Physical Therapy Guide to Peroneal Tendinopathy
Peroneal tendinopathy is an injury to the tendons of the foot and/or ankle. It often affects athletes like long-distance runners, basketball players, and dancers. People who have had ankle sprains, or those who have weak ankles, may also develop this condition. It commonly causes aching along the outside surface of the ankle that gets worse with activity, yet improves with rest. Physical therapists help people with peroneal tendinopathy reduce strain on the ankle and foot and strengthen their muscles.
Physical therapists are movement experts who improve quality of life through hands-on care, patient education, and prescribed movement. You can contact a physical therapist directly for an evaluation. To find a physical therapist in your area, visit Find a PT.
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What Is Peroneal Tendinopathy?
Peroneal tendinopathy is a tendon injury that causes pain on the outside of the ankle. Tendons are connective tissues in the body that attach muscles to bones. The muscles and tendons involved in peroneal tendinopathy move the foot in an outward direction and help point the foot and ankle downward. These muscles and tendons (called peroneal muscle-tendon complex) work together to balance the foot and ankle and keep them stable.
The condition often develops over time as a result of overuse. The peroneal muscle-tendon complex can be overworked. If your foot doesn’t hit the ground in a good position when walking or running, it creates more stress on the tendon. For example, if your foot hits the ground more on the outside, the muscles and tendons must work harder to keep the foot and ankle stable. With overuse, tendons can become enlarged, thickened, and possibly swollen. Peroneal tendinopathy also can develop following an untreated ankle sprain.
How Does It Feel?
Symptoms of peroneal tendinopathy include:
- Aching pain on the outside of the ankle, especially with activity.
- Pain that decreases with rest.
- Swelling or tenderness behind the ankle bone on the outside of the ankle.
- Pain and weakness when actively moving the foot in an outward direction.
- Pain when pushing off the ball of the foot during walking or running.
- Pain when walking on a sloped terrain that turns the foot inward, and the ankle outward.
How Is It Diagnosed?
Your physical therapist will conduct a thorough evaluation, including taking your health history. The goals of the initial exam are to determine how bad the injury is and its cause. Peroneal tendinopathy may be the result of a single injury or repeated stress on the tendons. Your physical therapist will ask questions about your condition that may include:
- How did your injury occur?
- How have you taken care of the condition so far? Have other health care providers ordered imaging (X-ray or MRI) or other tests?
- What are your current symptoms and how do they affect your day? Do symptoms change during a typical day?
- If there is pain, what is the location and intensity of your pain? Does your pain vary during the day?
- What activities, if any, do you find hard to complete?
- What activities are you unable to do since your injury?
After the interview, your physical therapist will complete a physical examination based on the information you provided. Your physical therapist may:
- Observe any movements discussed in the interview.
- Assess the movement and strength of your foot and ankle as well as other regions of the body.
- Gently and skillfully touch the front, side, and back of your ankle and foot to determine where it is painful.
Your physical therapist may also refer you to an orthopedic doctor or podiatrist for diagnostic imaging (i.e., X-ray, MRI). An X-ray can identify any abnormal bones such as fractures or deformities that may cause pain. An MRI can identify issues with the tendon, muscles, and cartilage.
After your diagnosis, your physical therapist will work with you to develop a personalized treatment program to begin your recovery.
How Can a Physical Therapist Help?
It is essential to get proper treatment for peroneal tendinopathy as soon as it occurs. Any muscle-tendon connection with ongoing symptoms and loss of function can become more serious. With early diagnosis, physical therapy can successfully treat peroneal tendinopathy.
Physical therapists are movement experts who provide treatments to improve quality of life. Treatment programs can include exercise, hands-on care, and patient education. Your physical therapist will design a targeted treatment program to speed your recovery. Your physical therapist's evaluation will determine the program they create for you. They will also consider your goals for a safe return to sport or daily activities.
Your personal treatment program may include:
Patient education. Your physical therapist will teach you how to gradually increase and maintain your training regimen. This guidance will help reduce any chance of future injury.
Symptom management. Your physical therapist will help you identify and avoid symptoms related to painful movements of the peroneal muscle-tendon complex. Ice, ice massage, or moist heat may be used for pain management. You may also receive treatments like iontophoresis (medication delivered through an electrically-charged patch) and ultrasound.
Use of proper footwear and orthotics. Your physical therapist will recommend proper footwear for the activities you enjoy to ensure your ankles and feet get the support needed. It also may be necessary to get fitted for a custom foot orthotic (corrective inserts for your shoes) to reduce stress on your tendons.
Manual therapy. Your physical therapist may use hands-on techniques (manual therapy) to gently mobilize the joints in your foot, ankle, and lower leg. Soft-tissue mobilizations may be performed to loosen tightness, increase circulation, and relieve pain and swelling.
Range-of-motion exercises. You will learn exercises to help the ankle, foot, and toes move properly. These exercises will help improve the way you walk or run. Stretching exercises will help ease any tightness in the calf muscles and the tissues at the bottom of the foot.
Strengthening exercises. Walking or running on uneven surfaces (grass, sand, gravel, or trails) requires a lot of strength to avoid added stress on the ankle. Your physical therapist may teach you resistance exercises with bands, weights, or medicine balls. These exercises will strengthen your ankle, foot, and lower leg muscles. Your exercise program will be based on your specific condition, needs, and goals.
Functional training. As your symptoms, strength, and motion improve, your physical therapist will help you return to your previous level of activity. You may learn sport-specific exercises to improve your movements. Your physical therapist also will design a personal home-exercise program for you to continue to perform after your physical therapy sessions have ended. Following your home program will help you maintain and continue to build your ankle and foot strength.
Can This Injury or Condition Be Prevented?
Peroneal tendinopathy may 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 ensure proper support for your ankles and feet.
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.
- A physical therapist whose practice focus is in orthopedic or sports rehabilitation.
- A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in orthopedic or sports physical therapy. This physical 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, an online tool built by the American Physical Therapy Association. You can 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) include:
- 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.
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The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and 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.
Bavdek R, Zdolsak A, Strojnik V, Dolenec A. Peroneal muscle activity during different types of walking. J Foot Ankle Res. 2018;11:50. Free Article.
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 [published correction 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.
*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. Revised by Lisa Maria Noceti-Dewit, PT, DPT, board-certified clinical specialist in orthopaedic and sports physical therapy. Reviewed by Stephen F. Reischl, PT, DPT, board-certified clinical specialist in orthopaedic physical therapy, on behalf of the Academy of Orthopaedic Physical Therapy.