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achilles tendonThere are two peroneal tendons in the foot and they run parallel, down from the calf muscles and behind the ankle bone on the outside of the foot. One peroneal tendon inserts onto the outer bones in the middle of the foot while the other attaches to the underside of the arch. The role of these tendons is to stabilize the ankle and foot to prevent sprains and strains. Peroneal tendonitis is the inflammation of one or both of these tendons.

The history is very important in the setting of peroneal tendinosis. As noted above, these are overuse injuries. People with peroneal tendinosis typically have either tried a new exercise or have markedly increased their activities. Characteristic activities include marathon running or others which require repetitive use of the ankle. Patients will usually present with pain right around the back of the ankle. There is usually no history of a specific injury.

The diagnosis of peroneal tendinosis can be made in large part by history (i.e. the story a patient tells). As noted above, patients will have an overuse activity, rapid increase in recent activity, or other training errors and will have pain in the back and outside of the ankle. There is pain on exam to palpation right on the peroneal tendons. It is important to distinguish this from pain over the fibula, which might indicate a different problem (i.e. stress reaction of the bone). Pain on the fibula occurs directly over the bone which is easily palpated. Pain in the peroneal, occurs slightly further behind. There is also pain with inversion or carrying the ankle to the outside. Patients may also have weakness in trying to bring the ankle to the outside (i.e. in eversion). It is important to look for the varus posturing of the heel which, as noted above, means that the heel is turned inwards. This can predispose a patient to the problem. The workup can also include using radiology. X-rays will typically be normal. Ultrasound is a very effective and relatively inexpensive way to assess the tendons and can show an abnormal appearance or tear which sometimes occurs. An MRI is also equally important and can also show a tear.

The vast majority of peroneal tendinosis will heal without surgery. This is because it is an overuse injury and can heal with rest. If there is significant pain, a CAM Walker boot for several weeks is a good idea. If there really is no tenderness with walking, an ankle brace might be the next best step. Patients should very much limit how much they are walking or on their feet until the pain abates. This usually takes several weeks. Resumption of training can then occur, but must occur very slowly and be based on pain. For those patients who have hindfoot varus, as noted above, an orthotic that tilts the ankle to the opposite side may well help to offload the tendons. It is important to talk to your doctor about changing your training. This includes using new shoes for running or also cross-training, which means alternating activities each day. Physical therapy is also very important. This, as with ankle sprains, can be done to strengthen the tendons.

There is some interest at the moment in using platelet-rich plasma (PRP) to help stimulate healing growth. Currently, there are no studies showing that this works for the peroneal tendons. Steroids are probably best avoided as they can actually damage tendon. Surgical treatment is indicated if the pain does not get better with rest. Conservative treatment - that is, without surgery - should last, however, even up to a year before considering surgery. If there is a tear, meaning a split that runs along the length of the tendons, one could consider cleaning it out and repairing the tendon. Sometimes, making the groove in the back of the bone of the fibula deeper allows the tendons more space and can help as well. Finally, if the tendon is very bad, one may need to resect the tendon and connect both the longus and brevis together. Only the specific tendon involved Patients usually recover fully but this can take considerable time. You must be patient and allow the tendon to heal before going back to activity. If you need surgery, your recovery time may be substantial. You may be instructed not to put your foot down with weight for about six weeks. Your foot and ankle surgeon likely will order physical therapy ensue.

With our foot doctors the outcome is usually good. However, sometimes it takes time for people to get back to their activity. When a tear develops and there is chronic thickening of the tendon, the outcomes are not as good.

If you have any of these symptoms, please call our doctor's at Southeast Podiatry, Dr. Brent Harwood and Dr. Bradford Egly, for an appointment.