Peroneal Tendinopathy

Original Editors - Pieter Jacobs

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Definition/Description

Peroneal tendinitis is a condition that can be acute or become chronic (peroneal tendinopathy)whereby there is irritation to one or both peroneal tendons with subsequent degeneration and inflammation.

Clinically Relevant Anatomy

The peroneus longus and peroneus brevis muscles reside in the lateral compartment of the lower leg and are innervated by the superficial peroneal nerve. The peroneal tendons receive their blood supply from the peroneal artery and the tibialis anterior artery. There are 3 avascular zones that may contribute to tendonitis: in both the tendons at the turn around the lateral malleolus and in the peroneus longus tendon where the tendon curves around the cuboid.

The peroneus longus arises from the head and proximal two-thirds of the lateral surface of the body of the fibula and the origine of the peroneus brevis is located on the distal two-thirds of the lateral surface of the body of the fibula, medial to the Peroneus longus. Both muscles become tendons proximal to the ankle joint and pass posterior to the lateral malleolus in a fibro osseus tunnel, the retromalleolar groove. This groove is formed by the superior peroneal retinaculum (SPR), the fibula, the posterior talofibular ligament, the calcaneofibular ligament and the posterior-inferior tibiofibular ligament. Both peroneal tendons are in a common synovial sheath behind the lateral malleolus, where they are held in place by the superior peroneal retinaculum to prevent subluxation of the ankle. Distal to the fibula, the tendons travel within individual sheaths, separated by the peroneal trochlea on the lateral surface of the calcaneus. The peroneus longus tendon turns medially between the cuboid groove and the long plantar ligament and inserts onto the plantar surface of the base of the first metatarsal and the lateral aspect of the medial cuneiforms. The peroneus brevis tendon continues directly to its insertion onto the tuberosity (base) of the fifth metatarsal.  Therefore the peroneus longus tendon remains posterior and inferior to the peroneus brevis until the lateral aspect of the foot.
The actions of the peroneus longus and brevis are plantarflexion and eversion of the foot in open kinetic chain motion. During weight bearing, the peroneus longus acts as a stabilizer of the transverse arch of the foot, as well as stabilizer of the first ray during propulsion

Epidemiology /Etiology

Peroneal tendonitis is common in running athletes (particularly endurance running due to a high number of cyclic muscle contractions), young dancers, ice skaters and sports requiring frequent change of direction or jumping such as basketball, skiing and even horse riding  Contributional factors to the development of peroneal tendonitis are tight calf muscles, inappropriate training, poor foot biomechanics such as overpronation of the foot or excess eversion of the foot, inappropriate footwear and muscle weakness of the m. peroneus longus.
Other causes include severe ankle sprains, repetitive or prolonged activity, direct trauma’s, chronic ankle instability, fractures of the ankle or calcaneus, and peroneal tubercle hypertrophy.

Tendonitis in general occurs when an individual returns to activity without proper training or after a period of extended rest. Specifically for athletes the type of footwear, training regimen and training surface can contribute to the problem. For workers increased hours, changes in workstation or changes in type of labour can contribute to symptoms.

Characteristics/Clinical Presentation

Patients with peroneal tendonitis present with pain and, occasionally, swelling and warmth in the posterolateral aspect of the ankle along the course of the peroneal tendons. Peroneus brevis tendonitis is usually symptomatic from the lateral malleolus distally to its insertion at the base of the fifth metatarsal. Peroneus longus tendonitis is characterized by tenderness over the lateral calcaneus, often extending distally to the plantar aspect of the cuboid. In both cases, patients may relate exacerbation with rising onto the ball of the foot, running, cutting, jogging, or walking on uneven surfaces

Differential Diagnosis

• Ankle Sprain: anterior drawer test, talar tilt test
• Ankle fractures: Ottawa ankle rules
• Os trigonum syndrome: MRI, passive forced plantarflexion
• Chronical lateral ankle pain with other cause: MRI
• Longitudinal peroneal tendon tear: MRI
• Peroneal subluxation: ultrasonography, CT, MRI or peroneal tenography
• Flexor Hallucis longus tendon injury
  

Diagnostic Procedures

A thorough subjective and objective examination from a physiotherapist can be sufficient to diagnose peroneal tendonitis. Diagnosis may be confirmed with an MRI scan  or ultrasound investigation showing oedema.

Ultrasonography may be used for detecting all types of peroneal lesions.

Patients with this condition usually experience pain behind and distal to the lateral malleolus during activities putting stress on the peroneal tendons (lateral running, fige-8 running), or following these activities or following a rest period, especially upon waking in the morning. There may be associated swelling in the acute phase. There will also be pain when testing resisted foot eversion.   Passive hindfoot inversion, passive ankle plantarflexion, active-resisted hindfoot eversion and active-resisted ankle dorsiflexion provokes pain posterior of the lateral malleolus.

The pain associated with peroneal tendonitis tends to be of gradual onset which progressively worsens over weeks or months with the continuation of aggravating activities. Acute tendonitis presents with recent (<6 weeks) onset of pain along the lateral ankle and foot .

You can isolate the peroneal muscles from each other when you use the peroneus longus and brevis tests and you can also evaluate their strength by muscle testing of the peroneus longus and brevis. If the peroneus brevis tendon alone is affected, the pain is located posterior and distal to the lateral malleolus. Peroneus longus tendonitis presents with pain along the lateral calcaneal wall extending to the cuboid.

Outcome Measures

• LEFS (Lower Extremity Functional scale): the objective of the Lower Extremity Functional Scale (LEFS) is to measure "patients' initial function, ongoing progress, and outcome" for a wide range of lower-extremity conditions. It can be administered to determine the level of difficulty of various functional tasks with a lower extremity disability and is scored from 0-80, with 80 indicating no limitations
  
• FAAM (The Foot and Ankle Ability Measure): it is a self-report outcome instrument consisting of 29 questions to evaluate physical function of patients with food or ankle disabilities. The questionnaire is divided into two subscales: activities of daily living and sports.
  

Examination

Examination frequently reveals decreased peroneal muscle strength and painful limitation of subtalar joint range of motion secondary to muscle splinting. Pain may also be demonstrated with passive plantarflexion and inversion, or active dorsiflexion and eversion of the foot. Muscular guarding or splintage often hinders thorough examination. Plain film radiographs do not reveal soft tissue abnormalities; however, they are useful for excluding arthritis, bone abnormalities, or fractures. In chronic cases, or in cases which may be difficult to differentiate from lateral ankle ligamentous injury, computed tomography or magnetic resonance imaging may be helpful. T2-weight MR images often show visible accumulation of fluid within the peroneal tendon sheath. Thickening of the synovial lining may be appreciated with high-definition images. Tenography may be especially helpful in the chronic setting with suspected stenosis within the tendon sheath.

A provocative test for peroneal pathology has been described. The patient’s relaxed foot is examined hanging in a relaxed position with the knee flexed 90°. Slight pressure is applied to the peroneal tendons posterior to the fibula. The patient then is asked to dorsiflex and evert the foot forcibly. Pain may be elicited, or subluxation of the tendons may be felt.

Medical Management

The primary aim of treatment is to afford pain relief, restore mechanics and return the patient to their desired level of activity participation. Patients diagnosed with peroneal tendinitis can be treated with non-steroid anti-inflammatory medication (NSAID) and decrease in activity to relieve of pain.

If nonoperative treatment is ineffective or failed after 3 to 6 months, an open tenosynovectomy is recommended.

Postoperatively patients are made nonweightbearing during the first 2 weeks. Then they are placed in a short leg weightbearing cast or boot. Range of motion and strengthening activities (eccentric exercise) are started 2 to 4 weeks after surgery Also the use of lateral heel wedges can help managing mild cases peroneal tendinitis

There is lack of evidence for the use of corticosteroid.

Physical Therapy Management

Treatment for peroneal tendonitis includes a program of stretching, strengthening, mobilisation and manipulation, proprioceptive excercises , icing, ankle bracing or taping during contact sports If symptoms are severe, a cast or ROM boot immobilisation is prescribed for 10 days. After symptoms resolve, the patient begins a progressive rehabilitation programme (see above) along with a gradual increase to full activity.

The use of a biomechanical ankle platform (BAPS), deep tissue friction massage, ultrasound electric stimulation can also be included in the physical therapy

Also extracorporeal shock wave therapy (ESWT), acupuncture are used to treat tendinopathy. But there is only limited evidence from studies for these treatments.

There is evidence for using manual therapy, specifically the lateral calcaneal glide: To mobilize the left calcaneus, the patient is in left side lying with the calcaneus hanging over the table. The foot is held in a neutral position with the talus stabilized while the therapist performs a medial to lateral glide (in the transversal plane).

Clinical Bottom line

Tendinitis is the inflammation of a tendon resulting from micro-tears. These tears happen during an acute overload of the tendon from too heavy or sudden forces. This pathologic process leads to pain, swelling and decreased strength and flexibility of the tendon.