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Peroneal Tendon Tendinopathy: Causes & Treatment
Peroneal tendon tendinopathy is a painful condition affecting the tendons on the outer side of the lower leg and foot, causing pain and swelling around the lateral ankle.
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Peroneal tendon tendinopathy is a painful condition affecting the tendons on the outer side of the lower leg and foot, causing pain and swelling around the lateral ankle.
What is Peroneal Tendon Tendinopathy?
Peroneal tendon tendinopathy refers to a painful and degenerative condition of the peroneal tendons, which are the tendons of the peroneal muscles (peroneus longus and peroneus brevis). These tendons run along the outer side of the lower leg, behind the lateral malleolus (outer ankle bone), and along the foot. They play a key role in stabilizing the ankle joint and in moving the foot outward (eversion). In tendinopathy, the tendon tissue undergoes degenerative changes, micro-tears, or inflammatory reactions.
Causes
Peroneal tendon tendinopathy is most commonly caused by overuse or repetitive stress. The most frequent causes include:
- Sports overuse: Particularly common in runners, cyclists, soccer players, and basketball players.
- Acute injuries: Rolling the ankle (ankle sprain or supination trauma) can damage the peroneal tendons.
- Biomechanical factors: High foot arch (pes cavus), ankle or foot malalignment increase tendon stress.
- Inappropriate footwear: Worn-out or poorly fitting shoes can lead to abnormal loading.
- Sudden changes in training: Rapid increases in training intensity, duration, or frequency without adequate adaptation time.
- Anatomical variants: An accessory muscle (peroneus quartus) or a prominent bony process on the fibula can irritate the tendons.
Symptoms
The typical symptoms of peroneal tendon tendinopathy include:
- Pain along the outer side of the lower leg, behind or below the lateral ankle bone
- Swelling around the outer ankle and along the tendons
- Tenderness when pressing along the course of the tendons
- Pain with activity, especially when running, climbing stairs, or walking on uneven surfaces
- Weakness when turning the foot outward (eversion)
- Snapping or creaking (crepitation) when moving the tendons
- In advanced cases, a possible tendon tear (partial or complete rupture)
Diagnosis
Diagnosis is typically established through a combination of clinical examination and imaging studies:
- Clinical examination: The physician palpates the tendons, evaluates ankle mobility, and performs specific provocation tests.
- Ultrasound (sonography): Allows assessment of tendon thickening, tears, and fluid accumulation within the tendon sheath.
- Magnetic resonance imaging (MRI): Provides detailed images of the tendon structure and helps determine the extent of damage and identify tears.
- X-ray: Used to rule out bony injuries or calcifications.
Treatment
Conservative Treatment
In most patients, conservative treatment is successful:
- Rest and offloading: Reduction or temporary cessation of aggravating activities.
- Physiotherapy: Targeted exercises to strengthen the peroneal muscles, improve flexibility, and enhance proprioception (balance and joint awareness).
- Eccentric training: Specific exercises shown to promote tendon healing and recovery.
- Orthoses and insoles: Ankle braces or orthopedic insoles to correct biomechanical imbalances and provide support.
- Ice therapy: Application of ice packs to reduce swelling and pain in the acute phase.
- Medications: Non-steroidal anti-inflammatory drugs (NSAIDs) may be used short-term to manage pain and inflammation.
- Shockwave therapy: An additional treatment option for chronic cases.
Surgical Treatment
If conservative measures fail after several months, or if a complete tendon tear is present, surgery may be necessary. Surgical options include debridement (removal of damaged tissue), repair of tears, or tendon reconstruction.
Prognosis and Prevention
With consistent treatment and adequate rehabilitation, the prognosis for peroneal tendon tendinopathy is generally good. Prevention includes a gradual increase in training load, appropriate footwear, regular strengthening exercises for the foot and calf muscles, and avoiding excessive strain or sudden spikes in activity.
References
- Philbin TM, Landis GS, Smith B. Peroneal tendon injuries. Journal of the American Academy of Orthopaedic Surgeons, 2009;17(5):306-317.
- Squires N, Myerson MS, Gamba C. Surgical treatment of peroneal tendon tears. Foot and Ankle Clinics, 2007;12(4):675-695.
- Raikin SM, Elias I, Nazarian LN. Intrasheath subluxation of the peroneal tendons. Journal of Bone and Joint Surgery, 2008;90(5):992-999.
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