Understanding Peroneal Tendinopathy: Causes, Symptoms & Physiotherapy Solutions post thumbnail image

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What is Peroneal Tendinopathy ?

Peroneal tendinopathy, often referred to as peroneal tendonitis (though tendinopathy is a more accurate term for the chronic degenerative changes that often occur), is a common condition characterized by pain and dysfunction of the peroneal tendons, which run along the outside of the ankle and foot.

Causes of Peroneal Tendinopathy

The primary cause of peroneal tendinopathy is overuse or repetitive stress on the peroneal tendons. When these tendons are subjected to loads beyond their capacity to adapt and heal, microscopic tears can occur, leading to pain and degeneration.

This can be due to:-

  • Sudden Increase in Activity: Rapidly increasing the duration, intensity, or frequency of weight-bearing activities (e.g., running, walking, jumping) without adequate preparation.
  • Inadequate or Unsupportive Footwear: Shoes that lack proper support or are worn out can alter foot mechanics and place excessive stress on the peroneal tendons.
  • Poor Biomechanics:
    • High Arches (Pes Cavus): Individuals with high arches may have a hindfoot varus (heel turned inward), which forces the peroneal tendons to work harder to evert (turn outward) the foot and stabilize the ankle.
    • Muscle Imbalances or Weakness: Weakness in the peroneal muscles themselves, or imbalances with other ankle muscles, can lead to increased strain on the tendons.
    • Tight Calf Muscles: Limited ankle dorsiflexion (bending the foot upwards) due to tight calf muscles can alter gait and increase stress on the peroneal tendons.
  • Chronic Ankle Instability: Repeated ankle sprains or a history of ankle instability can cause the peroneal tendons to overwork in an attempt to provide stability.
  • Repetitive Motions: Sports and activities that involve frequent ankle eversion and plantarflexion, or rapid changes in direction (e.g., running on uneven surfaces, basketball, soccer, dancing).
  • Training Errors: Poor technique, insufficient warm-up, or inadequate recovery between activities.
  • Anatomical Variations: In some cases, variations in the bone structure around the ankle (e.g., a shallow groove behind the lateral malleolus where the tendons run) can lead to increased friction and irritation.
  • Age: As people age, blood flow to tendons can decrease, making them more susceptible to injury.
  • Other Medical Conditions: Diabetes, inflammatory conditions (e.g., rheumatoid arthritis), and certain medications (e.g., fluoroquinolone antibiotics, oral corticosteroids) can increase the risk of tendinopathy.
Symptoms of Peroneal Tendinopathy

The symptoms of peroneal tendinopathy typically develop gradually and worsen with activity.

Common symptoms include:-

  • Pain on the Outside of the Ankle and Foot: This is the hallmark symptom, often located behind or just below the bony bump on the outside of the ankle (lateral malleolus), and can extend along the outside border of the foot.
  • Pain with Activity: Pain often increases during or after weight-bearing activities like walking, running, jumping, or activities that involve turning the foot inward or outward.
  • “Start-up Pain”: Pain that is worse after periods of rest, especially first thing in the morning or after sitting for a while, and may improve slightly with movement before worsening again with continued activity.
  • Swelling: Localized swelling around the outside of the ankle is common, especially in the early inflammatory stages or with acute exacerbations.
  • Tenderness to Touch: The affected tendons are typically tender when pressed, particularly behind the lateral malleolus.
  • Weakness or Instability: A feeling of weakness or instability in the ankle, especially on uneven surfaces.
  • Clicking or Popping Sensation: In some cases, if there is associated tendon subluxation (the tendon slipping out of its groove), a clicking or popping sensation may be felt.
  • Warmth: The affected area may feel warm to the touch.
Advanced Physiotherapy for Peroneal Tendinopathy
  • Acute Phase (Pain and Inflammation Management):
    • Rest and Activity Modification: Reducing or temporarily stopping activities that aggravate the pain.
    • Ice Therapy: Applying ice packs to the affected area to reduce pain and swelling.
    • Pain-relieving Modalities: TENS, ultrasound, or low-level laser therapy may be used to help manage pain and promote healing (though evidence for modalities is often limited for tendinopathy).
    • Immobilization: In severe cases, a walking boot or ankle brace may be used for a short period (10-20 days) to offload the tendons and allow initial healing.
    • Gentle Range of Motion (ROM) Exercises: Non-weight-bearing exercises to maintain ankle mobility without stressing the tendons.
    • Gait Analysis and Correction: Addressing compensatory walking patterns that may be placing undue stress on the peroneal tendons.
  • Sub-Acute/Rehabilitation Phase (Strength and Loading):
    • Progressive Loading Exercises: This is the cornerstone of tendinopathy rehabilitation. The exercises gradually increase the stress on the tendons to stimulate healing and strengthen them.
      • Isometric Exercises: Holding the ankle in an everted position against resistance (e.g., pressing against a wall or using a resistance band) without movement. This helps reduce pain and activate the muscles.
      • Eccentric Exercises: Focusing on the lengthening phase of the muscle contraction (e.g., slowly lowering the foot from an everted position against resistance). Eccentric training is highly effective for tendinopathies.
      • Concentric Exercises: Strengthening exercises for ankle eversion and plantarflexion using resistance bands, weights, or machines.
      • Calf Raises: Both double and single-leg calf raises, progressing to eccentric variations (e.g., lowering slowly off a step) to strengthen the calf muscles, which indirectly support ankle stability.
    • Proprioception and Balance Training:
      • Single-Leg Stance: Progressing from stable to unstable surfaces (e.g., foam pad, wobble board, balance disc).
      • Balance Exercises with Movement: Incorporating reaching, throwing, or stepping motions while maintaining single-leg balance.
    • Foot and Ankle Strengthening: Addressing weakness in other intrinsic foot muscles and surrounding ankle musculature.
    • Hip and Core Strengthening: Improving proximal stability of the hip and core can significantly influence lower limb biomechanics and reduce compensatory strain on the ankle.
  • Advanced/Return to Activity Phase (Functional Integration):
    • Sport-Specific Drills: Gradually reintroducing movements relevant to the patient’s activities or sport (e.g., cutting, pivoting, jumping, running drills).
    • Plyometrics: Jumping and hopping exercises to improve power and tendon resilience.
    • Agility Training: Drills that involve quick changes of direction.
    • Gradual Return to Sport/Activity Protocol: A carefully planned progression for returning to full activity, with close monitoring of symptoms.
    • Kinesio Taping: May be used for temporary support and pain relief during activity.

Manual Therapy in Peroneal Tendinopathy

Manual therapy techniques can be a valuable adjunct to exercise therapy in managing peroneal tendinopathy, particularly to address soft tissue restrictions, joint mobility deficits, and improve overall tissue health.

  • Soft Tissue Mobilization:
    • Deep Transverse Friction Massage (DTFM): Applied directly to the peroneal tendons at the site of tenderness. This technique aims to stimulate collagen production, improve blood flow, and break down adhesions. It can be uncomfortable but is often effective.
    • Myofascial Release: Gentle, sustained pressure applied to the peroneal muscles (peroneus longus and brevis) and surrounding calf muscles (gastrocnemius, soleus) to release fascial restrictions and improve muscle length and flexibility.
    • Trigger Point Release: Addressing painful knots or trigger points within the peroneal muscles or associated calf muscles that may contribute to referred pain or muscle tightness.
  • Joint Mobilization:
    • Ankle Joint Mobilizations: Techniques to improve the mobility of the talocrural joint (main ankle joint) and subtalar joint (joint below the ankle). Restricted ankle dorsiflexion, for example, can increase stress on the peroneal tendons. Mobilizations can address hypomobility in these joints.
    • Foot Joint Mobilizations: Mobilizing the joints of the midfoot and forefoot (e.g., cuboid, metatarsals) can improve overall foot mechanics and reduce compensatory strain on the peroneal tendons.
  • Stretching
    • Calf Muscle Stretches: Stretching the gastrocnemius and soleus muscles helps improve ankle dorsiflexion, which can reduce strain on the peroneal tendons.
    • Peroneal Muscle Stretches: Gentle stretches for the peroneal muscles, focusing on inverting and dorsiflexing the foot, but initially performed carefully to avoid irritating the tendon.

Manual Therapy

  • Pain Level: Manual therapy should always be performed within the patient’s pain tolerance. Aggressive techniques can exacerbate symptoms.
  • Stage of Injury: More gentle techniques are used in acute painful stages, while more direct or deeper techniques may be introduced as pain subsides and tolerance increases.

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