Peroneal Tendinopathy

What is Peroneal Tendinopathy?

Peroneal tendinopathy is described as inflammation and degeneration of the peroneus longus and brevis tendons located at the lateral ankle and foot. The tendons of peroneus longus and peroneus brevis are responsible for helping stabilize the ankle and assist with eversion and plantarflexion. Peroneal tendinopathy can be caused by overuse of the peroneus muscles, ankle sprains, ankle instability, improper footwear, and sudden increase in activity level.

Types of Peroneal Tendinopathy

There are two types of peroneal tendinopathy injuries: post traumatic and overuse.

Post-traumatic peroneal tendinopathy occurs after direct injury or trauma, such as an inversion ankle sprain, fracture, or subluxation at the lateral ankle. This type of tendinopathy has an acute onset. Overuse peroneal tendinopathy occurs due to an overuse of the peroneal muscles. This condition involves gradual degeneration of the peroneal tendons due to repetitive movements or an increase in activity levels.

It is important to recognize the type of peroneal tendinopathy as it will determine the treatment plan for the injury and diagnostic testing required.

Symptoms of Peroneal Tendinopathy

Pain is the most common symptom of peroneal tendinopathy and is usually located on the outside of the ankle and foot. Individuals with peroneal tendinopathy will often describe their pain as aching or throbbing.

Other common symptoms include:

• Swelling and warmth
• Tenderness
• Pain with activity
• Morning stiffness
• Instability and Poor Imbalance

In some cases, individuals may experience a snapping or clicking sensation with movements of the foot. If a nerve near the peroneal tendors is irritated, one may have decreased sensation or burning on the outside of the foot.

Diagnosis of Peroneal Tendinopathy

Diagnosis of peroneal tendinopathy includes clinical examination, assessment of foot type, and palpation of the peroneal tendons. Imaging techniques such as ultrasound and MRI could be helpful for confirming a diagnoses. Ultrasound imaging has high sensitivity in diagnosing peroneal subluxation, meanwhile MRI is more accurate for identifying tendon tears.

Anatomy of the Peroneal Tendons

Tendons are responsible for connecting muscles to bone. They help transmit forces from the muscle to the bone, allowing for movement control and stability. The peroneal tendons connect the peronus longus muscle and peroneus brevis muscle to bones of the foot.

Peroneus longus and peroneus brevis are stabilizers of the lateral ankle and foot which arise from the muscles in the lateral compartment of the leg, travel behind the lateral malleolus and are held in place by the superior peroneal retinaculum.

Pathways and Insertions

• Peroneus Brevis runs posterior to the lateral malleolus and inserts on the base of the 5th metatarsal. It is primarily repsonsible for ankle eversion and lateral foot stabilization.
• Peroneus Longus runs below peroneus brevis, wraps around the cuboid bone, and inserts on the medial cuneiform and 1st metatarsal base. This muscle acts as a dynamic arch supporter and assists in foot pronation.

Function

• Eversion: Both tendons work to evert the foot (turning outwards). This protects against ankle inversion sprains
• Arch support: The peroneus longus helps maintain the transverse and lateral longitudinal arches
• Dynamic stabilization: Providing ankle stability during movement

Clinical Relevance

• Tendinitis/tears: common in athletes due to overuse or ankle sprains
• Subluxation/dislocation: occurs if the retinaculum is torn, causing tendons to slip out of place

Understanding their anatomy is key for diagnosing and treating lateral ankle injuries effectively.

Causes and Risk Factors of Peroneal Tendinopathy

Peroneal tendinopathy can be caused by repetitive overuse (chronic) or direct trauma (acute). However, there are many risk factors to consider which could play a key role in the development of peroneal tendinopathy.

Understanding the possible causes and risk factors can help prevent or specifically treat peroneal tendinopathy. Risk factors are typically divided into intrinsic and extrinsic. Intrinsic factors are acting within the body, extrinsic factors are acting on the body.

Some intrinsic risk factors related to peroneal tendinopathy include: age, anatomical and biomechanical factors. Anatomical factors such as excessive pronation or high arches can predispose an individual to developing peroneal tendinopathy.

While these risk factors cannot be managed, it is important to recognize extrinsic risk factors to avoid an increase in risk of injury. Factors such as repetitive stress and increases in activity can result in associated tendons to degenerate. It is important to gradually ease into activity and ensure proper use of equipment to prevent injuries from occurring. Peroneal tendinopathy could also occur secondary to another injury or due to post-surgical complications.

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Why is Physiotherapy Critical for Peroneal Tendinopathy Recovery?

At Vaughan Physiotherapy Clinic, our physiotherapists can create a personal treatment plan based on the state of your tendinopathy and activity level to promote your recovery! Physiotherapy is a non-surgical intervention that focuses on using a combination of manual therapy, exercise, taping, and other therapeutic modalities to help a patient recover from peroneal tendinopathy.

Research shows that eccentric training is the most effective treatment. There is enhanced success in recovery when eccentric training is used in combination with stretching, isometrics, and manual therapy. Through a comprehensive physiotherapy plan, we can address scar tissue, strengthen tendons, and correct biomechanics to reduce the risk of re-injury and ensure longterm strength of your peroneal muscles!

Healing Timeline for Peroneal Tendinopathy

While the recovery time varies from patient to patient, an overuse peroneal tendinopathy could typcally take 6-12 weeks to recover with rehab. A post-traumatic peroneal tendinopathy could take about 3-6 months for recovery, depending on the severity of the initial injury.

Physiotherapy Treatment Approaches

Eccentric strengthening is one of the best exercises for peroneal tendinopathy. An exercise such as resisted ankle eversion is effective in reducing pain and increasing function. This will allow to strengthen your peroneal muscles, increasing your overall function!

Try at home: 3 sets and 15 reps of eccentric eversion with resistance bands

Proprioceptive and balance training is effective in improving joint mobility, stability, and muscle strengthening. This can help improve the function and range of motion at the ankle. Some Proprioceptive and balance training exercises include single leg balance drills, or using a wobble board for lateral ankle stability.

Manual Therapy is modality used in physiotherapy that can help with your healing process. Using a lateral calcaneal glide can help with peroneal tendon mobilizaiton and scar tissue release. This will further break down and realigning collagen fibers, allowing tissue flexibility, reduces pain, and improved range of motion!

Bracing and taping is a useful method of support during recovery. Using a low dye taping method will allow support of the peroneals and arch of the foot. This extra support promotes increased function and mobility during recovery.

Preventing Recurrence

Physiotherapy allows for strengthening of the hip and core muscles, which in turn reduces overload at the ankle. Putting less stress on the peroneals by strengthening surrounding muscles can help reduce the risk of re-injury. Physiotherapists may also suggest orthotics for arch support or overpronation to help reduce the risk of re-injury over time.

FAQs

Is surgery needed for chronic peroneal pain?Surgery is rarely required and typically considered only after 6+ months of failed conservative treatment (PT, bracing, injections). It may be needed for:

• Tendon ruptures (if severe or unstable)
• Chronic tears or degeneration
• Structural issues (i.e. bony spurs, unstable tendons)
• Conservative treatments should always be tried first (i.e. eccentric exercises, load management)

Can I run with peroneal tendinopathy?Yes, but cautiously and with modifications:

• Acute phase: Avoid running; focus on pain reduction (ice, NSAIDs).
• Recovery phase: Gradually reintroduce running if pain is ≤3/10, avoiding uneven surfaces.
• Chronic cases: Strengthen peroneals and monitor symptoms.

It is important to note that overuse can worsen tendinopathy or lead to rupture.

"Can peroneal tendinopathy lead to rupture?"

Yes, but it’s uncommon. Chronic degeneration (vs. acute trauma) raises the risk. Signs of rupture include sudden weakness, swelling, or a "snap" sensation.

What is the difference between Post-Traumatic and Overuse tendinopathy?

• Post-traumatic: Sudden injury (e.g., ankle sprain) → acute inflammation.
• Overuse: Repetitive strain (e.g., excessive running) → degenerative tendon changes ("tendinosis").
• Treatment differs: Rest + NSAIDs may help trauma; overuse requires load management + rehab.

Take Control of Your Recovery

Don’t navigate post-surgical rehab alone. Trust Vaughan Physiotherapy Clinic’s 15+ years of expertise in injury recovery.

Start Your Customized Rehab Plan Today!

• Phone: 905-669-1221
• Location: 398 Steeles Ave W #201, Thornhill, ON L4J 6X3
• Online Booking: www.vaughanphysiotherapy.com

Serving Thornhill, Langstaff, Willowdale, North York, Markham, Richmond Hill, and surrounding communities. Same-week assessments available.

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