Tips to avoid developing peroneal tendinopathy

Over 40 and participating in high-intensity activities? Tips to avoid developing peroneal tendinopathy.

Peroneal tendinitis (or peroneal tendinopathy) is a condition that causes pain around the outer side of the ankle and foot. There are two main tendons on the outside of your ankle – the peroneus longus and peroneus brevis. The role of these tendons is to stabilise the ankle, stabilise the arch of the foot when walking and to turn the foot outwards. They can become painful when structural changes occur in response to increased load and overuse of the tendons, without ensuring sufficient recovery time between activities. Around the ankle and foot, tendons are often protected by layers of connective tissue known as tendon sheaths. If symptoms are left to progress, inflammation of this tendon sheath worsens, and this causes greater ankle pain, and dysfunction. 

Typical symptoms of peroneal tendinitis include:

• Pain
• Swelling
• Pain on turning the foot outwards (eversion) or stretching the foot inwards (inversion)
• Pain that worsens with activity and improves with rest
• Pain when calf raising (ie rising up onto your toes)

There are a number of risk factors that can predispose someone to developing symptoms.
Peroneal tendinitis is most common in running athletes, particularly endurance runners, as well as dancers and jumping athletes. Risk factors also include:

• Over the age of 40 years.
• Overweight.
• Smoking.
• Tight and/or weak calf muscles.
• Poor control of training load ie “too much too soon”- especially after a period of extended rest.
• Poor foot mechanics.
• Inappropriate footwear.
• Other factors include having had previous foot or ankle surgery or a previous history of cortisone injections to the lateral ankle. Some medical conditions also increase the likelihood of developing peroneal tendinitis, these include rheumatoid arthritis, psoriasis, hyperparathyroidism, diabetic neuropathy and ankle fractures.

If you have some of these risk factors or are involved in activities such as endurance running, dancing or jumping sports, how can you prevent developing symptoms? 

1. Gradual progression of training load and physical activity. For example, we often go through periods where we don’t do as much exercise and then we feel motivated and race from the couch to running longer distances very quickly. Our muscles can cope with this relatively well, however tendons tend to take longer to adapt and this can lead to problems. A good guide is not to increase your overall training load by more than 10% per week. This can seem slow at first, but it goes a long way to prevent overload of the tendon. 
2. Another helpful strategy is implementing regular rest periods between your activity. For example, initially you may only exercise every second day, to allow the tendon to heal and adapt to the activity.
3. Maintaining a healthy bodyweight will help take pressure and load off the tendon.
4. Ensure you are wearing supportive footwear or consider the use of orthotics, especially for those with high arches in their feet. 
5. Quit smoking. Smoking affects our vascular system, which plays a role in helping repair our tissues. Smoking also promotes inflammatory processes in our body. 

If you are suffering from peroneal tendinitis symptoms, there are some simple treatment options you can commence straight away. These include: 

• Apply ice over the painful region
• Rest from aggravating activities
• Anti-inflammatory medication may be beneficial (it is important you discuss this with your doctor, to determine if these would be suitable for you). 

Call us for help on peroneal tendinitis
If symptoms continue or you are unsure if you have peroneal tendinitis, book a time to see one of our podiatrists or physiotherapists, who can perform a comprehensive assessment and work with you to develop the best treatment plan for you.  

Author: 
Adam Shaw
Musculoskeletal Physiotherapist
Physiologic (Allsports Robina)

References
Bagley, C., & Parker, L. (2023). Diagnosis and treatment of peroneal tendon disorders. Orthopaedics and Trauma. 
Folmar, E., & Gans, M. (2020). Conservative Treatment of Peroneal Tendon Injuries: Rehabilitation. The Peroneal Tendons: A Clinical Guide to Evaluation and Management, 143-171. 
van Dijk, P. A., Kerkhoffs, G. M., Chiodo, C., & DiGiovanni, C. W. (2019). Chronic disorders of the peroneal tendons: current concepts review of the literature. JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 27(16), 590-598.