Peroneal Tendonitis
Peroneal Tendonitis
Peroneal Tendonitis
Plantar View
Side View of Ankle
3/4 View of Ankle
Peroneal Tendon Injury is painful and can get in the way of normal activities.
There are two common types of injures. A Peroneal Tendon tear.
Or a tear to ligaments that anchor the Peroneal Tendons.
Understanding the Peroneal Tendon anatomy and getting a proper diagnosis is the key to healing.
It can be a challenging condition, and it is often mischaracterized as an overuse injury.
But know this, with rest and proper treatment you can heal and be stronger than you were before the injury.
You have two Peroneal Tendons on each leg.
The Peroneal Brevis and the Peroneal Longus.
You might also hear them called the Peroneus Brevis or Peroneus Longus.
The term Peroneal refers to the side of the leg.
The tendons attach to two muscles that have the same name, the brevis and longus.
They extend from the muscles, down the outside of the lower leg, behind the ankle bone and attach to the foot.
The Brevis attaches to the little toe and the Longus goes under the foot and attaches to the arch on the other side.
These tendons are like super strong rope.
The muscles on the lower leg pull on the rope to stabilize the foot and ankle especially when on uneven ground.
The tendons can tilt the foot or turn it to the side.
The tendons travel through a synovial sheath.
This sheath is like a pipe that the rope travels through to keep it from rubbing against other tissues.
The pipe has synovial fluid inside of it.
This fluid is like lubricating oil to keep the rope moving smoothly through the pipe.
It's very thick and slippery fluid with a consistency of raw egg white.
The fluid keeps everything moving but it also provides nourishment in the form of nutrients to the tendon.
The ropes and the pipe are held in place by a very strong, ribbon like band called a retinaculum.
The retinaculum, let's call it the band, is a ligament.
Ligaments are fibrous connective tissue, much like tendons, that connect bones together and keep things stable.
The retinaculum holds the pipe and tendons in place, traveling a precise path, behind the ankle bone.
There are actually two retinacula that hold the Peroneal Tendon Sheath in place.
So, you have two tendons, or ropes, sliding through a pipe full of lubricating oil, and that whole thing is held in place by two bands.
Most sites on the web are going to tell you that this is an overuse injury.
Wrong!
That is really a mischaracterization of Peroneal Tendonitis.
These parts of your ankle are designed to handle constant use.
A person can walk all day, every day, without getting an overuse injury.
It really takes some kind of trauma to set it off.
Like rolling or "twisting" the ankle.
Or some sort of very intense overuse, like going from sitting all day to a lot of really high jumping.
Even then, the end result is an event related injury that does not heal.
And when it doesn't heal - because it doesn't get proper rest after the initial injury, then it is treated like an overuse injury.
Many times people are unaware that they have a torn band.
Their doctor might not even know it.
They often do not realize they have a problem until they either have a feeling of instability, or they develop tendonitis.
This is often mistakenly diagnosed as an overuse injury.
This is because it seems like it developed over time when it really started at the moment the band got torn.
They might try to treat the tendonitis or other injury but it will not be able to fully heal until the band is repaired.
This is why proper diagnosis with an X-Ray or other imaging is important.
The torn band can set off chain reaction where one injury sets off another over time.
When the muscles in the lower leg flex and pull on the tendon it rubs against the edge of the ankle bone.
If this is happening repeatedly you can have irritation to the tendon, a torn tendon, or a split tendon.
The sheath or pipe can become irritated and inflamed as well.
All of these conditions need to be treated the same way.
Rest and protecting the area from more injury is the first step.
Once a band tears, your normal walking around will keep it from healing.
Technically, a full tear can heal on its own, but it would need to be immobilized for a very long period of time.
Maybe up to a year.
Most people get surgery to reattach the band if it is completely torn.
That is, if they are aware of the torn band.
Many people think they just have a mysterious chronic ankle problem that won't heal.
Or they think it's because they "are getting older".
Their doctor might have even told them they have chronic tendonitis.
You may need to push for an MRI or other imaging to make sure those bands (the retinacula) are not stretched or torn.
It's possible to tear one or both of the Peroneal Tendons alone without damage to the bands. This is less common though, and usually occurs just above the ankle bone on the side of the leg. Peroneal Tendon injuries are usually one of three types of injury. A partial tear, where the tendon has torn a bit, but is still connected. Or a full tear, where the tendon is no longer attached - this is much less likely. Or tendonitis, which is usually a small tear or a bunch of micro-tears.
If a band (retinaculum) is completely torn, surgery may be indicated since it is unlikely to heal on its own.
So, understanding the type and location of injury is important.
Understanding your injury will help you know whether to include surgery in the healing steps.
You really need imaging to find out if you have a torn band.
If you do have a torn band and you get surgery to repair it you should strongly consider getting follow up imaging.
This way you know if it is healing correctly.
If the bands are not healing properly, and anchoring the tendons in place, the tendonitis will come back and you will start the cycle all over again.
If you are considering surgery, make sure you fully understand your injury and know the details. Be sure to ask the following questions.
Surgery should generally be a last resort. But a few injuries do not heal well without surgery, and a torn retinaculum band is one of those cases where surgery may be needed. Be sure to get more than one opinion and make an educated choice. If you choose to get surgery, pick your surgeon well. Find out how many times they have done this surgery. Hundreds, is the answer you are looking for. Make sure they will do the surgery and not another surgeon under their supervision.
You can heal.
Whether you need surgery or not. You can heal and be back to how you were before the injury.
People end up making one of two big mistakes in this situation.
One is they think they can't heal because of age or they think they have some special injury that does not heal right.
But the vast majority of injuries are soft tissue injures that will heal if treated correctly.
The second mistake is not understanding how long it will take to heal.
People simply do not accept the fact that it is going to take longer than they want to heal.
When they don't see healing, they give up.
Or they try to push through and end up reinjuring themselves worse.
If you do not treat it, and let it steadily get worse over time by injuring it more, you could develop a chronic condition.
Chronic Peroneal Tendonitis can become degenerative and weaken the tendon, more and more, over time.
Everything ends up inflamed - tendons, bands, pipe - and nothing is doing its job right.
But you can avoid this by simply treating it.
If you are already in this position, don't worry, you can still heal.
It will just take longer.
It is important to note here, that you might hear a lot of terms thrown at these conditions.
Someone might tell you that you have Chronic Ankle Instability (CAI) or chronic tendon subluxation etc.
These are scary sounding terms and they may sound like things that you can't heal from or that you will never go back to being like you were before.
You can heal with the right treatment.
Yes, it is best to get proper treatment before you get to a more chronic condition.
But, regardless of where you are right now you can heal.
You can go back to playing sports.
You just need the right treatment.
Not only can you heal, but in the vast majority of cases, you can become stronger than you were before the initial injury.
For more in-depth information about how an injury heals click here for our Healing Page.
If you have a tear in one of the bands, you can have pain below the ankle and on the foot.
If you have a tear in one of the Peroneal Tendons you may have pain behind the ankle or just above it, depending on the location of the tear.
You might have general pain, redness, and swelling on and around the Lateral Malleolus, or as most people call it, the "ankle bone".
With an acute trauma some people hear a popping noise at the moment of injury.
You might have bruising and the more severe the tear the worse the bruising will be.
You may have swelling or warmth in the foot.
You could roll your ankle and have a lot of pain in the moment that quickly subsides.
If you tore a band though, you might not have ongoing pain from that alone.
But it might feel unstable.
However, if the tendon is not anchored by the band you will start to feel swelling and pain from the tendon rubbing on other tissues.
But each person is unique.
Your symptoms might be different from others and this is normal.
The healing path will be the same regardless of symptom variations or how the injury happened.
Even if you need surgery, you will still need to rest the area as much as possible, and use cold compression to reduce inflammation.
You will also need to protect the tendons and bands from reinjury.
You should treat this condition right away.
Once injured, the tendons are under continuous risk of additional injury because you have to use them so much.
It's very easy to make a tear a little bigger, add more tiny tears, or just add to the overall inflammation and irritation of the tendon.
An untreated Peroneal Tendon injury can progress to a chronic condition called Peroneal Tendinosis.
Peroneal Tendinosis is a condition where the tendon has started to thicken from continual micro-tears and damage.
This weakens the tendon over time and can eventually lead to complete rupture of the tendon.
Again though, you can heal with proper treatment.
The good news is there are clear steps to treating Peroneal Tendon injuries. You just need to avoid gimmicks, and treat the root cause, with the right treatment steps.
If you don't regularly exercise, and then one random weekend you play an intense sport all day long, you might stress a tendon to a level it just is not adapted to handle.
Tendons do not grow in size and strength the same way muscles do, but they do remodel.
Tendons are made of collagen fibers.
Collagen is a type of protein the body uses to make tendons and ligaments in the body.
When you regularly increase activity - not just once in a while - the body will make more collagen fibers in the tendon to adapt.
Like adding more strands to a cable making it stronger.
For strengthening tendons, doing the activity often - not doing it as hard as possible - is the key.
This is different than growing muscles which respond well to pushing them close to their maximum level for short durations.
The more often and longer you do a modest activity, the more your tendons increase their ability to handle the task.
Regardless of the activity, the tendons involved will adapt slowly over time.
This adaptation becomes noticeable in the first few weeks and then progresses for 3-6 months.
When the activity is stopped the tendons will slowly reduce the adaptation.
Just like muscles they will atrophy and become weaker over time when not used.
If you reduce the intensity of a regular activity, but keep the same frequency, your muscles will atrophy more and faster than your tendons.
If you reduce the frequency of a regular activity, but still keep the intensity high, your tendons will atrophy faster than your muscles.
Injury can happen when you ask the tendons to do too much again, too fast.
Especially after a period where the tendons have adapted to less activity.
This is why professional athletes often get injuries right after returning from the off-season.
They have not been working at the same activity level for months.
They go to the gym and work out intensely, but much less often than when they are doing their sports too.
They see that this keeps up their muscle strength fairly well, but they don't realize the lack of frequency is contributing to more tendon atrophy.
Then at the start of the season they go at it again.
Their memory and skills on how to perform at a high level are still there.
But often their tendons, aren't at that level of strength anymore.
So, when they try to do what they could before, their tendons are not ready for that level of exertion, and they get injured.
This happens to the average person all the time as well.
They suddenly ask their body to go to a level it is not adapted to handle, and injury occurs.
It could be by one day doing a sports activity they haven't done in a while.
Or it could be from any period of relative rest to a level of activity they have not experienced in a while.
Often people increase volume and intensity of their activity at the same time.
They do this with sports for example.
They discover pickleball and quickly change to playing all the time, and going all out.
Or they take up a fitness regimen, and they take the idea of "no pain, no gain" a bit too literal.
Whatever the reason, gradual increases in activity give the body a chance to adapt and avoid injury.
The first step is rest.
Stop doing things that add to the problem - at least until you have the injury under control.
This does not just mean sports.
Stop doing any strenuous activity for a bit.
If you have a bad Peroneal Tendon Injury, it's easy to irritate it and keep it going with even modest movement.
So, do as much resting as you can for a little while.
Reduce activities that require you to move around a lot.
You might need a modified lifestyle for a few weeks.
Just rest alone will go a long way toward healing.
Most people don't want to accept how long it can take for an injury to heal.
If you have a stubborn injury or just don't want to wait the time to heal naturally, there are proactive treatments to speed up the healing.
But in reality, rest is a requirement to healing.
Rest at least until your condition stabilizes.
There is so much bad advice out there when it comes to Peroneal Tendon injury. Many common recommendations that you see on the web will not help. In fact, some will make you worse and set your healing back considerably.
There are a ton of compression straps and socks on Amazon and other sites claiming to fix Peroneal Tendon Injuries and Tendonitis. The idea is that by holding the pressure on the injured tissue it will be protected from moving too much. They also claim it will keep the area from swelling by squeezing the area. Wrong!
In reality, ankle compression wraps and socks just make Peroneal Tendon injuries worse.
They fail to immobilize the injury when it should be.
Compression wraps and bands press your already injured tendons against other bone and tissue increasing the wear and tear as you move.
Compression bands and wraps are a bad idea, no matter how badly Amazon wants to sell you one.
If you have a bad enough tear, it is likely that your doctor will recommend a cast or brace to stop movement all together.
This will keep you from moving your foot and ankle and give your tendons, pipe and bands a chance to heal.
This is what you want.
You do not want something that squeezes your ankle while still letting you move your foot.
This just lets the tendons move around while they are being squeezed.
Which increases the amount that the tendons will rub against other parts of the ankle, like the bone.
This will make inflammation worse and increase the likelihood of more injury.
Instead, use cold compression to reduce pain and inflammation when you are at rest.
The mild and even compression, combined with cold, will dramatically lower pain levels and inflammation quickly.
You can use cold compression whenever you take the brace off for a bit.
Especially at the end of the day or after any activity.
Most people stop using the brace or crutches before they are fully healed.
The pain and swelling may be gone and the ankle may feel back to normal, but it really takes many months for the tendon and bands to completely heal.
At this point it's a great idea to use tape to protect your ankle from further injury.
Tape provides just the right amount of restriction of movement in the damaged tissues.
Tape does not wrap all the way around the ankle, causing excessive restriction and binding of the damaged tissues like a wrap does.
Just run a strip of tape right over the painful area. Make a "T" with the tape right where the pain is and you will be amazed at how much more stable the area feels immediately. Run one strip of tape left to right over the pain area. And another strip straight up the ankle and Peroneal Tendons. You will marvel at how much this stabilizes the tendon and helps you avoid further injury. Some people prefer to do an 'X' with both pieces on the diagonal. Pick whichever method you feel most support from. Your injury is unique so let the pain be the guide.
Exercising too soon is another mistake. You need to let the tendon rest at first.
If you exercise while the tendon is very irritated and inflamed you can set back your healing.
But many sites will suggest exercise.
Stretching will not help.
Tendons don't really stretch so, while it probably won't hurt, stretching will not get to the root of the problem to heal your tendon.
There are so many Myths when it comes to healing your Peroneal Tendon.
Injections, TENS, pain meds, and more don't help you heal and can make your condition worse.
There is so much "noise" out there about Peroneal Tendon healing.
Just focus on the well understood steps to healing any soft tissue injury.
Start with resting the injury, and protecting it from reinjury as it heals.
For more common mistakes to avoid click here for our Peroneal Tendon Myths page.
For more information on Proactive Treatments, you can click this link.
There are 3 Key Factors:
1. The severity of your injury.
2. The amount of reinjury you do.
3. Proactive treatments you apply.
What people really want to know is, "When will the pain be gone and I can return to normal life?".
That's very different than when your tissue is actually fully healed.
Long before your Peroneal Tendon Injury is fully healed, you will be doing most of what you could do before.
If it's very minor Peroneal Tendon Injury then most of the pain can be gone in a few weeks.
But be careful.
It takes 6 to 8 weeks to fully heal a minor injury to the Peroneal Tendons.
If you have torn bands, it often takes twice as long to heal.
Going right back to the same thing that caused the injury can land you right back where you were.
You can go back to being stronger than before but you need to ease your way back to normal activities.
If it's moderate Peroneal Tendon Injury then it can take 4-6 months to heal.
For bands 8-12 Months
It can be a bit tricky because you are using your ankle all the time and it is easy to reinjure.
You have to reduce the inflammation and rest your ankle.
If you are going back to sports then wait until you are fully healed and then go back gradually.
Going right back to a full day on the pickleball court is a great way to reinjure yourself all over again.
Ease back into activities.
For very bad Peroneal Tendon Injuries, with lots of swelling and inflammation it can take 8-10 months or more to fully heal.
Again, the bands can take twice as long.
You may get rid of the pain and feel pretty stable in the ankle much sooner.
But you need to realize it is not healed yet and continue to treat inflammation and keep protecting your ankle.
At this point, people want to know what they can do to speed up the process.
There are definitely things you can do to proactively speed the healing process.
You don't have to do them, but athletes and those who want to shorten the healing time as much as possible, will use diathermic processes like BFST and Ultrasound.
It will heal on its own, even without those proactive steps.
It will just take longer.
The short-list of things to avoid are to not drive through the pain, avoid using painkillers, and avoid exercising and stretching that can make the situation worse. As long as you are still in the painful stage, stretching is bad, not good. Physiotherapy is also for after you get past the painful period - it's good then, but it can be damaging if started too soon. If you aren't happy with the best-case healing times, don't do things that are going to drag out the injury.
To stop the inflammatory cycle and heal your Peroneal Tendons for good.
Rest is the first step to healing your Peroneal Tendons.
It is a good idea to use crutches for a week or two after any Peroneal Tendon Injury.
Letting the tendons have time to heal, without constant movement and work, may be enough to get milder injuries back on the healing path.
If you know you do not have a ligament band tear, but instead have a milder strain to one of the Peroneal Tendons you can use tape to protect the tendon when you have to walk.
If you have a bad tear to the tendon or if it is not healing you should immobilize it for a bit.
Use a removable cast and maybe crutches.
If you take the brace off be sure to use support tape.
Remember, if you have a tear to one or both of the retinaculum bands, your tendonitis will not heal without repairing the band.
And even if it does feel better for a while, it will come back, since the bands are not holding things in place properly.
This is why it's important to get an MRI or other imaging done, at the beginning and after you are feeling better, so you know what kind of injury you have and if it has truly healed.
If you have an injury to a retinaculum band, and require surgery to repair it, you will need a cast and crutches afterwards.
It is a good idea to use a cast and crutches for at least a month after the surgery to protect the bands while they are starting to heal.
You don't want to undo the work that has been done, so take the steps needed to support your body in the healing process.
During this time the main support your body needs is rest and protection from reinjury.
You can worry about strengthening your ankle after you have the injury stabilized.
Next use cold compression to reduce pain and bring down the inflammation in the painful area.
Cold compression pulls the pain out of the injury super fast and does not mask the pain.
Caution: There's a big temptation to take a bunch of pain meds for this injury because it hurts quite a bit. Don't do that if you can avoid it. The biggest reason is it does not help the tissues heal at all, and masks the pain, making it more likely that the condition will get worse.
If you use cold compression treatments regularly, you can reduce the inflammation and give it a chance to heal.
Wearing a cold pack on the area for longer periods of time can help this happen.
You need a type of cold pack that distributes the cold energy evenly and is just the right temperature.
Which is just above freezing.
The pack needs to stay in that safe and effective temperature zone for extended periods.
Ice pack injuries are common.
A proper gel pack, like ColdCure, will take the inflammation and pain right out without risk of "cold burns".
Don't use cold right before activity.
But always use it right after activity, even if it does not hurt at that time.
Any activity will increase inflammation, and the cold will reduce that inflammation.
This way, you can avoid more swelling in your ankle that can lead to more injury.
Then, during the first few weeks, you may want to brace the area depending on how severe the injury is.
When you take the brace off you can do a cold compression treatment.
If you feel like you are past the point of needing a brace, good.
But that does not mean you are healed yet so be sure to tape the area.
You have to avoid reinjury.
This is critical.
There is a reason pro athletes use tape. It works.
When you tape an injury, you keep the skin under the tape from moving.
This reduces the amount of movement in the injured tissues below the skin.
This works remarkably well for protecting damaged tissues.
It's like armor for your injury.
If you want to take your treatments to the next level, get blood flow to the area using diathermy.
Ultrasound is an example of diathermy that can increase blood flow without exercise.
But most people don't have ready access to Ultrasound.
Anyone, though, can use BFST to increase blood flow to damaged tissues.
It's easy to use, you can do it at home, and it's much more powerful than ultrasound.
This is the fastest way to get a Peroneal Tendon injury healing quickly.
If you have surgery, you can use BFST to prepare before surgery and to help speed up healing after surgery.
For more in-depth information about how injured tissue heals click here for our Healing Page.
For more information on Proactive Treatments, you can click this link.
Physiotherapists and doctors recommend stretching and strengthening exercises because it helps to promote blood flow through your injured Peroneal Tendon.
When we are injured, we need to reduce our activity, and that leads to a weakening of the muscles called atrophy.
In the early days of recovery, it is only the motion that we need to pump the joint.
We don't need to bear a lot of weight on the ankle.
Really, as long as you don't feel pain, whatever activity you are doing is probably okay.
So, in the early days of recovering, the early days of PT, the key is motion, not exercise.
Physiotherapy is also intended to help strengthen the surrounding muscles to rebuild that lost muscle once you are on the mend.
But it can be harmful if heavy exercises are started too early.
Your injury first needs to stabilize, and in order to stabilize the injury you need to rest.
If you still have significant injury, any PT you do should start off very light.
Our advice is, don't start Physical Therapy until your condition has stabilized. When you start, if you feel pain during or after PT, speak up! Your clinician can't feel what you feel, so it is very important to advocate for yourself during physio. Let them know how it feels at each stage so they can use that as a guide to treat you properly. PT is not supposed to hurt and if it does you may be re-injuring your Peroneal Tendon. Never drive through the pain. If your PT recommends you work through the pain you should consider a different therapist.
When you rest, your blood flow slows down which doesn't help your injury heal.
This is why BFST® is so important to start early on in your recovery.
The BFST® will increase blood flow when you can't exercise and stretch aggressively.
This enables exchange of nutrients and waste with the synovial fluid - to promote the healing process.
So, with BFST, you can have increased circulation for hours even though your actual motion of your joint is quite light and that is invaluable to your ankle.
BFST stimulation also helps prevent reinjury when you become more active.
Giving your Peroneal Tendons BFST therapy before any activity triggers the tendon as though there is significant exercise going on.
Think of it as a warm-up lap for your ankle before you actually start the exercise.
That warm-up is invaluable in preventing reinjury, particularly if you were fairly immobile before hand.
Start BFST early. The earlier the better!
Use the BFST® to warm up your ankle before PT and before any other heavy activity.
This will help prevent further injury as a result of the PT activity.
At the beginning of your injury, even before the injury has had a chance to stabilize and long before you start physio, the ColdCure® Wraps will help keep the pain and swelling under control.
Cold compression is highly recommended to stabilize a fresh injury.
And when you are active, invariably, you're going to aggravate your condition to some degree.
If you're very active, you may aggravate it a lot!
After any activity where you may have aggravated your injury, use cold compression to minimize the negative impact and stabilize your Peroneal Tendons.
Always use your ColdCure® wrap after any heavy activity and after PT.
The KB Support Tape™ should be applied every morning and worn all day long to help prevent re-injury, including to PT.
It protects you when you move.
KB Tape is armor for your injury.
For many people, King Brand® products, used in the comfort of your own home, are all that is required without having to attend and pay for Physical Therapy appointments.
Because you don't have to move to use them, the King Brand BFST® and ColdCure® Wraps can be started any time in your recovery process.
There are things you can do to speed up your healing.
Stabilize the injured area and protect from Reinjury with KB Support Tape™.
Use ColdCure® to reduce pain.
Use BFST® to bring blood flow to the area and speed healing.
ColdCure® will take the pain right out of the injured area.
And it will do it without dangerous pain killers and without masking the pain.
KB Support Tape will help protect the injured tissues.
It reduces how much the skin under the tape can move.
This in turn will limit the movement of the damaged tissues below the skin.
It works remarkably well.
Use only high quality medical grade tape.
Not athletic tape.
BFST will help the injured tissue heal by bringing blood flow right where it is needed most.
This way you can get all the benefit of increased blood flow to bring healing nutrients to the injured are without resorting to therapies that can be damaging like exercise or stretching.
For a little while - not forever - it is really helpful to give your Peroneal Tendons a rest. In many cases, resting your Ankle for a few weeks will give it time to heal to a point that your body gets ahead of the healing / reinjury cycle. It's important to realize that once the pain and any swelling go away, your underlying injury will not be healed completely, so take it easy. Go back to regular life gradually, once the pain and swelling are gone.
For more in-depth information about how an injury heals click here for our Healing Page.
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