Peroneal Tendinopathy
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Search Strategy
It is recommended to consult Pubmed. The keywords used gave several references:
- “peroneal tendonitis” (126 results with 9 free full articles)
- “peroneal tendonitis AND physical therapy” (7 results with 7 free full text)
- “peroneal tendonitis AND treatment” (16 results with 2 free full text)
Other useful sources include: Web of Science, Sciencedirect, Cochrane and Pedro databases.
Definition/Description
Peroneal tendonitis 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
<img src="/images/thumb/f/fe/Interactive_foot_-_ankle_and_foot_-_L10F26.jpg/250px-Interactive_foot_-_ankle_and_foot_-_L10F26.jpg" _fck_mw_filename="Interactive foot - ankle and foot - L10F26.jpg" _fck_mw_location="right" _fck_mw_width="250" _fck_mw_type="thumb" alt="© Primal Pictures" class="fck_mw_frame fck_mw_right" />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. A S. International Advances in Foot and Ankle London: Springer-Verlag Limited; 2012. (level of evidence 1A)
The m. 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. Scanlan RL, Gehl RS. Peroneal tendon injuries. Clin Podiatr Med Surg. 2002. (level of evidence 4)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. DS Heckman, Gluck S G, SG. Parekh. Tendon Disorders of the Foot and Ankle, Part 1: Peroneal Tendon Disorder. Am J Sports Med. 2009. (level of evidence 5) 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 MT Pfefer, SR Cooper, NL. Uhl. Chiropractic Management of Tendinopathy: a literature synthesis. Journal of Manipulative and Physiological Therapeutics. 2009. (level of evidence 1A)
Epidemiology /Etiology
Peroneal tendonitis is common in running athletes, young dancers, ice skaters and sports requiring frequent change of direction or jumping such as basketball. (level of evidence: C) 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.Omey ML, Lyle J M. Foot and ankle problems in the young athlete. Medicine &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; Science in Sports &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; Exercise. 1999;31(7):470-486. (level of evidence: C) Other causes include severe ankle sprains, fractures of the ankle or calcaneus, and peroneal tubercle hypertrophy.
Characteristics/Clinical Presentation
Patients with peroneal tendonitis present with pain and, occasionally, swelling in the posterolateral aspect of the ankle.
Differential Diagnosis
<a href="Ankle Sprain">Ankle Sprain</a>
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 oedemaTjin A Ton ER, Schweitzer ME, Karasick D. MR Imaging of peroneal tendon disorders. 1997 AJR:168:135-140. (level of evidence: C)
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.
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. (level of evidence: C)
You can isolate the peroneal muscles from each other when you use the <a href="http://www.physio-pedia.com/index.php5?title=Peroneus_longus_and_brevis_tests">peroneus longus and brevis tests</a> and you can also evaluate their strenght by <a href="Muscule testing of the peroneus longus and brevis">muscule testing of the peroneus longus and brevis</a>.
Outcome Measures
add links to outcome measures here (also see <a href="Outcome Measures">Outcome Measures Database</a>)
Examination
add text here related to physical examination and assessment
Medical Management
Patients diagnosed with peroneal tendinitis can be treated with non steroidal anti-inflammatory medication , physical therapy(see below), and rest. (level of evidence: C)
If nonoperative treatment is ineffective, an open tenosynovectomy is recommended. (level of evidence: C) Postoperatively patients are made nonweightbearing during the first 2 weeks. The, 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.Wukich DK, Tuason DA. Diagnosis and Treatment of Chronic Ankle Pain . The Journal of Bone&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;Joint surgery 2010; 92(10):2001-2016. (level of evidence: C)
The use of corticosteroid injections is not recommended. (level of evidence: C and A1)
Physiotherapy Management
Treatment for peroneal tendonitis includes a program of stretching, strengthening, mobilisation and manipulation, icing, ankle bracing or taping during contact sports.Pfefer MT, Cooper SR, Uhl NL. Chiropractic Management of Tendinopathy: a literature synthesis. Journal of Manipulative and Physiological Therapeutics. 2009; 32:41-52. (level of evidence: C and A1)
There is fair evidence for the use of eccentric exercise.Dérrick Patrick Artioli, Heitor Donizetti Gualberto, Diego Galace de Freitas, Gladson Ricardo Flor Bertolini. Tendinopatia dos fibulares. Rev Bras Clin Med. São Paulo, 2010 nov-dez;8(6):527-3 (level of evidence: A1)
The use of a biomechanical ankle platform (BAPS), deep tissue friction massage, ultrasound electric stimulation can also be included in the physical therapy. (level of evidence: A1)
Also extracorporeal shock wave therapy (ESWT),acupuncture are used to treat tendinopathy. But there is only limited evidence from studies for these treatments. (level of evidence: A1)
There is evidence for using manual therapy, specifically the lateral calcaneal glideCraig P. Hensleya, Alicia J. Emerson Kavchak. Novel use of a manual therapy technique and management of a patient with peroneal tendinopathy: A case report. Manual Therapy, Volume 17, Issue 1, February 2012, Pages 84-88.
Taping
Key Research
add links and reviews of high quality evidence here (case studies should be added on new pages using the <a href="Template:Case Study">case study template</a>)
Resources
Case Report
<a href="http://www.sciencedirect.com/science/article/pii/S1356689X11000725">This case report describes the evaluation and treatment incorporating manual therapy and therapeutic exercise for a patient diagnosed with peroneal tendinopathy</a>.
Recent Related Research (from <a href="http://www.ncbi.nlm.nih.gov/pubmed/">Pubmed</a>)
References
<a _fcknotitle="true" href="Category:Vrije_Universiteit_Brussel_Project">Vrije_Universiteit_Brussel_Project</a> <a _fcknotitle="true" href="Category:Videos">Videos</a> <a _fcknotitle="true" href="Category:Ankle">Ankle</a>
