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What is peroneal tendinopathy
Causes
Symptoms
Diagnosis
Treatment
Prevention
Outlook
FAQs

Peroneal tendinopathy causes pain and discomfort on the outside of the ankle. It can affect your ability to stay active on your feet, making it harder to navigate through your work day and exercise routines comfortably.

What Is Peroneal Tendinopathy?

You have two peroneal tendons in each leg called the peroneus longus and peroneus brevis. Starting from just below the knee, the peroneals run down your leg, to the outside of your ankle joint, and attach to the bottom of the midfoot. The peroneal tendons support the stability of the ankle and help prevent injuries including ankle sprains, meaning they have a very important role in our ability to walk and move comfortably. 

When the peroneal tendons become damaged or irritated, this is known as peroneal tendinopathy. Many medical resources use the terms peroneal tendonitis, tendinosis and tendinopathy interchangeably, even though they denote a different stage in the injury process. For ease of understanding, we’ll continue to refer to general damage to the peroneals as ‘peroneal tendinopathy’ - and your podiatrist will be able to explain more clearly which stage of injury you’re at during your appointment with us. 

What Causes Peroneal Tendinoathy?

Peroneal tendinopathy is an overuse injury that is caused by overloading (placing excess stress on) the peroneal tendons. When any tendons are pushed past the point that they can safely handle, damage will occur, which is what happens with this injury. Specifically, movements that roll the ankle outwards while the foot moves inwards (much like the way the foot moves during an inversion ankle sprain) will stretch and place greater strain on the peroneal tendons. These actions may also cause the tendons to rub against surrounding bones, which would also lead them to becoming inflamed.

Other contributing factors to the development of peroneal tendinopathy can include:

• Having tight calf muscles, which limits the ability of the foot to bend upwards and results in the foot working harder to compensate, which can then put further strain on the peroneals
  
• Your training technique, including during gait and when running. For example, the way your foot makes ground contact during running can add more strain to the peroneals
  
• Your foot biomechanics, or foot posture/alignment issues
  
• Certain physical activities such as running, dancing and basketball
  
• Physical activities that involve rapid changes in direction or quick side-to-side movements
  
• Developing chronic ankle instability, as this forces the peroneals to work harder to provide stability with every step
  
• Wearing unsupportive footwear
  
• Muscle weaknesses or imbalances in the feet or legs
  

Peroneal Tendinopathy Symptoms

If you have sustained damage to your peroneal tendons, you may feel:

• Pain on the outside of your ankle that may feel worse when standing or walking
  
• Swelling and tenderness on the outside of the ankle
  
• Pain that worsens when you twist your foot inwards so that the ankle twists outwards
  
• Unstable on your ankles, particularly if you try to balance on the affected foot
  
• Your pain and discomfort tends to ease at rest
  

How Is Peroneal Tendinopathy Diagnosed?

Our podiatrists are able to diagnose peroneal tendinopathy in our clinic by conducting a comprehensive assessment, including examining the injured area, performing muscle strength testing, a foot posture analysis, pressure plate testing, and more. We make sure to look at all the potential causative factors that have led to your peroneal tendons becoming damaged, and use this key information to best direct your management plan. This means we actively work towards preventing this injury from recurring in the future.

In some cases, we may refer you for medical imaging such as an ultrasound to confirm your diagnosis. We may do this if your symptoms closely match more than one injury or condition, or we suspect that multiple structures in your lower leg or ankle have become damaged, such as peroneal tendinopathy coupled with an ankle sprain or avulsion fracture.

How Is Peroneal Tendinopathy Treated?

Home treatment

If you’re at home and suspect that you may have peroneal tendinopathy, you can start managing your painful symptoms by following the PRICE principles: protection, rest, ice, compression and elevation. These principles are important to follow because peroneal tendinopathy can worsen if left untreated and ignored, especially given that your ankle will be weaker and less stable while the peroneals are in a damaged state.

Podiatrist treatment

Once you start working with a podiatrist, your treatment will then focus on addressing the cause of the tendinopathy so the tendons can effectively heal, meaning that your painful symptoms can fully resolve. We also do everything we can to help reduce the risk of your peroneal tendons becoming overloaded and damaged again in the future. Your treatment with us may include:

• Custom foot orthotics: these work by reducing the strain on peroneal tendons while optimising your stability at the ankle joint with every step. This not only facilitates healing and repair, but prevents further damage and injury by helping prevent events like another ankle sprain, which would further weaken the peroneals. The orthotics we create are custom prescribed and designed completely for your feet after a comprehensive assessment and 3D foot scan, making them as tailored for your feet as prescription glasses are for your eyes.
  

• Shockwave: shockwave is a safe and effective way to facilitate the healing of peroneal tendinopathy by increasing blood flow, stimulating collagen production, inducing faster healing and tendon repair, and reducing pain levels.
  

• Walker or brace: if the injury is severe, we may recommend a CAM walker or brace to help offload the foot and and help kickstart the healing and repair process
  

• Footwear assessment to ensure that your shoes are providing adequate stability and support to the foot and ankle, and minimise any unwanted movement that may be increasing the stress through the peroneals.
  

• Footwear modifications: in some cases, we may opt to make modifications to your existing footwear to best support your foot and ankle and ensure your shoes are doing an adequate job of keeping your feet and ankles secure and stable as you move throughout your day.
  

• MLS laser: MLS is an effective form of pain relief that works in many ways - from helping minimise your pain levels to supporting the repair and regeneration process to optimise your recovery.
  
• Physical therapy: as you progress throughout your recovery, stretching and strengthening exercises will be prescribed appropriately to help address any muscle imbalances that may be contributing to your symptoms. As muscle tightness and weakness is a common contributing factor to this problem, particularly weakness around the ankles, this is a priority to help prevent future injuries and pain.
  

• Activity modifications: until you’re able to have the right support in place for your feet, we may recommend some activity modifications, particularly if you regularly participate in activities like high impact interval training and sports with rapid changes in direction or side-to-side movements.
  

• Strapping the ankle during exercise or certain physical activities while the peroneals are healing will help to keep the ankle secure and stable while reducing the strain on the peroneals.
  

Surgical treatment

Due to the nature of a peroneal injury and the success of non-surgical treatment methods, surgery should only be considered in the few cases where the non-surgical treatments (above) fail to produce sufficient results.

How To Prevent Peroneal Tendinopathy

When it comes to peroneal tendinopathy, prevention is always better than cure. If you know you’re at risk, such as if you play sports such as netball, basketball or tennis, we recommend:

• Regularly stretching the calf muscles, Achilles tendon, and plantar fascia to maintain flexibility and reduce tension on the peroneal tendons.
  

• Actively working to strengthen the muscles of the lower leg and foot, including the peroneals, anterior tibialis, and intrinsic foot muscles, on a regular basis to support ankle stability and proper biomechanics.
  

• Taking a slow and steady approach to increasing your exercise or training intensity. Gradually increase the intensity, duration, and frequency of physical activity to avoid overloading the peroneal tendons and reduce the risk of overuse injuries.
  

• Wearing supportive footwear that provides adequate stability surrounding the ankle, as well as cushioning and arch support.
  

• Wearing your custom foot orthotics, if they have been prescribed to you by your podiatrist, any time you’re active on your feet. This includes walking to and from work.
  

• Always warming up before exercising to increase blood flow to the muscles and prepare them for activity. Similarly, cool down afterwards to promote muscle relaxation and reduce the risk of stiffness.
  

• Prioritising proper form and technique during physical activities, particularly those involving repetitive movements or changes in direction, to minimise the risk of injury to the peroneal tendons.
  

• Allowing adequate time for rest and recovery between workouts to prevent overuse injuries and give the peroneal tendons time to heal and adapt to training stress.
  

• Listening to your body - the best time to manage peroneal tendinopathy is in its earliest stages, before any significant damage has occurred. Stay mindful of your body and any early signs of discomfort or pain around your outer ankle. This will be the best time to protect your ankle and start your repair and recovery process, long before it has a chance to turn into a full-blown injury.
  

What Is The Outlook For Peroneal Tendinopathy?

The outlook for the patients we see and treat that are diagnosed with peroneal tendinopathy are generally very good. If the case of peroneal tendinopathy is straightforward, without tendon tears, ruptures or other complications, then most people are able to make a full recovery with no significant long-term issues. Some people may need extra care and measures, such as modifications to their footwear or custom foot orthotics with raised lateral sides. In cases where alongside their peroneal damage, there are also other issues such as repeated ankle sprains over the years that have led to chronic ankle instability, then the use of the EXO-L anti-sprain brace can be beneficial. 

Regardless of your circumstances, working with an experienced podiatrist will help you optimally manage your symptoms to best support your daily function and quality of life.

Frequently Asked Questions

What are the risk factors for developing peroneal tendinopathy?

Risk factors for peroneal tendinopathy include repetitively stressing or overusing the tendons, sudden increases in physical activity, poor footwear choices, participating in high-impact sports, anatomical variances like high arches or abnormal foot mechanics, tight calf muscles, and other factors.

Can peroneal tendinopathy be prevented with specific exercises?

Nothing is absolutely guaranteed to prevent any injury but there are definitely specific exercises focusing on calf stretching, strengthening of lower leg muscles, and improving ankle stability that can all help keep your lower limbs strong and minimise your risk of injury. Incorporating a well-rounded exercise routine that addresses muscle imbalances and promotes flexibility will always be beneficial.

How long does it take to recover from peroneal tendinopathy?

The recovery time for peroneal tendinopathy can vary quite a bit based on factors such as the severity of the condition for you, your adherence to treatment, and just your individual response to therapy. In mild cases, recovery may take a few weeks, while more severe cases (especially where you have several injuries at once) may take several months. Once you’re seen by your podiatrist, they’ll be able to give you a better idea of how long recovery may take in your specific circumstances.

Are there any shoes recommended for those with peroneal tendinopathy?

Instead of recommending a specific model of shoe, you really want to look for the features it has and how it is able to support your feet. We recommend choosing shoes with good arch support, with you ideally removing the inner liner to be able to place your custom foot orthotics inside. Cushioning will also help, as it will help with shock absorption that will help reduce the stress on the peroneals. One of the most important factors that we recommend looking for is that your shoes are high up enough on the ankle to be able to offer good, solid support there, as this can go a long way in preventing further strain on the peroneals and helping reduce the likelihood of re-injury in the future.

Can peroneal tendinopathy occur in both ankles simultaneously?

Yes, peroneal tendinopathy can occur in both ankles simultaneously. While it’s more common to see it in just the one ankle, factors such as systemic conditions, biomechanical issues, or bilateral overuse can contribute to the development of tendinopathy in both ankles.