peroneal tendinopathy - irritation to peroneal tendons.

1. PERONEAL TENDINOPATHY

2. CONTENTS
 Definition
 Relevant anatomy
 Epidemiology and aetiology
 Clinical presentation
 Examination
 Differential diagnosis
 Diagnostic procedures
 Treatment

3. DEFINITION
 Peroneal tendinitis is a condition that can be acute or become chronic
(peroneal tendinopathy) when there is irritation to one or both peroneal
tendons with subsequent degeneration and inflammation.

4. RELEVANT ANATOMY
 ORIGIN:
 Peroneus longus- from the head and proximal two-thirds of the lateral surface of the body of the fibula
 Peroneus brevis- distal two-thirds of the lateral surface of the body of the fibula, medial to the
Peroneus longus
 COURSE: Both muscles become tendons proximal to the ankle joint and pass posterior to
the lateral malleolus in a fibro osseous tunnel, the retro malleolar 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.

5. COURSE OF PERONEUS MUSCLE
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6.  Distal to the fibula, the tendons travel within individual sheaths, on the lateral
surface of the calcaneus.
 INSERTION:
 Peroneal longus- 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 cuneiform
 Peroneal brevis- onto the tuberosity (base) of the fifth metatarsal.
 ACTION: The actions of the peroneus longus and brevis are plantarflexion and
eversion of the foot

7. INSERTION OF MUSCLE
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8. EPIDEMIOLOGY AND AETIOLOGY
 Game: common in running (endurance running) athletes, young dancers, ice skaters and sports requiring
frequent change of direction or jumping such as basketball, skiing.
 Other contributing factors:
 Tight calf muscles,
 Inappropriate training,
 Poor foot biomechanics such as over pronation of the foot ,
 Inappropriate footwear and
 Muscle weakness of Peroneus longus.
 Other causes include severe ankle sprains, repetitive or prolonged activity, direct trauma’s, chronic ankle
instability, fractures of the ankle or calcaneus, and peroneal tubercle hypertrophy

9.  Tendonitis in general occurs when an individual returns to activity without proper
training or after a period of extended rest. Specifically for athletes the type of
footwear, training regimen and training surface can contribute to the problem. For
workers increased hours, changes in workstation or changes in type of labour can
contribute to symptoms.

10. CLINICAL PRESENTATION
 Pain and occasional swelling and warmth in the posterolateral aspect of the ankle along the course
of the peroneal tendons.
 Peroneus brevis tendonitis is usually symptomatic from the lateral malleolus distally to its
insertion at the base of the fifth metatarsal.
 Peroneus longus tendonitis- tenderness over the lateral calcaneus, often extending distally to the
plantar aspect of the cuboid.
 In both cases, patients may relate exacerbation with rising onto the ball of the foot, running,
cutting, jogging, or walking on uneven surfaces
 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. Acute tendonitis
presents with recent (<6 weeks) onset of pain along the lateral ankle and foot

11. EXAMINATION
 Passive hindfoot inversion, passive ankle plantarflexion, active-resisted hindfoot
eversion and active-resisted ankle dorsiflexion provokes pain posterior of the lateral
malleolus.
 Examination reveals tenderness and possible palpable tendon thickening along the
course of the peroneal tendons. Swelling and warmth along the peroneal tendon sheath
are a hallmark of acute peroneal tendinitis.
 Forefoot and hindfoot alignment should also be noted, as a hyper pronated foot is
associated with an increased rate of peroneal tendon disorders.

12. DIFFERENTIAL DIAGNOSIS
 Peroneal tendinitis- resisted isometric contraction painful, weak
 Ankle Sprain: anterior drawer test, talar tilt test
 Ankle fractures: Ottawa ankle rules
 Os trigonum syndrome: MRI, passive forced plantarflexion
 Longitudinal peroneal tendon tear: MRI
 Peroneal subluxation: ultrasonography, CT, MRI or peroneal tenography
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13. DIAGNOSTIC PROCEDURES
 Diagnosis may be confirmed with an MRI scan or ultrasound investigation
showing oedema.
 Plain film radiographs do not reveal soft tissue abnormalities; however, they are
useful for excluding arthritis, bone abnormalities, or fractures. In chronic cases, or
in cases which may be difficult to differentiate from lateral ankle ligamentous
injury, computed tomography or magnetic resonance imaging may be helpful.

14. MEDICAL MANAGEMENT
 Non-steroid anti-inflammatory medication (NSAID) and decrease in activity to
relieve of pain

15. PHYSIOTHERAPY MANAGEMENT
 At initial stage- icing and ankle bracing or support and patient is allowed to perform active
ankle ROM within pain free range.
 Then followed by program of strengthening, stretching, proprioceptive exercises, taping
during contact sports
 If symptoms are severe, a cast immobilisation or ROM boot (controlled ankle movement)
is prescribed for 10 days. Once the symptoms resolve, the patient begins a progressive
rehabilitation programme along with a gradual increase to full activity.
 The use of a biomechanical ankle platform (BAPS), deep tissue friction massage,
ultrasound can also be included.

16. BAPS- a sophisticated wobble board
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17.  There is evidence for using manual therapy, specifically the lateral calcaneal
glide:
 Procedure - To mobilize the left calcaneus, the patient is in left side lying with
the calcaneus hanging over the table. The foot is held in a neutral position with
the talus stabilized while the therapist performs a medial to lateral glide

18. SURGICAL MANAGEMENT
 If nonoperative treatment is ineffective or failed after 3 to 6 months, an open
tenosynovectomy is recommended.
 Postoperatively physiotherapy treatment includes non- weightbearing during
the first 2 weeks. Then 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

19. Short Leg Weightbearing Cast & Boot
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20. REFERENCES
 Scanlan RL, Gehl RS. Peroneal tendon injuries. Clin Podiatr Med Surg. 2002;19:419-43.
 Philbin TM, Landis GS, Smith B. Peroneal tendon injuries. J Am Acad Orthop Surg. 2009 May;17(5):306-17.
 Dombek MF, Orsini R, Mendicino RW, Saltrick K. Peroneus brevis tendon tears. Clin Podiatr Med Surg. 2001
Jul;18(3):409-27.
 Zgonis T, Jolly GP, Polyzois V, Stamatis ED. Peroneal tendon pathology. Clin Podiatr Med Surg. 2005 Jan; 22(1):
79-85.
 https://www.physio-pedia.com/Peroneal_Tendinopathy (8.8.17)

21. Thankyou