There are two peroneal tendons that run on the outside of the ankle, along the back of the fibula - the peroneus brevis and peroneus longus. Tendons connect muscle to bone and allow them to exert force across the joints. The peroneus brevis has a shorter muscle and starts lower in the leg and runs around the back of the fibula on the outside of the leg and connects to the fifth metatarsal (pinky toe). The peroneus longus on the other hand has a longer course; it starts higher on the leg and runs underneath the foot to connect to the first metatarsal (big toe) on the inside of the foot. These peroneal tendons help to control the position of the foot during walking and are also responsible for turning the ankle to the outside.
Peroneal tendinitis is the inflammation of the peroneal tendons and usually occurs because these tendons are subject to overuse and excessive repetitive forces during standing and walking. This is a natural response the body has to injury and often causes pain, swelling, or irritation. Peroneal tendinitis most commonly occurs in athletes and individuals with high-arched feet or feet with a misaligned heel that is inclined or tilted inwards. Also, individuals who have recently tried a new exercise or have significantly increased their level of activity in a short period of time are prone to developing peroneal tendinitis.
Most individuals who have developed peroneal tendinitis experience the following symptoms:
- Mild or severe pain on the outside of the ankle, below the lateral malleolus (bony bit) that worsens with activity
- Swelling on the outside of the ankle, below the lateral malleolus
- Pain when pressing in on the peroneal tendons on the outside of the ankle
- "Startup pain" or pain first thing in the morning around the ankle
- Inability to walk without limping
If there is persistent pain below the ankle or a "pop or snap" around the heel, consulting a physician immediately is highly recommended as an Achilles tendon rupture could be a likely cause.
The diagnosis of a peroneal tendinitis is generally made on physical examination and the patient history. The physician will examine the foot and ankle by gently pressing on the affected area to look for the symptoms mentioned above in addition to evaluating flexibility, range or motion, alignment, and reflexes. X-rays are typically normal, therefore, the physician may order an ultrasound or MRI scan to assess your condition and determine the proper course of treatment.
Peroneal tendinitis responds extremely well to non-operative measures and this approach will provide pain relief and minimizing symptoms which can take several weeks. However, in extreme cases if signs and symptoms are severe and persistent and more conservative treatments don't work or there is a significant tear in the peroneal tendons, the physician may recommend an operative treatment option as a last resort.
Rest - It is advised to decrease or completely stop the activity that makes the pain worse. As peroneal tendinitis is an overuse injury, continuing to train is not going to allow the inflammation to go and the injury to heal. A great way to stay active while allowing the symptoms to subside is to switch to low-impact, cross-training activities such as biking or swimming.
Ice - Placing ice on the most painful areas of the peroneal tendons throughout the day for up to 20 minutes every hour until symptoms reduce.
Medication - Over-the-counter medication such as ibuprofen and naproxen usually help reduce pain and swelling. If these are deemed insufficient by your physician, they might prescribe stronger medication (NSAID's) to relive pain and reduce inflammation.
Physical Therapy - Physical Therapists will often prescribe specific strengthening and stretching exercises that promote healing and strengthening of the peroneal tendons. They might even recommend orthotic devices with a recessed area under the first metatarsal to relieve pressure and strain on the tendons. If your pain is severe, your physician or therapist may recommend ankle bracing to decrease the inversion movement.
Surgery - Surgery should only be considered if there is evidence of significant tearing of the peroneal tendons or a bony prominence (such as a bone spur) that is physically irritating the tendons. The specific type of surgery depends on the severity of the damage and should be discussed with the physician when the need is identified.
Patients with peroneal tendinitis usually recover fully, but this can take quite some time. Patience is extremely important since an overuse injury require time and a period of rest. Proper healing of the peroneal tendons is extremely important before an individual goes back to activity. Each patient is unique, so the therapy program will vary based on his/her level of pain, extent of injury, and desired level of activity.
CALL 911 IMMEDIATELY IF YOU ARE HAVING A MEDICAL EMERGENCY!
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