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Physical Therapist's Guide to Peroneal Tendinopathy

Overuse injuries in sports account for 50% of all injuries. A majority of overuse injuries occur in runners, with 20% of injuries affecting the lower leg, 15% the ankle, and 15% the foot.

Peroneal tendinopathy is a type of overuse injury that often occurs in athletes, like long-distance runners and basketball players. Dancers, people who have had ankle sprains, or those who simply have weak ankles are also often affected. Peroneal tendinopathy is characterized by an aching along the outside surface of the ankle that worsens with activity, yet improves with rest. A physical therapist can help relieve symptoms caused by this condition by providing treatments, including stretching and strengthening exercises to help the ankle become more mobile, strong, and stable.

What is Peroneal Tendinopathy?

Peroneal tendinopathy is characterized by an aching pain and swelling in the peroneal tendons located in the lower, outside portion of the ankle. A tendon is soft-tissue that attaches a muscle to a bone. The muscles involved in this condition are the 2 peroneal muscles in the lower leg, called the peroneus longus and the peroneus brevis. (In some texts, the muscles are referred to as the fibularis longus and the fibularis brevis.)

The peroneus longus muscle originates on the fibula bone, which is located on the outside of the lower leg. It wraps around the bone on the outside of the ankle (the lateral malleolus) and attaches to the plantar (bottom) aspect of the base of the big toe. The peroneus brevis muscle also originates on the fibula, but attaches to the base of the fifth toe. These muscles are responsible for moving the foot in an outward direction, and pointing the toe and foot downward. Together, they help to balance and stabilize the foot and ankle. Most ankle sprains occur as a result of the ankle rolling inward. One reason for this is that the peroneal muscles and tendons are not as strong as the muscles on the inside of the ankle. If these muscles are weak, they may not be able to prevent the ankle from rolling inward. These muscles and tendons can also be overworked if the foot isn’t hitting the ground in proper alignment. If the foot hits the ground more on the outside of the foot (supination), the peroneal muscles have to work harder to stabilize the force of gravity with weight-bearing activities. Proper footwear or orthotics can help with proper foot alignment.

Peroneal tendinopathy will usually worsen with activity, such as running or walking and improve with rest. It is an overuse injury, meaning the tendons can become enlarged, thickened, and possibly swollen.

How Does it Feel?

Symptoms of peroneal tendinopathy include:

  • An aching pain on the outside of the ankle, especially with activity
  • Lateral (outside) ankle pain that decreases with rest
  • Swelling or tenderness to touch behind the ankle bone on the outside of the ankle
  • Pain and weakness when actively moving the foot in an outward direction or when pointing it down
  • Pain when pushing off the ball of the foot during walking or running
  • Pain when walking on a sloped terrain that turns the foot outward
  • Pain when stretching the foot in an inward and downward direction

How Is It Diagnosed?

Your physical therapist will conduct a thorough evaluation that includes asking about your health history. Your physical therapist may perform strength and motion tests on your ankle, ask about your job duties and hobbies, evaluate your gait (how you walk), and check for any muscle weakness in the entire leg and in your core. Your therapist will also check your posture and evaluate what type of shoes you wear to determine if they support your foot properly. Your physical therapist will gently touch your ankle in specific areas to determine which tendon or tendons may be inflamed. Special tests may be performed to determine exactly which tendons are involved.

How Can a Physical Therapist Help?

It is important to get proper treatment for peroneal tendinopathy as soon as it occurs. A degenerated tendon that is not treated can begin to tear, causing a more serious condition. With an early diagnosis, physical therapy can successfully treat peroneal tendinopathy. Your physical therapist will develop a treatment plan specific to your condition and goals. Your individual treatment program may include:

Pain Management. Your physical therapist will help you identify and avoid painful movements, allowing the inflamed tendon to heal. Ice, ice massage, or moist heat may be used for pain management. Therapeutic modalities, such as iontophoresis (medication delivered through an electrically charged patch) and ultrasound may be applied.

Manual Therapy. Your physical therapist may use manual therapy (hands-on) techniques to gently mobilize the joints in your foot, ankle, and lower leg. Soft-tissue mobilizations may also be performed to loosen any tightness, increase circulation, and relieve pain and swelling.

Range-of-Motion Exercises. You will learn exercises to help the ankle, foot, and toes to move properly, in order to normalize your gait pattern when walking or running. Stretching exercises will help ease any tightness in the calf muscles and the tissues in the bottom of the foot.

Strengthening Exercises. Your physical therapist will determine which muscle groups require strengthening to enable you to return to walking or running without pain. Navigating uneven surfaces, such as grass, sand, gravel, or trails requires significant ankle strength to avoid unnecessary stress on the ankle. Your physical therapist may teach you to perform resistance exercises with bands, weights, or medicine balls to strengthen the muscles in the ankle, foot, and lower leg.

Functional Training. As your symptoms improve, your physical therapist will help you return to your previous level of activity and sport. Sport-specific exercises will simulate certain activities. You may perform single-leg balance exercises or train on uneven surfaces to challenge the muscles that balance and stabilize the ankle. Your physical therapist will design an individual home-exercise program to perform after formal therapy has ended, to continue building your ankle and foot strength.

Patient Education: Your physical therapist will recommend proper footwear for the activities you enjoy, so that your foot and ankle have proper support. It may be necessary to get fitted for a custom foot orthotic (corrective inserts for your shoes) to wear, especially when performing more demanding activities, such as running or walking on uneven surfaces. You will also learn how to gradually increase and maintain your training regimen to reduce any chance of future injury.

Can this Injury or Condition be Prevented?

Peroneal tendinopathy can be prevented by:

  • Keeping the entire leg strong and flexible, including the hip, knee, and ankle.
  • Choosing proper footwear for running and walking activities.
  • Slowly increasing your running and walking mileage or speed.
  • Gradually adding hills or uneven terrain to your exercise route.
  • Changing footwear when necessary to properly support the foot.

Real Life Experiences

Kristin is a 35-year-old woman who has been running since she was a teenager. She runs 15 to 20 miles per week on level surfaces, and 1 day per week on uneven, hilly trails. She has had several mild ankle sprains when running on the trails over the years.

Recently, Kristin started training for a half-marathon. She began following a training plan that has her running 4 to 5 times per week. One of the days is a speed run, where she tries to maintain a faster-than-normal pace.

A few weeks into her new training plan, Kristin begins to experience some pain around the outside bone of her ankle as she pushes off the ball of her foot to increase her running speed. The pain goes away as soon as she stops running. Kristin decides to take a few days off from running, but when she resumes she begins experiencing the ankle pain again. She contacts her physical therapist.

Kristin's physical therapist performs a full evaluation of her ankle. He asks Kristin several questions about the behavior of her pain and about her running plan. He performs gentle range-of-motion and strength tests on her ankle. He finds that Kristin’s calf muscles are tighter than they should be, and the joint mobility in her heel is stiffer than normal. She feels pain and tenderness in the peroneal muscles on the outside of the ankle. She experiences pain when her foot is passively moved inward. He also observes some mild swelling in the area. He diagnoses her with peroneal tendinopathy.

Kristin and her physical therapist work together to establish short- and long-term goals for her treatment. He prescribes ice to help decrease her pain, and teaches her some gentle movement and strengthening exercises. He also suggests some cross-training exercises for Kristin to perform to maintain her fitness while taking a brief rest from running. After observing Kristin’s foot type and analyzing her gait pattern, her physical therapist helps her find a running shoe that better supports her foot. He teaches Kristin some strengthening and balance exercises to better stabilize her ankle when she is running on uneven surfaces like trails.

After a few weeks of diligent physical therapy sessions coupled with a home-exercise program, Kristin notices she is able to gradually begin running again without pain. Using the knowledge she has gained about proper footwear and the benefits of cross-training, stretching, strengthening, and stabilization exercises, she is able to meet her goal of running the half-marathon pain-free!

What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and experience to treat peroneal tendinopathy. However, you may want to consider:

  • A physical therapist who is experienced in treating people with ankle tendinopathies. Some physical therapists have a practice with an orthopedic or musculoskeletal focus.
  • A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in orthopedic or sports physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.

You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

General tips when you're looking for a physical therapist (or any other health care provider):

  • Get recommendations from family and friends or from other health care providers.
  • When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people who have ankle tendinopathies. During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.

Further Reading

The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions, and also prepare them for their visit with their health care provider.

The following articles provide some of the best scientific evidence related to physical therapy treatment of peroneal tendinitis. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.

Scott A, Docking S, Vicenzino B, et al. Sports and exercise-related tendinopathies: a review of selected topical issues by participants of the second international scientific tendinopathy symposium (ISTS) Vancouver 2012 [erratum in: Br J Sports Med. 2013;47(12):774]. Br J Sports Med. 2013;47(9):536–544. Free Article.

Rao S, Riskowski J, Hannan MT. Musculoskeletal conditions of the foot and ankle: assessments and treatment options. Best Pract Res Clin Rheumatol. 2012;26(3):345–368. Free Article.

Hensley CP, Kavchak AJ. Novel use of a manual therapy technique and management of a patient with peroneal tendinopathy: a case report. Man Ther. 2012;17(1):84–88. Article Summary in PubMed.

Lorenz D, Reiman M. The role and implementation of eccentric training in athletic rehabilitation: tendinopathy, hamstring strains, and ACL reconstruction. Int J Sports Phys Ther. 2011;6(1):27–44. Free Article.

Andres BM, Murrell GA. Treatment of tendinopathy: what works, what does not, and what is on the horizon. Clin Orthop Relat Res. 2008;466(7):1539–1554. Free Article.

Wilder RP, Sethi S. Overuse injuries: tendinopathies, stress fractures, compartment syndrome, and shin splints. Clin Sports Med. 2004;23(1):55–81, vi. Article Summary on PubMed.

DIGiovanni BF, Fraga CJ, Cohen BE, Shereff MJ. Associated injuries found in chronic lateral ankle instability. Foot Ankle Int. 2000;21(10):809–815. Article Summary on PubMed.

*PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.

Authored by Julie A. Mulcahy, PT, MPT. Reviewed by the editorial board.

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