Pain in the outer portion of your ankle may be due to a condition called peroneal tendonitis, or peroneal tendinopathy. The pain may prevent you from walking or running normally. It may interfere with your work or recreational activity.
Physical therapy (PT) for peroneal tendonitis may help you regain normal ankle mobility, strength, and function. This article will explore peroneal tendonitis and how a physical therapist can evaluate and treat the condition.
:max_bytes(150000):strip_icc()/GettyImages-1135813420-d59c8a5da2734798a0dce7f69330eeee.jpg "Lateral Ankle Pain May Point to Peroneal Tendonitis, and PT Can Help (1)")
Anatomy of the Peroneal Tendons
The peroneal tendons are on the lateral side (outer side) of your lower leg. There are three peroneal tendons: the peroneus longus, brevis, and tertius.
The tendons arise from the peroneal muscles on the outer part of your lower leg. (Some people do not have a peroneus tertius muscle; it is often considered vestigial—no longer functional.) The tendons are also known as fibularis longus, brevis, and tertius.
Your peroneal muscles originate in the upper part of the fibula, the bone on the outer side of your lower leg. The muscles course down the lateral aspect of your leg and become the peroneal tendons. Those tendons then travel just behind the lateral malleolus of your fibula, the bony bump on the outside part of your ankle.
The peroneus longus runs under the outer side of the foot and then diagonally along the bottom of your foot to attach at the first metatarsal (big toe) and the medial cuneiform bone, the largest of the bones of the middle foot.
The function of the peroneal muscles and tendons is to evert your foot, meaning that when the peroneal muscles contract, they pull your ankle outward. The peroneus longus and brevis also work together with the tibialis posterior muscle to plantarflex your ankle, pointing your toes downward.
Symptoms
Symptoms of peroneal tendonitis may vary from person to person. Symptoms may include:
- Lateral ankle pain
- Difficulty walking or running
- Pain when moving your ankle laterally (sideways)
- Swelling behind your lateral ankle bone
- Redness on the outer aspect of your ankle
Peroneal tendonitis is considered a repetitive strain or overuse injury that comes on gradually over time. It typically does not happen as a result of trauma. If you are feeling lateral ankle pain, check in with your healthcare professional to get an accurate diagnosis of your condition.
Diagnosis
There are several components that your healthcare professional may use to diagnose your peroneal tendonitis. These may include:
- A physical examination
- X-ray
- Magnetic resonance imaging (MRI)
- Computed tomography (CT) scan
The diagnostic tests show your physician the bones and soft tissue around your foot and ankle. An MRI would show the peroneal tendons in great detail. It can reveal micro tears and trauma to the tendon that indicate tendonitis.
PT Evaluation for Peroneal Tendonitis
Your first session with a physical therapist for peroneal tendonitis is called an initial evaluation. During this visit, your therapist will interview you and ask about your condition.
They will ask about the onset of your pain, how your pain is changing, and how the pain behaves. Your therapist will ask about previous treatments you may have had, and your past medical and surgical history will be reviewed. After the interview, your physical therapist will examine your foot, ankle, and leg.
Components of the physical therapy evaluation may include:
- Palpation (feeling the foot and ankle)
- Measurements of range of motion of your foot and ankle
- Strength measurements
- Gait assessment (how you walk)
- Analysis of your foot and ankle posture in standing and sitting
- Balance assessment
- Functional assessment including walking, running, or stair climbing
After the examination, your physical therapist should have a pretty good idea of the impairments (damage or weakening) that may be causing your peroneal tendonitis. These impairments may include:
- A pronated foot position (rolling inward as you step)
- Weakness in your foot, ankle, or leg muscles
- Tightness in your calf muscles
- Impaired balance and proprioception (sense of where your body is in the space around you)
Your therapist should discuss the impairments that may be causing your pain and develop a treatment plan. Therapy goals for your peroneal tendonitis may be discussed as well.
PT for Peroneal Tendonitis
Once your therapist has assessed your condition, you will begin treatment. Treatment goals for peroneal tendonitis typically include decreasing pain, improving strength and mobility, and improving function related to walking or running.
There are several different treatments that your physical therapist may provide for your peroneal tendonitis. These should be tailored to your specific needs and impairments.
Exercise
Exercise should be your main tool for the management of peroneal tendonitis. Exercises may focus on improving range of motion, flexibility, strength, or balance. Exercises may include:
- Calf stretching: Calf stretches can be done with a strap or towel to pull your foot and ankle up toward your shin. Each stretch can be held for 30 seconds, and three repetitions can be done.
- Ankle circles or ankle alphabet: Gentle range of motion exercises may be done by performing ankle circles or by drawing the alphabet with your toes and ankle.
- Ankle strengthening with a resistance band: A resistance band may be used to strengthen your ankle. Movements of eversion (turning outward), inversion (turning inward), plantar flexion (bending the ankle away from the body), and dorsiflexion (flexing in an upward direction) may be performed, with 10–15 repetitions of each motion.
- Single leg balance exercises: If limited balance and proprioception are found, balance exercises may be prescribed. To do this, stand on one foot and hold your balance for 15 seconds. If that is easy, try closing your eyes while holding your balance. For more of a challenge, stand on one foot on a soft object like a pillow or folded up towel.
Hopping Exercises and Plyometrics
Plyometric exercises involve jumping and hopping. They may be recommended if you are planning to return to high-level sports. Your rehab must have progressed to a point where you have minimal to no pain in your lateral ankle to try these.
These exercises help your ankle tolerate high-velocity forces from running and jumping. Exercises may include lateral hops or jumping up to and down from plyometric boxes of various heights.
Before starting any exercise program for peroneal tendonitis, check in with your physical therapist to be sure you are doing the right exercises for your condition. Also, your therapist can let you know whether it is safe for you to be exercising.
Massage
Your therapist may use soft tissue massage techniques to improve peroneal tendon mobility on the lateral side of your ankle. Massage may help improve tissue flexibility and circulation, and it may be used prior to exercise and stretching to improve overall mobility.
Heat and Ice
Some physical therapists may use heat or ice or a combination of both to help treat inflammation associated with peroneal tendonitis. Heat is used to improve circulation, while ice may be used to decrease swelling around the tissues.
Care should be used. Ice and heat have not been proven to provide improved outcomes for tendon problems. Some research indicates that the use of ice and heat may slow the natural healing process of your body.
A 2020 study concluded that the use of ice can lead to delayed healing of damaged muscle and tendon tissue.
Ultrasound
Ultrasound is a deep heating modality occasionally used in physical therapy to improve blood flow and to warm tissues. Research on the use of ultrasound for tendon problems is not very thorough. Many therapists avoid using it as it has not been shown to improve outcomes for peroneal tendonitis.
Electrical Stimulation
Electrical stimulation may be used in the PT clinic to help decrease pain and improve your ability to move your ankle more comfortably. Your physical therapist will apply small electrodes to your body and use electrical signals to block painful signals from your lateral ankle to your brain. Electrical stimulation may also improve local blood flow to the muscles and tendons.
Although some therapists use electrical stimulation for peroneal tendonitis, research shows that electrical stimulation does not improve functional outcomes when compared to not using it.
Shoe Inserts (Orthotics)
A fallen arch, or poor foot posture, may be one of the impairments causing your peroneal tendonitis. If this is the case, shoe inserts (orthotics) may be prescribed by your physical therapist.
The orthotics may be custom molded or off-the-shelf. They are designed to give your foot arch support and to keep your foot in the proper position while you are walking or running.
Taping
Kinesiology tape, or K-tape, may be used to decrease lateral ankle pain and improve the function of your peroneal tendons and muscles. This is a relatively new taping technique to help overall ankle motion. Research on the use of K-tape for peroneal tendonitis is sparse.
Activity Modification
One of the most important things you can do to treat your peroneal tendonitis is to avoid activities that cause your lateral ankle to hurt. If running causes pain, avoid it for a few weeks. Choose an alternative exercise, like biking or swimming, that may be a little less stressful for your ankle.
It's important for you to take an active role in your rehab. Work closely with your physical therapist to ensure you perform the right exercises for your condition and understand the various treatments prescribed and how they are performed.
Successful treatment involves managing the inflammation first. Next is to gradually build your load tolerance by figuring out how much weight your peroneal tendons can bear.
How Long Should PT Last?
Most physical therapy regimens for peroneal tendonitis last about three–six weeks. Your personal experience may differ slightly depending on the severity of your condition and any comorbidities (other medical conditions) you may have.
On average, though, in about six weeks, your peroneal tendons should be fully healed. You should also have learned a strategy to keep the pain from returning.
Be sure to speak with your physical therapist about your specific case and understand the prognosis (outcomes) for your peroneal tendonitis. If your pain continues, you may need to visit an orthopedic surgeon for more invasive procedures like cortisone injections or peroneal tendon surgery.
Summary
With peroneal tendonitis, you may benefit from physical therapy to help improve your pain and function related to walking and running. Your therapist can determine the impairments that may be causing your tendon pain. Then they can prescribe the right exercises and treatments to help you quickly and safely return to a pain-free life.
