Peroneal tendinopathy is a chronic condition of the foot with degradation and inflammation to Peroneus Longus and/or Peroneus Brevis tendons. If inflammation is present it is known as peroneal tendinitis. Peroneus Brevis tendinopathy is most common, the exact incidence of peroneus longus tendinopathy is not known. (Brandes & Smith, 2000). The tendons connect to the Peroneus Longus and Brevis muscles which evert the foot, arising from the fibular along with the lateral compartment of the lower limb. Peroneus longus and brevis tendons share a common synovial sheath under the retro malleolar groove and can be subject to injury under tensile stress (Choudhary & McNally, 2010). Injury to the peroneal longus and brevis tendons, including peroneal tendinopathy, have been associated with chronic and persistent lateral ankle instability and pain (Wilder & Sethi, 2004). Tendons have a poor blood supply and therefore functional overload can occur causing injury, and therefore subsequent heeling will be poor due to the avascular nature of tendons (Rees, Maffulli & Cook, 2009).

What are the signs and symptoms of peroneal tendinopathy?

Peroneal tendinopathy commonly presents as lateral ankle pain which is worsened with activity and relieved with rest. There is often tenderness of the peroneal tendons when tendinopathy is present, in addition to retro malleolar inflammation. Patients with peroneal tendinopathy often have resisted eversion and painful passive inversion (Brukner & Khan, 2012).

 

What is the cause of peroneal tendinopathy?

Our understanding of the cause of peroneal tendinopathy is in its earliest stages, with a need for more research in the pathological development of tendinopathy, particularly of the peroneal tendons. Overloading the peroneal tendons can cause injury and lead to peroneal tendinopathy (Brukner & Khan, 2012). The majority of cases of peroneal tendinopathy relate to a mechanical abnormality that can be either acute or chronic with tenosynovitis, tears, or subluxation of the peroneus brevis or longus tendons. Ankle instability commonly is associated with peroneal tendinopathy. Also, varus or valgus rearfoot and abnormalities such as a shallow retro malleolar groove have been linked to peroneal tendinopathy. Os Peroneum can be involved with fractures and necrosis due to trauma or mechanical overload in cases of peroneal tendinopathy (Zgonis, Jolly, Polyzois & Stamatis, 2005).  It is common for peroneal tendinopathy to occur posterior to the lateral malleolus, at the peroneal trochlea, and the plantar surface of the cuboid (Brukner & Khan, 2012). In cases without trauma, peroneal tendinopathy can be attributed to the anatomy of the peroneus longus tendon as it passes through anatomical tunnels and spaces. Furthermore, changes in direction of the peroneal tendon in the rearfoot may contribute to pathology (Wilder & Sethi, 2004).

Who is most likely to be affected with peroneal tendinopathy?

Diabetes and obesity have been associated with peroneal tendinopathy (Abate et al., 2009). Abate et al. (2009) also found that overuse injury resulting in peroneal tendinopathy can commonly be linked to sports activities and errors in training. There is an association between peroneal tendon injuries and pre-existing hindfoot varus deformities (Brandes & Smith, 2000). In Brandes and Smith’s study, 82% of patients had a varus rearfoot position and peroneal tendinopathy. Some studies demonstrate a link between peroneal tendinopathy and chronic ankle instability. DiGiovanni et al. (2000) found that 77% of patients with chronic lateral ankle instability also had acute peroneal tenosynovitis. More research needs to be conducted into the epidemiology of peroneal tendinopathy specifically, and not tendinopathy in general, as there is not enough research in this area.   

 

What other conditions can often be confused with peroneal tendinopathy?

Peroneal tendinopathy may have similar presentations to ankle sprains, ankle fractures, Os Trigonum syndrome, chronic lateral ankle pain, peroneal subluxation, and Flexor Hallucis Longus injury.

How do I diagnose peroneal tendinopathy?

 Book an appointment with our experienced podiatrist who can diagnose foot and lower limb conditions. Our podiatrist can perform a biomechanical assessment to find the cause of pain and offer suitable treatment options.

Peroneal tendinopathy can be formally diagnosed by MRI (recommended) or ultrasound. If there is a suspected inflammatory arthropathy suspected then it is recommended to obtain a blood test to find rheumatological or inflammatory indicators (Brukner & Khan, 2012).

 

How do I treat peroneal tendinopathy?

• Rest, Ice, Compression, and Elevation can be considered as a treatment for peroneal tendinopathy.

• Analgesic medication can be taken for peroneal tendinopathy to relieve pain temporarily in consultation with your doctor (Woo et al., 2005).

• Footwear assessment is important to evaluate whether footwear can be modified to relieve symptoms of peroneal tendinopathy, such as with the use of orthoses with lateral heel wedges and/or corrections to valgus or varus rearfoot deformities.

• Resisted eversion strengthening exercises can be used to relieve symptoms of peroneal tendinopathy. These exercises will strengthen the peroneus longus and brevis muscles and load the peroneus longus and brevis tendons for rehabilitation (Simpson, M et al.,2009). A physiotherapist may also be involved to further guide you on the best exercises.

• Platelet-Rich Plasma treatment can be considered in the treatment of peroneal tendinopathy. Significant positive outcomes were seen in a systematic review, with the best results among those treated with highly cellular leukocyte-rich PRP (LR-PRP) preparations. There is also good evidence that supports the clinical use of a single injection of LR-PRP under ultrasound guidance (Fitzpatrick, Bulsara & Zheng, 2016).

• Surgery can be considered as a treatment for peroneal tendinopathy if conservative management fails(Kumar et al., 2017). Peroneal endoscopy has been found to improve outcomes in patients with peroneal tendon disorders (Kennedy et al., 2016).

 

What is the long-term outlook (prognosis) for peroneal tendinopathy?

Full recovery will happen for most patients with peroneal tendinopathy over time. Minimal research has been conducted on the prognosis of patients’ peroneal tendinopathy in the short and long term. Rehabilitation is vital and it will minimize the risk for further or repeated injury. Peroneal tendinopathy can progress to tear without treatment or rehabilitation (Wilder & Sethi, 2004).

We treat feet from all over Sydney, particularly the Eastern Suburbs. As podiatrists in Bondi Junction, we are happy to treat anyone that comes to our Sydney clinic. Our local area includes Bondi Junction, Bondi, Bondi Beach, North Bondi, Rose Bay, Tamarama, Coogee, Randwick, Bellevue Hill, Dover Heights, Vaucluse, and Edgecliff.

References:                           

Abate, M., Gravare-Silbernagel, K., Siljeholm, C., Di Iorio, A., De Amicis, D., & Salini, V. et al. (2009). Pathogenesis of tendinopathies: inflammation or degeneration?. Arthritis Research & Therapy, 11(3), 235. DOI: 10.1186/ar2723

Boszczyk, A., Fudalej, M., Kwapisz, S., Klimek, U., Maksymowicz, M., Kordasiewicz, B., & Rammelt, S. (2018). Ankle fracture — Correlation of Lauge-Hansen classification and patient-reported fracture mechanism. Forensic Science International, 282, 94-100. DOI: 10.1016/j.forsciint.2017.11.023

Brandes, C., & Smith, R. (2000). Characterization of Patients with Primary Peroneus Longus Tendinopathy: a Review of Twenty-Two Cases. Foot & Ankle International, 21(6), 462-468. DOI: 10.1177/107110070002100602

Brukner, P., & Khan, K. (2012). Brukner and Khan’s Clinical Sports Medicine (4th ed.).

Choudhary, S., & McNally, E. (2010). Review of common and unusual causes of lateral ankle pain. Skeletal Radiology, 40(11), 1399-1413. DOI: 10.1007/s00256-010-1040-z

DiGiovanni, B., Fraga, C., Cohen, B., & Shereff, M. (2000). Associated Injuries Found in Chronic Lateral Ankle Instability. Foot & Ankle International, 21(10), 809-815. DOI: 10.1177/107110070002101003

Fitzpatrick, J., Bulsara, M., & Zheng, M. (2016). The Effectiveness of Platelet-Rich Plasma in the Treatment of Tendinopathy: A Meta-analysis of Randomized Controlled Clinical Trials. The American Journal Of Sports Medicine, 45(1), 226-233. DOI: 10.1177/0363546516643716

Grasset, W., Mercier, N., Chaussard, C., Carpentier, E., Aldridge, S., & Saragaglia, D. (2012). The Surgical Treatment of Peroneal Tendinopathy (Excluding Subluxations): A Series of 17 Patients. The Journal Of Foot And Ankle Surgery, 51(1), 13-19. DOI: 10.1053/j.jfas.2011.10.010

Hamilton, W. (1982). Stenosing Tenosynovitis of the Flexor Hallucis Longus Tendon and Posterior Impingement upon the Os Trigonum in Ballet Dancers. Foot & Ankle, 3(2), 74-80. DOI: 10.1177/107110078200300204

Kennedy, J., van Dijk, P., Murawski, C., Duke, G., Newman, H., DiGiovanni, C., & Yasui, Y. (2016). Functional outcomes after peroneal endoscopy in the treatment of peroneal tendon disorders. Knee Surgery, Sports Traumatology, Arthroscopy, 24(4), 1148-1154. DOI: 10.1007/s00167-016-4012-6

Kumar, Y., Alian, A., Ahlawat, S., Wukich, D., & Chhabra, A. (2017). Peroneal tendon pathology: Pre- and post-operative high-resolution US and MR imaging. European Journal Of Radiology, 92, 132-144. DOI: 10.1016/j.ejrad.2017.05.010

Nyska, M., & Mann, G. (2002). The unstable ankle. Champaign, Ill.: Human Kinetics.

Rees, J., Maffulli, N., & Cook, J. (2009). Management of Tendinopathy. The American Journal Of Sports Medicine, 37(9), 1855-1867. DOI: 10.1177/0363546508324283

Simpson, M. R., & Howard, T. M. (2009). Tendinopathies of the Foot and Ankle. American family physician, 80(10).

Sydney, NSW: McGraw Hill. Cotchett, M., Munteanu, S., & Landorf, K. (2014).

Tohyama, H., Beynnon, B., Renström, P., Theis, M., Fleming, B., & Pope, M. (1995). Biomechanical analysis of the ankle anterior drawer test for anterior talofibular ligament injuries. Journal Of Orthopaedic Research, 13(4), 609-614. DOI: 10.1002/jor.1100130417

Wakeley, C., Johnson, D., & Watt, I. (1996). The value of MR imaging in the diagnosis of the os trigonum syndrome. Skeletal Radiology, 25(2), 133-136. DOI: 10.1007/s002560050049

Wilder, R., & Sethi, S. (2004). Overuse injuries: tendinopathies, stress fractures, compartment syndrome, and shin splints. Clinics In Sports Medicine, 23(1), 55-81. DOI: 10.1016/s0278-5919(03)00085-1

Woo, W., Man, S., Lam, P., & Rainer, T. (2005). Randomized Double-Blind Trial Comparing Oral Paracetamol and Oral Nonsteroidal Antiinflammatory Drugs for Treating Pain After Musculoskeletal Injury. Annals Of Emergency Medicine, 46(4), 352-361. DOI: 10.1016/j.annemergmed.2005.01.023

Zgonis, T., Jolly, G., Polyzois, V., & Stamatis, E. (2005). Peroneal tendon pathology. Clinics In Podiatric Medicine And Surgery, 22(1), 79-85. DOI: 10.1016/j.cpm.2004.08.006