Peroneal Tendinopathy

The peroneal tendons run along the outside of the lower leg, behind the bone on the outside of the ankle. Overuse or injury to these tendons can lead to pain and inflammation, a condition known as peroneal tendinopathy.

Pain around the outside of the ankle or foot is usually caused by the tendons of the peroneal muscles. These muscles stabilise the ankle during weight-bearing movement, so inflammation can cause pain and instability.

Most people get peroneal tendinopathy from overuse or repetitive stress, and the condition can worsen without rest and physiotherapy to work and strengthen the tendons.

Keeping moving is crucial to recovery after the initial acute pain goes away. Don’t wait too long for treatment and seek physiotherapy to get moving again.

Peroneal tendinopathy symptoms

• Walking with a limp
• Easily going over on your ankle, ankle sprain
• Pain and/or swelling around the outside of the ankle
• Pain on the outside border or instep of the foot
• Poor single-leg balance on the affected side
• A feeling of instability when walking, especially on uneven surfaces

Note: Peroneal tendinopathy is not the same as Achilles tendinopathy, which affects the tendon connecting the calf muscles to the heel bone at the back of the ankle.

Causes of peroneal tendinopathy

Overuse

Overuse can result from prolonged standing, walking, running, and sudden increases in physical activity; think of sprinting for the bus or suddenly stopping your heavy supermarket trolley from rolling away (stretching the tendons in your foot).

Tightness

Tightness of the muscles in the backs of your legs and feet increases the likelihood that your peroneal tendons will become inflamed following heavy activities.

Poor training form

Improper running technique, such as excessive pronation or landing heel-first, and exercises or activities that cause poor ankle stability and control can cause peroneal tendinopathy.

Increasing the duration, intensity, or frequency of activities too quickly without allowing for adequate recovery can also cause problems.

Unsupportive footwear

Flat, rigid shoes with little cushioning or arch support and sandals or flip-flops that provide minimal stability can inflame the peroneal tendons.

High heels that shift weight distribution and alter ankle mechanics can stress multiple areas of the foot and make the tendon very sore.

Jumping and falls from height

Landing heavily on your feet creates a high-impact load transmitted through the tendons. This sudden impact can overload and strain the peroneal tendons, leading to microtrauma and inflammation.

Other contributing factors

• Weight
• Foot biomechanics
• Age
• Poor mobility
• Previous injuries
• Anatomical variants. For instance, an enlarged peroneal tubercle on the calcaneus can interfere with the normal motion of the peroneal tendons.

What to do if you think you have peroneal tendinopathy

Stop the aggravating activity, rest the affected area and use ice.

Wear comfortable, supportive footwear like running shoes or hiking boots during the day and avoid slippers at home so you walk with an arch.

Gentle strengthening exercises for the peroneal muscles, such as two-leg heel raises, single-leg heel raises, and resisted ankle eversion using a resistance band, are recommended.

Pace your activities to avoid overloading the tendons and take it easy – the last thing you want is to overload your feet and make things worse.

Ibuprofen and paracetamol are helpful with ice to manage symptoms, and you can use ibuprofen gels and deep heat for local pain relief. Heat pads can help with pain after 2-3 days because they increase blood flow to promote healing.

When to seek expert advice

Most peroneal tendinopathy cases heal independently with physiotherapy and advice from a qualified podiatrist.

Consider physiotherapy if your pain persists more than 2-3 weeks after the initial injury, despite rest and light activities to keep your blood flowing.

Your GP can refer you to a physiotherapist, or you can independently approach a specialist like ProPhysiotherapy for evaluation and personalised treatment (our Southwest London physiotherapists specialise in managing pain, sports injuries and disability).

Peroneal tendinopathy rarely requires surgery except in cases where there is an irreparable tear or rupture that requires treatment.

Treatment for peroneal tendinopathy

The first step is to modify your activity to reduce pressure on the tendon. Your physiotherapist will educate you on modifying movements and postures that strain the tendon.

A mobility assessment helps to determine your range of motion for exercises that stretch the calf and peroneal tendons, as well as the lower leg and ankle.

Foot mobilisations and manipulations, proprioceptive and balance training and soft tissue massage are useful techniques to improve healing.

Stretching helps improve flexibility and reduces tension in the affected area, and strengthening exercises target the peroneal muscles to improve their stability and load-bearing capacity to prevent future injuries.

Soft tissue massage of the lower and upper legs can help relieve pain and stiffness in the tendons and surrounding structures.

Targeted treatments include:

• Ice packs to reduce local inflammation
• Soft tissue massage to improve blood flow and release tension
• Eccentric loading exercises like the heel drop
• Taping, bracing with strapping to redistribute tendon forces
• Trialling insoles or orthotics to help optimise the foot positioning
• Stretching of the whole foot to address any mobility deficits
• Isometrics and isotonic strengthening to restore normal range of motion

Recovery timeline for peroneal tendinopathy

Peroneal tendinopathy is a persistent injury because tendons, unlike muscle tissue, don’t receive a significant supply of blood.

Most people’s symptoms last at least 12 weeks (3 months), but not everyone improves so quickly. For some, it can take six to nine months.

It generally takes at least 6 weeks to improve, and early activity on the healing tendon can result in a setback, hence the importance of a bespoke physiotherapy program.

Summing up

Peroneal tendinopathy can significantly impact your mobility, physical function, and quality of life for many months if left untreated.

You may feel like your ankle is unstable or constantly rolling or twisting it with a sharp pain followed by a dull ache.

Acute cases of peroneal tendinopathy are very tender with a throbbing sensation, making the pain impossible to ignore even during rest.

The good news is that peroneal tendinopathy is a treatable condition with modifications to activities and professional physiotherapy to strengthen the tendon.

We are always available to help. For more information, get in touch today.