The peroneal tendons are two tendons that run along the outer side of the foot and ankle. One of the tendons connects to the outside of the midfoot, and the other runs under the foot and connects to the midfoot. Both tendons work to evert and turn out the foot. They can also help to plantar flex (point your toes) the ankle and help stabilize the ankles during running and side to side activities. The tendons run in a bony groove on the posterior portion of the fibula, and a strong fibrous band called the peroneal retinaculum helps to hold them in place. [Learn about Knee Cartilage Injuries]

Peroneal Tendon Anatomy

Peroneal Injuries

Injuries to the peroneal tendons can occur in several ways. Most often, peroneal tendinitis occurs in runners. Tendonitis is inflammation of the tendon and the tissue surrounding the tendon. Tendonosis can also occur, which is thickening and swelling of the tendon. These changes in the tendon are usually a result of overuse and “microdamage” that accumulates over time. Occasionally the tendon itself can rupture or split. In other cases, the peroneal retinaculum that keeps the tendons in the peroneal groove ruptures, and the tendons “sublux” or slip out of the groove with certain movements. [Learn about patellar subluxation and dislocation]

What are the Signs and Symptoms of Peroneal Tendonitis/Tendonosis?

The most common symptom is pain in the lateral (outside)  and posterior (back) portion of the ankle with repetitive activities. It is commonly seen in athletes who have recently increased their activities, such as those training for a marathon or athletes starting a new portion of their season. This is especially true in sports which require repetitive ankle motion (most running sports). Athletes with hindfoot varus (heel turns in) and/or high arches are more susceptible to peroneal tendonitis/tendinosis because the tendon has to work harder during ankle stabilizing activities. Recent research has also indicated that athletes with weak hip and core musculature are more susceptible to these injuries.

Peroneal Tendonitis

How is Peroneal Tendonitis/Tendinosis Diagnosed?

The most important part of diagnosis is the history and physical examination. Patients with this condition have often started a new training regimen or have increased their mileage. On exam, they usually have pain that is localized to the posterolateral portion of their ankle and tracks along the normal course of the peroneal tendons. There can be pain with passive inversion or resisted eversion of the foot. If there has been disruption of the peroneal retinaculum (usually from a specific injury), the tendons can be felt to sublux, or slide out of, the peroneal groove on the back of the fibula during ankle circumduction maneuvers. 

It can be difficult to distinguish between peroneal injury and an injury to the fibular (bone on the outside of the ankle) or the 5th metatarsal (bone on the outside of the foot). The sural nerve also runs in this general area and can sometimes be associated with pain in this region. X-rays usually don’t show any signs of injury, but will sometimes show a bony “fleck” if there is an avulsion of the peroneal retinaculum. They can also show a fracture to the bones in that area. MRI is sometimes used to assess the tendons for a split, to look for a tear in the retinaculum, or to assess for a stress fracture.

Peroneal Tendon Exercises

How are Peroneal Injuries Treated?

Most peroneal tendon injuries are treated nonoperatively. The first step is to temporarily reduce the repetitive activities that stress the peroneal tendon. Most patients will need to be placed into a Cam walker boot or something similar to immobilize the ankle for a period of time. After the inflammation has settled down, rehabilitation should be started. This will consist of ankle specific exercises to stretch and strengthen the peroneal tendons, as well as exercises targeted at more proximal muscle groups such as the hip external rotators and the hip abductors.

Proper shoe wear should be fitted, and accommodations or orthotics may be needed for patients with hind foot varus. Steroid shots are usually not recommended in this area except in cases of extreme inflammation that is resistant to other forms of treatment. PRP inections have been utilized with some success, although the evidence is still early and PRP is somewhat unproven for this condition. In cases of peroneal retinacular tear or tears of the peroneal tendons themselves, surgical treatment is sometimes need to repair the retinaculum and/or tendon. Occasionally, the bone on the posterior portion of the fibula is deepened to provide a better groove for the tendons to fit in.

How are Peroneal Tendon Injuries Avoided?

The best way to treat peroneal tendonosis is to avoid it. This can be done most effectively by adequate training of the proximal lower extremity muscle groups. Poor lumbopelvic trunk and hip control can alter gait mechanics in a way that leads to lower extremity injury such as that seen in peroneal tendonsis/tendonitis. Proper shoewear is a must, especially if you have high arches or a cavovarus foot. And finally, make sure you gradually lead into significant increases in training volume.

Further information for runners: https://runnersconnect.net/peroneal-tendinitis-tendonitis/

FAQ. Frequently Asked Questions

How long does a strained peroneal tendon take to heal?

It can take several weeks for a strained peroneal tendon to heal. Depending on the severity of the injury, some people may need to rest and avoid activities that put stress on the tendon for several weeks. Others may need to wear a splint or brace to support the tendon as it heals. Physical therapy exercises may also be recommended to help strengthen the tendon and help prevent future injuries.

What does peroneal tendon pain feel like?

Peroneal tendon pain can feel like a sharp, burning pain in the ankle. It may also feel like a dull ache or throbbing sensation. The pain may be worse when you walk, run, or stand for long periods of time. You may also have difficulty moving your foot or ankle.

Is it OK to walk with peroneal tendonitis?

There is no definitive answer to this question since it depends on the severity of your peroneal tendonitis. If your condition is mild, you may be able to walk without pain or discomfort. However, if your peroneal tendonitis is more severe, walking may exacerbate your symptoms and cause further damage to the tendons. It is always best to consult with a physician or physical therapist before engaging in any type of physical activity.

How do you treat peroneal tendon pain?

There are a few things you can do to ease peroneal tendon pain. Rest and ice the area for the first few days. You can also take over-the-counter pain medication to help with the pain. After a few days, you can try exercises to stretch and strengthen the muscles and tendons around the peroneal tendons. If the pain persists, you may need to see a sports medicine doctor for further treatment.

What is the fastest way to cure peroneal tendonitis?

The fastest way to cure peroneal tendonitis is to rest the foot and avoid activities that aggravate the condition. Ice may also be applied to reduce pain and inflammation. If these conservative measures do not improve the condition, a doctor may recommend steroid injections or surgery.

What does peroneal tendonitis feel like?

Peroneal tendonitis is a condition that results in the inflammation of the peroneal tendons. These tendons are located on the outside of the ankle and attach the calf muscles to the bones in the foot. The main symptom of peroneal tendonitis is pain along the outside of the ankle, which is often worse with activity. The pain may also be accompanied by swelling and tenderness to touch. These symptoms can make it difficult to walk or even stand for long periods of time. Treatment for peroneal tendonitis typically includes rest, ice, and physical therapy. Surgery is rarely necessary.

How long does peroneal tendonitis take to heal?

Peroneal tendonitis on average takes 6-8 weeks to heal. In some cases this can be shorter or longer though. In general, the longer it has been going on, the longer it will take to heal. If it has only been going on for a week or two, it may be easier to get rid off.

How do you get rid of peroneal tendonitis?

1. Immobilization
2. Physical Therapy
3. Stretches
4. Alternating Ice & Heat

Will peroneal tendonitis ever go away?

Yes, most peroneal tendinosis cases will resolve on their own without the need for surgery. This is because it is an overuse injury and can heal with rest. Wearing a CAM walker boot for a few weeks is a good choice if there is a lot of pain. An ankle brace can be a good option if walking doesn’t cause any soreness.

Is walking good for peroneal tendonitis?

Walking specifically may not help peroneal tendonitis. Physical therapy and specific exercises however, can help.

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