Peroneal Tendonitis: Runners' Treatment and Prevention Guide

What’s causing pain on the outside of your ankle? One possible running issue is peroneal tendonitis which, simply put, means an inflamed tendon and specifically inflamed peroneal tendons.

As runners performing a repetitive motion, there’s always an inherent risk of injury so knowing how to not only prevent it, but also what steps to take if you’re suffering from one is absolutely essential.

This is a rarer, but not uncommon type of ankle injury.

Our peroneal tendons become inflamed when there is an increase in load and use of the tendons, which leads to them rubbing on the bone. Due to this friction, our tendons swell.

Runners, unfortunately, are prone to things like tendonitis because we ask our muscles to fire repetitively in the same motion. And if we have any type of ankle instability, pronation or knee falling inward those muscles are worked even harder.

But the good news is that it is something we can resolve and, also, prevent.

In this article, you’ll find everything you need to know about peroneal tendonitis along with a prevention plan specifically targeting runners.

What is Peroneal Tendonitis?

Tendonitis is the inflammation of tendons. Tendons are bands of tissue that attach muscle to bone.

So, what exactly is Peroneal Tendonitis? Simply put, it is the inflammation of the peroneal tendons.

There are two peroneal tendons located in our feet, one is called peroneus longus and the other peroneus brevis.

They run next to each other down the lower leg bone, known as the fibula, and behind our lateral malleolus, which is the bony lump on the outside of the ankle.

These tendons allow our feet to move in an outward direction and help point our feet and ankle downwards, providing that power in our push off from the ground.

The main function of our peroneal tendons is to provide stability to our ankles when it bears weight. They also protect our ankles from sprains.

With repetitive movement or overuse of the ankles, the ankles rolling inward or poor form, these tendons become inflamed and start to swell due to irritation. This tends to make the tendons rub against the bone further, exacerbating the inflammation even further.

This is not an injury that will magically go away. Instead, it’s one that continues to get worse without attention.

Other Common Ankle Pains While Running

Could it be something other than peroneal tendonitis? Definitely! There are a few possibilities that depend upon foot strike, running form, and any past ankle injuries, which we can dive into below.

Other potential outcomes of ankle pain while running include:

Of course those are the injury results, but some aches are just the body getting stronger.

If it’s not changing your running form, shooting pain or swollen it could be standard runner discomfort. Ease up a little on the mileage and know your body is going to keep getting stronger.

The causes of most runner pains from shin splints to the bigger issues stem from the same things:

Adding too much mileage
Adding too much speed work
Not doing enough hip, glute and core strength
Only moving our bodies forward and not maintaining that ability to move side to side
Life incidents like stepping off a curb wrong

Sprained Ankle

Unfortunately, a sprain can be a bigger problem than we realize as they often take longer to heal than a stress fracture! Possibly because we don’t stay off it in the same way that we would a fracture.

This article isn’t specifically to address sprains, but you will need to stay off of it and compression can help to manage swelling and increase blood flow.

What are the Causes of Peroneal Tendonitis?

There are a few main causes of peroneal tendonitis. Let’s look at these one by one:

Overuse of these tendons from repetitive movements, such as running
A sudden increase in the level of training, such as a quick increase in mileage for runners
A big change in surface. i.e. road to technical trails that require more ankle strength
Often running on the same side of the road – leading to running on a slope constantly
Lack of hip, core, and glute strength
Tight calves and feet muscles, thereby reducing mobility
Unsupportive footwear
Improper training techniques

What Increases Your Chances of Having It?

A few factors can increase the likelihood of developing peroneal tendonitis.

Peroneal Tendonitis tends to be most common amongst runners and other athletes such as basketball players. Dancers can also be affected by this type of injury. This is due to the repetitive nature of what is being done.

Running with higher foot arches increases the chances of a person developing peroneal tendonitis as your heel is turned inwards slightly, which requires these tendons to work harder to turn the ankle to the outside during movement.

If you’ve had a previous ankle injury, make sure you get the right treatment and get adequate rest before restarting your training plan. This is because having a previous ankle injury increases the chances of developing this form of tendonitis.

If you have tight calf muscles, it will increase the tension on the tendons which will cause them to rub more. The harder the tendons work, the more likely you are to develop tendonitis.

Symptoms to Look Out for

Peroneal tendonitis can come on suddenly, which means it can be acute, or it can develop over longer periods of time, which means it can be chronic.

Regardless of which type it is, here are a few common symptoms:

Pain on the outside of the ankle just below the ankle bone
Potentially swelling at the back of the ankle
Pain that improves with rest and worsens with activity
Pain that occurs when turning the foot in or out
Pain that happens when pushing off the ball of the feet during walking or running
Painful when pushing on the area
Instability in the ankle when bearing weight including popping or a snapping feeling
Area feeling warm to the touch
Thickened tendons, which could potentially include a mass or nodule that moves with your tendon

How to Get Diagnosed Properly?

If you have any of the symptoms listed above, you should definitely head to a doctor to get the correct diagnosis. This will most likely be a foot and ankle orthopedic surgeon.

You can try starting with your Phyiscal Therapist if you have a great relationship with them like I do! Otherwise you will probably be referred there later to help figure out if you need to change your form or work on any weaknesses.

Your doctor will ask and discuss your medical history. This will usually point towards the exact nature of the overuse of the tendons, as well as the increased activity that caused it.

PLEASE look for a sports medicine focused doctor so they don’t just tell you to rest, rest alone rarely resolves our injuries.

You might feel slight pain during the physical examination when the doctor touches the tendons. They will also, most likely, feel warm to the touch.

One of the most important elements of being diagnosed with peroneal tendonitis is to make sure it is, indeed, the peroneal tendons and not the fibula. The latter would point towards a different problem altogether.

Pain on the fibula occurs directly over the bone, while pain in the peroneal tendons occurs slightly further behind it. Your doctor will look at the alignment of the heel to check if it is turned inwards.

Common imaging techniques used to diagnose it include ultrasounds, MRI and X-rays. An ultrasound or MRI can show the thickening of the peroneal tendons as well as the inflammation of the tendon sheath.

An ultrasound is also particularly good at checking for a peroneal tendon subluxation (dislocation) or a peroneus brevis tear.

Recommended Peroneal Tendonitis Treatment

You’ve heard me say work on your hip strength a million times, but I’m going to say it again. Before I get in to that, let’s start with some of the pain management things you can do.

Stop running if you are having SHARP pain
Only use ice to inhibit pain, otherwise use heat to loosen tight muscles
Don’t take anti-inflammatories and run
Use compression socks (my favorites)
Foam roll to help release tension up the leg
Changing shoes or considering a running orthotic

Based on the above you’ll note that the old RICE method is not recommended. Yes, we want you to stop inflaming and yes we love compression, but not the ice and elevation isn’t going to do anything for this.

Let’s cover somethings to deal with immediate pain and then a long term plan.

1. Taping Ankle Pain

If you’re attempting to keep running or even having issues walking, this step could be very useful.

You know by know that I’m a huge fan of RockTape (stays on so much better). It was a lifesaver prior to my knee surgery and I’ve found it really useful for many other little aches pains or injuries my runners have gone through.

Watch this video for exact instructions.

2. Improving Mobility and Flexibility

Tight calves are a common issue for runners, in this case leading to pulling on muscles all the way in to your ankle and foot creating pain.

Do standing calf stretches against a wall – remember you aren’t stretching to the point of pain. Hold at least 30 seconds.
Try getting in to a deep Buddha squat to improve ankle range of motion and a full hip to foot stretch
Roll your foot over a PT ball prior to any run to help loosen muscles
Try the peroneal muscle stretch in the video below

3. Long term plan prevent ankle pain while running:

Start working through these strength and flexibility pieces to make them part of your weekly routine. Then begin to look at tools from the right shoes to insoles to see if they could help improve things.

Tips to resolve tight calves while running
Improving Hip Strength – a number of workouts here
Reviewing Your Footstrike – learn how to best land
Ankle stretches – similar to those for shin splints
Utilize a massage gun to help release ongoing tightness

Will I Need Surgery?

Surgery is very rarely needed with this injury. Non-surgical treatments typically lasting up to a year before surgery is considered. Peroneal tendonitis usually resolves over time with rest and the treatments listed above.

However, if your tendons have a tear (a split that runs along the length of the tendons) your doctor could consider surgery to repair the tendon.

Surgery can also consist of cleaning out the damaged outer layer of tissues from your peroneal tendons. This is called a synovectomy and there is a minimally invasive form of it also available, which involves smaller incisions and a faster recovery time.

Best Shoes for Peroneal Tendonitis

Pronation issues are one potential cause of ankle pain while running and while I always LOVE for us to start by fixing our weak hips, glutes and stride, sometimes we need a little extra support from the right shoe.

Insoles are an option to make your current shoe work. By picking one that provides more arch support to help your foot stop rolling inward you could get relief, but these shoes also have other benefits like the larger heel height.

While many of these have a higher heel to toe drop than I often recommend, they can be useful for Achilles or ankle pain because you’re shortening the amount the ankle has to stretch.

Additionally most of these are designed to help with under pronation.

Asics Gel Nimbus
Brooks Glycerin
Saucony Triumph
Nike React Infinity Run Flyknit — similar to my favorite running shoe

Hopefully the above tips and shoes have given you some options to help mitigate pain and decide exactly what might be causing your issues.

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Peroneal Tendonitis: Runners’ Treatment and Prevention Guide