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Peroneal Tendonitis

Peroneal tendonitis may present as a chronic ankle sprain that does not get better. Patients may also say there is pain, there is swelling and on occasion when they put their foot in different positions, they get popping in the posterior lateral corner of their ankle peroneal tendonitis, ankle pain, perineal tendonitis peroneal tendonitis, ankle pain, perineal tendonitis. They may also have some limitation in plantar flexion in the extreme case.

So these peroneal tendons, let me orient you to this slide, this line right here showing you the fibula, here is the front of the ankle, here is the calcaneus and here is the lateral border of the foot extending out this way. So there are those peroneal tendons as they turn the corner around the fibula to travel down the lateral border of the foot to the base of the fifth metatarsal, they have all this inflammation here in the tenosynovium, thatís painful and that hurts, and they are going to present with swelling in that region that just doesnít seem to go away, and they thought it was an ankle sprain. What is the source of that chronic inflammation that they have in that region? There is over-use or over-pull of the peroneal tendons.

Those peroneal tendons are supposed to sit in the groove behind the fibula. If you have a very shallow groove to begin with anatomically, then the soft tissue structures, namely the retinaculum, that acts as a band to keep those peroneal tendons behind the fibula, if that gets stretched out in an ankle sprain or in a mechanism that might be consistent with an ankle sprain, those tendons are popping out of their groove, they are riding up on the lateral side of the fibula and just like a frayed rope running over the side of a building, it pops up, it pops down, it pops up it pops down, you start to get tearing and fraying of that and you get tendonitis. So some of the secondary manifestations can be associated with a pes cavus foot or hind foot varus.

Another possibility is posterior lateral impingement. Some of them may have had a calcaneus fracture, for example. When you fracture a calcaneus, the calcaneus tends to get wider, so that space between the lateral wall of the calcaneus and the tip of the fibula is lost and the peroneal tendons are getting pinched between those two bony surfaces. I apologize for this slide, when I reproduced it, it came out very wide, but what I am trying to point out here to you is one sign that may be very indicative of peroneal tendon subluxation or an injury to that retinacular band that helps keep the peroneal tendons behind the fibula.

You see this, this helps make that diagnosis of subluxated peroneal tendons.

Again, our treatment is, we need to reduce the inflammation. We need to also put this foot at rest, which could again be immobilization, that over-use, over-pull syndrome that may be driving this inflammation. Eventually, we need to work on their eversion strengthening or turning that foot out to the side so they can do that more effectively so they donít overwork the tendon, and there may be a roll.

Orthotics, the main thing that helps here, if your hind foot is in varus or if itís tipped toward the midline, you need to put a strutter, a post on the lateral border of the heel, you need to try and rotate that calcaneus from being tipped in to being tipped out, so they donít have t overwork their peroneal tendons to do that. Sometimes in severe cases in very rigid deformities, you need to brace them from their foot onto their leg to help stabilize the ankle. 

When I look at someone who presents to me with a foot complaint, I try to break it up into what the primary pathology is, and what are the secondary manifestations that they are coming to me to complain about? The foot is a complex weight bearing surface. There re 28 bones and nearly 60 articulating surfaces, so there are a lot of inter-relationships going on between the different segments of the foot, the hind foot, mid foot and forefoot, and problems in one region can have manifestations elsewhere. So it is very important to recognize what the root cause of the problem is, as well as identifying all the secondary manifestations. So when I think of the problems, I start to look at the structural malalignments that might be present in the patientís foot, is the arch too high, is it too low? Is there some imbalance of the muscle forces that is causing that problem; or imbalance of those muscle balance forces driving the secondary manifestations.

There could be a problem in the hindfoot, but the patient comes in to see you because there is a forefoot problem. That is where it hurts them, that is where itís difficult for them to wear their shoes. So by way of the anatomy, the osteology of the foot.

There are the seven tarsal bones in the hindfoot region, we have that defined as the calcaneus, and the talus, that separates the hindfoot from the midfoot through the transverse tarsal joint. The remaining five tarsal bones are the middle, medial and lateral cuneiform, the cuboid bone, and the navicular. Then you enter into the forefoot which has the five metatarsal bones and the 14 phalanges. As you know, in the hallux, there are only two phalanges, whereas in the lesser toes, there are three, and then the two sesamoids that are under the first metatarsal head. Ligaments are important for static stabilization of the arch of the foot, both itís longitudinal arch and the transverse arch.

Another concept that I use frequently when I am looking at foot problems, is that the foot should have an axis of balance. That axis of balance runs along the sagittal plane. It goes from the center of the calcaneus, to the center of the midfoot, and runs between the second and third metatarsals in the forefoot. Weight bearing forces are balanced across that access medially and laterally, in fact, minimal muscle activity is required for quiet standing. The muscle forces, or the dynamic forces during the phases of gait are also balanced across this access for dorsiflexion, plantar flexion, but mostly for inversion and eversion of the foot.

It needs to be rigid when youíre standing on it, and it needs to be flexible as it strikes to the ground, so it can absorb the shock forces and the weight bearing forces as it strikes the ground. These static restraints such as the ligaments, as they start to weaken and the foot starts to collapse, you start to overwork or atrophy some of the dynamic restraints.

You can imagine structures over here become lax, both the tendons and the ligaments, structures over here become contracted. So now, you have the axis of balance disrupted and now you have further forces that are acting to contribute to worsening of the deformity. Foot posture - it is very important to get weight bearing x-rays, nonweight bearing x-rays of the foot.