Physical Therapist's Guide to Peroneal Tendinopathy

Overuse injuries in sports account for 50% of all injuries. A majority of overuse injuries occur in runners, with 20% of injuries affecting the lower leg, 15% the ankle, and 15% the foot.

Peroneal tendinopathy is a type of overuse injury that often occurs in athletes, like long-distance runners and basketball players. Dancers, people who have had ankle sprains, or those who simply have weak ankles are also often affected. Peroneal tendinopathy is characterized by an aching along the outside surface of the ankle that worsens with activity, yet improves with rest. A physical therapist can help relieve symptoms caused by this condition by providing treatments, including stretching and strengthening exercises to help the ankle become more mobile, strong, and stable.

What is Peroneal Tendinopathy?
Peroneal tendinopathy is characterized by an aching pain and swelling in the peroneal tendons located in the lower, outside portion of the ankle. A tendon is soft-tissue that attaches a muscle to a bone. The muscles involved in this condition are the 2 peroneal muscles in the lower leg, called the peroneus longus and the peroneus brevis. (In some texts, the muscles are referred to as the fibularis longus and the fibularis brevis.)

The peroneus longus muscle originates on the fibula bone, which is located on the outside of the lower leg. It wraps around the bone on the outside of the ankle (the lateral malleolus) and attaches to the plantar (bottom) aspect of the base of the big toe. The peroneus brevis muscle also originates on the fibula, but attaches to the base of the fifth toe. These muscles are responsible for moving the foot in an outward direction, and pointing the toe and foot downward. Together, they help to balance and stabilize the foot and ankle. Most ankle sprains occur as a result of the ankle rolling inward. One reason for this is that the peroneal muscles and tendons are not as strong as the muscles on the inside of the ankle. If these muscles are weak, they may not be able to prevent the ankle from rolling inward. These muscles and tendons can also be overworked if the foot isn’t hitting the ground in proper alignment. If the foot hits the ground more on the outside of the foot (supination), the peroneal muscles have to work harder to stabilize the force of gravity with weight-bearing activities. Proper footwear or orthotics can help with proper foot alignment.

Peroneal tendinopathy will usually worsen with activity, such as running or walking and improve with rest. It is an overuse injury, meaning the tendons can become enlarged, thickened, and possibly swollen.

How Does it Feel?

Symptoms of peroneal tendinopathy include:

• An aching pain on the outside of the ankle, especially with activity
• Lateral (outside) ankle pain that decreases with rest
• Swelling or tenderness to touch behind the ankle bone on the outside of the ankle
• Pain and weakness when actively moving the foot in an outward direction or when pointing it down
• Pain when pushing off the ball of the foot during walking or running
• Pain when walking on a sloped terrain that turns the foot outward
• Pain when stretching the foot in an inward and downward direction

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