When lateral ankle pain keeps causing trouble, you might be forced to sit on the sidelines. If peroneal tendonitis is your issue, in this article you’ll learn how to deal with it so it stays away.
Tendonitis or Tendinopathy?
Peroneal tendonitis is the common name for an annoying condition that can cause persistent pain on the outside (lateral side) of your ankle.
The name “tendonitis” suggests an inflammation of tendons, but that is not really the case here – inflammation isn’t typically CAUSING the pain [1]. What is to blame are structural changes and damage to the tendons of your peroneal muscles in your lower leg.
Because of this, peroneal tendinopathy (which means an injury of the peroneal tendon) is a more accurate term to describe the issue. It’s not because your tendon is inflamed that you have pain, it’s that your tendon is injured (which might then cause some swelling and irritation!).
Although this may seem like semantics, it’s important to have an accurate understanding of what’s going on so that we can more effectively treat it.
We’ll use both terms since both are common, but this is an important thing to keep in mind as we learn more. Simply trying to reduce inflammation is only treating one symptom of the issue – we’ve got to look deeper to understand what’s causing the injury and how to rehab from it.
Signs of Peroneal Pain
To determine if peroneal tendinopathy is the issue, there are a couple of common symptoms you can watch out for:
- Pain on the lateral side of your ankle that gets worse over time
- A feeling of ankle weakness and instability
- The pain and weakness worsens when you bear your weight down on your ankle, especially during activities like running
- Pain when dorsiflexing your foot (pointing your toes up)
- Pain when everting your foot (rolling your foot outwardly) [2]
So what’s causing these symptoms?
Let’s take a deeper look at the anatomy and biomechanical functions of your peroneal muscles – an important group of muscles that most people ignore.
Anatomy & Functions of the Peroneal Muscles
There are a couple of separate peroneal muscles that connect your lower leg to your foot and ankle.
The peroneus longus originates on the upper part of your fibula (the smaller, lateral bone of your lower leg). It crosses your ankle joint and inserts on to the bottom of your foot [3]. This muscle helps you evert your foot and plantarflex your ankle (pointing your toes down).
Your peroneus brevis is found underneath the longus. It runs from your lower fibula to the lateral underside of your foot [4]. This muscle also helps with foot eversion and plantar flexion.
Both these muscles also help provide support to the arches of your foot.
There is a third peroneal muscle, peroneus tertius that some folks have and some folks don’t [5]. If you’ve got it, this muscle runs from your lower fibula to the top of your foot and has a slightly different function. It helps evert your foot, like the other peroneals, but also aids in dorsiflexion (pointing your toes up).
The tendons of your peroneal muscles all wrap around your lateral malleolus (that big bony bump you can feel on the outside of your ankle). Because of this positioning, these muscles and tendons also play a very important role in helping to stabilize your ankle joint – especially during particular movements.
Ankle Stabilizers
As your peroneal muscles and tendons run from your lower leg, wrapping around your ankle, down to your foot, their contractions provide support during movements of your ankle. Their stabilizing role is especially important when you’re making multi-directional movements or walking on unstable terrain.
Think about a tennis player side stepping across the court to return a serve. Or imagine your foot landing unevenly as you walk over bumpy or shifting ground, like a sandy beach, a wooded path with rocks and branches, or an uneven soccer field that needs some grounds keeping attention.
In all of these situations, your peroneals, with their tendons wrapped around the outside of your ankle, are working to react and protect your ankle as your feet move.
And because these muscles help allow your foot to evert, they also have the protective job of working to prevent over INVERSION of the foot – as can happen in the most common type of ankle sprain.
So if your peroneals are weak or fatigued, not only could you be facing the lateral ankle pain of peroneal tendinopathy, you are also at a greater risk of an ankle injury.
Want proof? In one study of 58 runners with sprained ankles, a whopping 55 of them (95% of the group) were found to have peroneal tendinopathy [6].
Peroneal strength and function should be taken seriously as an injury prevention method. If you’ve been experiencing lateral ankle pain or the symptoms we described above, you’ll want to consider your risk factors for peroneal tendonitis and how to rehab.
3 Peroneal Tendonitis Risk Factors
There are three common risk factors for peroneal tendinopathy, all of which are root causes of the condition and tied to an overuse of your muscles.
1) Overuse when starting or re-starting running
Often people jump back into running thinking they can rack up the miles just because they used to – or because their new running buddy can. But if your peroneals aren’t allowed to build up strength gradually overtime, you are asking for an injury.
2) Having a high arch
If your foot has a high arch, it will affect the positioning of your foot and ankle, putting your ankle into constant inversion. As a result, your peroneals can be chronically over-activated as they try to counteract this inversion, leading to overuse and damage.
3) Supinated/Inversion Gait
Having excess foot and ankle supination or inversion in your gait can also be behind peroneal tendinopathy. Pay attention to your body mechanics as you walk or run around.
If you only notice excess supination or inversion on one side, there might be a pretty easy explanation, especially if you do a lot of road running.
Stop to consider whether you are running a lot on cambered roads – roads that slightly angle down on the sides to help with drainage. Now consider if you always run on the same side of these roads. This simple activity might be mimicking repeated foot supination, putting excess wear and tear on your peroneals.
Steps to Rehab Peroneal Tendonitis
The acute phase of your injury will occur right after major pain develops. At this point, your most important job is to give your body a chance to heal.
This is the time for the RICE strategy – Rest, Ice, Compression, and Elevation. Take it super easy, and apply some cold treatment. (Just make sure not to use either ice or compression for more than 10-15 minutes at a time.)
Instead of reaching for pain-killers, incorporate some natural anti-inflammatories into your routine to aid with healing. Try a turmeric supplement like PuraThrive, Omega-3’s, or bone broths (which are full of collagen).
Now remember that inflammation isn’t the CAUSE of this pain, so we can’t stop here. After 3-7 days of rest, you are ready to move beyond the acute phase. At this point, there are several strategies you can start to incorporate.
Joint Mobilizations
Putting some effort into improving ankle mobility can reduce excess tension in your peroneals and promote better muscular balance throughout the lower extremity.
To mobilize your ankle joint while training for proper dorsiflexion, set a band up low to the ground. Get the band just above your ankle joint and step forward so there’s a bit of tension.
Start to bend into the knee and drive forward slowly so that your ankle dorsiflexes. Be sure to keep your heel on the ground as you move back and forth with control. This motion will help to mobilize and re-align the joint.
Another ankle mobilization technique is the lateral calcaneal glide. To perform this one, use one hand to stabilize the joint by grabbing the lateral side of your ankle (so your hand is firmly over your lateral malleolus).
Then use your other hand to gently press onto your calcaneus (heel bone) from the inside of your foot, gently moving it laterally.
This will help provide important lateral mobilization to the bones of your ankle. And this technique has been found to help ease peroneal tendinopathy symptoms [7].
Self-Massage
You can help support the health of your peroneal muscles and tendons by trying some self-massage techniques. You’ll want to use a friction massage approach in this area, which means you’ll be working in a direction that is opposite to your muscle fibers [8].
Using your finger or thumb, press down as you rub back and forth around the ankle joint (in the direction of heel to toe). This motion is opposite to the direction your peroneal muscle fibers lay as the run from your lower leg bones to your foot.
Try different spots around the lateral malleolus of your ankle. This technique can help reduce knots and tension, break up scar tissue, and encourage healing blood flow.
Y-Balance Test
This strategy is not only great for assessing the strength, stability, and mobility of your ankle joint [9], it is also an awesome exercise to help protect against and rehab from peroneal tendonitis.
To perform it, set up a large “Y” on the ground with masking tape. Stand in the center on your right foot as you reach your left foot as far out in front of you as you can (along one line of the Y), and then back while maintaining balance and control.
Image by www.synapse.koreamed.org
Repeat several times before switching standing legs. Next, stand on your right leg as your reach your left foot out along the line laterally and behind you. Switch feet.
Finally, stand on your right leg as you cross your left leg behind you to draw it along the line final line, moving backwards and medially. Switch feet again.
Overtime, your reach distance and balance should improve as your ankle and surrounding muscles become stronger and more mobile.
Proper, effective peroneal tendonitis treatment requires a well-rounded approach*. In order to properly restore strength and function, you’ve to understand the root causes and aim to improve the mechanics of the entire foot/ankle/knee complex.
*Although the information shared on PrecisionMovement.coach is based on a well-researched, scientific approach towards exercise and movement, every person is unique and individual results may vary.
The issue of peroneal tendinopathy doesn’t occur in the vacuum of a single tendon or even a single joint. Your functions and muscular balance all along the kinetic chain of your body contribute to having healthy, strong, and well-balanced peroneal tendons and muscles, which in turn can help keep your ankles protected and pain-free.
