So some things to add on top of the strengthening exercises, just to bear in mind. Still on this article of Van Dyck, they said that steroid injections are not recommended because they accelerate the degenerative process and potentially lead to a tendon rupture. This is the same with all tendinopathies. We want to avoid injections into the tendon because we know that it reduces or it just components of the tendon degrades the structure and may lead to tendonopathies, tendon ruptures in the future. And similarly with this particular tendon, this paper looked at, well suggested that stem cell treatment and shockwave therapy are probably not recommended. What else? I had a look at a paper, Davda, I think is how you pronounce it, in 2017. The title was... treatment of peroneal tendinosis, which is thickening of the tendon. And they said that having confirmed the diagnosis through ultrasound or MRI, they treated, um, uh, a few patients and they consisted of non, uh, steroidal anti-inflammation medication. So NSAIDs, uh, rest, uh, activity modification and orthoses, which allowed for a lateral forefoot posting. So this allowing for more stability. And they recommended in this study that if they were non-responsive to those things listed above, so activity modification or those use medication. Um, if non-responsive then immobilization in a short leg cast or a controlled ankle movement walker for six weeks may be helpful, the use of corticosteroid injection, um, carries a risk of tendon rupture. They mentioned that in this paper, um, surgical debridement. So surgery. should only be considered when conservative management fails, which sounds right in my mind. When it comes to surgery, this Dombeck study in 2003 said that although non-surgical measures are usually attempted, surgical repair of perineal tears is usually indicated and successful results have been expected with proper patient selection, evaluation and treatment. So if you do have a tendon tear and conservative management, strengthening, all this stuff isn't helping, then surgery might be your answer. And then they mentioned in this study that post-operatively, the foot and ankle are placed in a cast, weight bearing in the cast for a couple of weeks, then the cast comes off, range of movement and strengthening is started, and that can go for four to six weeks. So as we wrap up, I've got one additional note, actually. The last one that I have here is talking about that subluxation, which I kind of mentioned at the start anyway, kind of just set that off the cuff, but realized that I have it written down here, but acute traumatic subluxation of the tendons is uncommon, but acute injuries to the retinaculum. So that anchor that holds it down may be damaged and maybe need to the way that we need to manage this if it is subluxated and the retinaculum is undergone some sort of damage. It can be treated or managed conservatively through immobilization with a non-weight-bearing cast and usually has a success rate of around about 50% with pre-adolescent patients showing higher rates of resolution after conservative management. So if you're a bit younger, sometimes this conservative management is a bit better. Okay, let's recap because I know there was a lot to get through. So the peroneal tendons Two tendons run behind that bone of that ankle and insert onto the outer most and the innermost part of the foot. They assist with eversion of that ankle and assist with that calf raise type of action. Can be diagnosed like get a health professional to assess you but usually tenderness around those tendons and pain with like exercise, pain with walking, those sort of things. Usually brought on by a sudden change in training or a sudden change in footwear or weak muscles. Um, or like I said, like a sock rolled up or a pebble in your shoe or something like that, and then what we do with our treatment, if it's really aggravated, relative rest, try and settle down those symptoms. So, um, a couple of things to settle down that might be relative rest, might be appropriate footwear, might be some medication. but then we get straight into strengthening when it's appropriate. So strengthening would be some banded resistance band exercises, some calf raise, um, with that modification of the coin underneath the toes, then just getting to various balancing exercises, then slowly building up your running tolerance and slowly building you back to pre injury levels. And we do that through that rehab ladder that we've talked about several times in this podcast of just. having your overall goal, having where you're currently at and just trying to slowly bridge the gap step by step. And that might be a walk run program. It might be cross training to slowly build you back up. If there is a tear and it's quite severe and there is no response to conservative management, then surgery might have to be the option. And yeah, I think that's it. So I can now finally point people in the direction when they're asking about peroneal tendinopathy tendons. Um, so yeah, I hope you enjoyed this episode. Um, when it comes to say prevention, it comes along with the same type of things when, um, when it comes to treatment and the causes, usually tre- uh, prevention is just about avoiding what causes it in the first place. So making sure you have really strong calves, make sure you have a really strong kinetic chain and lower chain and then just make sure that you wear appropriate footwear. There's no abrupt shift in footwear and making sure that if there is a pebble in your shoe or if you do change your footwear or change your foot strike abruptly, make sure that's dealt with very quickly because if you continue to run like that, not only it might develop a peroneal tendon. but it most definitely will cause other issues as well. So be very, very careful and yeah, hopefully you learned a lot. And do I have my next episode planned? It's currently the 9th of July. And so this is gonna be like maybe three weeks away before this gets released. I don't have anything else scheduled. So I can't give you a little teaser there, but I can give you a teaser that it's in the works for me to do a new meniscal episode. So hopefully you enjoy. Uh, look forward to bring you that episode and we'll catch you next time. And that concludes another run smarter lesson. I hope you walk away from this episode feeling empowered and proud to be a run smarter scholar, because when I think of runners like you who are listening, I think of runners who recognize the power of knowledge, who don't just learn, but implement these lessons who are done with repeating the same injury cycle over and over again. who want to take an educated active role in their rehab, who are looking for evidence-based long-term solutions and will not accept problematic quick fixes. And last but not least, who serve a cause bigger than themselves and pass on the right information to other runners who need it. I look forward to bringing you another episode and helping you on your Run Smarter path.