In this installment of our “injury of the week” series we’re going to be talking about peroneal tendonitis. We’re going to keep the same format we’ve had all along. First we’re going to start off with a review of what the injury is and talk about if this is what you have and when you need to worry/consult your doctor. From there we’re going to take you through the steps of the A-T-A self treatment system so that you’ll have a “sample treatment session”.

What are the peroneals?

Before we get into the actual muscles, let’s look at the anatomy quick. I’m sure most have you have heard of or at least googled the bones in the lower leg. You have the big tibia bone which is on the inside and then you have the little fibula bone on the outside. In the picture below, #3 is the tibia while numbers 1 and 2 are the two ends of the fibula. #1 is the “head” of the fibula and #2 is the lateral malleolus. When talking about the peroneal muscles (we’ll be talking about two of them in this post), it’s important to realize that they are located just behind the fibula and run down behind that malleolus and into the foot.

For the sake of this post we’re going to talk about two peroneal muscles (the longus and brevis). The long muscle runs from the fibular head, down the outside of the leg, behind the lateral malleolus and wraps under the foot just before heel. The short muscle starts midway down the fibula and follows the same path.

Typical injuries for these muscles include a tendonitis at one end or the other (usually at the bottom end going into the foot), or a muscle strain in the middle.

So how did I hurt these skinny little muscles?

There are two ways to really hurt these guys. The first is an ankle sprain where you roll the ankle and stretch them to the point of injury. The second (and more common way in endurance athletes) is to beat them up until you end up with an overuse injury. When it comes to the peroneals the thing to remember is that they are a stabilizer muscle. They help the ankle and foot keep you upright when you hit uneven/loose terrain. They work as a pair with the posterior tibialis muscle.

The peroneals pull the foot out and the post tib pulls the foot in. Together they help to keep the foot level so that the ankle can move through it’s full range of motion and the big muscles of the calf and upper leg can propel you forward off of your big toe. This is important! If there is a limitation in the ankle (either the joint itself is tight or your calves are tight or your big toe doesn’t extend all of the way), this mechanism will not work. The only way to keep yourself moving forward is to rotate the foot in or out. The same goes for the other end of the leg chain- the hip. If you can’t extend your hip all of the way and push off using the glutes, you end up with a short stride that doesn’t give the ankle enough time to move through it’s motion. The body will compensate by rotating that leg so that you don’t fall over your own two feet. If your motion seems fine in the ankle and hip and you’re still getting this- time to look at your shoes. Too much/too little support can have the same effect!

In this picture you can see how the foot twists out and effectively twists the whole leg. When this happens the peroneals can get cooked because now they are getting loaded with every step and trying to shock absorb and then push off instead of the gastroc/soleus. These are skinny little muscles that aren’t designed to handle that. Over time they will break down.

In this picture you can see how the foot twists in. Again, the whole leg twists to compensate for this. Here the posterior tibialis takes on the increased work load of shock absorbing and then trying to push off. The problem for the peroneal is that it is repetitively stretched out when this happens. The tendon can get irritated or the muscle itself trying to pull it back to it’s neutral position.

So what’s the take away from all of that? This is one of those injuries where you have two things to fix: 1) the injured muscle, and 2) the mechanism that caused it (tight ankle, tight calf, big toe, or tight hip). If you only fix the muscle, this will haunt you for a long, long time. Take the time to get to the root of the problem.

The outside of my calf hurts? NOW WHAT?

1) The first step is determining if it is truly a peroneal injury or something else. Remember, the goal of this series is not to keep you away from your doctor so that you can self treat everything. It’s to teach you how to catch the early symptoms and take care of them before it becomes a full blown injury. That being said, peroneal injuries can start as a gradual ache/pain during workouts or even after. It can also be one of those injuries where nothing is wrong until you sit down and stiffen up. Then all of the sudden- ouch!

Typical symptoms with peroneal injuries include pain or tightness on the outside of the calf  just below the level of the knee cap. They can move all the way down the outside of the calf to the ankle, as well as, into the bottom of the foot. Symptoms are typically worse with activity and better with rest, and swelling can occur at the lower tendon (between the lateral maleolus and foot) if the inflammation is severe enough.

Here are some guidelines for when seeing a doc should be your top priority: 1) If you see any bruising and/or swelling, and 2) numbness/tingling along the outside of the leg (knee to foot). An injury to the peroneals is a symptom of a bigger problem. Think of it like a link in the chain. Something stopped working and that chain got snapped due to the increased strain on it.

2) Be smart. If you aren’t getting better, get some help. I can’t tell you how many patients I get who wait months and even years before coming in for treatment. The longer you wait, the harder it is to get rid of. Here are some tips for finding the right health care professional:

• Find someone certified in soft tissue mobilization, whether it’s instrument assisted like Graston Technique or hands on like Active Release (ART). This is where you need to do your homework to see who’s near you. Follow the links to those sites to search their provider lists and read up on what each is all about. Peroneal injuries respond well to hands on/massage work. If this is something that’s been around for a while, exercise alone won’t cut it as the whole leg has learned to compensate.
• Not every PT and chiropractor are created equally. Some do very little soft tissue work and rely mostly on exercise and manipulations, others do not. We all specialize in our own little areas. Frustrating right? Not really. Most of us have websites to tell you what we are certified in. If we don’t? Pick up the phone and call us. There’s nothing worse than wasting 8 insurance visits not getting better only to switch places and have them fix it in two.

How to treat it.

 **download PDF with links, sets, reps, progressions, etc here**

Step 1- Traditional R.I.C.E. treatment:

When a new injury occurs, the first and most important goal is always to decrease pain and any swelling that may be present. In other words, we want to decrease inflammation. That means ice is mandatory. Absolutely no heat no matter how good it feels. Don’t short cut this stuff. It’s boring but it works, especially if your symptoms worsen as the day goes. It’s now easier than ever to smuggle an ice pack into the office fridge and wear compression gear under your dress clothes. Use that to your advantage.

Rest: This may sound obvious, but I’m going to say it anyway. An injured muscle/joint will require a decreased activity level to fully heal. The severity of the injury will determine if this is a full rest or more of an active recovery.

Ice: while heat may feel better on stiff and sore muscles, ice only during the first 7 days following injury. This will help to decrease swelling, inflammation and pain. 10-15 minutes is sufficient and you can perform every hour as needed. Avoid direct ice to skin contact.

Compression: thanks to the recent explosion of compression sleeves, tights, shorts, etc, you have several options in this department. Ideally you want something that is snug without being uncomfortably tight (think recovery tights if you’ve ever worn them or calf sleeves). In the case of a peroneal injury, full compression socks (versus the calf sleeve where the foot is free) are best.

Step 2- Kinesiology taping:

By now you’ve probably seen athletes covered in all kinds of colored tape. Some of you have probably even tried it out. Make sure to read the application instructions first! This stuff should last 3+ days, not fall off in an hour. That means you need to prep the skin so that it is hair free and clean.

1) Peroneal application. Click here.

2) Foot application. Click here. Why the foot? It’s common to have pain down on the foot at the tendon with a peroneal injury. This application also helps to support the mid-arch of the foot and evenly distribute the weight. Apply this application first, and then the one above!

Step 3 – Getting mobility back

The second goal is going to be to loosen up the injured area. Below I have the treatment techniques set up in levels. As a rule, you must be able to complete #1 without pain to progress to the next level. Be smart! Healing a peroneal injury isn’t about no pain, no gain. Don’t overdo it in an attempt to speed up your recovery.

1) R.I.C.E. + gentle stretching. There should be no pain with stretching.

2) Begin using the foam roller to work around the injury first. The goal here is to start getting slack into the peroneals without aggravating the injury itself. No tennis ball work or active/joint mobilizations. The order should be foam roll the muscles around the area of pain -> stretch -> RICE. (** Remember- with peroneal injuries you need to fix two things: 1) the muscle injury itself and 2) the muscles/restrictions that led to the injury. Fix just one and the other will be back to stir up problems again.)

3) Begin using the foam roller over the painful area to tolerance. The order should be foam roll the muscle around the injury-> over the injury -> stretch -> RICE.

4) Begin using the tennis ball for cross friction. Remember, you will want to work perpendicular to the peroneals (that means side to side versus left to right). Not sure on cross friction? Review here (there is a link for a video demonstration of the cross friction technique as well as directional advice for the lower peroneal tendon). Start with light pressure at one end of the tendon and work your way all the way down it. Repeat as needed (and as tolerated) with increased pressure. If it’s too painful- wait and try again the next day. The order should be foam roll around the injury -> over the injury-> cross friction -> stretch -> RICE.

5) As the tendon/muscle heals, we can really start to go after the muscles using the mobilization techniques. For the peroneals, this will mean muscle mobilizations as well as joint mobilizations at the hip and down at the ankle. The order should be foam roll around the injury -> over the injury-> cross friction -> mobilizations -> stretch -> RICE.

How long do you need to R.I.C.E for??? Until it’s 100% gone.

Here’s what it looks like. Use the guidelines above.

Here is a video specific to the working on the peroneals.

Step 4- Strengthening

We’ve broken the exercises down into three levels based on pain levels. This stuff should NOT hurt. If it does, go back a level or ease up on the resistance. Only progress as pain free.

What you’ll need: 1) resistance band/tubing. This is easy to find in any sporting good store these days. You can probably even get it in walmart or target.

Optional equipment: a balance disc. Always good to add difficulty to your strength exercises. Affordable too at $20.

Video’s for each level are here. Please note, in the PDF download you will find details for reps and difficulty progression, as well as, benchmarks you should meet before progressing to the next level. The number one thing to remember is that these exercises should be pain free. If you’re getting discomfort, go back a level. You can’t force this injury to heal, but you certainly can make it worse if you over do it.

Level One

Level Two

Level Three

To help put it all together, I’ve also created a PDF you can download to walk you through what a “treatment session” would look like. In it you will find everything you need including links to the videos and posts. Click here.

Hope that helps, and fire away with any questions in the comments.

References

1) Capobianco, Dr. Steven and van den Dries, Greg. (2009). Power Taping, 2nd Edition, Rock Tape Inc, Los Gatos, CA.

2) Hammer, Warren. (2007). Functional Soft-Tissue Examination and Treatment by Manual Methods, 3rd edition. Jones and Bartlett Publishers, Inc, Sudbury, MA.

3) Hyde, Thomas and Gengenbach, Marianne. (2007). Conservative Management of Sports Injuries, 2nd edition. Jones and Bartlett Publishers, Inc, Sudbury, MA.

4) Kase, Kenzo, Wallis, Jim, and Kase, Tsuyoshi. (2003). Clinical Therapeutic Applications of the Kinesio Taping Method.

5) Michaud, Thomas C. (2011). Human Locomotion. Newton Biomechanics, Newton, MA.

6) Muscolino, Joseph. (2009). The Muscle and Bone Palpation Manual. Mosby, Inc, St. Louis, MO.