John Davis

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Do You Have Peroneal Tendonitis? Here is How to Fix it

As runners, we accept that there is a certain amount of risk involved with our sport. When we are well into our marathon training schedule, hooked on trail running, or first 5k, we hear about the high injury rates, and know that there is a good chance we will end up as one of the many injured runners.

We expect that maybe we will end up with runner’s knee or achilles tendonitis, but what about if your pain roes not seem to fit into any of the usual categories, and when you search for running injuries, the sore spot and tender area just does not seem to match any of the other runner injuries.

Peroneal tendonitis, also referred to as peroneal tendinopathy, is a rare but aggravating injury that can cause pain in the outside of your foot and up the outside of your lower leg when you run.

This guide will explain how and why often peroneal tendon issues occur, and what you can do to limit the time it takes to heal it if you are suffering from peroneal tendon aching, soreness, or sharp pains when you run (or after).

The pain on the outside of your ankle or foot could be caused by peroneal tendonitis. Here is how to know if you have it, understand what caused it (so it does not happen again), and treat it, so you can get back to running quickly.

What are the Peroneal Tendons?

Although peroneal tendinitis is not as common as the other forms of tendon pain, it does not make it any less frustrating, especially when we cannot pinpoint the exact source of the pain.

Now:

There are actually two peroneal tendons, the peroneus longus and the peroneus brevis, which run parallel to each other, connecting the outside of your foot to the peroneus longus and brevis muscles in your lower leg.

These tendons act in concert to evert your foot (roll it outwards) and also help assist your calf muscles in plantarflexing your foot.  They also assist in stabilizing your ankle during weight-bearing activities like running.

Here’s the deal:

As with all cases of “tendonitis,” the problem is really one of degeneration and damage, not inflammation, so a more proper term would be “peroneal tendinopathy” or “peroneal tendon dysfunction.”

However, since the term tendonitis is still more common, that’s what this article will use.

How Common are Peroneal Tendonitis Injuries in Runners?

Like any tendon, the peroneal tendons—both of them—can get injured from overuse.

Unlike injuries to the Achilles or patellar tendon, which are fairly common and well-understood, peroneal tendon injuries are quite rare.

A study by Taunton et al., which categorized the injuries of over two thousand runners at a sports injury clinic, found only thirteen cases of peroneal tendonitis.1  This means that peroneal tendonitis makes up only about 0.6% of all running injuries. With such a small number of cases, it’s hard to draw too many conclusions, but Taunton et al. did note that nine of the thirteen cases were in men.

It’s hard to say whether peroneal tendonitis really is more common in men than women, or if this is just random statistical noise, but injuries to the Achilles and patellar tendon are more common among men, too, so there may be something to this trend.

The pain on the outside of your ankle or foot could be caused by peroneal tendonitis. Here is how to know if you have it, understand what caused it (so it does not happen again), and treat it, so you can get back to running quickly.

What Does Peroneal Tendonitis Feel like?

Peroneal tendonitis presents as a sharp or aching sensation along the length of the tendons or on the outside of your foot.

It can occur at the insertion point of the tendons, along the outside edge of your fifth metatarsal bone, or further up along the outside of your ankle.

Running will be painful, as will trying to dorsiflex and evert your foot, especially against resistance.  There might be some stiffness and soreness if you do “ankle circles” too, or even when passively stretching the tendon.

There shouldn’t be much pain while standing or when you push gently on the injured area, however—if the outside of your foot is very tender to the touch, and if you have a lot of pain standing or even while non-weightbearing, you may instead have a fracture on your fifth metatarsal. 

These are uncommon, but can cause a lot of trouble if they aren’t addressed right away, so if you’re not sure whether you have peroneal tendonitis, see your doctor as soon as you can.

You might be wondering:

Does it matters which of the two peroneal tendons you’ve injured?  From the relatively meager scientific literature on peroneal tendonitis, it does not seem like this is the case.

In fact, somewhere around 33% of all cases of peroneal tendonitis appear to involve both tendons anyways, so any rehab program will have to address both the peroneus longus and the peroneus brevis.2

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Common Causes of Peroneal Tendonitis in Runners

Since peroneal tendonitis is so rare, there aren’t any large-scale studies on risk factors. The only reports extant in the medical literature analyze a relatively small number of cases.

However, one risk factor does seem to stand out.

A review of twenty-two cases of peroneal tendonitis by Clayton B. Brandes and Ronald W. Smith revealed that over eighty percent of these patients had a high-arched foot—according to the authors, feet with higher arches put more tension on the peroneal tendons, predisposing them to injury.2

This makes sense, because having a low arched foot seems to be a risk factor for posterior tibial tendon injury (the tendon on the inside of the ankle).3  We already went into detail on how your arch height affects your shoe choice and the type of injury you are most at risk for.

Research published in 1993 also suggests that faster running speeds could put extra stress on the peroneal tendons.

Lyle Reber, Jacquelin Perry, and Marilyn Pink at the Centinela Hospital Biomechanics Laboratory in California investigated how muscular activation patterns in the muscles surrounding the ankle changed as a function of running speed in a group of healthy, injury-free distance runners.4

The researchers found that higher running speeds created a significant increase in activity in the peroneus brevis muscle: the intensity of the muscle contraction doubled when comparing an easy jog to race-pace running.

Reber, Perry, and Pink hypothesized that the rapid transfer of forces to the midfoot when running at fast speeds, and the concomitant increase in the necessity of a stable ankle, is responsible for the increased demands on the peroneus brevis.

So it follows that faster runners, and runners who do high-intensity interval workouts, are at a greater risk for peroneal tendonitis.

Might be best to stay away from the traditional forms of speed work if a lot of what we have said so far is ringing true for you.

Interestingly:

Some cases of peroneal tendon injury are precipitated by an ankle sprain. We have already told you how to sprain proof your ankles for trail running , but given the tendons’ location on your foot, it’s easy to see how an inversion sprain could provoke tendon damage.

A 1993 report by Mark Sobel, Mark Geppert, and Russell Warren at the Hospital for Special Surgery in New York connected ankle instability from previous ankle sprains with damage to the peroneal tendons.5  This was confirmed by a 1998 article in Foot & Ankle International by researchers from the Mayo Clinic.6

If you have lingering pain after an ankle sprain, you may have injured one of your peroneal tendons as well—in some cases, even ruptured it.  This can be detected on an MRI.

How Can I Treat my Peroneal Tendonitis Pain?

When it comes to treatments, the rarity of the injury again makes things difficult—there’s no controlled clinical trials that lay out a rehab program to follow.

Nevertheless, we can make some inferences from what we know about the injury, and follow the recommendations of scientists and doctors with clinical experience.

According to Daniel S. Heckman and others at the University of North Carolina, treatment should include rest (obviously), stretching, strengthening, and proprioceptive exercises to restore proper functioning of the tendon.7

From what we know about the function of the peroneal tendons, it follows that any strengthening program should be focused on eversion of the foot against resistance, probably using an elastic band.

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A similar strengthening program is proposed for posterior tibial tendonitis by Alvarez et al., which we can adapt for peroneal tendonitis by focusing on eversion (roll out) of the foot instead of inversion (roll in).8

The adapted program involves doing 200 repeats of the eversion exercise every day, starting with a very weak resistance band, and taking breaks if you need to.

Over time, you should progress towards being able to do all 200 repeats consecutively, and towards using a stronger resistance band.

The pain on the outside of your ankle or foot could be caused by peroneal tendonitis. Here is how to know if you have it, understand what caused it (so it does not happen again), and treat it, so you can get back to running quickly.

For stretching, your best bet is to focus on stretching out your calf muscles, since tight calves could cause a more rapid transfer of stress onto your midfoot during running, which would increase demands on the peroneal tendons.

You can do straight knee and bent knee calf stretches in three sets of thirty seconds each, three times per day.

The pain on the outside of your ankle or foot could be caused by peroneal tendonitis. Here is how to know if you have it, understand what caused it (so it does not happen again), and treat it, so you can get back to running quickly.

Single-leg balance exercises are the best way to improve proprioception and restore proper function to the peroneal tendons.

As with other single-leg balance programs for running injuries, you can start with basic single-leg balancing, then progress to adding more complex motions, like reaching forward, to the left, and to the right with your upper body, or working on a wobble board or foam balance mat.

These balance exercises should be done in a structured, progressive way to improve proprioception.9

The pain on the outside of your ankle or foot could be caused by peroneal tendonitis. Here is how to know if you have it, understand what caused it (so it does not happen again), and treat it, so you can get back to running quickly.

When you’re first starting out, work on improving your single-leg balance until you can do two and a half minutes of single-leg balancing continuously.

After that, you can start increasing the difficulty by closing your eyes, doing directional body leans, or using a wobble board.

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What Other Possible Treatment Options are There?

As with any tendon injury, you may find icing or contrast baths to be helpful with peroneal tendonitis, though there’s no solid research backing either of these options.

If rest and some basic balancing, stretching, and strengthening exercises don’t fix the problem, you should consider seeing a physical therapist. Jeremy Stoker goes into the details of what to look for in a medical professional (and what kind of pains are okay to run through) in this podcast.

It’s possible you have some unique biomechanical problems that are contributing to your case of peroneal tendonitis, or you may require a different set of exercises to get back on track.

If this is one of a number of injuries, your running form may be to blame.

Our running form course will analyze this for you, to make sure injuries become a rare occurrence, rather than it being rare you are healthy. One of the main reasons runners end up with injuries is because they are overstriding. Make sure you read up on our overstriding, cadence, and heel striking post for more on this.

Both Heckman et al. and Selmani, Gjata, and Gjika suggest getting custom orthotics to take stress off the peroneal tendons.7, 10

Now:

Unlike many other injuries, it does seem like there should be a difference between custom orthotics and standard over-the-counter inserts like SuperFeet or PowerStep.

Usually, the goal of an insert is to support the arch, which transfers stress to the outside of the foot.

This can be very helpful in injuries like plantar fasciitis or shin splints, but in the case of peroneal tendonitis, this could be a bad thing—remember, over eighty percent of people who get peroneal tendonitis have high arches.

Building up arch support even more, and shifting stress to the outside of the foot (where the peroneal tendons are), could actually make the problem worse!

Custom orthotics can change this equation by keeping the arch height of the insert lower, and adding a “wedge” underneath the outside of your heel, which should take stress off the outside of your midfoot.

If your case of peroneal tendonitis isn’t responding to rest and physical therapy exercises, a custom orthotic might be worth a shot.

If conservative treatments fail, you should see an orthopedist and get an MRI to check for a rupture in the tendon.

Especially when peroneal tendon injury coincides with an ankle sprain, there is a chance what feels like tendonitis is really a tendon rupture that needs to be repaired surgically.

Fortunately, MRI seems to be an effective method for determining the extent of damage to the peroneal tendon.7  If you have a tendon rupture, or if there is very severe tendon damage, you may need surgery to fix it.

Outline of Treatment

Conservative treatments

These are methods that are fairly simple, inexpensive, and can be done on your own at home.

  • Calf stretching, 3 sets of 30 seconds, both with a straight knee and a bent knee, 3 times per day.
  • Eversion exercise with a resistance band: 200 repeats, taking breaks if needed and using a weak resistance band. Progress over time to doing the repeats without any breaks, and then start using a stronger resistance band.  Be sure to do the exercise on both your injured and non-injured legs.
  • Balance exercise progression: start with one minute of single-leg balance, and build as quickly as you can to 2.5 minutes of single-leg balancing on both sides. Once you can do this, add difficulty by doing directional body leans, closing your eyes, or using a wobble board.

Aggressive treatments

These are treatments with more cost and less certainty about outcomes, but may prove useful in recalcitrant cases.

  • See a podiatrist or an orthopedist and ask about getting a custom orthotic. In the case of peroneal tendonitis, standard over-the-counter orthotics are probably not going to be very helpful because of the biomechanics of the injury.
  • Consider dry needling. Some runners find it works very well with peroneal tendon issues, and if you are desperate, it might be worth a try.
  • See a physical therapist who is familiar with running injuries to ensure that you don’t have any weakness, tightness, or gait abnormalities that are causing your tendon problems.
  • If conservative treatments still aren’t working after several weeks or months, see a trusted orthopedist so you can get an MRI to check for a tendon rupture or severe tendon damage and discuss the possibility of surgery.

When Can I Return to Running?

Avoiding running on the tendon while it’s injured seems to be the right idea.

A 1994 case study describes a 49-year-old runner who suffered an acute rupture of the peroneus longus tendon in the middle of a ten-mile road race after running on chronic tendon pain for several months. This runner did recover and return to training, but only after surgery and a year of rehab! 11

As with any injury, you should be gradual and patient in your return to running.

Research on Achilles and patellar tendonitis suggests that mild pain when returning to running is not a cause for major concern as long as the pain does not get progressively worse.12

This “pain monitoring” approach (which Brad Beer talked about in a recent podcast interview) has not been tested in injuries to the smaller tendons of the feet, however, so if you’re in doubt, be cautious and wait for your tendon to heal before returning to full training.

The good news is that the peroneal tendons are not known to be particularly resistant to healing like the posterior tibial tendon or the plantar fascia, so with some patience and the right rehab program, you should be back to training soon.

And please do us a little favor and share this guide with others, for there’s a good chance that it could be the guide they are looking for with this frustrating injury!

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Download our full Peroneal Tendonitis Prevention Routine inside your Insider Members area.

It’s a PDF with the conservative and aggressive treatment options for runners suffering from peroneal tendonitis

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References

Taunton, J.; Ryan, M.; Clement, D.; McKenzie, D.; Lloyd-Smith, D.; Zumbo, B., A retrospective case-control analysis of 2002 running injuries. British Journal of Sports Medicine 2002, 36, 95-101.
Brandes, C. B.; Smith, R. W., Characterization of patients with primary peroneus longus tendinopathy: A review of twenty-two cases. Foot & Ankle International 2000, 21 (6), 462-468.
Rabbito, M.; Pohl, M. B.; Humble, N.; Ferber, R., Biomechanical and Clinical Factors Related to Stage I Posterior Tibial Tendon Dysfunction. Journal of Orthopaedic & Sports Physical Therapy 2011, 41 (10), 776-784.
Reber, L.; Perry, J.; Pink, M., Muscular control of the ankle in running. The American Journal of Sports Medicine 1993, 21 (6), 805-810.
Sobel, M.; Geppert, M. J.; Warren, R., Chronic ankle instability as a cause of peroneal tendon injury. Clinical Orthopaedics and Related Research 1993, 296, 187-191.
Clarke, H. D.; Kitaoka, H. B.; Ehman, R. L., Peroneal tendon injuries. Foot & Ankle International 1998, 19 (5), 280-288.
Heckman, D. S., Operative Treatment for Peroneal Tendon Disorders. The Journal of Bone and Joint Surgery (American) 2008, 90 (2), 404.
Alvarez, R.; Marini, A.; Schmitt, C.; Saltzman, C. L., Stage I and II Posterior Tibial Tendon Dysfunction Treated by a Structured Nonoperative Management Protocol: An Orthosis and Exercise Program. Foot & Ankle International 2006, 27 (1), 2-8.
Verhagen, E., The Effect of a Proprioceptive Balance Board Training Program for the Prevention of Ankle Sprains: A Prospective Controlled Trial. American Journal of Sports Medicine 2004, 32 (6), 1385-1393.
Selmani, E.; Gjata, V.; Gjika, E., Current concepts review: peroneal tendon disorders. Foot & Ankle International 2006, 27 (3), 221-228.
Kilkelly, F. X.; McHale, K. A., Acute rupture of the peroneal longus tendon in a runner: A case report and review of the literature. Foot & Ankle International 1994, 15 (10), 567-569.
Silbernagel, K. G.; Thomee, R.; Eriksson, B. I.; Karlsson, J., Continued Sports Activity, Using a Pain-Monitoring Model, During Rehabilitation in Patients With Achilles Tendinopathy: A Randomized Controlled Study. The American Journal of Sports Medicine 2007, 35 (6), 897-906.

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2 Responses on “Do You Have Peroneal Tendonitis? Here is How to Fix it

  1. My eyes didn’t want to believe when I saw this article, you describe point-by-point everything that I needed to know about this injury and a way to fix it that totally makes sense.
    After almost 2 years in useless visits to doctors and physical therapists, this is a glace of fresh air and hope. I started yesterday the exercises and they feel so good, it really makes sense. Thank you so much.

  2. There is another cause of peroneal tendinitis. While it seems pretty rare it’s something I’m dealing with right now. Some people have accessory navicular (an extra bone in their foot). Usually this “extra bone” is on the inside of the foot, but in my case it’s on the outside by the fifth metatarsal. It’s been there my entire life, but it hasn’t started causing issues with my peroneal tendon until recently.

    The treatments you’ve documented are pretty much the same as what my doctor prescribed with one addition. Since I actually have a fairly low arch she recommended wearing a foot/ankle brace that helps to turn the foot outwards. That takes some pressure off the tendon.

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